Surgical outcome after standard abdominoperineal resection: A 15-year cohort study from a single cancer centre.

BACKGROUND: Abdominoperineal resection (APR) is associated with a poorer oncological outcome than anterior resection. This may be due to higher rates of intra-operative perforation and circumferential resection margin involvement. The aim of this study was to audit our short and long-term results of abdominoperineal resection performed using conventional techniques and to compare this with other published series. MATERIALS AND METHODS: A retrospective review of all patients who had standard APR between January 2000 and December 2016 in a single institution, Cabrini Hospital, Melbourne, Australia. A total of 163 cases performed by nine different colorectal surgeons for primary rectal adenocarcinoma were identified, with their clinicopathological data analysed. RESULTS: Using standard APR, only six patients (3.7%) were found to have a positive circumferential resection margin (CRM). There were two cases of intra-operative perforation (1.2%). Local recurrence rate was 5.6% of patients, with distant recurrence found in 24.9%. Disease-free survival at five years was 73.1%. Five-year overall survival was 66.7%, 67.9% of all deaths were cancer-related. CONCLUSION: Short and long-term outcomes after standard APR in this study were comparable to previous published studies. The CRM rate of 3.7% compares favourably to published positive CRM rates for standard APR which ranged from 6 to 18%. Standard APR remains a viable technique for the treatment of rectal cancer. Patient selection and adequate training remain important factors.

The first 1000 patients on an internet-based colorectal neoplasia database across private and public medicine in Australia: development of a binational model for the Colorectal Surgical Society of Australia and New Zealand.

BACKGROUND: Collection of multi-institutional data pertaining to the treatment of bowel cancer has been hindered by poor clinician compliance with data entry and the lack of incentive to participate. OBJECTIVE: This study aimed to establish if a novel browser-based model of data collection results in complete data capture. DESIGN: A Web-based data collection interface was custom written, offering automated reporting modules for clinical outcome to participants and an automated reporting system for outstanding data fields, and summary reporting of surgical quality outcomes. The software was combined with a clinical feedback system incorporating fortnightly data review meetings, at the time of clinical multidisciplinary meetings. PATIENTS AND SETTING: Selected were 932 consecutive patients with opt-out consent from 3 hospital sites, including public and private medicine. MAIN OUTCOME MEASURES: The primary outcomes measured were the analysis of data completeness and accuracy and ensuring that the highest-quality data were used for clinical audit of the surgical practices of Australian colorectal surgeons for the purpose of quality assurance. RESULTS: A total of 932 men and women, 22 to 94 years of age, treated for colorectal neoplasia were evaluated. We obtained 100% completion (>27,000 data points) of perioperative data registered by 8 specialist colorectal surgeons and a full-time database manager. CONCLUSIONS: Data completeness and validity are essential for clinical databases to serve the purpose of quality assurance, benchmarking, and research. The results confirm the safety and efficacy of colorectal cancer surgery in both the public and private sector in Australia. The combination of a simple multiuser interface, defined data points, automated result-reporting modules, and data-deficiency reminder module resulted in 100% data compliance in nearly 1000 clinical episodes. The unprecedented success of this model has lead to the Colorectal Surgical Society of Australia and New Zealand adopting this model for data collection for Australia and New Zealand as the binational database.

Effect of botulinum toxin injection on length and lengthening velocity of rectus femoris during gait in hemiparetic patients.

BACKGROUND: In hemiparetic patients, rectus femoris spasticity is one of the main causes of reduced knee flexion in swing phase, known as stiff knee gait. Botulinum toxin is often used to reduce rectus femoris spasticity and to increase knee flexion during swing phase. However, the mechanisms behind these improvements remain poorly understood. The aim of this study was (1) to quantify maximal rectus femoris length and lengthening velocity during gait in ten adult hemiparetic subjects with rectus femoris spasticity and stiff knee gait and to compare these parameters with those of ten healthy subjects and (2) to study the effect of botulinum toxin injection in the rectus femoris muscle on the same parameters. METHODS: 10 patients with stiff knee gait and rectus femoris spasticity underwent 3D gait analysis before and one month after botulinum toxin injection of the rectus femoris (200 U Botox, Allergan Inc., Markham, Ontario, CANADA). Rectus femoris length and lengthening velocity were quantified using a musculoskeletal model (SIMM, MusculoGraphics, Inc., Santa Rosa, California, USA). FINDINGS: Maximal length and lengthening velocity of the rectus femoris were significantly reduced on the paretic side. There was a significant increase in muscle length as well as lengthening velocity during gait following botulinum toxin injection. INTERPRETATION: This study showed that botulinum toxin injection in the spastic rectus femoris of hemiparetic patients improves muscle kinematics during gait. However maximal rectus femoris length did not reach normal values following injection, suggesting that other mechanisms are likely involved.

Stapled anopexy for short segment Hirschprungs disease in adults.

Traditional treatment of short segment Hirschprungs disease in adult consists of major resectional procedures, often with the use of a temporary stoma. Patients with this disease may have significant morbidities that increase their risk of post-operative morbidity and mortality. In an attempt to minimize the procedural related morbidity, we describe the application of the stapled anopexy technique to treat short segment Hirschprungs disease.

Local invasion of the bladder with colorectal cancers: surgical management and patterns of local recurrence.

PURPOSE: Colorectal cancers may be adherent to the urinary bladder. To achieve oncologic clearance of the cancer, en bloc bladder resection should be performed. This study describes the multicenter experiences of en bloc bladder resection for colorectal cancer in the major New Zealand public hospitals. METHODS: A retrospective database of patients undergoing surgery for colorectal cancer adherent to the bladder between 1984 and 1999 was constructed. Data was analyzed for age, gender, disease stage, and outcome (local recurrence and survival). RESULTS: Fifty-three patients were identified: International Union Against Cancer and American Joint Committee on Cancer Stage 1=0; Stage 2=23; Stage 3=22; Stage 4=6; unknown=2. Forty-five had en bloc partial cystectomy performed, four en bloc total cystectomy, and four had the adhesions disrupted and no bladder resection. The most common site of the primary colorectal cancer is sigmoid colon, with local invasion into the dome of the bladder. All patients who did not have en bloc resection developed local recurrence and died from their disease. Mean follow-up was 62 months. The extent of bladder resection did not seem important in determining local recurrence. CONCLUSIONS: En bloc resection of the urinary bladder should be performed if the patient is to be offered an optimal oncologic resection for adherent colorectal cancer. The decision to perform total rather than partial cystectomy should be based on the anatomic location of the tumor. Because the sigmoid is usually the primary site, most patients will not have received preoperative radiation. Therefore, postoperative radiotherapy may reduce local recurrence in these patients.

Parastomal hernia.

BACKGROUND: Parastomal hernia following formation of an ileostomy or colostomy is common. This article reviews the incidence of hernia, the technical factors related to the construction of the stoma that may influence the incidence, and the success of the different methods of repair. METHODS: A literature search using the Medline database was performed to locate English language articles on parastomal hernia. Further articles were obtained from the references cited in the literature initially reviewed. RESULTS: Parastomal hernia affects 1.8-28.3 per cent of end ileostomies, and 0-6.2 per cent of loop ileostomies. Following colostomy formation, the rates are 4.0-48.1 and 0-30.8 per cent respectively. Site of stoma formation (through or lateral to rectus abdominis), trephine size, fascial fixation and closure of lateral space are not proven to affect the incidence of hernia. The role of extraperitoneal stoma construction is uncertain. Mesh repair gives a lower rate of recurrence (0-33.3 per cent) than direct tissue repair (46-100 per cent) or stoma relocation (0-76.2 per cent). CONCLUSION: The incidence of parastomal hernia is between 0 and 48.1 per cent, depending on the type of stoma and length of follow-up. No technical factors related to the construction of the stoma have been shown to prevent herniation. If repair is required, a prosthetic mesh technique should be considered. Further randomized clinical trials (particularly of extraperitoneal stoma construction) are needed.

The validation of a 7-locus multiplex STR test for use in forensic casework. (II), Artefacts, casework studies and success rates.

PCR-based DNA typing of biological evidence is now widely used in forensic analyses due to the obvious advantages of enhanced sensitivity, the ability to distinguish discrete alleles and efficacy with degraded samples. A multiplex short tandem repeat (STR) system has been previously developed which successfully co-amplifies six STR loci HUMTH01, D21S11, D18S51, D8S1179, HUMVWF31/A and HUMFIBRA (FGA) in conjunction with the X-Y homologous gene Amelogenin. This is known as the second generation multiplex system (SGM). Detection of the PCR products is undertaken on ABD 373A or 377 automated sequencers using denaturing polyacrylamide gels coupled with fluorescent-based technology. We have evaluated this system for routine forensic use and demonstrated that the technique is robust and reproducible under conditions consistent with those encountered in a forensic environment. A total of 132 stains from simulated and actual casework were analysed, together with relevant control areas and reference samples. The success rate was high with 76% of stains giving full profiles; we were also able to successfully detect and interpret mixtures. No mistyping was observed. A detailed examination of each of these profiles has assisted in the development of guidelines for casework interpretation. Although artefacts, stutter peaks and undenatured DNA were occasionally observed, these did not interfere with the accuracy of interpretation. In addition 38 samples, previously examined using the quadruplex system, were analysed with the SGM to enable a direct comparison to be made between the systems. The performance of the system with poor quality samples demonstrated its use as a rapid and powerful technique for individual identification.

A practitioner's guide to HIV testing.

So far Could it be HIV? has examined many of the clues obtained from the clinical history and physical examination that might make an alert health care worker consider the diagnosis of HIV infection. Here we examine strategies for seeking permission for HIV testing and give advice on interpreting the results.

Nonsurgical treatment of ankle sprains using the modified Sarmiento brace.

The Sarmiento brace, originally designed by Dr. Augusto Sarmiento for treatment of tibial fractures, was used in this study as a nonsurgical treatment for ankle sprains. The brace allows sufficient immobilization of the ankle while leaving it accessible for local therapy. The fast relief of pain and early reeducation associated with our method permits a much more rapid resumption of normal physical activity. We have been using this method for 5 years and still remain firm believers in it.

Early vesico-ureteral reflux following conus medullaris injury: case report.

The authors describe severe vesico-ureteral reflux and simultaneous renal insufficiency which occurred after a spinal cord injury to the conus medullaris. They point out the misleading character of these injuries when there are only minimal neurological signs in the trunk and limbs. The main clinical consequence may be an isolated neuropathic bladder which, if not detected, delays treatment. Additionally, they underline the role of mixed bladder and sphincter lesions in the development of renal insufficiency; also the role of increased intravesical pressure during filling and emptying with bilateral vesico-ureteral reflux.