Long-term outcome of stenting as a bridge to surgery for acute left-sided malignant colonic obstruction.

AIM: This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon. METHOD: Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed. RESULTS: Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991). CONCLUSION: Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

The impact of POSSUM score on the long-term outcome of patients with rectal cancer.

AIM: The TMN staging system is the most important tool for predicting the long-term survival of colorectal cancer patients. However, physiological conditions and the operation may also influence survival. This study evaluated the impact of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and the colorectal version (CR-POSSUM) on the long-term survival of patients with rectal cancer. METHOD: Prospectively collected data were included of consecutive patients who underwent rectal cancer resection between 2000 and 2004. The relationship between the POSSUM and CR-POSSUM scores and the physiological components with outcomes and survivals was analysed. RESULTS: The study included 343 patients (196 men, 263 open resections, 74 laparoscopic resections, six local resections) with a mean follow-up of 56.5 months. Thirty-five patients had had neoadjuvant chemoradiation and 115 had adjuvant chemotherapy. Their median POSSUM score was 34 (interquartile range 31-39) and the median CR-POSSUM score was 19 (interquartile range 18-21). The log rank test showed a significant difference (P < 0.05) in long-term survival for patients who belonged to different POSSUM score groups and POSSUM physiological score groups. Factors found on multivariate analysis to have significant association with long-term survival included TNM stage, perineural invasion, local invasion, obstruction, emergency operation, POSSUM score and POSSUM physiological score. CONCLUSION: The mortality of patients after rectal cancer surgery can be predicted by POSSUM, P-POSSUM (a subsequent version of POSSUM) or CR-POSSUM with no significant difference between them. Both POSSUM and the POSSUM physiological score were significantly related to survival. The POSSUM score was one of the factors that independently predicted long-term survival.

Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients.

AIM: The aim of this study was to evaluate the outcomes of self-expanding metallic stent (SEMS) placement in acute left-sided large-bowel obstruction. METHOD: From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left-sided large-bowel obstruction. One-hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed. RESULTS: The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24-55) months. CONCLUSION: SEMS placement is safe and effective in relieving acute left-sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.

Prognostic value of lymph node ratio in stage III colorectal cancer.

AIM: Recent reports show that a positive metastatic to examined lymph nodes ratio (LNR) has prognostic value in malignancies. This study aimed to evaluate the prognostic value of LNR in patients having resection for stage III colorectal cancer. METHOD: From January 2000 to December 2006, patients who underwent resection for stage III colorectal carcinoma were included. All clinicopathological and follow-up data were prospectively collected. The impact of LNR and other clinicopathological factors on survival were evaluated. RESULTS: The study included 533 (52.3% male) patients with a median age of 70 years. The median number of lymph nodes harvested and the median number of positive lymph nodes examined were 11 and 2, respectively. The median LNR was 0.263 (range, 0.03-1). After a median follow up of 52.65 months, the 5-year overall survival and disease-free survival were 55.9% and 49.4%. The patients were stratified into four groups according to LNR quartiles (1, LNR ≤ 0.125; 2, 0.1250.500). The 5-year overall and disease-free survival were 72.8%, 63.1%, 50.0%, 39.6% (P<0.001) and 68.5%, 54.1%, 47.2%, 29.9% (P<0.001), respectively, with increasing LNR groups. On multivariate analysis, age, T stage and LNR were independent predictors of both overall and disease-free survival. Subgroup analysis revealed that the LNR had a prognostic value for disease-free survival irrespective of number of lymph nodes harvested and location of tumour. CONCLUSION: The LNR is an independent prognostic factor for survival in colorectal cancer and is superior to the pN category in TNM staging.

Single incision laparoscopic left colectomy for carcinoma of distal transverse colon.

OBJECTIVE: We report a single-incision laparoscopic left colectomy for a patient with a distal transverse colon cancer. METHOD: A 78-year-old man with carcinoma of the transverse colon close to the splenic flexure underwent a single-incision laparoscopic left colectomy with full mobilization of splenic flexure using the TriPort Access System and ordinary laparoscopic instruments. RESULTS: The operation was successfully performed. The patient recovered uneventfully and was discharged after 3 days. Histopathological examination showed a T3N1 tumour with clear resection margins. CONCLUSION: This case demonstrates that single-incision laparoscopic colectomy can be applied safely to large bowel cancer close to the splenic flexure. The technique warrants further investigation.

A study of surgeons' postural muscle activity during open, laparoscopic, and endovascular surgery.

BACKGROUND: Different surgical procedures impose different physical demands on surgeons and high prevalence rates of neck and shoulder pain have been reported among general surgeons. Past research has examined electromyography in surgeons mainly during simulated conditions of laparoscopic and open surgery but not during real-time operations and not for long durations. The present study compares the neck-shoulder muscle activities in three types of surgery and between different surgeons. The relationships of postural muscle activities to musculoskeletal symptoms and personal factors also are examined. METHODS: Twenty-five surgeons participated in the study (23 men). Surface electromyography (EMG) was recorded in the bilateral cervical erector spinae, upper trapezius, and anterior deltoid muscles during three types of surgical procedures: open, laparoscopic, and endovascular. In each procedure, EMG data were captured for 30 min to more than 1 h. The surgeons were asked to rate any musculoskeletal symptoms before and after surgery. RESULTS: The present study showed significantly higher muscle activities in the cervical erector spinae and upper trapezius muscles in open surgery compared with endovascular and laparoscopic procedures. Muscle activities were fairly similar between endovascular and laparoscopic surgery. The upper trapezius usually has an important role in stabilizing both the neck and upper limb posture, and this muscle also recorded higher activities in open compared with laparoscopic and endovascular surgeries. Surgeons reported similar degrees of musculoskeletal symptoms in open and laparoscopic surgeries, which were higher than endovascular surgery. CONCLUSIONS: The present study showed that open surgery imposed significantly greater physical demands on the neck muscles compared with endovascular and laparoscopic surgeries. This may be due to the lighter manual task demands of these minimally invasive surgeries compared with open procedures, which generally required more dynamic movements and more forceful exertions.

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm.

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.

Standards of pancreaticoduodenectomy in a tertiary referral centre in Hong Kong: retrospective case series.

OBJECTIVE: To evaluate the perioperative outcomes of pancreaticoduodenectomy in a tertiary referral centre in Hong Kong. DESIGN: Retrospective case series. SETTING: University teaching hospital, Hong Kong. PATIENTS: One hundred and forty patients who underwent pancreaticoduodenectomy from July 1989 through June 2001. MAIN OUTCOME MEASURES: Mortality and morbidity. RESULTS: Overall hospital mortality among 140 patients was 2.9% (n=4), and 30-day operative mortality was 2.1% (n=3). There was no significant difference in the hospital mortality rate between 43 elderly patients aged 70 years or older and 97 younger patients (2.3% versus 3.1%). The overall morbidity rate was 38.6% (n=54). Intra-abdominal abscess (13.6%) and pancreaticojejunal anastomotic leakage (12.9%) were the two most common complications. Presence of co-morbid illness (risk ratio, 2.823; 95% confidence interval, 1.541-4.385; P=0.01), preoperative cholangitis (risk ratio, 2.565; 95% confidence interval, 1.166-5.643; P=0.02), and intra-operative blood loss >/=1.5 L (risk ratio, 2.236; 95% confidence interval, 1.132-6.213; P=0.03) were independent risk factors for postoperative morbidity. CONCLUSIONS: Pancreaticoduodenectomy is associated with a low risk of operative death when performed in a tertiary referral setting in Hong Kong. The postoperative morbidity rate remains high, however. Further improvement by reducing intra-operative blood loss may help curtail the high postoperative morbidity.