Morning colonoscopies are associated with improved adenoma detection rates.

BACKGROUND: Higher adenoma detection rates are associated with decreased risks for subsequent colorectal cancers. Studies have suggested that adenoma detection rate (ADR) may be affected by timing of colonoscopy due to endoscopist fatigue later in the day. The aim of our study is to assess the influence of the timing variables on ADR. METHODS: Univariate analysis and multivariate logistic regression analysis were performed on a prospective colonoscopy database, comparing ADR for colonoscopies performed in the morning shift (AM) and in the afternoon shift (PM) over a 1-year period. Each shift lasted 4 h. Only elective outpatient completed colonoscopies with adequate bowel preparation, performed by four certified staff endoscopists, were included. Surveillance colonoscopies for cancers were excluded. ADR was defined as the detection of at least one histologically confirmed polyp during colonoscopy. RESULTS: A total of 533 colonoscopies were included. ADR was 25 % in the cohort. Mean age was 59 (SD 14.1). Two hundred and seventy (50.6 %) were done in the AM and 263 (49.4 %) were done in the PM. ADR was 29 % in the AM group compared to 21 % in the PM group (p = 0.03). Excluding time needed for polypectomy, the mean time taken for scope withdrawal was significantly longer in the morning group (12 min) compared with the afternoon group (10 min) (p = 0.002). The longer withdrawal time in the morning was significantly associated with increased ADRs (OR 1.104, 95 % CI 1.063-1.147) (p < 0.0001). CONCLUSION: Timing of colonoscopy is an independent predictor for ADR. Colonoscopies performed in the morning have a longer mean withdrawal time, thus leading to a significantly higher ADR. As endoscopists concentration decreases as the day progresses, this may account for the shorter time spent on colonoscopies on the afternoon.

Incidence of incisional hernia after major colorectal cancer surgery & analysis of associated risk factors in Asian population: Is laparoscopy any better?

BACKGROUND: Incisional hernia is one of the common morbidities after major colorectal cancer surgery. We aim to compare the incidence of incisional hernias between laparoscopic and open surgery. We also aim to identify associated risk factors of incisional hernia among Asian population who has undergone major resection for colorectal cancer. METHODS: Data of patients who had undergone major colorectal cancer surgery in year 2015 from a single institution was collected. Data were extracted from electronic clinical records from our institution's database. Incisional hernias were identified by clinical examination and computed tomography (CT) scan performed during post-operative follow up as part of colorectal cancer surveillance. Follow up data of up to 3 years were extracted. Univariate and multivariable logistic regression analysis were performed to identify associated risk factors for development of incisional hernia. Propensity score matching analysis was performed for laparoscopic and open resection. RESULTS: 502 patients were included in the study. With a minimum follow up of 3 years, overall incisional hernia incidence rate of 13% was identified. Incisional hernias after laparoscopic and open surgery were 12.3% and 13.8% (p = 0.688) respectively. Univariate logistic regression analysis showed that body mass index (BMI) of >23kg/m2, ASA of III/IV and post-operative anastomotic leak were associated with development of incisional hernias. On multivariable analysis, female gender (OR 2.102, 95%CI: 1.155, 3.826), BMI of ≥23 kg/m2 (OR 2.862 95%CI: 1.582, 5.181), ASA III/IV (OR 2.052, 95%CI: 1.169, 3.602), were significantly associated with development of incisional hernia. Propensity scores matched analysis showed laparoscopic surgery did not significantly reduce the incidence of incisional hernia. CONCLUSION: The overall incidence of incisional hernia seems lower in Asian population. Our study demonstrated no significant difference in incisional hernia rates between patients undergoing laparoscopic versus open colorectal cancer surgery. Female gender, higher BMI, and higher ASA are associated with increased risk of developing incisional hernia after major colorectal cancer resection.

Transvaginal Natural Orifice Specimen Extraction (NOSE) in Laparoscopic Colorectal Cancer Surgery With New Insights on Technique and Patient Selection.

BACKGROUND: Following laparoscopic colorectal surgery, transabdominal specimen extraction requires a mini-laparotomy or Pfannenstiel incision, associated with increased postoperative pain and wound complications. The vagina has several unique properties that make natural orifice specimen extraction (NOSE) ideal. We report our experience with transvaginal NOSE for colorectal cancer surgery. MATERIALS AND METHODS: A transvaginal sizer allows the posterior vagina to be incised under tension. A transverse or cruciate incision is made, followed by the insertion of a double-ring wound protector. The external ring is opened against the perineum to shorten the length of the conduit for specimen delivery. Vaginotomy closure is performed via laparoscopy using a barbed suture. RESULTS: Seventeen consecutive female patients underwent elective colorectal cancer surgery with attempted transvaginal NOSE. Median age and body mass index was 67 (range: 50 to 82) years and 26.5 (range: 19.7 to 35.8) kg/m 2 , respectively. Fourteen patients (82%) underwent left-sided resections and 3 (18%) underwent right-sided resections. Median operating time, blood loss, and length of hospital stay was 245 (range: 155 to 360) minutes, 30 (range: 10 to 500) mL, and 3 (range: 2 to 9) days, respectively. Transvaginal extraction was unsuccessful in 1 (6%) patient. Two (12%) patients experienced early postoperative morbidity, neither attributable to the extraction procedure. Median tumor circumferential diameter was 3.3 (range: 2.2 to 7.0) cm. Median follow-up duration was 17 (range: 8 to 27) months. There was no instance of sexual dysfunction. CONCLUSIONS: Transvaginal NOSE for colorectal cancer surgery is feasible and safe in selected patients. Overall specimen diameter, inclusive of tumor and mesentery, relative to pelvic outlet and conduit diameter is the most important consideration for transvaginal NOSE.