Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial.

INTRODUCTION: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. METHODS: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. RESULTS: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003). CONCLUSIONS: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

Immunohistochemistry to detect hereditary nonpolyposis colorectal cancer in young patients: the 7-year Auckland experience.

BACKGROUND: In accordance with the Bethesda Guidelines, Auckland's metropolitan hospitals routinely perform immunohistochemistry for mismatch repair proteins on the tumor specimens of all patients with colorectal cancer aged 50 years and younger. When loss of expression is evident, patients are offered genetic counseling and gene mutation analysis. OBJECTIVES: This study aimed to determine the completeness of young patient capture over the first 7 years of routine testing, to find whether patients were referred for genetic testing, and to determine the proportion of patients found to have a mismatch repair gene mutation. DESIGN: This study retrospectively reviewed clinical, pathological, and genetic data. SETTINGS: The study was conducted at 3 public hospitals in Auckland, New Zealand. PATIENTS: All patients aged 50 years and younger treated for colorectal cancer at Auckland's metropolitan hospitals between January 2001 and December 2007 (n = 243) were included. MAIN OUTCOME MEASURES: The loss of expression of mismatch repair proteins by immunohistochemistry, referral for genetic testing, and proportion with mismatch repair gene mutation were the main outcome measures. RESULTS: Two hundred fourteen (88%) eligible patients had immunohistochemical analysis of their tumor and 33 (14%) had loss of expression of one or more mismatch repair proteins. Twenty-six patients were referred for genetic counseling, of whom 22 underwent genetic testing. A mismatch repair gene mutation was identified in 10 patients. LIMITATIONS: Seven patients with loss of expression of mismatch repair proteins by immunohistochemistry were not referred for genetic assessment. CONCLUSIONS: We have identified a mismatch repair gene mutation diagnostic of hereditary nonpolyposis colorectal cancer in 5% of all patients with colorectal cancer who were aged 50 years and younger. Routine immunohistochemical prescreening has important clinical benefit for these patients and their relatives.

Haemorrhoid energy therapy versus rubber band ligation for the management of grade I and II haemorrhoids: a randomized trial.

BACKGROUNDS: Grade I and II haemorrhoids are commonly managed in colorectal practice. Management often involves rubber band ligation. The haemorrhoid energy therapy (HET) device (Medtronic, Minneapolis, MN, USA) has been developed as an alternative to rubber band ligation (RBL). This study is the first to prospectively evaluate the device versus RBL in the management of grade I and II haemorrhoids. METHODS: A single blind, randomized controlled trial was conducted in the colorectal outpatient department. Patients with symptomatic haemorrhoids suitable for banding were prospectively recruited and randomized. Primary outcome was post procedural pain at 1 h as recorded on a 10-point Likert scale. Secondary outcomes were efficacy in reduction of haemorrhoidal symptom score at 12 weeks, daily average and maximum pain scores for 14 days and complications arising from the intervention. RESULTS: Thirty patients were randomized (14 HET, 16 RBL). There was no significant difference between the two group's pre-intervention symptom score and haemorrhoidal grade. The mean pain scores at 1 h in the HET group were 1.5 ± 068 (95% confidence interval), and in the RBL group 4.64 ± 1.74 (95% confidence interval) (P < 0.05). Average (0.7 versus 2.95, P < 0.05) and maximum (1.25 versus 4.4, P < 0.05) pain were lower in the HET group on day one post procedure. At 12 weeks there was no significant difference in the reduction of haemorrhoid symptom scores between the groups (HET 2.27, RBL 1.5 (P > 0.2)). CONCLUSION: HET causes less pain then RBL, and is at least as effective in treating the symptoms associated with grade I and II haemorrhoids in the outpatient setting.

Palliative colonic stenting: a safe alternative to surgery in stage IV colorectal cancer.

BACKGROUND: The morbidity associated with surgery for obstructing or near-obstructing stage IV colorectal cancer can be high including the frequent need for a stoma. Self-expandable metal stents (SEMS) offer an alternative to surgery. Our aim was to analyse our palliative SEMS outcomes and compare this with a palliative surgery group. METHODS: A retrospective study of a single institutions' experience with SEMS or surgery in the management of stage IV colorectal cancer was performed. RESULTS: Sixty-five patients treated with SEMS were included in the study. These were compared with an unmatched group of 63 patients who underwent surgery. Within the SEMS group was a 98.5% technical success and 100% clinical success of deployed SEMS. Overall complication rate was low at 23.1% (restenosis 7.7%, migration 7.7%, perforation 4.6% and bleeding 3.1%). Only 7.7% of patients in the SEMS group required an operation. SEMS insertion was associated with a shorter hospital stay (2.9 days versus 14.6 days; P < 0.001) and reduced requirement for a stoma (4.6% versus 44.4%; P < 0.001). There was no statistically significant difference in 30-day mortality (13.8% versus 11.1%; P = 0.640), 1-year survival (42.9% versus 41.4%; P = 0.949) or 2-year survival (24.5% versus 21.4%; P = 0.700). Overall survival was equivalent between the two groups (hazard ratio 1.27; 95% confidence interval 0.88-1.88; P = 0.212). CONCLUSION: SEMS is a safe alternative to surgery in obstructing or near-obstructing stage IV colorectal cancer. It offers high success rate, a shorter hospital stay and a reduced stoma rate while not impacting overall survival.

The colorectal cancer patients' journey: the Auckland region.

AIM: To identify the time taken from referral to first treatment of patients with colorectal cancer (CRC) in the Auckland region and benchmark these against available guidelines for timeliness. METHOD: Retrospective study of clinical records of all patients diagnosed with CRC identified from the national registry and Auckland regional databases in the years 2001 and 2005. Data extracted included demographics, dates and types of interventions and the patient journey from referral to initiation of first treatment. RESULTS: Of the 1128 patients diagnosed and treated in these cohorts, 68% were referred through their general practitioner and 58% saw a surgeon at their first specialist appointment. Seventy-nine percent received initial treatment with curative intent. The median time from initial referral to first treatment was 35 days, with only 68% of patients being treated within 62 days of initial referral. CONCLUSION: The colorectal patient journey is complicated by multiple pathways of presentation and treatment and by patient choice. These factors need to be considered when assessing the acceptability of transit times based on summary data. That nearly one-third of patients did not complete the United Kingdom-based target of 62 days from referral to first treatment indicates there is a need for further improvement in service delivery for patients developing CRC in the Auckland region.