The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial.

OBJECTIVE: • To ascertain if filling the bladder with warm normal saline before trial of void (TOV) reduces time to decision of outcome of TOV and time to discharge compared with standard in-dwelling catheter (IDC) removal in the outpatient setting. PATIENTS AND METHODS: • A prospective randomized controlled trial (not blinded) was carried out in the day procedure unit. Randomization was done using computer-generated random numbers. The sample size was calculated based on initial pilot data using α= 0.05 and ß= 0.2 and a clinically important reduction of ≥60 min for time to decision of outcome of TOV (primary outcome measure). • In all, 60 consecutive patients were recruited from two referral sources: presentations of acute urinary retention to the emergency department and patients discharged home after failing TOV postoperatively. • The infusion method group (32 patients) had 300-500 mL warm normal saline infused into the bladder before removing their IDC and the control group (28) had standard IDC removal. • Data were collected and analysed using the two-tailed Mann-Whitney U-test. Statistical significance was set at P < 0.05. RESULTS: • The median time to decision was 135.0 (95% confidence interval CI 95.0-190.0) min in the infusion group and 247.5 (95% CI 189.6-294.1) min in the control group. • Patients undergoing a bladder infusion had a shorter discharge time [180.0 (95% CI 126.0-226.9) min] than patients in the standard-IDC-removal group [262.5 (95% CI 233.8-315.0) min]. • The infusion arm shortened time to decision by 112.5 min (P < 0.001) and time to discharge by 82.5 min (P < 0.001). • Furthermore, patients in the infusion group were 1.56 times more likely to achieve catheter-free state after TOV (risk ratio 1.56, 95% CI 1.03-2.36; P= 0.03). CONCLUSION: • The infusion method for TOV is safe and expeditious, making it ideal for the outpatient setting. This randomized study shows that the infusion method enables a rapid determination of outcome of TOV with a greater chance of success and shortened discharge times.

Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients.

BACKGROUND: Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking. METHODS: Data of 1576 patients who underwent primary resection and anastomosis for colorectal adenocarcinoma at a single institution from 1984 to 2004 were prospectively collected. Anastomotic leaks (LEK) were classified as radiological (RAD), local (LOC), or generalised (GEN). Logistic regression analysis of 21 variables was undertaken. Overall survival, cancer-related survival, and disease-free survival were analysed using the Kaplan-Meier method. RESULTS: Mean age of the patients was 67 years (SD = 12.5) and 834 (52.9%) were male. An LEK was more likely when relatively major gynaecological (tubo-oophorectomy, P = 0.004; hysterectomy, P = 0.006) or urological (total cystectomy, P = 0.014) procedures were performed during the same operative session. Other significant factors were anterior resection (P < 0.001), anastomosis using an intraluminal stapling device (P = 0.005), abdominal drain via laparoscopic port (P = 0.024), postoperative blood transfusion (P < 0.001), primary cancer site at the rectum (P = 0.016), and TNM stage of T2 or higher (P = 0.026). Having an LEK showed significant impact on overall (P = 0.021), cancer-related (P = 0.006), and disease-free (P = 0.001) survival. CONCLUSION: In this prospective study, advanced tumour stage, distal site, and need for postoperative blood transfusion were associated with increased rates of anastomotic leakage. In addition to their high risk of immediate postoperative morbidity and mortality, both localized and generalized leaks had similarly negative impacts on overall, cancer-related, and disease-free survival.

Surgical correction and reconstruction of the nipple-areola complex: current review of techniques.

Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.

Reconstruction of the irradiated extended abdominoperineal excision (APE) defect for locally advanced colorectal cancer.

PURPOSE: There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk. METHODS: Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I-IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed. RESULTS: All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4-20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome. CONCLUSION: As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.

Reducing anastomotic leakage in oncologic colorectal surgery: an evidence-based review.

BACKGROUND: Anastomotic leak rates following colorectal anastomosis range from 4 to 26%, and the development of a leak is known to be correlated with worse prognosis after a curative resection for colorectal cancer. In addition, anastomotic leakage has been associated with increased mortality and risk of permanent stoma. While techniques to improve the leakage rates in colorectal surgery have been described, these have largely been through isolated case series. We sought to undertake an evidence-based approach to reviewing the use of such techniques. METHODS: A systematic review of the literature was performed, evaluating the current evidence for techniques to improve leakage following colorectal anastomosis. RESULTS: There is Level I evidence to support the use of intra-operative leak testing, defunctioning ileostomy and drain tube insertion in the correct settings, including those associated with poor patient, disease and/or operative factors. There is no clear evidence to support the use of handsewn techniques, stapling techniques or laparoscopy over other techniques. CONCLUSION: Reductions in morbidity and mortality from colorectal anastomotic leaks can be gained by performing intraoperative leak testing, defunctioning ileostomy and drain tube insertion in the correct settings. The technique for performing the anastomosis remains at the discretion of the surgeon and largely depends on experience, patient characteristics and the operative setting, rather than there being any clear evidence for one technique over another. New techniques and devices that overcome drawbacks in current practice are consistently being developed and tested, making further risk reduction in colorectal anastomosis of great future promise.

Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects.

BACKGROUND: With the progressive use of more radical surgical resections and pre-operative chemo-radiotherapy for locally advanced anorectal cancers, there has become an increasing need for reconstructive options that import well-vascularised tissue of sufficient bulk to the perineum. We present our technique of inferior gluteal artery myocutaneous (IGAM) transposition flaps for reconstruction after extended abdomino-perineal excision (APE) for anorectal cancer. METHODS: Six consecutive male patients with T2/T3 rectal carcinoma underwent neoadjuvant chemo-radiotherapy followed by extended APE and immediate reconstruction with an islanded IGAM transposition flap. The operative technique and surgical outcomes were assessed with follow-up ranging from 3 to 18 months (median 5 months). RESULTS: In all cases, there were clear histological margins with no flap failures or partial flap losses, and no post-operative hernias. There were no major wound complications, with only one superficial breakdown associated with high body mass index (BMI) and adhesive tape allergy, treated with dressings alone. There was no donor site morbidity evident following flap harvest. CONCLUSION: The IGAM island transposition flap provides excellent tissue bulk, a large reliable skin paddle and a long pedicle that permits flexible positioning with tension free closure. Our successful results and high patient satisfaction make it a favourable option that should be considered when faced with this reconstructive challenge.