Comparing return of bowel function after right versus extended right hemicolectomy: a retrospective analysis.

BACKGROUND: Prolonged postoperative ileus (PPOI) is associated with higher morbidity and extended inpatient stay. Although evidence suggests that PPOI is more common following right-sided resections, it is uncertain if return to bowel function is similar following extended right (ERH) versus right hemicolectomy (RH). METHODS: The recovery of patients undergoing ERH and RH in a regional hospital in New Zealand was retrospectively compared, from 2012 to 2021. Rates of PPOI, return of bowel function and postoperative complications were compared. Other factors potentially relating to PPOI were analysed. RESULTS: 293 patients were included (42 who underwent ERH, and 251 RH). PPOI was more common following ERH than RH (43% vs. 25%, P = 0.02). When accounting for the operative approach, rate of PPOI was not significantly different (42% open ERH vs. 36% open RH; P = 0.56). Excluding PPOI, return of bowel function did not differ between groups. Patient undergoing ERH versus RH had significantly higher length of stay (1 day) and Hb drop (2.5 g/L) postoperatively. CONCLUSION: Higher rates of PPOI have been demonstrated in ERH versus RH however when controlling for approach, there was not a significant difference. Further interrogation into rates of PPOI (particularly after laparoscopic surgery) are warranted to tailor locoregional ERAS protocols.

Perioperative shared decision-making in the Bay of Plenty, New Zealand: Audit results from a complex decision pathway quality improvement initiative using a structured communication tool.

Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk-benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.

The other colonic polyposis syndromes.

Familial colorectal cancer syndromes have been increasingly recognized and through their characterization have contributed to our understanding of the genetic basis of colorectal cancer. The two main syndromes of familial adenomatous polyposis and hereditary non-polyposis coli are the commonest. There is however a number of lesser known syndromes described, which is the focus of this article.

Early ileostomy closure: is there a downside?

BACKGROUND: A loop ileostomy is a common adjunct to formation of a low colorectal anastomosis. However, it is not without significant physical and psychological morbidity, and financial cost. Feasibility of early closure during the index admission has previously been reported. This pilot study examines the safety of early closure compared with traditional timing. METHODS: A retrospective audit of consecutive ileostomy closures performed in a tertiary colorectal unit from January 2008 to January 2010. Demographic data, treatment data and complications were collected by a single investigator from a prospective clinical audit database and hospital records. Patients undergoing early closure (within 10 days of the index operation) were compared with the traditional timing group. RESULTS: A total of 93 patients underwent closure of loop ileostomy during the study period (44 female; 49 male). Median patient age was 61 years. Nineteen patients (20%) underwent early closure. There were six wound infections in the early closure group (32%), and five in the traditional timing group (7%) (P = 0.01). There was no significant difference in other complications between the two groups. There was a significantly shorter overall hospital stay in the early closure group with a median stay of 14 days (range 10-26), and in the traditional timing group a median stay of 17 days (range 7-80) (P = 0.05). Seven patients (9%) in the traditional timing group had ileostomy-related complications. CONCLUSION: Early ileostomy closure appears to be associated with an increased wound infection rate but otherwise appears to be a safe alternative to traditional closure in selected patients and may reduce overall hospital stay.

Patient recall after diagnostic laparoscopy for abdominal pain.

BACKGROUND: The purpose of the study was to ascertain how well patients recall their discharge diagnosis and details of their surgical procedure after a diagnostic laparoscopy at our institution. METHODS: Three hundred and forty-five patients were identified as being eligible in the study. Patient characteristics and treatment details were recorded. They were then contacted by telephone and 258 patients participated (response rate 75%). They were asked the same seven questions by an investigator who was blinded to their treatment details and their responses recorded. RESULTS: The sample consisted of 248 (96%) women and 10 (4%) men. Only seven persons (3%) were incorrect about the state of their appendix. However, 108 persons (42%) were incorrect about their discharge diagnosis. Seventy-one patients (28%) were unhappy with the information they received while in hospital. Age, whether pathology was found, dissatisfaction or type of operation was not found to significantly influence patient recall of diagnosis. CONCLUSION: We found that patients having a diagnostic laparoscopy at our institution often leave the hospital dissatisfied and with a poor understanding of their discharge diagnosis. This has important implications for future assessments of acute abdominal pain in these patients and can lead to misinformation and unnecessary surgical procedures.

Outcomes after oesophagogastrectomy for carcinoma of the oesophagus.

BACKGROUND: Carcinoma of the oesophagus is a rare but a highly lethal malignancy. The incidence of adenocarcinoma in particular is increasing in the Western world. Despite improvements in staging, perioperative care and the use of adjuvant/neoadjuvant regimen the prognosis remains poor. METHODS: All patients who had biopsy-proven oesophageal carcinoma between the years 1992 and 2004 in the Wellington region, New Zealand, were retrospectively reviewed. The personal and tumour characteristics, operation details, complications and the details of hospital stay of patients who had had a resection were recorded in a database . Survival data were recovered from the notes, hospital database or general practitioner records and were available for all patients who had surgery. Survival analyses were calculated using Kaplan-Meier estimates. RESULTS: One hundred and ninety-one patients were diagnosed with oesophageal carcinoma during the study period (59% adenocarcinoma, 32% squamous cell carcinoma). Only 35% (n = 67) had a resection (81% adenocarcinoma, 13% squamous cell carcinoma). Fifty-one (77%) had an Ivor Lewis procedure, 9 (14%) had only a laparotomy and 6 (9%) had a laparotomy, right thoracotomy and cervical incision. Forty-six (70%) tumours were in the distal third of the oesophagus and 13 (20%) were at the oesophagogastric junction. Perioperative mortality was 10% (n = 7) and anastomotic leak rate 9% (n = 6). Five-year survival was 23%. CONCLUSION: Results from our institution for the resection of oesophageal cancer compare favourably with those in the published work. Staging with computed tomography and laparoscopy has resulted in acceptable resection and survival rates. Survival for this disease is still largely stage dependent and earlier diagnosis probably holds the key to improved prognosis.

Delay to appendicectomy and associated morbidity: a retrospective review.

BACKGROUND: This retrospective review was undertaken to determine if time between presentation and appendicectomy is a factor affecting morbidity and length of hospital stay for patients with proven appendicitis. METHODS: The notes of patients who underwent an appendicectomy at Wellington Public Hospital, New Zealand between June 2002 and February 2004 were retrospectively reviewed. Delay from admission until surgery was noted. Other variables recorded were age, sex, operation type (laparoscopic or open), white cell count, pulse rate and temperature at admission, antibiotic usage, ancillary investigations (e.g. ultrasound), operative findings, length of admission and in-hospital complications. RESULTS: A total of 480 appendicectomies were carried out. Four hundred and fifty-seven (95%) records were retrieved, and 436 (91%) included the required information and were analysed. Ninety-one (21%) resected appendices were pathologically normal, 275 (63%) were nonperforated, 61 (14%) were perforated and 9 (2%) had appendicular abscesses. The mean waiting time from admission to operation was 14.5 h (range, 1.6-99 h). There were 36 complications in 31 (7%) patients. The mean hospital stay was 74.4 h (range, 9.2-372 h). Three hundred and forty-five admitted patients had histologically proven appendicitis. Patients who waited 12-24 h for their surgery, when compared with those that waited less than 12 h, did not have a statistically significant difference in either perforation rates (P = 0.66) or abscess formation (P = 0.14). There was also no statistically significant difference in the postoperative length of hospital stay (P = 0.6) or complication rate (P = 0.92) in patients who waited >24 h for their surgery. Patients with appendicitis who waited for >24 h (n = 44) had more abscesses (P = 0.0001). There was also a statistically significant difference in the perforation rate (P = 0.0001), postoperative length of stay (P = 0.04) and overall complication rate (P = 0.01). CONCLUSION: Time to surgery of up to 24 h does not lead to an increase in complicated appendicitis or morbidity. When the time exceeds 24 h, there is an increased rate of complicated appendicitis and morbidity, including complications that are not directly related to the appendicitis.