Outcomes of medial to lateral vs. lateral to medial approaches in laparoscopic colorectal cancer resections.

Introduction: Bowel cancer is a significant global health concern, ranking as the third most prevalent cancer worldwide. Laparoscopic resections have become a standard treatment modality for resectable colorectal cancer. This study aimed to compare the clinical and oncological outcomes of medial to lateral (ML) vs lateral to medial (LM) approaches in laparoscopic colorectal cancer resections. Methods: A retrospective cohort study was conducted at a UK district general hospital from 2015 to 2019, including 402 patients meeting specific criteria. Demographic, clinical, operative, postoperative, and oncological data were collected. Participants were categorised into LM and ML groups. The primary outcome was 30-day complications, and secondary outcomes included operative duration, length of stay, lymph node harvest, and 3-year survival. Results: A total of 402 patients (55.7% males) were included: 102 (51.6% females) in the lateral mobilisation (LM) group and 280 (58.9% males) in the medial mobilisation (ML) group. Right hemicolectomy (n=157, 39.1%) and anterior resection (n=150, 37.3%) were the most performed procedures. The LM group had a shorter operative time for right hemicolectomy (median 165 vs. 225 min, P<0.001) and anterior resection (median 230 vs. 300 min, P<0.001). There was no significant difference between the two groups in terms of wound infection (P=0.443), anastomotic leak (P=0.981), postoperative ileus (P=0.596), length of stay (P=0.446), lymph node yield (P=0.848) or 3-year overall survival rate (Log-rank 0.759). Discussion: The study contributes to the limited evidence on ML vs LM approaches. A shorter operative time in the LM group was noted in this study, contrary to some literature. Postoperative outcomes were comparable, with a non-significant increase in postoperative ileus in the LM group. The study emphasises the safety and feasibility of both approaches.

Relationship between the m-FI 11 score and 2-year survival in octogenarians undergoing colorectal cancer resection.

Introduction: The modified Frailty Index (m-FI) offers a simple scoring tool, predicting short-term outcomes in elderly colorectal cancer (CRC) patients. However, links between m-FI scores and 2-year postoperative mortality in octogenarian CRC resection patients remain underexplored. A streamlined frailty index can aid in preoperative assessments to identify elderly patients who are likely to live longer after curative resection surgery to then tailor postoperative care. Our study aims to assess the association between m-FI scores and 2-year postoperative mortality in elderly CRC surgery patients. Methods: A retrospective analysis was conducted on a cohort of consecutive patients aged older than or equal to 80 years who underwent colorectal cancer resection at a tertiary referral centre between 2010 and 2017. The m-FI-11 scores less than or equal to two denoted the non-frail category, whereas m-FI scores equal to or exceeding 3 were categorised as frail. The primary outcome measure was defined as 2-year all-cause mortality. Results: A total of 337 patients were studied. The 2-year overall survival rate was 83% with an overall median survival time of 84 months (95% CI: 74-94 months). Patients with m-FI scores less than or equal to 2 had a 2-year survival rate of 85% and a median survival time of 94 months (95% CI: 84-104 months). Conversely, patients with m-FI scores greater than or equal to 3 had a 2-year survival rate of 72% and a median survival time of 69 months (95% CI: 59-79 months). An m-FI score greater than or equal to 3 showed a hazard ratio of 1.73 (95% CI: 0.92-3.26, P=0.092) for 2-year mortality compared to an m-FI score less than or equal to 2. Conclusion: Higher m-FI scores significantly correlate with an increased 2-year mortality risk among octogenarian CRC resection patients. This highlights the potential of the m-FI as a preoperative tool for identifying patients likely to survive longer post-surgery. Its integration aids in tailored postoperative care strategies, ensuring efficient recovery to functional baselines in this cohort.

Circumferential resection margin positivity due to direct or indirect tumour involvement in rectal cancer - a call for better stratification.

BACKGROUND: A positive circumferential resection margin (CRM) after rectal cancer surgery, which can be the result of direct or indirect tumour involvement, has consistently been associated with increased local recurrence and poorer survival. However, little is known of the differential impact of the mode of tumour involvement on outcomes. METHODS: 1460 consecutive patients undergoing rectal cancer resection between 2003 and 2018 were retrospectively assessed. Histopathology reports for patients with a positive CRM were reviewed to determine cases of direct (R1-tumour) or indirect tumour involvement (R1-other). Disease-free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier analysis. The role of the mode of CRM positivity was examined by univariate and multivariate Cox proportional hazards models. RESULTS: Eighty-five patients had an R1 resection due to CRM involvement (5.8%). Of those, 69 were due to direct tumour involvement, while 16 were from indirect causes. Kaplan-Meier analysis revealed that R1-other was associated with increased OS (hazard ratio 0.40, log-rank P = 0.006) and DFS (P = 0.043). Multivariate regression confirmed that the mode of CRM positivity was an independent predictor of OS. More interestingly, the patterns of recurrence were different between the two groups, with R1-tumour leading to significantly more local recurrence (P = 0.04). CONCLUSIONS: Our data strongly suggests that direct tumour involvement of the CRM confers worse prognosis after rectal cancer surgery. Importantly, differences in the site and frequency of recurrences make a case for better stratification of patients with a positive CRM to guide treatment decisions.

Outpatient Management of Epistaxis During COVID-19 to Reduce Inpatient Stay: A Quality Improvement Project.

Introduction In March 2020, new guidelines allowed patients with epistaxis to be discharged home with nasal packs in situ to reduce the risk of inpatient coronavirus disease 2019 (COVID-19) transmission rates. Our objective is to review how successful these new guidelines have been and whether they could be safely maintained in future practice. Methods This was a retrospective data analysis at a local tertiary ENT referral hospital. The study group consisted of patients admitted with epistaxis over one year. The "Pack and Home" criteria pathway was implemented. We reviewed this pathway six months pre- (loop 1) and six months post- (loop 2) introduction. Primary outcome measures included compliance with the "Pack and Home" criteria and length of inpatient admissions. Results A total of 131 patients required nasal packing, with 72 patients (55%) in loop 1 and 59 patients (45%) in loop 2. In loop 1, all 72 patients (100%) were admitted for inpatient care. However, in loop 2, 21 patients (36%) were discharged home with nasal packs in situ and 59 patients (64%) were admitted. Of those discharged, two patients were represented after 48 hours with rebleeding. The average total length of inpatient stay in loop 1 was significantly higher at 45.7 hours and 29.6 hours in loop 2 (p<0.05). All discharged patients attended their outpatient appointment in under three days. Conclusion The "Pack and Home" criteria can successfully identify patients who are suited for an outpatient management pathway. This could reduce surgical inpatient stay and the way we manage epistaxis.

A Prolonged History of Denture Impaction for 12 Weeks In Situ.

Foreign body ingestion has serious consequences if left untreated. Impacted dentures for a prolonged period can lead to life-threatening complications. Therefore, prompt diagnosis and immediate intervention are lifesaving. Our patient presented to his local accident and emergency department after having swallowed his dentures during a meal. Initial investigations and workup detected no abnormalities and he was discharged back to the community. Twelve weeks following ingestion, he had developed dysphagia and weight loss which prompted an urgent referral for oesophago-gastro-duodenoscopy (OGD). This identified the dentures impacted within the upper oesophagus and initial attempts at removal were unsuccessful, therefore he required hospital admission for alternative feeding in the interim. A joint procedure with the Ear, Nose and Throat and upper gastrointestinal surgeons was carried out to successfully remove the dentures endoscopically. The patient made an immediate recovery, resuming his normal oral diet with appropriate follow up after discharge. It is suspected our patient had an impacted denture for a period of 12 weeks without sustaining any life-threatening complications, which makes this case rather unique. This case highlights the importance of thorough and careful clinical history taking and examination.

Perforated gallbladder in a parastomal hernia.

We present an 87-year-old woman who presented to the emergency department with a 7-day history of severe abdominal pain at her ileostomy parastomal hernia site. Prior to presentation, her general practitioner had started her on a reducing steroid dose for suspected Crohn's disease exacerbation. On examination, she had a distended abdomen with localised guarding and tenderness over her hernia site. A CT scan demonstrated an incarcerated perforated gallbladder within her parastomal hernia. Successful surgical management was performed involving an enterotomy, refashioning her ileostomy and an open cholecystectomy. The patient recovered well with a short postoperative stay. This report is intended as a guide for clinicians in the differential diagnoses for acute abdominal pain and an unusual presentation of a gallbladder perforation.