Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis.

PURPOSE: The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. METHODS: A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. RESULTS: Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. CONCLUSION: Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.

Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons.

BACKGROUND: Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. METHODS: A questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX). RESULTS: Of 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01-9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96-9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83-9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49-9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58-8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17-8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32-8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49-7.66]). CONCLUSIONS: This survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.

3D mesenteric angiogram-based assessment of Arc of Riolan crossing the inferior mesenteric vein: important considerations in high ligation during splenic flexure takedown in anterior resection.

BACKGROUND: Recent studies have described the finding of the Arc of Riolan (AoR) crossing the inferior mesenteric vein (IMV) seen during high ligation of IMV while performing minimally invasive colectomies. However, the AoR usually has a medial course, and this variant AoR anatomic course and the clinical importance of its preservation during splenic flexure takedown in anterior resection remains controversial. METHODS: After institutional approval (QA-5775), radiological identification of and mapping of the vessel horizontally crossing the IMV under the pancreas, when present, was performed at a single institution (Westmead Hospital, New South Wales, Australia). One hundred consecutive computed tomographic (CT) mesenteric angiograms conducted in 2018 were reviewed retrospectively to determine the presence of a vessel horizontally crossing the IMV. 3D reconstructions were used to map out its course to understand its origin and full course. Baseline characteristics, including demographic and comorbidity data, were obtained from the medical record. RESULTS: On 3D mesenteric angiogram reconstructions, a vessel crossing anterior to the IMV was present in 11 of 98 cases (11.2%). Two cases were excluded as the presence of this vessel was indeterminate. Eight of 11 patients (72.7%) were male, and the mean age was 49.3 years (range: 21-80 years). There was no statistically significant difference in age and comorbidities between the groups. Importantly, in all 11 cases, there was an arterial vessel crossing the IMV originating from the SMA and communicating with the IMA or a branch of the IMA, proving definitively that this vessel was by definition the AoR. CONCLUSION: This 3D mesenteric angiogram mapping study has shown definitively that the vessel horizontally crossing anterior to the IMV and inferior to the pancreas is an arterial vessel from the SMA to IMA, and by definition the Arc of Riolan. When present, identification and preservation of this collateral arterial vessel during splenic flexure takedown in anterior resection may be important in reducing the risk of post-operative bowel ischaemia.

The role of mechanical bowel preparation and oral antibiotics for left-sided laparoscopic and open elective restorative colorectal surgery with and without faecal diversion.

BACKGROUND: There is significant variation in the use of mechanical bowel preparation and oral antibiotics prior to left-sided elective colorectal surgery. There has been no consensus internationally. METHODS: This was a retrospective analysis of the 2015 American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into four groups: those who had mechanical bowel preparation with oral antibiotics, mechanical bowel preparation alone, oral antibiotics alone and no preparation. The main outcome measures included overall, superficial, deep and organ/space surgical site infections. Secondary outcomes included anastomotic leak, ileus and rate of Clostridium difficile. RESULTS: A total of 5729 patients were included for analysis. The overall surgical site infection rate (any superficial, deep or organ/space infection) was significantly lower in the mechanical bowel preparation and oral antibiotics approach when compared to no preparation (OR = 0.46, 95% CI 0.36-0.59, P < 0.0001). On multivariable logistic regression analysis, mechanical bowel preparation with oral antibiotics maintained a lower risk of overall surgical site infections. MBP and OAB also had a protective effect on anastomotic leak in both the laparoscopic and open cohorts (laparoscopic multivariable adjusted OR = 0.42 (0.19-0.94), P = 0.035; open multivariable adjusted OR = 0.3 (0.12-0.77), P = 0.012). Mechanical bowel preparation alone and oral antibiotics alone was not associated with a significant decrease in surgical site infections. There was no increase in C. difficile occurrences with the use of oral antibiotics. CONCLUSION: Mechanical bowel preparation with oral antibiotics significantly minimised surgical site infections and anastomotic leak following both laparoscopic and open left-sided restorative colorectal surgery. Mechanical bowel preparation alone did not reduce surgical site infections. There was a trend to reduction in surgical site infections with oral antibiotics alone.

Rare case of strangulated primary acquired perineal hernia causing small bowel obstruction requiring emergency operative repair.

Primary acquired perineal hernia is rare with only 100 reported cases in the literature. Emergency presentations of intestinal obstruction secondary to perineal hernia are very rare and to-date, there are only eight cases reported in the literature. We present a case of a 74-year-old lady who presented with a small bowel obstruction secondary to strangulated perineal hernia in the absence of pelvic exenteration or abdominoperineal resection requiring operative repair via combined open transabdominal and transperineal approach. To our knowledge, this case represents the first reported case of intestinal obstruction secondary to primary acquired perineal hernia in the absence of pelvic exenteration or abdominoperineal resection.

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators.

AIM: To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS: The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS: A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION: This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

An unusual case of colonic duplication cyst in an adult with dysplasia.

Duplication cysts are rare benign congenital malformations typically identified in children by the age of 2 years. We report a rare case of colonic duplication cyst with dysplasia in an adult. A 32-year-old male was diagnosed with non-specific abdominal symptoms. Abdominopelvic computed tomography scan demonstrated a submucosal cystic lesion in the right colon. He underwent laparoscopic right hemicolectomy. Histopathology showed colonic duplication cyst with low grade dysplasia. He is due for a surveillance colonoscopy in 3 years. Duplication cyst in an adult colon with dysplasia is extremely rare. They are usually present in the terminal ileum. They have non-specific abdominal symptoms or can be asymptomatic. They are often identified incidentally or intraoperatively. Imaging may demonstrate a cystic lesion. Histopathology is required for definitive diagnosis. There are no guidelines or consensus on managing duplication cysts in adults. We recommend an oncological resection of the involved colon. Surveillance with routine colonoscopy is advisable.

Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis.

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Morbid obesity was defined as a BMI greater than or equal to 35 kg/m2. The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m2), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.

Neutrophil Extracellular Trap Density Increases With Increasing Histopathological Severity of Crohn's Disease.

BACKGROUND: Intestinal neutrophil recruitment is a characteristic feature of the earliest stages of inflammatory bowel disease (IBD). Neutrophil elastase (NE) and myeloperoxidase (MPO) mediate the formation of neutrophil extracellular traps (NETs); NETs produce the bactericidal oxidant hypochlorous acid (HOCl), causing host tissue damage when unregulated. The project aim was to investigate the relationship between NET formation and clinical IBD in humans. METHODS: Human intestinal biopsies were collected from Crohn's disease (CD) patients, endoscopically categorized as unaffected, transitional, or diseased, and assigned a histopathological score. RESULTS: A significant linear correlation was identified between pathological score and cell viability (TUNEL+). Immunohistochemical analysis revealed the presence of NET markers NE, MPO, and citrullinated histone (CitH3) that increased significantly with increasing histopathological score. Diseased specimens showed greater MPO+-immunostaining than control (P < .0001) and unaffected CD (P < .0001), with transitional CD specimens also showing greater staining than controls (P < .05) and unaffected CD (P < .05). Similarly, NE+-immunostaining was elevated significantly in diseased CD than controls (P < .0001) and unaffected CD (P < .0001) and was significantly higher in transitional CD than in controls (P < .0001) and unaffected CD (P < .0001). The CitH3+-immunostaining of diseased CD was significantly higher than controls (P < .05), unaffected CD (P < .0001) and transitional CD (P < .05), with transitional CD specimens showing greater staining than unaffected CD (P < .01). Multiplex immunohistochemistry with z-stacking revealed colocalization of NE, MPO, CitH3, and DAPI (cell nuclei), confirming the NET assignment. CONCLUSION: These data indicate an association between increased NET formation and CD severity, potentially due to excessive MPO-mediated HOCl production in the extracellular domain, causing host tissue damage that exacerbates CD.

Our data show for the first time that the density of neutrophil extracellular trap formed in the bowel of Crohn's disease patients increases with increasing disease severity, suggesting that myeloperoxidase-mediated host-tissue damage may play a role in disease pathogenesis.

An in situ analysis pipeline for initial host-pathogen interactions reveals signatures of human colorectal HIV transmission.

The initial immune response to HIV determines transmission. However, due to technical limitations we still do not have a comparative map of early mucosal transmission events. By combining RNAscope, cyclic immunofluorescence, and image analysis tools, we quantify HIV transmission signatures in intact human colorectal explants within 2 h of topical exposure. We map HIV enrichment to mucosal dendritic cells (DCs) and submucosal macrophages, but not CD4+ T cells, the primary targets of downstream infection. HIV+ DCs accumulate near and within lymphoid aggregates, which act as early sanctuaries of high viral titers while facilitating HIV passage to the submucosa. Finally, HIV entry induces recruitment and clustering of target cells, facilitating DC- and macrophage-mediated HIV transfer and enhanced infection of CD4+ T cells. These data demonstrate a rapid response to HIV structured to maximize the likelihood of mucosal infection and provide a framework for in situ studies of host-pathogen interactions and immune-mediated pathologies.

Can adjuvant pelvic radiation therapy after local excision or polypectomy for T1 and T2 rectal cancer offer an alternative option to radical surgery?

PURPOSE: To determine outcomes after adjuvant pelvic local radiation therapy (RT) +/- concurrent chemotherapy for T1 and T2 rectal carcinomas treated with local excision or polypectomy. METHODS: We retrospectively identified adult patients with histologically proven T1 and T2 rectal adenocarcinoma, diagnosed incidentally at time of local excision or polypectomy between 01 January 2007 and 31 December 2019, and appropriately staged to confirm N0 M0 status. Patients were excluded if they had recurrent cancer or had received total mesorectal excision (TME): anterior resection (AR) or abdominoperineal resection (APR). Patient, tumour and treatment factors, together with disease and toxicity outcomes were collected from institutional medical records, correspondence and investigation reports. Descriptive statistical analyses were employed. The primary endpoint was loco-regional control and secondary endpoints were treatment-related toxicity, disease free survival, overall survival and rate of surgical salvage for pelvic recurrence. RESULTS: The median age of the 15 eligible patients was 73 (range 49-82 years). There were 9 men (60%) and 6 women (40%). The majority had T1 disease (80%) and most had received endomucosal resection (80%). All patients received 43-52Gy (EQD2) to the primary and 43-48Gy (EQD2) to the pelvis with 46.6% receiving concurrent chemotherapy (infusional 5-FU or oral capecitabine). At median follow up of 51 months, there were no local or regional recurrences. One patient experienced an isolated distant relapse at 48 months without any locoregional recurrence. CONCLUSION: Our findings demonstrate good locoregional disease control with the use of adjuvant pelvic RT for T1 and T2 rectal adenocarcinoma initially treated with polypectomy or local (non-oncological) excision. These findings indicate that adjuvant pelvic RT may provide an alternative to TME surgery in patients with incidentally detected early rectal cancers.

Outcomes of young patients diagnosed with locally advanced rectal cancer.

BACKGROUND: The incidence of rectal cancer is higher in the older population. In developed nations, there has been a rise in incidence in young onset colorectal cancer (CRC). We examined the outcomes of locally advanced rectal cancer (LARC) in younger patients (yRC) compared with older patients, using a retrospective audit. METHODS: All cases of LARC referred to two tertiary referral cancer centres in Western Sydney were examined. Patient demographics, presenting symptoms, treatment, relapse free survival (RFS), overall survival (OS) and progression free survival (PFS) were obtained. Under 50 years old was used as the cut-off age for defining yRC. RESULTS: All 145 consecutive patients were treated for LARC, including 28 in the yRC and 117 in the older patient group. Median follow-up was 54 months. yRC were more likely to complete neoadjuvant therapy (100% vs. 86%; P=0.032) and to undergo more extensive surgical procedures (24% vs. 2%, P<0.0001). yRC were more likely to have microsatellite high (MSI) tumours (30% vs. 4.7%; P=0.003). yRC demonstrated significantly poorer RFS compared with the standard group (HR 2.79; median RFS 4.67 vs. 16.02 months; P=0.023). In the relapsed setting, yRC had poorer PFS compared with the standard group (median PFS 2.66 vs. 9.70, P=0.006, HR 3.04). A difference in OS was also seen between the two groups, with yRC demonstrating poorer OS (median OS 40.46 vs. 58.26 months, HR 3.48, P=0.036). CONCLUSIONS: Patients under 50 years with LARC are more likely to have MSI tumours with a more aggressive disease course and poorer RFS, PFS and OS. Initiatives to improve early detection of these patients may improve outcomes. Further research is necessary to understand this disease and optimise its treatment.

Optimal Isolation Protocols for Examining and Interrogating Mononuclear Phagocytes From Human Intestinal Tissue.

The human intestine contains numerous mononuclear phagocytes (MNP), including subsets of conventional dendritic cells (cDC), macrophages (Mf) and monocytes, each playing their own unique role within the intestinal immune system and homeostasis. The ability to isolate and interrogate MNPs from fresh human tissue is crucial if we are to understand the role of these cells in homeostasis, disease settings and immunotherapies. However, liberating these cells from tissue is problematic as many of the key surface identification markers they express are susceptible to enzymatic cleavage and they are highly susceptible to cell death. In addition, the extraction process triggers immunological activation/maturation which alters their functional phenotype. Identifying the evolving, complex and highly heterogenous repertoire of MNPs by flow cytometry therefore requires careful selection of digestive enzyme blends that liberate viable cells and preserve recognition epitopes involving careful selection of antibody clones to enable analysis and sorting for functional assays. Here we describe a method for the anatomical separation of mucosa and submucosa as well as isolating lymphoid follicles from human jejunum, ileum and colon. We also describe in detail the optimised enzyme digestion methods needed to acquire functionally immature and biologically functional intestinal MNPs. A comprehensive list of screened antibody clones is also presented which allows for the development of high parameter flow cytometry panels to discriminate all currently identified human tissue MNP subsets including pDCs, cDC1, cDC2 (langerin+ and langerin-), newly described DC3, monocytes, Mf1, Mf2, Mf3 and Mf4. We also present a novel method to account for autofluorescent signal from tissue macrophages. Finally, we demonstrate that these methods can successfully be used to sort functional, immature intestinal DCs that can be used for functional assays such as cytokine production assays.

Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: There is a relatively high risk of anastomotic leak in low anterior resection (LAR), associated with significant morbidity and mortality. This systematic review and meta-analysis aims to compare diverting stoma vs. no stoma for LAR in terms of leak rates, reoperations, mortality rates and complication rates. METHODS: We systematically performed electronic searches of databases Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club and DARE from inception to present. Only randomized controlled trials comparing LAR for rectal cancer with versus without stoma diversion were included for analysis. Main outcomes were anastomotic leak, reoperation rate and mortality. Secondary outcomes included other operative and stoma-related complications. RESULTS: Eight randomized controlled trials were included in the study for qualitative and quantitative analyses. A significantly longer operative duration for patients with stoma diversion was seen (WMD 19.50 min; 95% CI: 7.38, 31.63; I2=0%, P=0.002). The pooled rate for anastomotic leak was significantly lower for those with stoma diversion (6.3% vs. 18.3%; RR 0.36; 95% CI: 0.24, 0.54; I2=0%; P<0.00001). There was lower reoperation rate for patients with stoma diversion compared to no stoma (5.9% vs. 16.7%; RR 0.40; 95% CI: 0.26, 0.60; I2=0%; P<0.00001). No significant difference was found in terms of leak-related mortality between stoma vs. no-stoma cohorts (0.47% vs. 1.0%; P=0.51). CONCLUSIONS: The present meta-analysis suggests a diverting or defunctioning stoma following LAR for rectal cancers can reduce anastomotic leak and reoperation rates, without increased risk of mortality or other complications.

Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection: A Network Meta-analysis.

Importance: There has been a resurgence of interest in the use of mechanical bowel preparation (MBP) and oral antibiotics (OAB) before elective colorectal surgery. Until now, clinical trials and meta-analyses have not compared all 4 approaches (MBP with OAB, OAB only, MBP only, or no preparation) simultaneously. Objective: To perform a network meta-analysis to clarify which approach in colorectal surgery is associated with the lowest rate of surgical site infection (SSI). Data Sources: Five electronic databases were searched, including PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club. and Database of Abstracts of Review of Effectiveness from database inception to November 27, 2017. Study Selection: Only data from randomized clinical trials were included. Inclusion criteria were RCTs that reported on SSI rates or other complications based on MBP or OAB status. Quality of studies was appraised by the Cochrane Collaboration risk of bias tool. Data Extraction and Synthesis: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Main Outcomes and Measures: Total, incisional, and organ/space SSI rates. Secondary outcomes included rates of anastomotic leak, mortality, readmissions/reoperations, urinary tract infection, and pulmonary complications. Results: Thirty-eight randomized clinical trials among 8458 patients (52.1% male) were included, providing 4 direct comparisons and 2 indirect comparisons for 8 outcome measures. On Bayesian analysis, MBP with OAB vs MBP only was associated with reduced SSI (odds ratio [OR], 0.71; 95% equal-tail credible interval [CrI], 0.57-0.88). There was no significant difference between MBP with OAB vs OAB only (OR, 0.95; 95% CrI, 0.56-1.62). Oral antibiotics without MBP was not associated with a statistically significant reduction in SSI compared with any other group (except for a risk reduction in organ/space SSI when indirectly compared with no preparation) (OR, 0.13; 95% CrI, 0.02-0.55). There was no difference in SSI between MBP only vs no preparation (OR, 0.84; 95% CrI, 0.69-1.02). Conclusions and Relevance: In this network meta-analysis of randomized clinical trials, MBP with OAB was associated with the lowest risk of SSI. Oral antibiotics only was ranked as second best, but the data available on this approach were limited. There was no difference between MBP only vs no preparation. In addition, there was no difference in rates of anastomotic leak, readmissions, or reoperations between any groups.

Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy.

BACKGROUND: Various treatment measures have been described in achieving splenic preservation following splenic injury. We describe an additional measure in achieving haemostasis during mesh splenorrhaphy. METHODS: Oxycel (BD, Franklin Lakes, NJ, USA) (topical haemostatic agent composed of oxidized cellulose) is sutured onto the inside of Dexon (Sherwood, Davis & Geck, St Louis, MO, USA) (polyglycolic acid) mesh. RESULTS: Two patients with splenic lacerations were operated on from July 2002 to February 2003 using this technique and both patients did not experience postoperative abdominal complications and were clinically well at follow up 1-2 months later. CONCLUSIONS: In our experience this technique made the Dexon mesh bulkier and easier to secure as well as more haemostatic.

Multicenter randomized trial of centralized nurse-led telephone-based care coordination to improve outcomes after surgical resection for colorectal cancer: the CONNECT intervention.

PURPOSE: To investigate the effectiveness of a centralized, nurse-delivered telephone-based service to improve care coordination and patient-reported outcomes after surgery for colorectal cancer. PATIENTS AND METHODS: Patients with a newly diagnosed colorectal cancer were randomly assigned to the CONNECT intervention or usual care. Intervention-group patients received standardized calls from the centrally based nurse 3 and 10 days and 1, 3, and 6 months after discharge from hospital. Unmet supportive care needs, experience of care coordination, unplanned readmissions, emergency department presentations, distress, and quality of life (QOL) were assessed by questionnaire at 1, 3, and 6 months. RESULTS: Of 775 patients treated at 23 public and private hospitals in Australia, 387 were randomly assigned to the intervention group and 369 to the control group. There were no significant differences between groups in unmet supportive care needs, but these were consistently low in both groups at both follow-up time points. There were no differences between the groups in emergency department presentations (10.8% v 13.8%; P = .2) or unplanned hospital readmissions (8.6% v 10.5%; P = .4) at 1 month. By 6 months, 25.6% of intervention-group patients had reported an unplanned readmission compared with 27.9% of controls (P = .5). There were no significant differences in experience of care coordination, distress, or QOL between groups at any follow-up time point. CONCLUSION: This trial failed to demonstrate substantial benefit of a centralized system to provide standardized, telephone follow-up for postoperative patients with colorectal cancer. Future interventions could investigate a more tailored approach.