Routine pathologic evaluation of circular stapler anastomotic rings is not useful after resection for colorectal cancer: retrospective study and systematic review with meta-analysis.

BACKGROUND: Circular staplers are commonly used for reconstruction after radical resection for colorectal cancer. Pathological analysis of the anastomotic rings is common practice, although the benefits are unclear. The purpose of this study was to evaluate the usefulness of routine histopathological analysis of anastomotic rings in an original series and in a systematic review of the literature. METHOD: The retrospective study was performed at two university-associated academic hospitals in Winnipeg, Canada, including patients investigated for colorectal cancers (within 30 cm of the anal verge) who underwent resection between 2007 and 2020. The systematic review involved Ovid MEDLINE, Embase, Scopus, and Web of Science databases, selecting for adult human studies involving analysis of anastomotic rings in elective colorectal cancer resections. The main outcome measure was the proportion of patients with cancer in the anastomotic ring specimens. The frequency of benign pathology findings and changes to patient management were also examined. RESULTS: Out of 673 eligible patients, 487 were included in the retrospective analysis. No patients had cancer within the anastomotic ring specimens. Twenty-five patients (5.1 per cent) had benign pathological findings within the anastomotic ring specimens, and patient management was never affected. In the systematic review, 27 articles were included in the final analysis out of 5848 records reviewed. The rate of cancer within anastomotic ring specimens was 0.34 per cent, and the rate of change in patient management was 0.19 per cent. CONCLUSION: The likelihood of finding cancer within anastomotic rings is rare and their histopathological examination seldom changes patient management.

Rectal Cancer Metastasis to the Anal Verge: An Unusual Case Presentation and Review of the Literature.

BACKGROUND: Anal metastasis of colorectal adenocarcinoma is very rare, represented by only a handful of case reports in the literature. Previously, reports of metastasis to this region had occurred following a history of anorectal disease, such as anal fistulae. Antecedent trauma to the area from hemorrhoidectomy, fissures, or perineal retractor injury have also been implicated. CASE PRESENTATION: Herein we report the case of 69-year-old man without any history of anal disease presenting with a metachronous metastasis of a colorectal-type adenocarcinoma to the anal verge. He was previously treated for T1N0 rectal adenocarcinoma at the rectosigmoid junction with a low anterior resection 5 years prior, then had a T3N0 local recurrence at the colorectal anastomosis treated with neoadjuvant chemoradiation, and eventually a Hartmann's procedure 4 years later. Subsequently, on surveillance flexible sigmoidoscopy, a new tumor was identified on the perianal skin extending from the anal verge. Histopathology demonstrated colorectal-type adenocarcinoma. Flexible endoscopy identified no other residual or recurrent disease in the colon or rectal stump. The patient was treated with wide local excision and advancement flap reconstruction. CONCLUSION: Isolated metastasis to the anus is an extremely rare occurrence for colorectal adenocarcinoma. There exists little evidence to inform management. One option is to treat like a locally recurrent rectal cancer with aggressive tri-modality management consisting of chemoradiation, abdominal perineal resection, and adjuvant chemotherapy. In the absence of metastatic disease, local resection and close surveillance remain an option. As always, patient factors should guide management.

Synoptic operative reports enhance documentation of best practices for rectal cancer.

BACKGROUND: Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. METHODS: Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. RESULTS: SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. CONCLUSIONS: SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives.

BACKGROUND: Where cancer patients receive surgical care has implications on policy and planning and on patients' satisfaction and outcomes. We conducted a population- based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients' perspectives on location of surgical care. METHODS: We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach. RESULTS: From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants' treatment experiences. CONCLUSION: A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.

CONTEXTE: Le lieu où les patients atteints du cancer subissent une intervention chirurgicale a des répercussions sur les politiques et la planification, et sur la satisfaction du patient et ses résultats. Nous avons étudié dans une population le lieu où des patients atteints de cancer du rectum subissent leur chirurgie et effectué une analyse qualitative des points de vue exprimés par les patients au sujet du lieu où les soins chirurgicaux sont dispensés. MÉTHODES: Nous avons consulté le Registre du cancer du Manitoba pour trouver des données sur des patients atteints de cancer colorectal diagnostiqué entre 2004 et 2006. Nous avons interviewé des patients de régions rurales atteints de cancer du rectum pour connaître leurs préférences et les facteurs dont ils avaient tenu compte en choisissant le lieu où ils allaient être traités. Nous avons analysé les données recueillies à l'aide d'une méthode théorique fondées sur les faits. RÉSULTATS: Entre 2004 et 2006, au Manitoba, 2086 patients ont reçu un diagnostic de cancer colorectal (cancer du côlon : 1578; cancer du rectum : 508). Parmi les patients qui vivaient en milieu rural (n = 907), ceux atteints d'un cancer du rectum avaient plus tendance à subir leur chirurgie dans un établissement urbain que ceux atteints de cancer du côlon (46,5 % c. 28,8 %, p < 0,001). Vingt patients de milieu rural atteitns de cancer du rectum ont participé aux entrevues. Trois principaux éléments se dégagent des données recueillies : le décideur, des facteurs reliés au traitement et des facteurs d'ordre personnel. Les participants ont décrit diverses contributions qu'ils ont apportées à la décision relative à la référence de leur cas et dit que souvent, ils n'ont pas senti qu'un choix de lieux de traitement leur était offert. Les facteurs liés au traitement lui-même, y compris ceux liés au chirurgien et à l'hôpital, ont été importants dans le choix du lieu de traitement. Les facteurs d'ordre personnel, dont le déplacement, le soutien, l'hébergement, la situation financière et l'emploi ont aussi influé sur l'expérience thérapeutique des participants. CONCLUSION: Une proportion considérable de patients atteints du cancer du rectum et vivant en milieu rural subissent leur chirurgie dans des établissements urbains. Les raisons sont complexes et ne sont qu'en partie reliées au choix du patient. Il faudrait mener d'autres études pour mieux comprendre l'accès aux services offerts aux personnes atteintes de cancer dans les populations géographiquement dispersées et pour les appuyer dans le processus de prise de décision et de traitement.

Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.

BACKGROUND: Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery. METHODS: Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded. RESULTS: Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01]. CONCLUSIONS: Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.

Linear pressure profiles and symmetric findings in the stimulated gracilis muscle.

PURPOSE: This is the first report of linear pressure profiles and symmetric findings in preoperative and postoperative (after gracilis muscle retraining) patients. Length of the anal canal and symmetry have been well documented in the literature as significant parameters in the maintenance of anal incontinence. Significant improvement of these parameters should play a critical role in the functional outcome of the stimulated gracilis. METHODS: Six patients underwent preoperative and postoperative anorectal manometry using an eight-channel radial catheter. Pressures were collected at 8 Hz using an automated continuous pullout technique (1 mm/sec). Preoperative and posttraining resting and squeeze pressures, pressure volumes, anal canal length, and linear and cross-sectional images were compared. RESULTS: Resting pressures significantly improved from 13.7 mmHg to 26.8 mmHg (P < 0.02). The squeeze pressure significantly improved from 28.67 mmHg to 62.9 mmHg (P < 0.02). The pressure volume increased from 10,429 mmHg to 26,162 mmHg. Anal canal length increased from an abnormal length of 2.95 cm to normal length of 3.55 cm (P < 0.04). The percentage of sphincter asymmetry decreased from 28.6 percent to 23.5 percent (P < 0.01). The most striking observation was the impact the gracilis muscle had on correcting the geographic cross sections as it wrapped more than 360 degrees from the proximal to distal anal canal. Patients were significantly improved, with four of the six patients completely continent to solid stool. Two of the six patients had minor episodes of seepage. Preoperatively, all patients were grossly incontinent to solid stool. CONCLUSIONS: Significant improvement in resting pressure, pressure volume, anal canal length, and cross-sectional symmetry has led to a significant improvement in anal incontinence after dynamic myoplasty.

Pudendal nerve terminal motor latency testing: assessing the educational learning curve: can we teach our own?

PURPOSE: Pudendal nerve terminal motor latency testing is useful as a diagnostic tool in fecal incontinence. It has also been used as a predictive factor in sphincteroplasty repairs. The technique is seldom taught and mastered in colorectal training programs. The purpose of this study was to assess a learning curve for teaching this procedure. METHODS: The student was a formally trained colorectal surgeon with no pudendal nerve terminal motor latency experience; the instructor has performed more than 3,000 pudendal nerve terminal motor latency studies. Fifty consecutive patients had manometry and pudendal nerve terminal motor latency testing. Both the student and instructor performed pudendal nerve terminal motor latency in a sequential fashion. Variables collected included pudendal nerve terminal motor latency, completion of test, time to complete test, and accuracy of the test. Variables were analyzed with paired t-test and chi-squared analysis. RESULTS: The study group included 41 female and 9 male patients. The average age of the patients was 53 years. Bowel complaints included constipation in 16 and incontinence in 34 patients. Data were analyzed in their entirety and at ten-patient intervals. The student tended to record longer latencies (P < 0.001). This led to false-positive rates of 23 and 21 percent, respectively, for left and right pudendal nerve terminal motor latency. On average, the time to complete the procedure was three times longer for the student than for the instructor (P < 0.001). At ten-patient intervals, the pudendal nerve terminal motor latency difference between the two groups disappeared at the 41-to-50-patient mark. CONCLUSION: Given the proper learning environment, pudendal nerve terminal motor latency testing can be mastered in a relatively short period. On the basis of this study, our estimation is 40 patients are required for a student to master this technique. The novice examiner can expect false-positive results early in the learning curve, and these should be validated accordingly.