Retrospective review of all-terrain vehicle accidents in Alberta

Background

All-terrain vehicles (ATVs) are frequently associated with injuries and deaths. In spite of this, very few guidelines, let alone legal restrictions, exist to guide users of these machines.

Methods

We conducted a standardized review of prospectively collected data from the Alberta Trauma Registry. All patients who were involved in ATV-related traumas from 2003 to 2008 with an Injury Severity Score (ISS) greater than 12 were included. The variables studied were age, sex, type of vehicle, purpose of use, person injured (driver or passenger), ISS, distribution of injuries, length of hospital stay, helmet use and death.

Results

We evaluated 435 patients with ATV-related injuries and ISS greater than 12. The average ISS was 22.8, with an overall mortality of 4.6%; 55% of patients were not wearing helmets, and most of the deaths (85%) occurred among these individuals. Helmet use was associated with a lower risk of mechanical ventilation and of injury to the head and/or cervical spine. Children accounted for 18.9% of all patients and 15% of deaths; 57% of them were wearing helmets at the time of their accidents.

Conclusion

All-terrain vehicle use in Alberta carries a significant risk of injury and death, and there is an association between death and lack of helmet use. A minimum age for ATV use of at least 16 years and a legal requirement for helmet use may increase public awareness of these risks and decrease morbidity and mortality.     

Extraperitoneal rectal cancer surgery

Despite recent advances in radiation and chemotherapy, surgical resection remains the only potentially curative procedure for rectal cancer. The introduction of total mesorectal excision with autonomic pelvic nerve sparing and new modalities in restoring bowel continuity has improved significantly the prognosis as well as life quality of rectal cancer patients. Better results will be achieved only with a correct multidisciplinary approach. The Authors report their experience with surgical treatment of extraperitoneal rectal cancer, examine some important technical innovation and emphasize the oncological principles of radical surgery.     

腹腔镜手术联合术中放射治疗局部进展期直肠癌的回顾性研究

目的:分析腹腔镜手术联合移动式直线加速器术中放射治疗(intraoperative radiotherapy,IORT)对局部迸展期直肠癌(locally advanced rectal cancer,LARC)的疗效.方法:回顾性分析我院2012年1月至2016年1月应用腹腔镜手术联合IORT治疗的22例LARC病人...     

Functional preservation in rectal cancer surgery

Improvement in the cancer eradication and prevention of pelvic organ dysfunction are the most important strategy in rectal cancer surgery. More than 90% of rectal cancer in my experiences received APR resection before 1962. However, after 1963 anal function preserving operations were adopted 45% or more of rectal cancer. Pull-through was adopted at the beginning, however, anterior resection took the place of this procedure after 1969. When the suture instruments were applied to rectal surgery in 1984, 65% of patients were treated by instrumental end-to end reconstruction. Cancers, which have depth invasion a1, are treated enough with 2 cm length of distal stump, while cancers further depth invasion need 3 cm or more distal stump. Dysuria and male sexual impotence are caused by intrapelvic nerve injuries during surgery. Dysuria was found in 49% and impotence in 38% following conventional surgery. The incidence of dysuria and impotence, however, increased to 67% and 97% by extended dissection, respectively. To prevent these deteriorations, the pelvic node dissection should be limited to do for the locally advanced cases. Nerve preserving operation was performed for cancer with flat sm and slight invasion into pm layer, and the incidence of dysuria and impotence was decreased to 15% and 21%, respectively.     

Sphincter-saving surgery in low rectal cancer

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.     

Laparoscopic surgery for rectal cancer

Although laparoscopic colon cancer surgery is widely accepted as a feasible alternative to open surgery, there is still limited evidence on the use of the laparoscopic approach for rectal cancer. Although laparoscopic rectal surgery is a technically demanding procedure with a steep learning curve because of adherence to the oncologic principle of total mesorectal excision, the laparoscopic approach has some advantages over open surgery, including not only less invasiveness but also a good surgical view of the deep pelvis through its magnification effect. At this time, information is still lacking on the long-term outcomes and efficicacy of laparoscopic rectal cancer surgery based on large-scale, randomized, controlled trials, and many clinical guidelines recommend that laparoscopic rectal cancer surgery should only be performed with expertise under a clinical trial setting. Nationwide surveys show the numbers of laparoscopic rectal cancer surgery cases are increasing in Japan, and about 20% of rectal cancer operations are performed laparoscopically, but concerns about the concurrently increasing anastomotic leakage rate should be noted. The development of laparoscopic instruments specifically to facilitate dissection and transection of the rectum in the deep pelvis is expected to increase the future widespread adoption of this procedure.     

Nerve-preserving operations in surgery of rectal cancer

Forty-eight patients underwent surgery for rectal cancer. In all the patients total mesorectumectomy was combined with one of the types of nerves-preserving surgeries. Three groups were divided depending on types of this surgery: 1-- complete preservation of elements of autonomic nervous system (n=31), 2 -- partial preservation (n=16), 3 -- complete ablation (n=1). In 30 patients of group 1 normal urination recovered on postoperative day 2 to 4. In 2 patients of group 2 stable atony of urinary bladder was seen, and in 2 patients -- reflex ischuria. In patient of group 3 normal urination recovered on day 14 after surgery without vesical tenesmus. Long-term results were assessed in 1 to 12 months. No recurrences occurred. It is concluded that nerve-preserving surgeries improve functional results without loss of oncological radicalism.     

Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.     

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME.

Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria.

Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called “low anterior resection syndrome” (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation.

Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.     

Laparoscopic rectal surgery for middle and lower rectal cancer

Background  

The usefulness of laparoscopic low anterior resection for middle and lower rectal cancer remains controversial.     

Health‐related quality of life after surgery for primary advanced rectal cancer and recurrent rectal cancer: a review

Aim Health‐related quality of life is an important outcome measure in treatment of cancer. A review of the literature was undertaken to provide an overview of health‐related quality of life (HRQoL) after surgery for primary advanced or recurrent rectal cancer and to outline proposals for future HRQoL studies in this area. Method A systematic literature search was undertaken. Only studies concerning surgery for primary advanced or recurrent rectal cancer and describing methods used for measuring HRQoL were considered. Results Seven studies were identified, including two prospective longitudinal studies, three cross‐sectional studies and two based on qualitative data. Global quality of life, and physical, social, role and sexual function seemed to be impaired for a varying time after surgery. All the studies had methodical problems due to small sample size (12–44 patients) and different points of time for the assessment of HRQoL (12.3–47 months), which made it difficult to determine the period of time of impaired HRQoL and also if this is different after surgery for locally advanced or recurrent disease compared with after total mesorectal excision used for earlier tumours. Conclusion Several aspects of HRQoL are impaired for a variable time after treatment for locally advanced or recurrence of rectal cancer. Larger prospective longitudinal studies are needed to provide further information regarding the effects of this extensive surgery on quality of life.