Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units.

BACKGROUND: Defunctioning loop ileostomies (DLIs) are a frequent adjunct to rectal cancer surgery. Delayed closure of DLIs is common and associated with increased morbidity. The reasons for delayed DLI closure are often unknown. The economic burden of delayed DLI closure is not quantified. The present study aimed to determine the reasons for, and economic burden of, delayed DLI closure. METHODS: Clinical and economic data were audited from a prospective database of patients in two Australasian colorectal cancer centres. Patients treated at each unit with low/ultra-low anterior resection for rectal cancer with formation of DLI between January 2014 and December 2019 were included. Post-operative complication rate, stoma-related complication rate and costs of hospital admissions and stoma care were recorded and analysed. Multivariate linear regression analysis was used to investigate risk factors for delay to closure. RESULTS: 146 patients underwent low/ultra-low anterior resection with DLI; 135 patients (92.5%) underwent reversal. The median duration to reversal was 7 months (IQR 4.5-9.5). Sixty-six percent of patients underwent reversal >6 months after their index surgery. Neoadjuvant and adjuvant chemotherapy were associated with delayed reversal (P < 0.001). Non-English speakers waited longer for DLI closure (P = 0.028). The costs of outpatient stoma care (P < 0.001), post-operative care (P = 0.004), and total cost of treatment (P = 0.014) were significantly higher in the delayed closure group, with a total cost of treatment difference of $3854 NZD per patient. CONCLUSIONS: Causes of delay include systemic factors and demographic factors that can be addressed directly, addressing such causes may alleviate a significant economic burden.

Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic.

INTRODUCTION: Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an 'as required' basis in contrast to the traditional physician-initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments. METHOD: The purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed - 'Painful PR bleeding' and 'Painless PR bleeding'. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments. RESULTS: There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups. CONCLUSION: Initiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.

Perioperative immunonutrition in patients undergoing liver transplantation: a randomized double-blind trial.

UNLABELLED: Preliminary work suggested that perioperative immunonutrition (IMN) enriched in n-3 fatty acids, arginine, and nucleotides may improve preoperative nutritional status, enhance postoperative recovery, and reduce postoperative infectious complications in patients undergoing liver transplantation (LT). The current study examined these outcomes in a double-blind, randomized, controlled trial. Patients wait-listed for LT (n = 120) were randomized to either supplemental (0.6 L/d) oral IMN or an isocaloric control (CON). Enteral IMN or CON was resumed postoperatively and continued for at least 5 days. The change in total body protein (TBP) measured by neutron activation from study entry until immediately prior to LT was the primary endpoint and TBP measurements were repeated 10, 30, 90, 180, and 360 days after LT. Infectious complications were recorded for the first 30 postoperative days. Nineteen patients died or were delisted prior to LT. Fifty-two IMN and 49 CON patients received supplemental nutrition for a median (range) 56 (0-480) and 65 (0-348) days, respectively. Preoperative changes in TBP were not significant (IMN: 0.06 ± 0.15 [SEM]; CON: 0.12 ± 0.10 kg). Compared to baseline, a 0.7 ± 0.2 kg loss of TBP was seen in both groups at 30 days after LT (P < 0.0001) and, at 360 days, TBP had not increased significantly (IMN: 0.08 ± 0.19 kg; CON: 0.26 ± 0.23 kg). Infectious complications occurred in 31 (60%) IMN and 28 (57%) CON patients (P = 0.84). The median (range) postoperative hospital stay was 10 (5-105) days for IMN and 10 (6-27) days for CON patients (P = 0.68). CONCLUSION: In patients undergoing LT, perioperative IMN did not provide significant benefits in terms of preoperative nutritional status or postoperative outcome.

Conventional adverse features do not predict response to adjuvant chemotherapy in stage II colon cancer.

BACKGROUND: The role of adjuvant chemotherapy in patients with stage II colon cancer is unclear. Current guidelines recommend adjuvant chemotherapy for high-risk patients, although the benefit demonstrated to date is small. Our study examined if adjuvant chemotherapy is associated with improved cancer-specific survival in high-risk patients with stage II colon cancer. METHODS: A retrospective review was performed on patients with stage II (T3-4N0M0) colon cancer in a multi-institutional database from 1999 to 2007. Additionally, histology slides were reviewed and cancer-specific survival data were obtained from the state cancer registry. Adverse features examined were perforation, obstruction, T4 disease, poor differentiation, nodal yield less than 12, lymphovascular invasion and perineural invasion. Survival analysis was performed using the Kaplan-Meier method and Cox regression. RESULTS: There were 458 patients in the study, with a median follow-up of 5.2 years. Four patients (0.8%) were lost to follow-up. There were 290 (63%) high-risk patients, defined as having at least one adverse feature. Patients who had adjuvant chemotherapy were significantly younger (median 61 years versus 72 years, P < 0.001) but had comparable ASA score (median 2 versus 2, P = 0.3). There was no significant survival benefit observed associated with any one factor or when grouped. In high-risk patients the 5-year cancer specific survival with adjuvant chemotherapy was 84.8% (95% CI 78.7-91.9) compared to surgery alone 92.7% (95% CI 88.5-96.1), P = 0.85). CONCLUSION: Adjuvant chemotherapy did not significantly improve cancer-specific survival in patients with stage II colon cancer with adverse features. Other markers for selecting appropriate patients for adjuvant treatment are required.