Long-term mental and physical quality of life outcomes following ileal pouch anal anastomosis surgery.

INTRODUCTION: This study presents the authors' experience over 14 years of performing restorative procto-colectomy with ileal pouch anal anastomosis (IPAA). The aim was to study the long-term quality of life outcomes and analyse the predictors of pouch function as well as physical and mental wellbeing. METHODS: This is a single-centre retrospective study conducted in a specialised colorectal surgery unit in the UK. The study included patients who underwent two- or three-staged panproctocolectomy with defunctioning ileostomy for ulcerative colitis (UC) or familial adenomatous polyposis between 2004 and 2018. Data were collected from a prospectively, surgeon-maintained database. Pouch function and quality of life scores were obtained via validated questionnaires. A multivariate analysis was utilised to explore predictors of quality of life and pouch function. RESULTS: The study reports 105 patients who underwent IPAA with a covering ileostomy. The majority of operations were performed for UC (97, 92.4%). The median age of patients was 36 years and the male to female ratio was 1:1. Thirty patients (28.5%) suffered early post-IPAA complications, while pouch failure rate was 11.4% (12/105). Late complications were reported at a rate of 45%. On long-term follow-up, the median Pouch Function Score was 7 (IQR 3-14). Both the physical and mental sections of the quality of life score were at a median indistinguishable from the normal population but had different predictors associated with them. CONCLUSION: Our findings recognise the complex interplay between physical and psychological wellbeing after pouch surgery and advise psychological counselling where appropriate.

Safety profile and outcomes of intraoperative ultrasound-guided remnant cholecystectomy.

INTRODUCTION: Subtotal cholecystectomy (STC) is a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study evaluates the safety profile and perioperative outcomes of remnant cholecystectomy (RC) performed under intraoperative ultrasound guidance. METHODS: We retrospectively reviewed the records of all patients that underwent RC under intraoperative ultrasound guidance in 2009 and 2019. Pre-, intra- and postoperative details of patients who underwent RC were obtained from patients' electronic and paper copy records. RESULTS: Ninety-seven patients underwent STC during the study period. Of this cohort, 16 patients (16.5%) presented with symptomatic gallbladder remnant over a median follow-up period of 14 months (interquartile range [IQR] 2-26). The median age was 64 years (IQR 54-69) with an equal male-to-female distribution. The median body mass index was 31kg/m2 (IQR 28-33). Twelve of 16 patients (75%) then proceeded to elective RC. Intraoperative ultrasound was used in all cases to identify the location of the remnant gallbladder and biliary anatomy. The median operative time was 88min (IQR 80-96), with 67% completed laparoscopically. No patients suffered bile duct injury. The median hospital stay was 3 days (IQR 1-5). During the follow-up period, eight patients (67%) reported symptom resolution. CONCLUSIONS: RC is a safe operation that can be performed laparoscopically even after previous open subtotal cholecystectomy. We recommend the routine use of intraoperative ultrasound as an adjunct for identifying remnant gallbladder and biliary anatomy in all patients.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION: Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC. METHODS: We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study. RESULTS: A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC. CONCLUSIONS: STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Prognosis of non-operative management of non-metastatic colorectal cancer in octa- and nonagenarians.

INTRODUCTION: The aim of the study was to establish the natural history of elderly patients with non-metastatic colorectal cancer who underwent non-operative management in comparison with those who underwent operative management. MATERIALS AND METHODS: A retrospective analysis of patients aged 80 years and above diagnosed with colorectal cancer between 2007 and 2015 in a tertiary care hospital in the Southwest of England was done. Patients were divided into non-operatively managed and operatively managed groups. Clinical demographics, Charlson Comorbidity Index, location of the tumour and overall survival between the two groups were compared. RESULTS: A total of 407 patients were studied; 132 were treated non-operatively and 275 operatively. The non-operative group included fewer right-sided colon cancers (28.7% vs 54.9%), but significantly more rectal cancers were managed non-operatively (43.9 vs 23.6%, respectively). The two and five year overall survival was 38.9% and 11.3% respectively in the non-operative group, significantly lower than patients in the operative group where the two and five year survival was 78.9% and 59.6% respectively (p = .0001). The median Charlson Comorbidity Index was 7.99 for the non-operative group and 7.49 in the operative group (p = 0.109). Patients treated non-operatively were deemed unfit without objective frailty assessment and only 43/132(32.6%) had formal anaesthetic assessment before being deemed unfit for surgery. CONCLUSION: The survival of octa- and nonagenarians with non-metastatic colorectal cancer managed conservatively is significantly less than counterparts managed operatively. Our present strategy of deciding and denying treatment of the elderly patient with colorectal cancer is arbitrary, highlighting the need for robust geriatric and frailty assessment.

Management of patients with incurable colorectal cancer: a retrospective audit.

AIM: Counselling patients and their relatives about non-curative management options in colorectal cancer is difficult because of a paucity of published data. This study aims to determine outcomes in patients unsuitable for curative surgery and the rates of subsequent surgical intervention. METHOD: This was an analysis of all colorectal cancers managed without curative surgery in a district general hospital from a prospectively maintained cancer registry between 2009 and 2016, as decided by a multidisciplinary team. Primary outcomes were overall survival and secondary outcomes were subsequent intervention rates and impact of tumour stage. RESULTS: In all, 183 patients out of 976 patients (18.8%) were identified. The median age at diagnosis was 81 years [interquartile range (IQR) 71-87 years]. Overall median survival from diagnosis was 205 days (IQR 60-532 days). One-year mortality was 62.3%. Patients were classified into two groups depending on the reason for a non-curable approach: patient-related (PR) or disease-related (DR). The difference in survival between PR (median 277 days, IQR 70-593) and DR (median 179 days, IQR 51-450) was 98 days (P = 0.023). Twenty-four patients were alive at the end of the study period; 19 out of 91 cases in PR (20.8%) and five out of 92 cases in DR (5.4%). Overall intervention rates were 11.9%, with higher rates in the DR group (P = 0.005). Disease stage was not associated with subsequent surgical intervention between the two groups (P = 0.392). CONCLUSION: Life expectancy for non-curatively managed patients within our unit was 6.8 months with one in nine patients requiring subsequent surgical admission for palliation. This information may be useful when counselling patients with incurable colorectal malignancy.