Permanent stoma rates: a misleading marker of quality in rectal cancer surgery.

AIM: The latest National Bowel Cancer Audit Programme (NBOCAP) audit identified our colorectal unit as an outlier with regard to the high permanent stoma rate. The aim of this study was to perform an audit of the rationale for stoma formation in patients undergoing rectal cancer resection in our unit. METHOD: A review was conducted of all rectal cancer operations between April 2011 and March 2013. Preoperative staging investigations and operation reports were reviewed to identify the reasons for nonrestorative surgery. Postoperative histology reports were used to identify circumferential resection margin (CRM) involvement and tumour height. RESULTS: One-hundred and twenty-five patients underwent surgery for rectal cancer, of whom 102 underwent elective resection with curative intent. The permanent stoma rate was 63.2% when emergency and palliative procedures were included and 54.9% when only elective curative cases were considered. Tertiary referrals made up 31.4% of elective cases. The main reasons for nonrestorative surgery included multivisceral resection (n = 24) for locally advanced cancer and operations for lesions close to the anal sphincter (n = 21). The median length of stay was 8 days, the 90-day mortality was 2.9% and the rate of CRM involvement was 2.0%. CONCLUSION: Our unit provides multivisceral surgery for locally advanced rectal cancer and receives a substantial number of tertiary referrals. Many of the rectal cancers referred are locally advanced or threaten the anal sphincter. This study demonstrates that the complexity of a unit's case-mix can have a profound effect on the permanent stoma rate. Stoma rates taken at face value do not therefore provide an accurate representation of surgical quality. What does this paper add to the literature? The study reviews the practice of a colorectal surgical unit with an interest in multivisceral surgery with regard to the permanent stoma rate. The reasons for nonrestorative surgery are analysed, and the problems associated with the use of stoma rates as a marker of quality in colorectal surgery are highlighted.

Case controlled study of the hospital stay and return to full activity following laparoscopic and open colorectal surgery before and after the introduction of an enhanced recovery programme.

AIM: The short-term benefits of laparoscopic surgery are well established and in particular within an enhanced recovery programme. Early return to activity is to be expected but has not been quantified widely. The aim of this study was to measure the hospital stay and return to full activity following laparoscopic colorectal surgery and compare this with a matched group of patients undergoing open colorectal resections before and after the introduction of an enhanced recovery programme. METHOD: Retrospective analysis of all laparoscopic colorectal operations performed between January 2003 and June 2007 on an intention to treat basis compared with a matched group of patients undergoing elective open colorectal surgery at the same institution. RESULTS: The median hospital stay following 179 laparoscopic colorectal resections was 6 days whilst following 144 conventional open operations it was 8 days. Following the introduction of an enhanced recovery programme the hospital stay fell from 7 to 5 days and from 9 to 7 days for laparoscopic and open groups respectively. The median return to full activity from surgery for laparoscopic patients was 13 days in comparison to 56 days for patients undergoing open colorectal surgery. CONCLUSIONS: Following laparoscopic colorectal resection, patients can be expected to have a hospital stay of under a week and return to their usual activities as early as a week after discharge from hospital and < 2 weeks from surgery in comparison to patients undergoing open surgery who take 8 weeks or more to recover.

Portal venous gas--case report and review of the literature.

A 74-year-old man with chronic renal failure was admitted to the renal unit with non-specific symptoms and positive blood cultures. He later deteriorated and was admitted to the Intensive Care Unit with septic shock, respiratory failure and deranged liver function. Initial improvement was followed by abdominal distension and discomfort. Portal venous gas (PVG) and thrombosis were diagnosed on computed tomography. A conservative line of management was adopted. Improvement was soon followed by deterioration with septic shock. Extensive portal venous gas and free intra-abdominal gas were now evident on repeat computed tomography. The patient was too unwell to withstand surgery and a decision was made not to escalate therapy. He died on day 16. Portal venous gas is not a disease; it is a diagnostic clue in patients who may be harbouring an intra-abdominal catastrophe. Successful management of these cases requires early identification of the underlying pathology and can range from simple observation to extensive surgical intervention.

Systematic review of the efficacy and safety of colorectal stents.

BACKGROUND: Colorectal stents are being used for palliation and as a 'bridge to surgery' in obstructing colorectal cancers. METHODS: A systematic review of the published data on stenting for the treatment of colorectal obstruction was carried out by searching Medline and other online databases for the period from January 1990 to December 2000. A total of 58 publications (case series, single case reports and reviews) was found, of which 29 case series were included in the analysis. Technical and clinical success, complications and reobstruction, both in palliation and as a 'bridge to surgery', were assessed. Both descriptive statistics and pooled analyses were carried out. RESULTS: Pooled results showed that stent insertion was attempted in 598 instances. Technical success was achieved in 551 (92 per cent) and clinical success in 525 (88 per cent). Palliation was achieved in 302 (90 per cent) of 336 cases, while 223 (85 per cent) of 262 insertions succeeded as a 'bridge to surgery' (95 per cent had a one-stage surgical procedure). There were three deaths (1 per cent). Perforation occurred 22 times (4 per cent). Stent migration was reported in 54 (10 per cent) of 551 technically successful cases. The rate of stent reobstruction was 52 (10 per cent) of 525, mainly in the palliative group. CONCLUSION: Evidence suggests that colorectal stents offer good palliation, and are safe and effective as a 'bridge to surgery'. Stent usage can avoid the need for a stoma, and is associated with low rates of mortality and morbidity. Dilatation of malignant strictures at the time of stent placement appears to be dangerous and should be avoided.