Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital?

AIMS: Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy. MATERIALS AND METHODS: Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews. RESULTS: Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022). CONCLUSION: This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.

Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery.

BACKGROUND: Alpha-2-adrenergic agonists have peripheral analgesic effects. We have assessed the potential analgesic effect of dexmedetomidine after intra-articular administration in arthroscopic knee surgery. METHODS: Sixty patients undergoing arthroscopic knee surgery were randomly assigned into three groups in a double-blind placebo controlled study. The control group received i.v. and intra-articular saline, the intra-articular group received i.v. saline and intra-articular dexmedetomidine, and the i.v. group received i.v. dexmedetomidine and intra-articular saline. Haemodynamic changes, pain visual analogue scale (VAS), sedation score, the time to first postoperative analgesic request, and the total postoperative analgesic use during the first 24 h were evaluated. RESULTS: Dexmedetomidine administration resulted in a significant reduction in pain scores for 6 h after operation in the intra-articular group but only for 1 h in the i.v. group. The time to first postoperative analgesic request was longer in the intra-articular group [312.0 (SD 120.7) min] compared with the control group [71.0 (50.1) min] and the i.v. group [102.1 (54.4) min] (P<0.001). Total diclofenac requirement was significantly lower in the intra-articular group [90.0 (46.2) mg] than in the control group [165.0 (52.2) mg] and in the i.v. group [129.3 (54.3) mg] (P<0.05). CONCLUSIONS: Intra-articular dexmedetomidine enhanced postoperative analgesia after arthroscopic knee surgery, with an increased time to first analgesic request and a decreased need for postoperative analgesia.

Risk factors of acute ulcer bleeding.

Peptic ulcer disease is the most common cause of upper gastrointestinal bleeding. Most ulcers stop bleeding spontaneously; however, a poorer prognosis is indicated by clinical features such as severe bleeding, inability to clear gastric lavage, advanced age, and serious co-morbid illness. NSAID usage is an important risk factor particularly in the elderly population. Endoscopic stigmata of recent bleeding may provide the most helpful prognostic information which helps identify high risk patients and direct management specifically at preventing rebleeding in this cohort of patients.