An enhanced recovery programme reduces length of stay after rectal surgery.

PURPOSE: Enhanced Recovery Programmes (ERP) result in shorter hospital stay after colonic resection with no increase in complication, mortality or readmission rates. There is little data regarding the use of an ERP after rectal resection. We investigated the effect of introducing laparoscopic surgery and the ERP on outcomes in our unit. METHODS: From February 2007, elective patients undergoing rectal resection (laparoscopic or open) under the care of two colorectal surgeons were placed into the ERP. Length of stay (LOS) was recorded as total LOS, including readmissions. Comparison was made with a cohort of patients from 2004-2005 before the onset of laparoscopic surgery/ERP. RESULTS: Forty patients in the ERP group were compared with 42 patients from 2004-2005. Morbidity and mortality rates were similar. LOS was shorter in the ERP group cf. the retrospective group (median 7 days vs. 11 days; p=0.002). Median LOS was shorter in both laparoscopic ERP patients (6 days cf. 11 days; p= 0.004) and open ERP patients (7 days cf. 11 days; p=0.014) cf. the retrospective group. CONCLUSION: Patients having rectal resections benefit from a multimodal approach to surgery with significant reductions in LOS, but no change in morbidity or mortality.

The inferior mesenteric vessels as recipients when performing free tissue transfer for pelvic defects following abdomino-perineal resection. A novel technique and review of intra-peritoneal recipient vessel options for microvascular transfer.

Successful microvascular transfer of tissue is dependent upon suitable vessels not only of the donor tissue but also at the recipient site. Congenital deformities, previous surgery, infection or irradiation at the recipient site may render vessels less suitable for this purpose. Under such circumstances it becomes desirable to identify suitable recipient vessels remote to the compromised area. In cases where external beam radiotherapy has been delivered, the superficial surface area damaged can be rather extensive precluding the use of even the longest of flap pedicles--a problem potentially addressed by searching for recipient vessels deep to the tissue planes affected. We report one such case where the inferior mesenteric vessels were used as recipient vessels for the microvascular transfer of a free Latissimus Dorsi musculocutaneous flap to reconstruct an extensive perineal defect following abdomino-perineal resection where the vessels would otherwise serve no purpose. Whilst a limited number of intra-peritoneal vessels have previously been reported as recipient vessels for free flap surgery there has not been, to our knowledge, any report of utilising the inferior mesenteric artery (Inf Mes A). Whilst based on a single case report, this article examines the literature describing microvascular transfer of tissue to compromised recipient sites and it reviews previously reported recipient vessel options available when reconstructing the perineum, abdominal wall or trunk with particular emphasis on intra-peritoneal options.

Reconstruction of the perineum following anorectal cancer excision.

PURPOSE: Most patients with anal cancer receive chemoradiotherapy as first-line treatment. Persistent/recurrent tumours will subsequently require an abdomino-perineal resection (APR). A proportion of the 20,000 new cases of rectal carcinoma diagnosed in the UK each year receive neo-adjuvant chemoradiation and then an APR. Healing of the irradiated perineal bed is compromised, resulting in high morbidity. Reconstruction of the perineam with well-vasularised tissue is thought to enhance healing. This study investigates a series of 18 patients who underwent APR for anorectal cancer with flap reconstruction of their perineum. MATERIALS AND METHODS: A retrospective analysis of all anorectal cancers requiring an APR and flap reconstruction was performed. Casenotes were reviewed and documentation made of risk factors putting them at increased risk of wound complications. Length of stay, morbidity and outcome variables including primary flap healing were recorded. RESULTS: Between November 2000 and October 2007, 18 cases were performed (M/F = 7:11), six for anal cancer and 12 for low rectal tumours. Pre-operative treatment was chemoradiotherapy in 14 (78%), radiotherapy alone in two (11%) and none in two (11%). Perineal reconstruction consisted of 14 vertical rectus abdominis myocutaneous flaps, three free latissimus dorsi flap and one transverse rectus abdominis myocutaneous flap. Mean hospital stay was 21.8 days (10-54 days). Complete healing was noted in 16 cases with the remaining two continuing to improve under current follow-up. There were no flap losses. CONCLUSIONS: Despite most patients being treated with pre-operative radiotherapy, we have had significant success in obtaining primary healing of the perineal defect after APR.

Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer?

INTRODUCTION: This study was designed to assess whether preoperative magnetic resonance imaging scans were able to predict 1) pathologic tumor and node stage, and 2) those patients with a pathologically clear circumferential resection margin. METHODS: Patients with histologically proven carcinoma of the rectum were staged preoperatively using magnetic resonance imaging. Histologic specimens from patients undergoing mesorectal excision were reported according to the Royal College of Pathologists minimum dataset. Agreement between radiologic staging of tumor, local lymph nodes and circumferential resection margin involvement, and pathologic reporting was assessed by means of the Kappa statistic. RESULTS: After exclusions (10 radiotherapy, 3 failed scans, 10 no surgery, 9 local surgery), 40 patients remained. Magnetic resonance imaging correctly staged the tumor in 20 patients, understaged in 12, and overstaged in 8. Statistically, there was poor correlation between pathologic and radiologic tumor staging (Kappa, 0.18; 95 percent confidence interval, -0.13 to 0.42). Magnetic resonance imaging correctly staged node status in 27 patients, overstaged in 9, and understaged in 4. Statistically, there was poor correlation between pathologic and radiologic node staging (Kappa, 0.38; 95 percent confidence interval, 0.08-0.64). Magnetic resonance imaging correctly reported the status of the circumferential resection margin in 39 patients and understaged 1. Statistically, there was good correlation between pathologic and radiologic reporting of circumferential resection margin involvement (Kappa, 0.66; 95 percent confidence interval, 0.03-1). CONCLUSIONS: Preoperative magnetic resonance imaging scans provide poor predictive data as to subsequent pathologic tumor and node stage. Preoperative magnetic resonance imaging does produce reliable prediction of clear circumferential resection margins and provides valuable information in assessing whether patients can proceed to surgery without the need for preoperative radiotherapy.