Does complete pathological response increase perioperative morbidity risk in rectal cancer?

AIM: The optimal management of patients with clinical complete response after neoadjuvant treatment for rectal cancer is controversial. The aim of this study is to compare the morbidity between patients with locally advanced rectal cancer who have had a pathological complete response (pCR) or not after neoadjuvant chemoradiotherapy (NCRT) and total mesorectal excision (TME). The study hypothesis was that pCR may impact the surgical complication rate. METHOD: A retrospective cohort study was conducted of a prospectively maintained database in Australia and New Zealand, the Binational Colorectal Cancer Audit, that identified patients with locally advanced rectal cancer (<15 cm from anal verge) from 1 January 2007 to 31 December 2019. Patients were included if they had locally advanced rectal cancer and had undergone NCRT and proceeded to surgical resection. RESULTS: There were 4584 patients who satisfied the inclusion criteria, 65% being male. The mean age was 63 years and 11% had a pCR (ypT0N0). TME with anastomosis was performed in 67.8% of patients, and the majority of the cohort received long-course radiotherapy (81.7%). Both major and minor complications were higher in the TME without anastomosis group (17.3% vs. 14.7% and 30.6% vs. 20.8%, respectively), and the 30-day mortality was 1.31%. In the TME with anastomosis group, pCR did not contribute to higher rates of surgical complications, but male gender (p < 0.0012), age (p < 0.0001), preoperative N stage (p = 0.0092) and American Society of Anesthesologists (ASA) score ≥3 (p < 0.0002) did. In addition, pCR had no significant effect (p = 0.44) but male gender (p = 0.0047) and interval to surgery (p = 0.015) contributed to higher rates of anastomotic leak. In the TME without anastomosis cohort, the only variable that contributed to higher rates of complications was ASA score ≥3 (p = 0.033). CONCLUSION: Patients undergoing TME dissection for rectal cancer following NCRT showed no difference in complications whether they had achieved pCR or not.

A rare cause of colonic pseudo-obstruction due to light chain amyloidosis.

In this case report, we discuss the rare presentation of a 56-year-old-gentleman with a history of light chain amyloidosis (AL), causing colonic pseudo-obstruction and requiring open subtotal colectomy and end ileostomy. This should remain a differential diagnosis in patients with known light chain AL presenting with nonspecific gastrointestinal symptoms such as constipation and abdominal pain. This prompts early investigation, such as endoscopy and tissue biopsy, and surgical intervention may be warranted.

Rare direct embolism of urothelial carcinoma causing acute mesenteric ischaemia during remission.

Metastatic abdominal carcinomas have been reported in the literature to cause bowel ischaemia. However, these are often associated with diffuse disease or direct invasion of adjacent bowel secondary to high-grade malignancies. There are no reported cases of extensive small bowel wall nor arterial occlusion as a result of metastasis from treated early-stage urothelial carcinoma. We present an octogenarian male patient who was diagnosed with small bowel ischaemia secondary to extensive metastatic urothelial carcinomatous to the small bowel. Thorough consideration of the patient's clinical presentation and high index of suspicion was required to differentiate this from other causes of ischaemic bowel. The pathophysiology of the disease differentiated the end treatment most suitable for the patient.

An unwelcome guest: two cases of colonic metastatic lobular breast cancer.

Metastatic spread of invasive lobular breast cancer is rare. It can have a delayed and varied presentation that can mimic other bowel pathologies, such as colorectal cancer and inflammatory bowel disease, making its diagnosis difficult. In this study, we present two patients who required colonic resection due to malignant obstruction caused by metastatic invasive lobular carcinoma of the breast.

Outcomes in octogenarians following elective colorectal cancer surgery.

Background: Colorectal surgery in octogenarians is increasing in prevalence and good surgical outcomes have been demonstrated. However, functional status and independence remain the main patient consideration with limited data on the long-term functional outcomes. Methods: A retrospective analysis was conducted for all patients aged above 80 undergoing surgery for colorectal cancer (CRC) from January 2018 to December 2019. Functional status assessment was made as part of pre- and post-operative allied health clinic appointments. Eastern Cooperative Oncology Group (ECOG) performance scores were recorded. Loss of independence (LOI) was defined as the reduced capacity to perform pre-morbid activities of daily living (ADL) and requiring increased supports. Results: Forty-one patients aged 80 years or older had elective CRC resections with a median follow-up of 15 months [interquartile range (IQR): 8-20]. The median American Society of Anesthesiology (ASA) score was 3 and 90.2% (37/41) of patients had an ECOG score of 0 or 1. There was no 30-day mortality and 2 (4.9%) deaths occurred within 1 year. The median Clavien-Dindo score was 1, and 2 patients (4.9%) required unplanned intensive care unit (ICU) admissions. Twelve re-hospitalizations occurred with falls being the most common reason. LOI occurred in only 2 patients (4.9%) and on multivariate regression analysis, age and pre-morbid requirement of gait aids were predictive of LOI (P=0.042 and P=0.003, respectively). Gait aids were also associated with higher Clavien-Dindo scores (P=0.057) and increased length of stay (LOS) (P=0.009). Conclusions: Patients with advanced age undergoing surgery for CRC surgery can still have good post-operative outcomes and adequate functional recovery with pre-operative optimization and appropriate post-operative supports.

Robotic natural orifice specimen extraction surgery (NOSES) for anterior resection.

Minimally invasive colorectal surgery is currently well-accepted, with open techniques being reserved for very difficult cases. Laparoscopic colectomy has been proven to have lower mortality, complication, and ostomy rates; a shorter median length of stay; and lower overall costs when compared to its open counterpart. This trend is seen in both benign and malignant indications. Natural orifice specimen extraction surgery (NOSES) in colorectal surgery was first described in the early 1990s. Three recent meta-analyses comparing transabdominal extraction against NOSES concluded that NOSES was superior in terms of overall postoperative complications, recovery of gastrointestinal function, postoperative pain, aesthetics, and hospital stay. However, NOSES was associated with a longer operative time. Herein, we present our technique of robotic NOSES anterior resection using the da Vinci Xi platform in diverticular disease and sigmoid colon cancers.

Age of the leftie: the lived experience of left-handed surgeons.

BACKGROUND: Left-handers make up 10%-12% of all surgeons. Surgical education and practice by nature has significant technical demands but there is a paucity of data on left-handers and training in surgery. The surgical curriculum has no specific salutation or recognition of left-handers and the contributions and challenges they represent. METHODS: The purpose of the study was to explore, describe and understand the lived experience of left-handed surgeons in relation to surgical education and training in Australia. Semi-structured interviews were used to gather in-depth information relating to the participants' experiences, viewpoints, beliefs and motivations. RESULTS: The responses of the participants involved were categorized using the data analysis method described by Colaizzi. Seven themes were identified: left-handed surgeons are universal adapters; left-handed instruments are not necessary for left-handed trainees; most left-handed trainees have experienced discrimination or negativity due to their laterality; ambidexterity is considered an advantage; communicating one's laterality is important; a formal mentoring program is not necessary; and simulation can be a complementary tool for left- handed trainees. Being a left-handed surgical trainee need not be a negative experience. CONCLUSION: With appropriate support and teaching, left-handed trainees can develop into excellent surgeons. The themes from this study can be used by trainees, trainers and Colleges of surgical training to build awareness and optimize the training of future left-handed surgeons.

Robotic retroperitoneal lymph node dissection in colorectal cancer.

In select colorectal cancer patients with metastatic retroperitoneal lymph node disease, surgical resection can be performed. We discuss our robotic technique.

Benchmarking Performance in Pancreatic Surgery: a Systematic Review of Published Quality Metrics.

BACKGROUND: Pancreatic surgery is performed in relatively few centres. There are validated quality benchmarks for pancreatic surgery, although it remains unclear how published benchmarks compare with each other. This study aimed to systematically review published literature to summarise metrics that define quality benchmarks for pancreatic surgery. METHOD: A search of MEDLINE, EMBASE and CENTRAL was undertaken until June 2019. Articles that developed or validated published quality benchmarks for pancreatic surgery were included. Benchmarks were classified into three domains using the Donabedian framework, and their quality assessed using the AIRE Instrument. RESULTS: Nineteen studies included 55 quality metrics, of which 8 developed new metrics, and 11 studies validated previously published metrics. The methodology of metric development was either expert opinion-driven or data-driven. All metrics demonstrated moderate quality scores. There was partial agreement in some metrics (e.g. < 10 h total operative duration), but lack of consensus for most others (e.g. lymph node yield ≥ 10, ≥ 12, ≥ 15, ≥ 16). No metrics related to patient reported outcomes. CONCLUSIONS: Published quality benchmarks for pancreatic surgery predominantly arise from eight studies, with heterogeneity in how the metrics were developed. There was not consensus for all metrics. Metrics need to be reviewed as new data emerge, technologies develop and opinions change.