Incidence and treatment of positive pelvic sidewall lymph nodes in patients with rectal cancer.

AIM: The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. METHODOLOGY: This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. RESULTS: There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. CONCLUSIONS: This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

A systematic review of Clostridium difficile infection following reversal of ileostomy.

AIM: The incidence of Clostridium difficile infection (CDI) has been reported to be as high as 4% following ileostomy reversal. CDI can be associated with significant morbidity. A systematic review on this subject has not been previously reported; our aim was to review the literature to establish incidence and to evaluate the factors that may contribute to an increased risk of CDI following ileostomy reversal. METHOD: A systematic review of Ovid, Embase and Medline was undertaken. Search terms included C. difficile, reversal of ileostomy and ileostomy closure. Articles were included where at least one case of C. difficile-associated diarrhoea following reversal of defunctioning ileostomy was reported. Data extraction for articles was performed by two authors, using predefined data fields. The primary outcome measure was incidence of CDI amongst patients undergoing ileostomy reversal. Secondary outcomes were defunctioning time, antibiotic regime, acid suppression, time to onset of symptoms and study conclusions including colectomy and mortality rate. RESULTS: Eleven articles were included (five case reports and six cohort studies). The overall incidence of CDI was 1.8% (242/13 728). The mean defunctioning time was 8.7 months (range 6-12). A variety of antibiotic regimes were described. Mean time to onset of symptoms was 6 days (range 3-14). Use of acid suppression, colectomy or mortality rate were frequently not reported. CONCLUSION: CDI should be recognized as a potentially life-threatening complication of ileostomy closure. Careful consideration should be given to peri-operative antibiotic regime, acid suppression, timing of reversal and appropriate preoperative counselling of patients.

Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer.

AIM: Lymph node (LN) metastases are present in up to 17% of early colorectal cancers (pT1). Identification of associated histopathological factors would enable counselling of patients regarding this risk. METHOD: Pubmed and Embase were employed utilizing the terms 'early colorectal cancer', 'lymph node metastasis', 'submucosal invasion', 'lymphovascular invasion', 'tumour budding' and 'histological differentiation'. Analysis was performed using REVIEW MANAGER 5.1. RESULTS: Twenty-three cohort studies including 4510 patients were analysed. There was a significantly higher risk of LN metastasis with a depth of submucosal invasion > 1 mm than with lesser degrees of penetration (OR 3.87, 95% CI 1.50-10.00, P = 0.005). Lymphovascular invasion was significantly associated with LN metastasis (OR 4.81, 95% CI 3.14-7.37, P < 0.00001). Poorly differentiated tumours had a higher risk of LN metastasis compared with well or moderately differentiated tumours (OR 5.60, 95% CI 2.90-10.82, P < 0.00001). Tumour budding was found to be significantly associated with LN metastasis (OR 7.74, 95% CI 4.47-13.39, P < 0.001). CONCLUSION: Meta-analysis of the current literature demonstrates that in early colorectal cancer a depth of submucosal invasion by the primary tumour of > 1 mm, lymphovascular invasion, poor differentiation and tumour budding are significantly associated with LN metastasis.

A systematic review of peripheral nerve injury following laparoscopic colorectal surgery.

AIM: The risk of peripheral nerve injury associated with laparoscopic colorectal surgery has not been well established. We aimed to identify the number and type of peripheral nerve injuries associated with patient positioning in laparoscopic surgery. METHOD: A systematic review of MEDLINE and Embase was undertaken of English and non-English language articles. Search terms included the key words: laparoscopic, colorectal, nerve injury, nerve damage, brachial plexus, peripheral neuropathy, peripheral nerve injury, nerve and colonic injury. Articles were included where at least one peripheral nerve injury had been documented related to patient positioning at laparoscopic colorectal surgery. Data extraction for articles was conducted by two authors, using predefined data fields. RESULTS: Ten cases have been reported in the literature. All injuries involved the brachial plexus. They were associated with a lengthy procedure and abduction of the arm. CONCLUSION: Although rare, the surgeon and theatre team must be aware of the risk of peripheral nerve injury when positioning patients for laparoscopic colorectal procedures.

How safe is it to manage diverticular colovesical fistulation non-operatively?

AIM: Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented. METHODS: The clinical outcomes of all patients diagnosed with a CVF over a 7-year period from an uro-radiological database were reviewed. Cases secondary to diverticular disease were analysed with respect to the approach by which they were managed: those treated surgically and those managed conservatively. RESULTS: Sixty-two patients (32 men) were diagnosed with CVF of whom 53 (85%) had diverticular disease. Twenty-seven (mean age 69 years, range 42-90) underwent surgery (with a stoma in 59%) with a 30-day mortality of 15%. Those managed conservatively (n = 26) were older (mean age 76 years, range 39-87) and frailer (62% American Society of Anesthesiologists Grades III and IV). At 1 and 3 years following diagnosis there was no difference in mortality between these two groups and only one death was as a consequence of urosepsis. CONCLUSION: Many patients with CVF secondary to diverticular disease can be safely managed non-operatively.

A comparative study of colorectal surgical outcome in a national audit separated by 15 years.

AIM: The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening. METHOD: Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008. RESULTS: In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period. CONCLUSION: Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

CT evaluation for 'quiescent' herniation following closure of diverting loop ileostomy.

AIM: The prevalence of abdominal wall herniation at the site of a previous temporary stoma is uncertain. This cohort study investigated the frequency of radiological abnormalities at the site of a closed diverting loop ileostomy. METHOD: All patients in whom an ileostomy was raised and later closed during a 5-year period formed the study group. When colorectal cancer surveillance computed tomography (CT) was undertaken the images were scrutinized and graded as to defined anatomical abnormalities. RESULTS: One hundred and seventy-nine patients had an ileostomy, of which 92 were diverting. Fifty-nine (64%) were closed at various intervals (median time to closure 6 (2-22) months and 43 underwent a surveillance CT at 1-3 (median 2) years. At 1 year an abnormality (atrophy or defect) at the site of closure was seen in 16 (37%) CT scans. These were more frequent with increasing duration of follow-up. One asymptomatic hernia was detected at 2 years but there was no deterioration in the abdominal wall at 3 years when compared with that at 2 years. CONCLUSION: Abnormalities in the abdominal wall at the site of a closed diverting ileostomy are common but true herniation is unusual. The routine use of prophylactic mesh at ileostomy closure may be unnecessary.

Avoiding extraction site herniation after laparoscopic right colectomy.

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6 cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

'Mind if I record this?' Patients making audio-visual recordings of consultations: a survey of surgeons' experiences.

INTRODUCTION: Audio-visual recordings made by patients of their clinical encounters are increasingly common. This may be done with or without their doctors' knowledge or consent and is considered admissible legal evidence. Many surgeons may feel uncomfortable with being recorded and lack knowledge regarding the legal implications. The aim of this study was to gauge how surgeons react to being recorded, and what specific medico-legal insight they have regarding these matters. METHODS: In total, 150 surveys were distributed to surgeons in two hospitals in South Wales by email, Survey Monkey and paper copy between 28 October 2019 and 9 March 2020. The survey was anonymous and recorded level of training, as well as four simple questions regarding how surgeons may react to being recorded and what they felt their legal rights were. RESULTS: There were 91 respondents: 28 consultants, 36 registrars and 27 junior surgical trainees. Of the respondents, 56% were uncomfortable with being recorded and 23% would stop a consultation if their patient insisted on recording it. These issues were most marked for junior surgical trainees. Sixty-two per cent of respondents were unaware of their legal rights and 21% believed they were legally able to refuse to continue a consultation. This belief was particularly marked among consultants. CONCLUSION: Many surgeons are uncomfortable with being recorded and lack knowledge regarding their medico-legal standing. Education and guidance from the Royal Colleges would help address this issue and avoid misunderstanding when surgeons are faced with these potentially difficult scenarios.

Kisspeptin activates the hypothalamic-adenohypophyseal-gonadal axis in prepubertal ewe lambs.

The onset of puberty in mammals involves an increase in the pulsatile release of GNRH and LH. The KISS1 gene is essential for pubertal development, and its product, kisspeptin, stimulates the release of LH. The objective of this study was to determine the effects of kisspeptin in the hypothalamic-adenohypophyseal-gonadal axis of prepubertal ewe lambs. Ewe lambs (28 weeks of age) were treated intravenously with saline (control, n=6) or kisspeptin (20 µg kisspeptin; n=6) every hour for 24 h. Kisspeptin stimulated pulse-like release of LH within 15 min following injections, and increased the frequency and amplitude of LH pulses, and mean circulating concentrations of LH and estradiol. A surge-like release of LH was observed in four kisspeptin-treated lambs beginning 17 h after the onset of treatment, and all four lambs had elevated circulating concentrations of progesterone within 5 days post-treatment. However, circulating concentrations of progesterone decreased within 2 days after the initial rise in three of the four ewe lambs, indicating that induced luteal activity was of short duration. The proportion of lambs that were pubertal (defined by circulating concentrations of progesterone above 1 ng/ml for at least 7 days) by 35 weeks of age (8/11) and the mean age at puberty (32 ± 1 weeks) for those reaching puberty within the experimental period did not differ between treatments. Results support a role for kisspeptin in the activation of the hypothalamic-adenohypophyseal axis leading to the onset of puberty in ewe lambs.

Induced prostaglandin release alters steroid concentrations but not pregnancy survival in cows.

Embryonic mortality (EM) is a major factor limiting reproductive efficiency in cattle, and despite negative connotations related to reproductive performance, prostaglandin F2α (PGF2α) is capable of being released by the uterus by Day 30 of gestation. Therefore, the objective was to evaluate differences in PGF2α release after an oxytocin challenge between cows with high circulating concentrations of pregnancy-associated glycoproteins (PAGs) vs low PAG because of the association of increased PAG concentrations with pregnancy success. At Day 30 of gestation, pregnant cows were divided into oxytocin treatment (OT; n = 13) and control (CON; n = 12) groups. Treatment cows were further subdivided by circulating PAG concentration (high PAG, n = 7; and low PAG, n = 6). Blood samples were collected every 30 min beginning 1 h before oxytocin administration and continuing for 4 h. Prostaglandin F2α metabolite (PGFM), progesterone, estradiol-17ß (E2), and PAG concentrations were quantified. The peak concentration of PGFM occurred 2 h after oxytocin injection in treatment animals and returned to baseline levels by 4 h. No correlations were observed between PAG and PGFM, progesterone, or E2 concentrations (P > 0.05). There was no difference in initial or final PGFM concentrations between groups (P > 0.05). Progesterone and E2 concentrations decreased in cows after treatment of oxytocin (P < 0.05); however, only progesterone returned to basal concentrations by the end of the sampling period. In summary, cows with high vs low PAG concentrations at Day 30 of gestation have a similar PGFM response to oxytocin challenge.

Minimal anatomical disruption in stoma formation: the lateral rectus abdominis positioned stoma (LRAPS).

AIM: Parastomal hernias are difficult to manage and recent attention has focused on their prevention including the use of prophylactic mesh at the time of initial surgery. METHOD: A novel 'anatomical' approach to stoma formation, the lateral rectus abdominis positioned stoma (LRAPS), involving minimal anterior abdominal wall disruption is described. RESULTS: LRAPS was carried out electively (n = 25) or as an emergency (n = 4) for benign or malignant pathology. Twenty-two had a midline laparotomy and all types of stomas were fashioned. There were two early and three later deaths from advanced malignancy. No parastomal hernias have been detected at a mean follow-up of 13 (range 7-18) months and none detected by CT scanning in 20 of 24 patients with colorectal cancer at a mean follow-up of 14 (range 10-18) months. CONCLUSION: LRAPS reduces the incidence of early stomal herniation.