Current practices and barriers to referral for cytoreductive surgery and HIPEC among colorectal surgeons: A binational survey.

INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has gained traction for the management of peritoneal metastases. The number of specialist units globally offering CRS/HIPEC is increasing. The aim of this survey was to assess current practices and barriers to referral for CRS/HIPEC among colorectal surgeons in Australia and New Zealand (ANZ). MATERIALS AND METHODS: An online questionnaire was emailed to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey contained 3 sections: namely; demographics, referral patterns and clinical scenarios. Questions on referral patterns included number of peritoneal metastases patients seen per year and referred to a CRS/HIPEC unit, awareness of such a unit and distance from principle place of practice. Different pathologies referred were also explored, as well as investigations performed. Barriers to referral were also surveyed. RESULTS: The response rate was 28% (83/296). Twenty-five percent received CRS training. Most surgeons (95%) were aware of a CRS/HIPEC unit and had referred to one previously. Thirty-nine percent would refer all patients. Provision of good service and/or relationship with CRS/HIPEC specialist were the main reasons for referring to the nearest unit, followed by accessibility. Major factors preventing referral included extent of peritoneal disease (48%), patient characteristics and comorbidities (44%) and lack of evidence (20%). The most common pathologies referred included colorectal and appendiceal peritoneal metastases and pseudomyxoma peritonei. CONCLUSION: Colorectal specialist awareness of CRS/HIPEC units and accessibility is high. Strategies to improve referring physician/surgeon knowledge on patient selection and indications for CRS/HIPEC should be investigated and instituted to ensure all appropriate patients are referred to specialist units for discussion of suitability.

Thirteen-year experience with hand-assisted laparoscopic surgery in colorectal patients.

BACKGROUND: We report outcomes on 324 consecutive cases of hand-assisted laparoscopic surgery (HALS) in colorectal patients over 13 years performed by a single surgeon. METHODS: A prospectively maintained database was used to identify all patients undergoing HALS colorectal procedures for benign or malignant indications from September 2004 to February 2018, at two major tertiary centres in Sydney, Australia. RESULTS: Median age was 64 years, 51% were female and median body mass index was 26. Colorectal cancer (55%), diverticular disease (13%) and polyp related conditions (13%) were common indications. Anterior resection (65%) and right hemicolectomy (18%) were most commonly performed. Median operative time was 244 min (190-300) and 75% of Gelport incisions were Pfannenstiel. Sixty-three percent of colorectal cancer patients had a T3 or T4 cancer. Median tumour size was 35 mm (25-45). Seven percent required conversion to open and 4% a re-operation in the early post-operative period. Thirty-six percent had a post-operative complication, and 11% were major complications. Follow-up extended to 12.8 years and there were 33 late deaths. Being in a high dependency unit or intensive care unit was significant for late mortality (odds ratio 2.8, 95% confidence interval 1.06-7.78, P = 0.037). Three percent developed an incisional hernia and 6% had small bowel obstruction at long-term follow-up. CONCLUSION: HALS is an effective technique for both benign and malignant colorectal indications with the added advantage of tactile feedback and a lower rate of conversion to open.

Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand.

BACKGROUND: Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention. AIM: To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand. METHODS: An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios. RESULTS: There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain. CONCLUSION: Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.

Midcarpal Arthrodesis Biomechanics: Memory Staples versus Cannulated Screws.

BACKGROUND: Midcarpal arthrodesis is a treatment of choice in patients with midcarpal arthritis. Traditionally a four corner fusion has been favoured, however recent research has shown improved results when the triquetrum and scaphoid are excised. There is no clear evidence as to which remaining bones should be fused or which implants should be used. The purpose of this study is to compare the biomechanics of midcarpal arthrodesis after scaphoid and triquetrum excision, using memory staples or cannulated screws, in recognised construct patterns. METHODS: 36 identical sets of carpal bones were 3D printed from acetyl butyl styrene. Midcarpal arthrodeses were performed in three configurations with shape memory alloy staples or headless compression screws. This gave 6 treatment groups; lunocapitate single staple or screw, lunocapitate with 2 staples or screws, three corner fusion with 2 staples or screws. Peak torque to distraction was measured and analysed. RESULTS: The peak torque to distraction was significantly greater in almost all constructs utilizing screws compared to staples, with two lunocapitate screws having the highest peak torque at both 1 and 3 mm distraction with 244 Nmm and 749 Nmm respectively (p < 0.05). CONCLUSIONS: Constructs utilizing screws have a peak torque to distraction significantly higher when compared to staples. Our recommendation when performing a midcarpal arthrodesis after scaphoid and trapezium excision is to fuse the midcarpal joint with 2 headless compression screws.

Colorectal surgeon consensus with diverticulitis clinical practice guidelines.

AIM: To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand. METHODS: A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios. RESULTS: The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher's exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001). CONCLUSION: While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.

Outcomes after operations for bicuspid aortic valve disease in the pediatric population.

BACKGROUND: Outcomes after operations for bicuspid aortic valve disease in pediatric patients were determined. METHODS: Between 1977 and 2011, 146 consecutive patients underwent surgical repair of bicuspid aortic valve. Median age at operation was 207 days (range, 5 days to 16 years). Indication for surgery was stenosis in 113, insufficiency in 25, and both in 8. Valve debridement was done in 76 patients, and complex repairs in 70, including 61 who required addition of pericardial patches, consisting of the creation of a neocommissure in 55, cusp extension in 33, and a perforation repair in 6. The valve was made tricuspid in 38 patients (29 cusp extensions). RESULTS: Twenty-year survival was 88% (95% confidence interval, 73% to 95%). After a mean follow-up of 8 ± 7 years, 35 patients needed a reintervention. Freedom from reintervention at 18 years was 43% (95% confidence interval, 28% to 56%). At the latest follow-up, an additional 13 patients without reoperation had moderate or severe stenosis, and 17 had moderate regurgitation. Seventy-eight patients had an event-free long-term outcome (no reintervention, stenosis, or regurgitation). The only independent predictive factors of an event-free outcome were not having addition of patch material at repair (hazard ratio, 12; p = 0.05) and shorter bypass time (HR, 1.01; p = 0.023). The 10-year freedom from any significant event was 60% (95% confidence interval, 46% to 71%) for those without use of patch material, whereas nearly all those with a patch repair had an adverse event at that time. CONCLUSIONS: Outcomes after surgical repair of bicuspid aortic valves in the pediatric population are excellent, especially if the repair can be performed without the addition of patches. Primary repair should be offered because long-lasting results can be achieved if the disease can be relieved by simple procedures.

Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization.

OBJECTIVES: This study sought to compare outcomes after surgical valvuloplasty and balloon dilation of the aortic valve in neonates and infants. BACKGROUND: Surgical techniques of aortic valve repair have improved and there is today controversy on the best approach to treat neonatal congenital aortic valve stenosis. METHODS: Retrospective review of data and follow-up of 123 consecutive neonates and infants (35 females, 88 males) undergoing intervention for congenital aortic stenosis. RESULTS: From 1977 to 2009, 123 consecutive neonates (<30 days) and infants (31 days to 1 year) underwent relief of congenital aortic stenosis. Median age at procedure was 27 days (6 to 76 days). Twenty-year survival was 80 ± 7%. Fifty-four patients required a re-intervention and freedom from re-intervention was 55 ± 6% at 10 years and 40 ± 6% at 20 years. By multivariate analysis, having the relief of stenosis by balloon valvuloplasty and undergoing initial treatment as a neonate were predictive of re-intervention. Freedom from re-intervention at 5 years was 27% after balloon valvuloplasty versus 65% after surgery. At latest follow-up, an additional 16 patients had moderate or severe stenosis and 8 had regurgitation. Freedom from re-intervention or stenosis was 39 ± 5% at 15 years. By multivariate analysis, balloon valvuloplasty (p < 0.001) and treatment as a neonate (p = 0.003) were again predictive of stenosis or re-intervention. Thirty-five patients ultimately needed a valve replacement. Significant predictor of the requirement of valve replacement was unicuspid aortic valve (p < 0.001). Freedom from valve replacement was 55 ± 7% at 20 years. CONCLUSIONS: Surgical valvuloplasty remains the best approach to treat neonates and infants with congenital aortic stenosis. After surgery, a higher proportion of patients remain free of re-intervention than after interventional catheterization and the relief of their stenosis lasts longer.

Long-term results of a strategy of aortic valve repair in the pediatric population.

OBJECTIVES: To determine rate of reoperation subsequent to primary valve repair in a pediatric population. METHODS: Between 1996 and 2009, 142 consecutive patients underwent aortic valve repair in our institution. Median age at surgery was 9 years, with 30 being younger than age 1 year. Indication for surgery was stenosis (n = 76), regurgitation (n = 55), and both (n = 11). Forty-six patients underwent repair with no addition of patch, whereas 96 patients required addition of patches of glutaraldehyde preserved autologous pericardium for cusp extension (n = 51) and other repair (n = 45). RESULTS: In the early postoperative period after cusp extension repair, 2 patients had a sudden unexplained death and 1 had cardiac arrest requiring mechanical support and heart transplantation. Two additional patients with cusp extension displayed signs of coronary ischemia. After a mean follow-up of 3.4 ± 3.5 years, only 1 patient died of a noncardiac cause. Seven-year freedom from reoperation was 80% (95% confidence interval [CI], 66-89). By multivariate analysis, the only predictors of reintervention were cusp extension (hazard ratio [HR], 5.4; 95% CI, 1.7-16.8; P = .004) and infants (HR, 5.6; 95% CI, 1.7-18.4; P = .005). At final echocardiography follow-up, 23 of 119 survivors without reoperation had moderate (19%), 1 had moderate-severe (1%), and 1 had severe regurgitation (1%), whereas 12 (10%) had a moderate degree of stenosis. CONCLUSIONS: Aortic valve repair in pediatric populations is effective in postponing reintervention. The longevity of the repair is shorter after cusp extension and when performed in infants. Caution should be used when performing tricsupidization and cusp extension of bicuspid valves because it can be responsible for mortality related to occlusion of the coronary ostia by patches.