Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial.

AIM: Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC. METHOD: Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival. RESULTS: One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05). CONCLUSION: A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.

Navigating the mesentery: part II. Vascular abnormalities and a review of the literature.

AIM: Vascular abnormalities present advantages and/or disadvantages for the patient undergoing surgery. The aims of this study were to define, classify and demonstrate the courses, and to assess the clinical value, of arterial and venous abnormalities in the central mesentery. METHOD: We conducted a review of the anatomy of 340 patients planned for enrolment in the 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography' trial, 312 of whom were submitted to surgery. Vascular abnormalities were analysed in context with surgical notes and images. A meta-analysis of the literature was performed. RESULTS: Arterial Abnormalities were found in 28 (8.2%) of the 340 patients and were classified into the following three groups based on anticipated surgical difficulty: group 1, accessory or replaced arteries to solid organs [14 (4.1%)]; group 2, arterial shunts [11 (3.2%)] between the coeliac trunk and the superior mesenteric artery, which resulted in bleeding in three patients; and group 3, common stem abnormalities [3 (0.9%)]. Two groups of superior mesenteric vein abnormalities were noted. The first included morphological abnormalities in a single vein [4 (1.2%)]: aneurysm [1 (0.3%)]; and ring variants of principal tributaries [3 (0.9%)]. The second included double superior mesenteric vein trunks [31 (9.1%)]: genuine bifid [10 (2.9%)]; and pseudo bifid [21 (6.2%)]. The meta-analysis revealed 26 articles, including 10 series of anatomical dissections or angiographies [1970 cases with 205 (10.4%) arterial abnormalities] and 16 case reports, none of which described a clinical or surgical setting. CONCLUSION: Vascular abnormalities occur frequently. Arterial abnormalities are a hazard when inadvertent injury occurs during surgery. Preoperative knowledge of a bifid superior mesenteric vein is useful.

Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy.

AIM: Awareness of anatomy is critical for performing safe surgery within the root of the mesentery. Our aim was to investigate the anatomical relationship between the superior mesenteric artery (SMA) and vein (SMV) and their branches within a predefined D3 area of the right colon and to compare preoperatively established three-dimensional (3D) mesenteric vessel anatomy from CT with that found at surgery. METHOD: Prospective data were collected on 139 patients included in the 'Safe Radical D3 Right Hemicolectomy for Cancer Through Preoperative Biphasic Multi-detector Computed Tomography (MDCT) Angiography' trial. CT data sets were 3D reconstructed before surgery and compared with photographs taken during the operation. RESULTS: The ileocolic artery was present and correctly identified in all patients and crossed the SMV anteriorly in 58 (41.7%). Seventeen patients had a right colic artery at surgery and there were three false-negative and one false-positive CT findings, yielding a diagnostic accuracy of 97.1%, sensitivity of 85.7% and specificity of 95.2%. Positive and negative predictive values were 94.7% and 97.5%, respectively. The middle colic artery was absent in one (0.7%) patient and multiple (nine double and one triple) in 10 (7.2%) patients. A mean of 3.8 ± 1.2 jejunal arteries and 2.0 ± 0.8 jejunal veins arose from the SMA and SMV. Jejunal veins crossed the SMA in the D3 area anteriorly in 30.9% of patients. In 26 (18.7%) patients, additional veins drained into the SMV, including pancreaticoduodenal in 16, right colic in six and both in two. The inferior mesenteric vein entered the SMV in 58 (41.7%) patients and crossed the D3 area in three (2.2%). CONCLUSION: CT-reconstructed anatomy has high specificity, sensitivity, accuracy and reliability.

Surgical management of duodenal diverticula.

Surgical treatment of duodenal diverticula, although infrequently indicated, implies a high risk of postoperative complications. Diverticuloplasty was performed on five patients, four of whom had biliary or pancreatic duct obstruction and also underwent cholecystectomy and sphincteroplasty. The fifth patient had chronic abdominal pain. Complications occurred in three cases--postoperative diverticular bleeding, retroperitoneal hematoma and peroperative perforation of the common bile duct. The long-term results (3-10 years) were excellent in all cases.