Pudendal nerve testing does not contribute to surgical decision making following anorectal testing in patients with faecal incontinence.

PURPOSE: Faecal incontinence (FI) is a debilitating condition, which affects approximately 2-17 % of the population. Clinical assessment, physiological testing and imaging are usually used to evaluate the pathophysiology and guide management of FI. By analysing patient characteristics, symptoms and investigative findings, the aim of this study was to identify which patient characteristics and investigations influence patient management. METHODS: Data was prospectively collected for all patients with FI presenting to a single surgeon at the Royal Prince Alfred Hospital, Sydney, between March 2002 and September 2013. Continuous data was analysed using the independent T-test. Categorical data was analysed using chi-square tests and logistic regression. RESULTS: Three hundred ninety-eight patients were reviewed; 96 % were female and the mean age was 57 years. Surgical intervention was recommended for 185 patients (47 %) should biofeedback fail. Independent predictors for surgical recommendation were prolapse (p < 0.001, adjusted OR = 4.9 [CI 2.9-8.2]), a functional sphincter length <1 cm (p = 0.032, OR = 1.7 [CI 1.1-2.8]), an external anal sphincter defect (p = 0.028, OR = 1.8 [CI 1.1-3.1]) and a Cleveland Clinic Incontinence Score ≥10 (p = 0.029, OR = 1.7 [CI 1.1-2.6]). CONCLUSION: Independent predictors of surgical recommendation included the presence of prolapse, a functional sphincter length <1 cm, an external anal sphincter defect and a Cleveland Clinic Incontinence Score ≥ 10. Pudendal neuropathy was not a predictor of surgical intervention, leading us to question the utility of this investigation.

Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion.

BACKGROUND: Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents. OBJECTIVE: The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression. DESIGN: This study reports on a randomized control trial (registry number ACTRN012606000199516). SETTING: This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne. PATIENTS AND INTERVENTION: Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion. MAIN OUTCOME MEASURES: The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions. RESULTS: Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022). LIMITATIONS: This study was limited by the lack of an EQ-5D Australian-based population set. CONCLUSIONS: Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.

Which information source is best? Concordance between patient report, clinician report and medical records of patient co-morbidity and adjuvant therapy health information.

RATIONALE, AIM AND OBJECTIVES: Previous studies investigating agreement between data sources for co-morbidity and adjuvant therapy information have suggested agreement varies depending on how the information is collected. The aim of this study was to compare agreement among three data sources: patient report, clinician report and medical record. METHOD: Data were collected as part of a nurse-delivered telephone intervention (the CONNECT programme). Patient report was collected using a self-administered questionnaire. Clinician report was collected from the patient's treating surgeon. Medical record information was extracted by a member of the research team. The proportion of specific agreement [positive (PA) and negative agreement (NA)] and Kappa statistics were calculated. RESULTS: The study sample comprised 756 surgical patients with colorectal cancer. For the majority of co-morbidities the lowest level of agreement was found between the patient and clinician (PA 0.29-0.64, Kappa values ranged from 0.22 to 0.58). The highest agreement and Kappa values for co-morbidities were generally found between the patient report and medical record (PA 0.36-0.80 and NA 0.92-0.99; Kappa 0.34-0.77). There was good agreement between patient and clinician reports for receipt adjuvant therapy {Kappa 0.78 [confidence interval (CI) 0.72-0.84] and 0.84 [CI 0.80-0.88], respectively; PA 0.87 and 0.92, respectively}. No consistent pattern in the predictors of non-agreement was found. CONCLUSION: Given there was higher agreement between patient report and medical record review, the use of patient self-report questionnaires to ascertain co-morbid conditions remains a valid method for health services research.

Attitudes and risk of withdrawal in general surgical registrars.

AIMS: To determine the risk of withdrawal from training of Australian and New Zealand general surgical registrars, and to investigate factors associated with increased risk. METHODS: An invitation to participate in an online survey was distributed to all Australian and New Zealand general surgical registrars by the Royal Australasian College of Surgeons. RESULTS: 142 of 550 (26%) participants completed the survey. Overall, 54% (n=77) of respondents had considered leaving surgical training. Female trainees were significantly more likely to consider leaving training compared to males (65% vs 47%, p=0.036, OR 2.1). Respondents who studied in Australia or New Zealand, compared to overseas, were also significantly more likely to consider leaving surgical training (59% vs 35%, p=0.023, OR 2.7). The most common reason for potential withdrawal was poor lifestyle and quality of life during surgical training. Trainees at risk of withdrawal felt less supported, less satisfied with teaching and less confident in their operative skills. CONCLUSION: Female and locally-trained general surgical registrars are at a higher risk of withdrawal during their training programme for a number of reasons. At risk trainees are also less satisfied with their programme.

Prognostic factors for supraglottic laryngeal carcinoma: Importance of the unfit patient.

BACKGROUND: The purpose of this study was to define prognostic factors for supraglottic laryngeal cancer that may influence management. METHODS: This ethics-approved study captured information on patients who presented with supraglottic laryngeal cancer between 1967 and 2008. Endpoints were local/ultimate failure and cancer-specific survival (CSS). Analysis was performed using chi-square, Fisher exact test, and logistic regression. Kaplan-Meier and Cox regression analysis were used to describe time-to-event data. RESULTS: Three hundred sixty-nine patients were analyzed. Two hundred seventeen patients received radiotherapy, 30 were treated with surgery, and 122 were treated with radiotherapy and surgery. The 5-year ultimate local control and CSS rates were 79.5% and 62.8%. Treatment type was a univariate predictor for outcome; however, it was not an independent predictor for ultimate local control or CSS. CONCLUSIONS: This study highlights the fact that by documenting information it is possible to define prognostic factors. It also shows the importance of adjusting for clinical predictors such as patients being unfit for surgery.

Medulloblastoma: progress over time.

INTRODUCTION: Medulloblastoma is the most common central nervous system tumour in children aged 0-4 years, with 75% of cases occurring in patients <16 years, and rare in adults. The intent of this audit is to review a single centre's experience and to compare outcomes with other centres' outcomes. METHODS: This Ethics approved retrospective audit evaluates the paediatric population aged <16 years who received radiotherapy as their initial or salvage treatment at the Prince of Wales Hospital Cancer Centre between 1972 and 2007. The primary and secondary end-points were progression-free survival (PFS) and cancer-specific survival (CSS), with comparisons made between patients treated before and after 1990, and the impact of high- and low-risk disease. RESULTS: There were 80 eligible patients, 78 who had radiotherapy at initial presentation, and 2 at the time of recurrence. Median age was 6.5 years, 52 were boys and 28 were girls. Seventy-eight patients had a surgical procedure and ultimately received craniospinal radiotherapy. Of these 78 patients, 32 (40%) had a macroscopically complete resection. The 5-year PFS was 69.7%. The 5-year PFS for patients treated pre and post 1990 was 66.1% and 71.8%, respectively. The 5-year CSS for high- and low-risk patients was 61.1% and 78.4%, respectively. Ultimately, 33% of patients were dead due to disease. CONCLUSION: This audit demonstrates those children referred to this facility for treatment have comparable survival to that of other major centres.