RESUMO
AIM: Prehabilitation, defined as enhancement of the preoperative condition of a patient, is a possible strategy for improving postoperative outcome. Lack of muscle strength and poor physical condition, increasingly prevalent in older patients, are risk factors for postoperative complications. Eighty-five per cent of patients with colorectal cancer are aged over 60 years. Since surgery is the cornerstone of their treatment, this review systemically examined the literature on the effect of physical prehabilitation in older patients undergoing colorectal surgery. METHOD: Trials and case-control studies investigating the effect of physical prehabilitation in patients over 60 years undergoing colorectal surgery were retrieved from MEDLINE, EMBASE, CINAHL and the Cochrane library. Patient characteristics, the type of intervention and outcome measurements were recorded. The risk of bias and heterogeneity was assessed. RESULTS: Five studies including 353 patients were identified. They were small, containing an average of 77 patients and were of moderate methodological quality. Compliance rates of the prehabilitation programme varied from 16 to 97%. None of the studies could identify a significant reduction of postoperative complications or length of hospital stay. Four studies showed physical improvement (walking distance, respiratory endurance) in the prehabilitation group. Clinical heterogeneity precluded a meta-analysis. CONCLUSION: Prehabilitation is a possible means of enhancing the physical condition of patients preoperatively. The quality of studies in older patients undergoing colorectal surgery is poor, despite the increase in elderly people with colorectal cancer. Defining specific patient groups at risk and standardizing the outcome are essential for improving the results of treatment.
Assuntos
Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Terapia por Exercício/métodos , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Idoso , Humanos , Tempo de Internação , Resistência Física , Teste de CaminhadaRESUMO
BACKGROUND: Surgical errors result from faulty decision-making, misperceptions and the application of suboptimal problem-solving strategies, just as often as they result from technical failure. To date, surgical training curricula have focused mainly on the acquisition of technical skills. The aim of this review was to assess the validity of methods for improving situational awareness in the surgical theatre. METHODS: A search was conducted in PubMed, Embase, the Cochrane Library and PsycINFO using predefined inclusion criteria, up to June 2014. All study types were considered eligible. The primary endpoint was validity for improving situational awareness in the surgical theatre at individual or team level. RESULTS: Nine articles were considered eligible. These evaluated surgical team crisis training in simulated environments for minimally invasive surgery (4) and open surgery (3), and training courses focused at training non-technical skills (2). Two studies showed that simulation-based surgical team crisis training has construct validity for assessing situational awareness in surgical trainees in minimally invasive surgery. None of the studies showed effectiveness of surgical crisis training on situational awareness in open surgery, whereas one showed face validity of a 2-day non-technical skills training course. CONCLUSION: To improve safety in the operating theatre, more attention to situational awareness is needed in surgical training. Few structured curricula have been developed and validation research remains limited. Strategies to improve situational awareness can be adopted from other industries.
Assuntos
Competência Clínica/normas , Educação de Pós-Graduação em Medicina/métodos , Erros Médicos/prevenção & controle , Especialidades Cirúrgicas/educação , Conscientização , Tomada de Decisões , Humanos , Corpo Clínico Hospitalar/educação , Procedimentos Cirúrgicos Minimamente Invasivos/educação , Salas Cirúrgicas , Ensino/métodos , Materiais de EnsinoRESUMO
BACKGROUND: Use of topical antibiotics to improve perineal wound healing after abdominoperineal resection (APR) is controversial. The aim of this systematic review was to determine the impact of local application of gentamicin on perineal wound healing after APR. METHODS: The electronic databases Pubmed, EMBASE, and Cochrane library were searched in January 2015. Perineal wound outcome was categorized as infectious complications, non-infectious complications, and primary perineal wound healing. RESULTS: From a total of 582 articles, eight studies published between 1988 and 2012 were included: four randomized controlled trials (RCTs), three comparative cohort studies, and one cohort study without control group. Gentamicin was administered using sponges (n = 3), beads (n = 4), and by local injection (n = 1). There was substantial heterogeneity regarding underlying disease, definition of outcome parameters and timing of perineal wound evaluation among the included studies, which precluded meta-analysis with pooling. Regarding infectious complications, three of six evaluable studies demonstrated a positive effect of local application of gentamicin: one of four RCTs and both comparative cohort studies. Only two RCTs reported on non-infectious complications, showing no significant impact of gentamicin sponge. All three comparative cohort studies demonstrated a significantly higher percentage of primary perineal wound healing after local application of gentamicin beads, but only one out of three evaluable RCTs did show a positive effect of gentamicin sponges. CONCLUSION: Currently available evidence does not support perineal gentamicin application after APR.
Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Gentamicinas/uso terapêutico , Neoplasias Retais/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Abdome/cirurgia , Antibacterianos/administração & dosagem , Gentamicinas/administração & dosagem , Humanos , Períneo/cirurgia , CicatrizaçãoRESUMO
BACKGROUND: At least a third of patients with a colorectal carcinoma who are candidate for surgery, are anaemic preoperatively. Preoperative anaemia is associated with increased morbidity and mortality. In general practice, little attention is paid to these anaemic patients. Some will have oral iron prescribed others not. The waiting period prior to elective colorectal surgery could be used to optimize a patients' physiological status. The aim of this study is to determine the efficacy of preoperative intravenous iron supplementation in comparison with the standard preoperative oral supplementation in anaemic patients with colorectal cancer. METHODS/DESIGN: In this multicentre randomized controlled trial, patients with an M0-staged colorectal carcinoma who are scheduled for curative resection and with a proven iron deficiency anaemia are eligible for inclusion. Main exclusion criteria are palliative surgery, metastatic disease, neoadjuvant chemoradiotherapy (5 × 5 Gy = no exclusion) and the use of Recombinant Human Erythropoietin within three months before inclusion or a blood transfusion within a month before inclusion. Primary endpoint is the percentage of patients that achieve normalisation of the haemoglobin level between the start of the treatment and the day of admission for surgery. This study is a superiority trial, hypothesizing a greater proportion of patients achieving the primary endpoint in favour of iron infusion compared to oral supplementation. A total of 198 patients will be randomized to either ferric(III)carboxymaltose infusion in the intervention arm or ferrofumarate in the control arm. This study will be performed in ten centres nationwide and one centre in Ireland. DISCUSSION: This is the first randomized controlled trial to determine the efficacy of preoperative iron supplementation in exclusively anaemic patients with a colorectal carcinoma. Our trial hypotheses a more profound haemoglobin increase with intravenous iron which may contribute to a superior optimisation of the patient's condition and possibly a decrease in postoperative morbidity. TRIAL REGISTRATION: ClincalTrials.gov: NCT02243735 .
Assuntos
Anemia Ferropriva/tratamento farmacológico , Neoplasias Colorretais/cirurgia , Compostos Férricos/administração & dosagem , Compostos Ferrosos/administração & dosagem , Fumaratos/administração & dosagem , Hematínicos/administração & dosagem , Maltose/análogos & derivados , Cuidados Pré-Operatórios/métodos , Administração Oral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia Ferropriva/etiologia , Protocolos Clínicos , Neoplasias Colorretais/complicações , Suplementos Nutricionais , Feminino , Compostos Férricos/uso terapêutico , Compostos Ferrosos/uso terapêutico , Fumaratos/uso terapêutico , Hematínicos/uso terapêutico , Humanos , Infusões Intravenosas , Masculino , Maltose/administração & dosagem , Maltose/uso terapêutico , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Neoadjuvant chemoradiotherapy (CRT) has been proven to increase local control in rectal cancer, but the optimal interval between CRT and surgery is still unclear. The purpose of this study was to analyse the influence of variations in clinical practice regarding timing of surgery on pathological response at a population level. METHODS: All evaluable patients who underwent preoperative CRT for rectal cancer between 2009 and 2011 were selected from the Dutch Surgical Colorectal Audit. The interval between radiotherapy and surgery was calculated from the start of radiotherapy. The primary endpoint was pathological complete response (pCR; pathological status after chemoradiotherapy (yp) T0 N0). RESULTS: A total of 1593 patients were included. The median interval between radiotherapy and surgery was 14 (range 6-85, interquartile range 12-16) weeks. Outcome measures were calculated for intervals of less than 13 weeks (312 patients), 13-14 weeks (511 patients), 15-16 weeks (406 patients) and more than 16 weeks (364 patients). Age, tumour location and R0 resection rate were distributed equally between the four groups; significant differences were found for clinical tumour category (cT4: 17·3, 18·4, 24·5 and 26·6 per cent respectively; P = 0·010) and clinical metastasis category (cM1: 4·4, 4·8, 8·9 and 14·9 per cent respectively; P < 0·001). Resection 15-16 weeks after the start of CRT resulted in the highest pCR rate (18·0 per cent; P = 0·013), with an independent association (hazard ratio 1·63, 95 per cent confidence interval 1·20 to 2·23). Results for secondary endpoints in the group with an interval of 15-16 weeks were: tumour downstaging, 55·2 per cent (P = 0·165); nodal downstaging, 58·6 per cent (P = 0·036); and (near)-complete response, 23·2 per cent (P = 0·124). CONCLUSION: Delaying surgery until the 15th or 16th week after the start of CRT (10-11 weeks from the end of CRT) seemed to result in the highest chance of a pCR.
Assuntos
Quimiorradioterapia/métodos , Neoplasias Retais/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Neoplasias Retais/cirurgia , Tempo para o Tratamento , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: Crohn's disease is a chronic relapsing inflammatory bowel disease requiring surgery in a large number of patients. This review describes new developments in surgical techniques for treating Crohn's disease. RESULTS: Single-incision laparoscopic surgery decreases abdominal wall trauma by reducing the number of abdominal incisions, possibly improving postoperative results in terms of pain and cosmetics. The resected specimen can be extracted through the single-incision site or the future stoma site. Another option is to use natural orifices for extraction (i.e. transcolonic/transanal), but actual benefits of these procedures have not yet been determined. In patients with extensive perianal disease or rectal involvement, transperineal completion proctectomy is often feasible, thereby avoiding relaparotomy. By using a close rectal intersphincteric resection, damage to the pelvic autonomic nerves is avoided. In addition, the risk of presacral abscess formation is reduced by leaving the mesorectal tissue behind. CONCLUSION: Minimally invasive surgery and associated techniques have become standard clinical practice in surgical treatment of patients with Crohn's disease. New developments aim at further reducing the hospital stay and morbidity, and improving the cosmetic outcomes.
Assuntos
Doença de Crohn/cirurgia , Laparoscopia , Anastomose Cirúrgica , Estética , Humanos , Laparoscopia/métodos , Tempo de Internação , Qualidade de Vida , Prevenção Secundária , Resultado do TratamentoRESUMO
Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para-anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.
Assuntos
Abscesso/prevenção & controle , Fístula Anastomótica/cirurgia , Drenagem/métodos , Infecção Pélvica/prevenção & controle , Sigmoidoscopia/instrumentação , Técnicas de Fechamento de Ferimentos , Adulto , Idoso , Canal Anal/cirurgia , Anastomose Cirúrgica/efeitos adversos , Colite Ulcerativa/cirurgia , Colo/cirurgia , Feminino , Humanos , Ileostomia , Íleo/cirurgia , Masculino , Pessoa de Meia-Idade , Proctocolectomia Restauradora , Neoplasias Retais/cirurgiaRESUMO
Background: High perianal fistulas require sphincter-preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas. Methods: A systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta-analysis was performed using a random-effects model. Results: Some 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) versus 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) versus 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) versus 1·6 (0·4 to 2·8) per cent). Conclusion: Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.
Assuntos
Canal Anal/patologia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Ligadura/métodos , Fístula Retal/cirurgia , Adulto , Canal Anal/cirurgia , Doença de Crohn/complicações , Fístula Cutânea/complicações , Procedimentos Cirúrgicos do Sistema Digestório/tendências , Incontinência Fecal/epidemiologia , Feminino , Humanos , Ligadura/efeitos adversos , Masculino , Pessoa de Meia-Idade , Fístula Retal/etiologia , Recidiva , Retalhos Cirúrgicos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: The objective of this study was to examine the modulating effect of an appendectomy on the disease course of therapy-refractory ulcerative colitis [UC] patients, and to analyse appendiceal pathological characteristics predictive of pathological response. METHODS: Patients with therapy-refractory UC, and referred for proctocolectomy, were invited to undergo laparoscopic appendectomy first. The primary end points were clinical response after 3 and 12 months. Secondary end points were endoscopic remission, failure, and pathologic response. Appendiceal specimens, and pre- and post-operative biopsies were histologically graded according to the validated Geboes score. RESULTS: Thirty patients [53% male] with a median age of 40 (interquartile range [IQR], 33-47) underwent appendectomy, with a median preoperative total Mayo score of 9 [IQR, 8-11]. After 12 months, 9 patients [30%] had lasting clinical response, of whom 5 [17%] were in endoscopic remission. Pathological evaluation was possible in 28 patients. After a median of 13.0 weeks [range 7-51], pathological response was seen in 13 patients [46%], with a median decrease of 2 points [range 1-3]. Appendiceal inflammation was highly predictive of pathological response when compared with no inflammation or extensive ulcerations [85% vs 20%, p = 0.001]. CONCLUSIONS: Appendectomy was effective in one-third of therapy-refractory UC patients, with a substantial proportion of patients demonstrating complete endoscopic remission after 1 year. Pathological response was seen in almost 50% of patients and was related to active inflammation in the appendix, limited disease, and shorter disease duration. These early results suggest that there is a UC patient group that may benefit from appendectomy.
Assuntos
Apendicectomia , Colite Ulcerativa/cirurgia , Adulto , Apêndice/patologia , Colite Ulcerativa/patologia , Colo/patologia , Colonoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
The aim of surgical treatment of perianal fistulas is to treat the patient's symptoms, with low recurrence rates and risk of incontinence. In recent years there have been developments regarding the classification and diagnosis ofperianal fistulas. MRI is the most appropriate diagnostic tool. In the hands of an experienced operator anal endosonography is a suitable, less expensive and readily-available alternative. As a result of developments in fistula surgery it is now more practical to classify perianal fistulas as low or high fistulas, as this has implications for the further treatment. Low perianal fistulas are defined as fistulas of which the fistula tract is located in the lower third of the external anal sphincter. High fistulas are fistulas in which the fistula tract runs through the upper two-thirds of the external sphincter muscle. Low perianal fistulas can be treated safely by fistulotomy. At present, rectal advancement is the gold standard for the surgical treatment of high transsphincteric perianal fistulas. The anal fistula plug might be an alternative for the treatment of high transsphincteric perianal fistulas.
Assuntos
Canal Anal/cirurgia , Fístula Retal/diagnóstico , Fístula Retal/cirurgia , Endossonografia/métodos , Incontinência Fecal/prevenção & controle , Humanos , Imageamento por Ressonância Magnética/métodos , Complicações Pós-Operatórias/prevenção & controle , Técnicas de Sutura , Resultado do TratamentoAssuntos
Neoplasias do Sistema Digestório/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Laparoscopia , Competência Clínica , Neoplasias do Sistema Digestório/patologia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Curva de Aprendizado , Destreza Motora , Cirurgia Endoscópica por Orifício Natural , Complicações Pós-Operatórias/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Fast track (FT) programmes optimize perioperative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The aim of this review was to assess FT programmes for elective segmental colonic resections. METHODS: A systematic review was performed of all randomized controlled trials and controlled clinical trials on FT colonic surgery. The main endpoints were number of applied FT elements, hospital stay, readmission rate, morbidity and mortality. Quality assessment and data extraction were performed independently by three observers. RESULTS: Six papers were eligible for analysis (three randomized controlled and three controlled clinical trials), including 512 patients. FT programmes contained a mean of nine (range four to 12) of the 17 FT elements as defined in the literature. Primary hospital stay (weighted mean difference - 1.56 days, 95 per cent confidence interval (c.i.) - 2.61 to - 0.50 days) and morbidity (relative risk 0.54, 95 per cent c.i. 0.42 to 0.69) were significantly lower for FT programmes. Readmission rates were not significantly different (relative risk 1.17, 95 per cent c.i. 0.73 to 1.86). No increase in mortality was found. CONCLUSIONS: FT appears to be safe and shortens hospital stay after elective colorectal surgery. However, as the evidence is limited, a multicentre randomized trial seems justified.
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Doenças do Colo/cirurgia , Cirurgia Colorretal/métodos , Tempo de Internação , Idoso , Convalescença , Humanos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/métodos , Resultado do TratamentoRESUMO
BACKGROUND: The objectives of this study were to evaluate body image, cosmetic results, and quality of life in patients with Crohn's disease of the terminal ileum who had either laparoscopic-assisted or open ileocolic resection, and to determine how patients experienced the pre- and postoperative periods after both procedures. METHODS: Thirty-four patients participated: 11 patients after open resection (OR), 11 patients after laparoscopic-assisted resection (LR), and 12 patients without resection (WR). Retrospectively, the patients filled out several questionnaires pertaining to body image, hospital experiences, and quality of life. One-way analysis of variance, Student's t-tests, and Pearson's correlation were used for statistical analysis. RESULTS: The cosmetic score was significantly higher in the LR than in the OR group (p < 0.01). Body image correlated strongly with cosmesis and with quality of life. The hospital experiences of the laparoscopic and open groups were similar. CONCLUSIONS: Laparoscopic surgery was associated with better cosmesis than open surgery. Patients do not experience laparoscopic surgery any differently from open surgery.