The association of body composition on chemotherapy toxicities in non-metastatic colorectal cancer patients: a systematic review.

BACKGROUND: In recent years, certain body composition measures, assessed by computed tomography (CT), have been found to be associated with chemotherapy toxicities. This review aims to explore available data on the relationship between skeletal muscle and adiposity, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intramuscular and intermuscular adipose tissue and their association with chemotherapy toxicity in non-metastatic colorectal cancer (CRC) patients. METHODS: A systematic literature search following PRISMA guidelines was conducted in Medline, Embase, Cochrane and Web of Science, for papers published between 2011 and 2023. The search strategy combined keywords and MESH terms relevant to 'body composition', 'chemotherapy toxicities', and 'non-metastatic colorectal cancer'. RESULTS: Out of 3868 studies identified, six retrospective studies fulfilled the inclusion criteria with 1024 eligible patients. Low skeletal muscle mass was strongly associated with increased incidence of both chemotherapy toxicities and dose-limiting toxicity (DLT). The association of VAT, intramuscular and intermuscular adiposity was heterogeneous and inconclusive. There was no association between SAT and chemotherapy intolerance. No universal definitions or cut-offs for sarcopenia and obesity were noted. All studies utilized 2-dimensional (2D) CT slices for CT body composition assessment with varied selection on the vertebral landmark and inconsistent reporting of tissue-defining Hounsfield unit (HU) measurements. CONCLUSION: Low skeletal muscle is associated with chemotherapy toxicities in non-metastatic CRC. However, quality evidence on the role of adiposity is limited and heterogeneous. More studies are needed to confirm these associations with an emphasis on a more coherent body composition definition and an approach to its assessment, especially regarding sarcopenia.

The changing face of maxillofacial trauma during the 2020 COVID-19 lockdowns in Melbourne, Australia.

PURPOSE: To compare the incidence, aetiology, and patterns of maxillofacial fracture presentations during the various stages of the 2020 Melbourne COVID-19 lockdown restrictions to periods outside lockdown in 2019 and 2020. METHODS: This is a retrospective study of 344 subjects. The patterns of facial trauma presentations to a tertiary hospital in metropolitan Melbourne during the 2020 COVID-19 restrictions were compared to periods with no restrictions over 22 months from March 2019 to December 2020. RESULTS: The incidence of maxillofacial fractures decreased by 28% during lockdown (0.41 vs. 0.57 injuries/day, P = 0.0003). Falls overtook interpersonal violence as the leading cause of fractures (44% of lockdown presentations vs. 25.7% of presentations outside lockdown, P = 0.002), while sporting injuries dropped drastically (4% vs. 17.1%, P = 0.005). Lockdowns saw an increase in the proportion of female patients (40% vs. 26.8%, P = 0.03) and a fivefold increase in proportion of domestic violence-related fractures (6.7% vs. 1.1%, P = 0.006). Alcohol-related injuries decreased significantly (11% vs. 21%, P = 0.03). CONCLUSIONS: While restrictions reduced rates of interpersonal violence and alcohol-related maxillofacial trauma, there was a higher proportion of injuries to females, increased falls, and domestic violence-related injuries.

Are health outcomes in the older colorectal cancer patients treated by curative intent surgery any different to the younger patients?

BACKGROUND: Colorectal cancer poses a major burden. Its incidence increases with age and older patients with comorbidities have a higher likelihood of major complications. This study investigated the impact of age on health outcomes in colorectal cancer patients treated by surgery. METHODS: A prospective database of all patients undergoing colorectal cancer surgery with curative intent between 2012 and 2017 was used to identify patients. A retrospective review of existing medical records investigating health-related outcomes in colorectal cancer patients undergoing surgery was performed. Primary outcomes measured were overall survival (OS) and disease-free survival (DFS). Difference in restricted mean survival times (RMST) up to a pre-specified time point of 24 months was used to compare four age groups. RESULTS: Six-hundred and fifty-one patients were divided into four age group categories: ≤65-years (n = 244), 66 to 75-years (n = 213), 76 to 85-years (n = 162) and >85-years (n = 32). Older patients were found to have a higher rate of post-operative medical complications (including confusion) (P = 0.001) and a longer length of stay (LOS) (P = 0.01). There was no difference between the 76 to 85-year age group and >85-year age group in OS and DFS. However, there was a reduced OS in older patients (>65) compared to their younger cohorts (<65) (P = 0.04). CONCLUSION: Older patients who undergo curative surgery have reduced OS, increased LOS and higher complication rates. Complex older patients may benefit from geriatric assessment and management in the peri-operative period.

Chronic rectal anastomosis complications prior to ileostomy reversal: development of a pilot classification system and associated outcomes.

BACKGROUNDS: A loop ileostomy may reduce the severity of acute anastomotic complications after low rectal resection, but some patients have persistent rectal anastomotic problems. No consensus exists for the management of patients with a chronic low rectal anastomosis complication and a loop ileostomy. There is need for a standard description of these anastomotic complications and to determine whether it is safe to reverse the ileostomy. This study proposes a classification of chronic rectal anastomotic complications and to report the correlation with successful restoration of rectal continuity. METHODS: This was a retrospective project from a prospectively maintained database at a single colorectal unit in a large tertiary hospital in Metropolitan Melbourne. Patients with rectal anastomotic complications following rectal cancer resections between March 2012 and October 2019 were included. A classification of chronic rectal anastomotic complication was developed by reviewing the interval assessments of the rectal anastomosis. The classification categories were correlated with outcomes after stoma closure. RESULTS: Of the 149 patients, 20 patients had an anastomotic complication identified during work up prior to loop ileostomy reversal. Eleven patients had an anastomotic stenosis and nine had an anastomotic defect. Eighteen patients were eligible for stomal closure. The majority (11/12) of patients with a Type 1 stenosis or defect had no rectal complications after stoma closure. CONCLUSION: The classification system helps to describe chronic rectal anastomotic abnormalities and guide management. Although these patients may be a challenge, many can undergo successful ileostomy reversal.

Outcomes of perineal reconstruction with inferior gluteal artery myocutaneous flaps and primary closure following abdominoperineal resection.

BACKGROUND: Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction. METHODS: A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence. RESULTS: One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified. CONCLUSION: Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.

Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance.

BACKGROUND: Single-stage approach with bile duct exploration is considered the most efficient and cost-effective method of bile duct clearance. In Australia, apart from centres with subspecialty interests, notably in Brisbane, Queensland, a multi-stage approach with endoscopic retrograde cholangiopancreatography (ERCP) is used more frequently. We aim to evaluate the impact of single stage laparoscopic trans-cystic exploration (LTCE) versus multi-stage approach for choledocholithiasis. METHODS: This was a retrospective cohort study. Medicare Benefits Schedule codings were used to identify patients who had the following procedures between December 2011 and December 2019: laparoscopic cholecystectomy (LC) and ERCP, LC and LTCE, LC and LTCE and ERCP. Primary outcomes were number of hospital procedures, admissions and additive length of stay (aLOS), the cumulative hospital stay from admission to discharge. RESULTS: Of 607 patients, 204 (34%) patients received a single-stage LTCE, while 403 (66%) patients had a multi-stage approach. In the LTCE group, 82% (168) patients and 93% (190) patients had one procedure and one admission respectively for stone clearance (P = 0.001). The median aLOS was 4 days for LTCE versus 7 days for multi-stage approach (P = 0.001; 95% CI for difference - 3 to -2). In the multi-stage group, 16% (65) patients had three or more procedures and 49% (199) patients required two or more hospital admissions to achieve stone clearance. CONCLUSION: LTCE for stone clearance can be successfully accomplished with reductions in hospital admissions, number of procedures and length of stay. This has further economic and health resource implications.

Anaemia and its impact on colorectal cancer patients: how can we better optimize surgical outcomes?

BACKGROUND: Anaemia is a common manifestation of colorectal cancer (CRC). However, appropriate workup prior to surgery and the effect of anaemia on outcomes have not been well defined. This study aimed to describe preoperative anaemia incidence, investigations performed, treatment and associated complications in a CRC surgical population at a single large tertiary institution in Australia. METHODS: Patients who received surgery with curative intent for CRC between 2012 and 2017 were identified from a prospectively maintained database. Demographic and clinical outcome data were analysed. RESULTS: In total, 754 patients with CRC were included. Anaemia was found in 350 (46.4%) patients, of which 124 (35.4%) were microcytic, 20 (5.7%) were macrocytic and 206 (58.9%) were normocytic. Older patients were more likely to have anaemia (mean age 70.28 years, standard deviation (SD) 12.98 versus 64.74 years, SD 11.74). Only 89 patients (25.4%) were tested for iron deficiency, and of these, 76 (85.4%) were found to be iron deficient and 42 (47.7%) had low ferritin. Preoperative anaemia was associated with a higher incidence of postoperative complications (adjusted odds ratio (OR) 1.46, 95%, CI 1.04-2.05; P = 0.03) and a longer length of stay (LOS; average 1.8 days; 95% CI 0.3-3.3 days). CONCLUSION: A significant proportion of CRC patients had anaemia and the majority were normocytic. Only a small number of anaemic patients were tested for iron deficiency. Preoperative anaemia had an adverse effect on LOS and postoperative complications. The evaluation of anaemic patients is essential in CRC patients undergoing surgery.

Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven-years' experience.

BACKGROUND: Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS: From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS: There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION: This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

How does thyroidectomy for benign thyroid disease impact upon quality of life? A prospective study.

BACKGROUND: Choosing which patients to recommend surgery for benign thyroid conditions can be difficult due to the subjective nature of compressive thyroid and hormonal symptoms. The aim of this prospective study was to analyse changes in quality of life (QOL) following thyroid surgery using a validated disease-specific assessment tool, the thyroid-related patient-reported outcome (ThyPRO) questionnaire. METHODS: Participants undergoing elective thyroid surgery for benign conditions were recruited. Patient demographics and clinical data were collected. ThyPRO consists of 85 questions grouped into 13 physical, mental and social symptom domains. Patients completed a ThyPRO questionnaire pre-operatively and at 6 weeks and 6 months post-operatively. ThyPRO items were scored according to protocol to produce 13 subscales. Repeated measures linear models with no random effects were performed using data for each outcome. RESULTS: Results were available for a total of 72 patients. The sample was predominately female (n = 63, 88%) with average age 49.8 years. The majority of patients underwent surgery for multi-nodular goitre. At 6 weeks post-operatively, significant improvement was demonstrated in the goitre, hypothyroid, hyperthyroid and anxiety symptom domains. At 6 months post-operatively, significant improvement was demonstrated in all but four domains. No domains demonstrated significant increase in impairment post-operatively. CONCLUSION: Patients had significant improvement in nine of 13 symptom domains following surgery. Patients did not experience a negative impact on QOL following surgery. Further studies with larger patient cohorts may be able to identify potential pre-operative predictive factors for a post-operative improvement in QOL for benign thyroid disease.

Continuous Suction Isoperistaltic Gastroesophagostomy for Esophageal Perforation.

Esophageal perforation is a surgical emergency with significant morbidity. Management of this condition is complex and constantly evolving. To our knowledge, this is the first case series describing repair of esophageal perforation with the use of an isoperistaltic gastroesophagostomy tube connected to continuous suction. We present three patients successfully managed using this technique.

Increased burden on metropolitan urological services: The era of the Australian National Emergency Access Targets (NEAT or the "4-h target").

BACKGROUND: The National Emergency Access Targets (NEAT) was introduced in Australia in 2011 and guides the clearance of presentations within 4-h of initial presentation from the Emergency Department (ED). We aim to assess the impact of the introduction of NEAT on acute urological services at a large metropolitan center. METHODS: A retrospective cohort study was performed and data were collected from electronic patient management systems. The control group was represented by ED presentations between June and September 2011, 1 year prior to the introduction of NEAT. The two study groups consisted of ED presentations between June and September 2012 and 2013, respectively. Outcome measures included time to the ureteric stent and scrotal exploration, inpatient length of stay (IPLOS), out-of-hours operating, and hospital mortality rates. RESULTS: Across the three study periods, a total of 76,935 patients were assessed by the EDs of the health service. 225 urological inpatient episodes were included across all periods with a trend showing increasing numbers of admissions (P = 0.003). For patients admitted under the urological service: Waiting room time and ED length of stay decreased significantly (P < 0.001). Proportion of operative cases decreased insignificantly (P = 0.275). Time from emergency presentation to emergency ureteric stent remained unchanged, however, proportions of procedures performed out-of-hours showed an increasing trend (P < 0.001). A significant increase in inter-unit transfer was observed, however, median IPLOS and mortality for operative and nonoperative cases remain unchanged. CONCLUSIONS: Concerning urological admissions, the implementation of NEAT has been associated with improvement in ED key performance indicators. Such changes have been correlated with reductions in operative cases and increases in out-of-hours emergency operating. Further research is required to evaluate the direct effect of NEAT on urological patient care.

Systematic differences between ultrasound and pathological evaluation of thyroid nodules: a method comparison study.

BACKGROUND: The size of thyroid nodules as measured by ultrasound (ultrasound size, USS) is routinely used in clinical decision-making. Reports of discrepancy between USS and pathological size (PS) evaluation have not analysed their systematic differences. The objective of this study was to uncover the lack of agreement (bias) between USS and PS measurements. METHODS: A retrospective study was performed on 121 patients who had a total or hemi-thyroidectomy for a solitary nodule. Ordinary least product regression was used to detect and distinguish constant and proportional bias in unidimensional size measurements between USS and PS evaluation. Three-dimensional volume measurements were compared in a subgroup of 31 patients. Pre-specified acceptable limits of interchange were defined as 20% difference. RESULTS: Ordinary least product regression demonstrated no constant or proportional bias between the two methods; regression equation: USS = (0.863) + (1.040) × PS. When nodules were grouped by size, discrepancies between the two methods were observed in nodules <10 mm (P = 0.004). However, potential overtreatment of patients with USS >10 mm but PS <10 mm only accounted for 4.1% of total patients. Subgroup analysis of volume measurements showed no bias between USS and PS evaluation. CONCLUSIONS: USS and PS measurements were interchangeable, as there was no evidence of constant or proportional bias between the two measurements. However, USS may misclassify the size for smaller nodules and potentially lead to unnecessary workup and treatment. Discrepancy in size measurements between USS and PS should be taken into account in clinical practice, particularly in smaller nodules.

Randomized trial of laparoscopic cholecystectomy procedure-specific consent form.

BACKGROUND: Prior to all surgical procedures, possible risks are outlined to patients during an informed consent discussion, and they are invited to ask questions. Written consent records this discussion and signals a patient's willingness to proceed with surgery. This study aims to improve the documentation of complications discussed during laparoscopic cholecystectomy consent through the introduction of a procedure-specific consent form. METHODS: Phase 1 included a retrospective analysis of possible complications documented on standard consent forms for laparoscopic cholecystectomy. Phase 2 was a prospective randomized comparison of existing standard consent forms versus procedure-specific consent forms measuring the documentation of significant complications as identified from the Royal Australasian College of Surgeons brochure for laparoscopic cholecystectomy. These include bile duct injury, bile leak, bleeding, infection, conversion and damage to other organs. The proportion of participants in each cohort with the documentation of specific complications was assessed using the two-sample test of differences in proportions. RESULTS: Phase 1 of the study found that the possible risk of bleeding was documented in 82.1% of cases, while damage to other organs was only documented in 7.7%. Phase 2 of the study showed significant improvements in the documentation of specific complications for both standard and procedure-specific consent cohorts; 76.5% of participants in the procedure-specific consent cohort had all complications documented, while no participants in the phase 1 cohort had all complications documented. CONCLUSION: Introduction of a procedure-specific consent form for laparoscopic cholecystectomy has improved the documentation of a standard set of complications.

Incidental parathyroidectomy during total thyroidectomy is not a direct cause of post-operative hypocalcaemia.

BACKGROUND: Post-operative hypocalcaemia is the most common complication after total thyroidectomy, with a reported incidence of transient hypocalcaemia up to 50% and permanent hypocalcaemia 1.5-4%. The impact of incidental parathyroidectomy (IPE) on post-operative hypocalcaemia remains controversial. This study evaluated the risk factors for IPE following total thyroidectomy and compared post-operative calcium levels serially between patients with and without IPE. METHODS: A retrospective analysis of patients undergoing total thyroidectomy from January 2009 to October 2016 at Western Health was conducted. Histopathology reports were reviewed to identify specimens that included parathyroid tissue. Risk factors and dichotomous data were analysed by exact test of difference in binomial proportions. Group comparison of serial calcium levels (preoperative to 48 h post-operative) between the no IPE and IPE patients were analysed by calculating the area under the curve producing a time series summary. RESULTS: Four hundred and sixty-eight patients were included: 395 were females (81%), with a median age of 51 years. IPE was confirmed histologically in 84 patients (17.7%) and was more likely to occur in patients undergoing total thyroidectomy with central neck dissection (P = 0.0003), and in patients with malignant disease (P = 0.0005). The difference in area under the curve for serial post-operative calcium levels between the no IPE and the IPE groups was 0.61 (P = 0.21, 95% confidence interval: -0.37 to 1.58). CONCLUSION: Total thyroidectomy for malignancy and with central node dissection had a higher risk of IPE but did not result in significant changes in post-operative serum calcium levels.