Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme.

AIM: The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision. METHOD: Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score (GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire. RESULTS: Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC. CONCLUSION: Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure.

MRSA infections following colorectal surgery in an enhanced recovery programme.

AIM: The aim of this study was to evaluate the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in a cohort of patients undergoing elective colorectal resections within an enhanced recovery programme. METHOD: A prospective database of all patients undergoing colorectal resections by a single surgical team over a 3.5-year period was reviewed. Demographics including age, gender, body mass index, American Society of Anesthesiologists classification, type of surgery (abdominal or pelvic) and whether or not the procedure was laparoscopic or open were analysed. All patients were screened preoperatively and postoperatively and on discharge for MRSA. Patients found preoperatively to be MRSA positive were excluded from the study. RESULTS: In all, 186 patients underwent colorectal resection over the time reviewed. There were 113 laparoscopic resections, 70 open resections and three laparoscopic converted to open resections. Five patients (2.7%) were found to be MRSA positive postoperatively. All of these had open rather than laparoscopic surgery (P < 0.01). Length of stay for patients that had MRSA infections was significantly longer than those remaining MRSA free (P < 0.05). CONCLUSION: These results suggest that patients who successfully undergo laparoscopic colorectal resections within an enhanced recovery programme have a lower incidence of postoperative MRSA infections.

A randomized controlled trial comparing a standard postoperative diet with low-volume high-calorie oral supplements following colorectal surgery.

AIM: Postoperative oral nutritional supplementation is becoming a part of most patient care pathways. This study examined the effects of low-volume high-calorie prescribed supplemental nutrition on patient outcome following elective colorectal surgery. METHOD: Patients undergoing elective colorectal resections were randomized to a prescribed nutritional supplementation group (SG) [standard diet + 6 × 60 ml/day of Pro-Cal (60 ml = 200 kcal + 4 g protein)] or conventional postoperative diet group (CG) (standard diet alone). Preoperative and daily postoperative hand-grip strengths were measured using a grip dynamometer after randomization. Daily food intake, return of bowel activity, nausea score for the first 3 days and postoperative length of hospital stay (LOS) were prospectively recorded. Micro-diet standardized software was used to analyse food diaries. Nonparametric tests were used to analyse the data. RESULTS: Fifty-five patients were analysed (SG 28, CG 27). There was no difference in median preoperative and postoperative handgrip strengths at discharge within each group (SG 31.7 vs 31.7 kPa, P = 0.932; CG 28 vs 28.1 kPa, P = 0.374). The total median daily calorie intake was higher in SG than CG (SG 818.5 kcal vs CG 528 kcal; P = 0.002). There was no difference in median number of days to first bowel movement (SG 3 days vs CG 4 days, P = 0.096). The median LOS was significantly shorter in SG than CG (6.5 vs 9 days; P = 0.037). CONCLUSION: Prescribed postoperative high-calorie, low-volume oral supplements in addition to the normal dietary intake are associated with significantly better total daily oral calorie intake and may contribute to a reduced postoperative hospital stay.

A prospective case-matched comparison of clinical and financial outcomes of open versus laparoscopic colorectal resection.

BACKGROUND: We aimed to assess the clinical outcomes and costs associated with laparoscopic resection within an elective colorectal practice. METHOD: Over a 12-month period data were prospectively collected on patients undergoing elective colorectal resection under the care of a single consultant surgeon. Thirty patients undergoing laparoscopic colorectal resection were case-matched by type of resection, disease process, and, where appropriate, cancer stage to patients having open surgery. A cost analysis was carried out incorporating cost of surgical bed stay, theater time, and specific equipment costs. RESULTS: In the 30 patients having laparoscopic resection, a conversion rate of 13% was observed. Surgery was performed for colorectal cancer in 83% of patients, and 53% of resections were rectal. No significant differences were found in age (65 versus 69 years, p = 0.415), BMI (27.4 versus 26.1, p = 0.527), POSSUM physiology score (16 versus 16.5, p = 0.102), American Society of Anesthesiologists (ASA) grade (2 versus 2, p = 0.171), or length of theater time (160 min versus 160 min, p = 0.233) between the laparoscopic and open patients. Hospital stay was reduced in the laparoscopic group (5 versus 9 days, p < 0.001). Average cost of surgical equipment used for a laparoscopic resection was greater than for open surgery (912.39 versus 276.41 pounds, p = 0.001). Cost of hospital stay was significantly less (1259.75 versus 2267.55 pounds, p < 0.001). Cost of operating room time was similar for the two groups (2066.63 versus 1945.07 pounds, p = 0.152). Overall no significant cost difference could be found between open and laparoscopic resection (4560.9 versus 4348.45 pounds, p = 0.976). More postoperative complications were seen in the open resection group (14 versus 4, p < 0.001). CONCLUSIONS: Intraoperative equipment costs are greater for laparoscopic resection than for open surgery. However, benefits can be seen in terms of quicker recovery and shorter hospital stay. Laparoscopic surgery is a financially viable alternative to open resection in selected patients.

The role of cyclic adenosine monophosphate in the suppression of cellular immunity after thermal injury.

BACKGROUND AND OBJECTIVE: Cyclic adenosine monophosphate (cAMP) is an intracellular second messenger that is known to convey inhibitory signals for T-cell proliferation and function. We investigated the association between this molecule and the profound immunosuppression that accompanies thermal injury. DESIGN: Mice were randomized into two groups: one group was subjected to a 20% full-thickness scald burn; the second to a sham burn (control). The mice were killed on days 4, 7, or 10 after the burn injury and splenocytes were pooled and cultured for 15 minutes in the presence or absence of prostaglandin E2 (PGE2). RESULTS: Levels of cAMP in splenocytes were significantly elevated on day 7 after burn in the burn group compared with the sham controls (P < .05, Wilcoxon Rank Sum Test). Incubation of splenocytes with PGE2 resulted in significantly greater levels of intracellular cAMP in cells from the burn group compared with controls on days 4, 7, and 10. Incubation of normal splenocytes with dibutyryl cAMP in the presence of concanavalin A significantly decreased cell proliferation and the production of interleukin-2. The decrease in interleukin-2 production was evident at the level of messenger RNA expression. Stimulation of splenocytes with a combination of phorbol ester and calcium ionophore, bypassing all membrane-associated events prior to protein kinase C activation, reversed the inhibitory effects of dibutyryl cAMP. Incubation of splenocytes from burned animals with H-8, a selective inhibitor of cAMP-dependent protein kinases, restored the proliferative response to that of sham controls on days 4, 7, and 10 after thermal injury. CONCLUSIONS: These data indicate that elevated levels of intracellular cAMP, combined with an increased production of cAMP in response to circulating PGE2, may play a fundamental role in suppression of the immune response following thermal injury and that cAMP exerts its immunomodulatory effects prior to protein kinase C activation.

Outcome of patients undergoing ileal pouch-anal anastomosis for left-sided chronic ulcerative colitis.

Chronic ulcerative colitis is not a uniform disease entity because the clinical pattern and disease characteristics differ on the basis of the anatomic location of the inflammation. The aim of this study was to compare the preoperative characteristics, postoperative complications, and long-term functional outcome of ileal pouch-anal anastomosis (IPAA) in patients with left-sided colitis to those same characteristics in patients with pancolitis. Between 1990 and 1996, a total of 565 patients underwent IPAA for chronic ulcerative colitis at our institution. Of these, 111 patients were determined to have left-sided involvement, whereas 283 patients had pancolitis. The mean age at surgery was greater in the patients with left-sided colitis (37 years vs. 34 years, P = 0.01), and the mean duration of disease (8.7 years vs. 7.7 years, P = 0.05) tended toward a significant difference between the left-sided colitis and pancolitis groups. The complication rates were similar with the exception of small bowel obstructions, for which there was a higher incidence in the group with left-sided colitis (27% vs. 13%, P = 0.002) at 5 years. The incidence of pouchitis (43% vs. 39%) at 5 years was comparable. Long-term functional results and quality-of-life assessment did not show any significant differences between the two groups. We were unable to detect any correlation between the extent of colon involvement and the subsequent incidence of pouchitis, long-term pouch function, and quality of life. Patients with left-sided colitis were older, had a relatively longer duration of disease, and were at increased risk for postoperative small bowel obstruction as compared to patients with pancolitis.

V-Y island flaps for repair of large perianal defects.

BACKGROUND: Some perianal diseases such as Paget disease and Bowen disease are extensive and require a wide circumferential excision including the entire anoderm of the anal canal. METHODS: We describe a technique of V-Y island flaps to cover the large perianal defects and the denuded anal canal. It is important to excise the base of the flaps in order to fit them into the anal canal. RESULTS: There were 10 women and 5 men with an average age of 54 years (range 32 to 77). The mean follow-up was 45 months (range 6 to 92). The underlying pathology included various kinds of neoplastic and nonneoplastic diseases. There were no major complications such as flap loss or infection. Most complications were minor, including superficial wound separation, flap hematoma, and anal stricture. Although initially all patients had some degree of incontinence for gas and liquid stool or discharge, none of them had significant fecal incontinence at the time of last follow-up. A diverting ileostomy or colostomy was created in 5 patients. Its role was not clear but it did help in the management of the wounds and minimized the pain.

The neonatal duodenal windsock web--a case report and description of a new technique for its operative excision.

Duodenal obstruction in the neonate may be caused by an intraluminal diaphram or so-called windsock web. This can present special technical difficulties at operation. This report of a case describes a new technique in the surgical treatment of such a web.

Abdominal aortic aneurysms: the importance of elective repair.

Repair of abdominal aortic aneurysms (AAA) is being performed with a progressively lower mortality and morbidity. We reviewed 111 patients who underwent repair of their AAA. Sixty-two were electively repaired and 49 had emergency surgery. Eight patients had cocomitant non-vascular procedures carried out. Operative mortality was 3.2% and 49% for elective and emergency cases respectively. Postoperative complications occurred in 40% of elective cases and 72% of emergency cases, respiratory complications being the most common, occurring in 25% and 40% of elective and emergency cases respectively. Subsequent graft complications occurred in six patients, five following emergency surgery.

Tumour cell dissemination following endoscopic stent insertion.

BACKGROUND: This study examined whether colonoscopy or endoscopic stent insertion increases levels of carcinoembryonic antigen (CEA) and/or cytokeratin (CK) 20 mRNA expression in the peripheral circulation of patients with colorectal cancer. METHODS: Peripheral venous blood samples were obtained before and after colonoscopy (38 patients) or colonic stent insertion (20). Twenty patients undergoing colonoscopy for benign conditions served as controls. Expression of mRNA was quantified using real-time reverse transcriptase-polymerase chain reaction. RESULTS: Circulating CK20 mRNA was detected in 13 of 38 patients who had a colonoscopy and eight of 20 patients with stent insertion. CK20 mRNA expression was increased following stent insertion (P = 0.007) but not after staging colonoscopy (P = 0.454). CEA mRNA was detected in one patient who had colonoscopy and two who had a stent inserted. Neither CEA nor CK20 mRNA was found in blood samples from controls. CONCLUSION: Endoscopic insertion of colonic stents but not staging colonoscopy results in increased levels of CK20 mRNA in the peripheral circulation.

Nurse led flexible sigmoidoscopy in primary care--the first thousand patients.

OBJECTIVES: Secondary care Trusts have traditionally been providers of flexible sigmoidoscopy services in the United Kingdom. The aim of this study was to establish a Nurse-led flexible sigmoidoscopy clinic that would provide a patient orientated service in a primary care setting. PATIENTS AND METHODS: A protocol driven flexible sigmoidoscopy clinic was established in a primary care setting. The first thousand patients who underwent flexible sigmoidoscopy at the community clinic were prospectively studied. RESULTS: A nurse endoscopist performed 1002 procedures on 1000 patients. Median time from referral to flexible sigmoidoscopy was 35 days (Range 1-180 days). Two hundred and twenty-two (22%) patients were diagnosed with significant colonic pathology including 25 (2.5%) patients with colorectal cancer. Median time from referral to histological diagnosis of colorectal cancer was 26 days (range 7-87 days). No complications were encountered. Patients who required further follow-up were referred to a Consultant led (29%) or Nurse led clinic (5%) in secondary care. Patient satisfaction as assessed by postal questionnaire indicated that 447 (99%) patients were satisfied with the service. CONCLUSIONS: A community endoscopy clinic can provide a safe and effective flexible sigmoidoscopy service with high levels of patient satisfaction. Nurse Endoscopists can extend their role in primary care with adequate training and support from secondary care hospitals.

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection.

BACKGROUND: Protocolized fluid administration using oesophageal Doppler monitoring may improve the postoperative outcome in patients undergoing surgery. METHODS: A total of 108 patients undergoing elective colorectal resection were recruited into a double-blind prospective randomized controlled trial. An oesophageal Doppler probe was placed in all patients. The control group received perioperative fluid at the discretion of the anaesthetist, whereas the intervention group received additional colloid boluses based on Doppler assessment. Primary outcome was length of postoperative hospital stay. Secondary outcomes were morbidity, return of gastrointestinal function and cytokine markers of the systemic inflammatory response. Standard preoperative and postoperative management was used in all patients. RESULTS: Demographic and surgical details were similar in the two groups. Aortic flow time, stroke volume, cardiac output and cardiac index during the intraoperative period were higher in the intervention group (P<0.050). The intervention group had a reduced postoperative hospital stay (7 versus 9 days in the control group; P=0.005), fewer intermediate or major postoperative complications (2 versus 15 percent; P=0.043) and tolerated diet earlier (2 versus 4 days; P=0.029). There was a reduced rise in perioperative level of the cytokine interleukin 6 in the intervention group (P=0.039). CONCLUSION: A protocol-based fluid optimization programme using intraoperative oesophageal Doppler monitoring leads to a shorter hospital stay and decreased morbidity in patients undergoing elective colorectal resection.

Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial.

OBJECTIVE: Surgery induces a catabolic response with stress hormone release and insulin resistance. The aim of this study was to assess the effect of pre-operative carbohydrate administration on grip strength, gastrointestinal function and hospital stay following elective colorectal surgery. METHODS: Thirty-six patients undergoing elective colonic resection were randomized into one of three groups. Group 1 were fasted; Group 2 were given pre-operative oral water, Group 3 received equivalent volumes of a Maltodextrin drink. Time to first flatus, first bowel movement and hospital stay were recorded. Muscle strength was measured pre-operatively, and on alternate days thereafter until discharge using a grip strength dynamometer. RESULTS: Patients in the carbohydrate group had a median postoperative hospital stay of 7.5 days compared with 13 days in the water group (P > 0.01) and 10 days in the fasted group (P = 0.06). The median time postsurgery to first flatus was 3 days for both the fasted and water groups compared with 1.5 days in the carbohydrate group (P = 0.13). First bowel movement occurred on day 3 in the carbohydrate group, day 4 in the fasting group and day 5 in the water group. The fasted group showed a significant reduction in postoperative grip strength (P < 0.05) with a median drop of 10% at discharge. Neither the water nor the carbohydrate groups showed significant reductions in muscle strength. CONCLUSION: We found that pre-operative administration of oral carbohydrate leads to a significantly reduced postoperative hospital stay, and a trend towards earlier return of gut function when compared with fasting or supplementary water.

Evolution of the two-week rule pathway--direct access colonoscopy vs outpatient appointments: one year's experience and patient satisfaction survey.

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.

Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy.

BACKGROUND: Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging. METHODS: A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum. RESULTS: The perioperative mortality rate was 0.9 per cent and anastomotic dehiscence occurred in 2.8 per cent. Local recurrence developed in 4 per cent of patients in the 'curative' group and in seven of 15 of those assigned to the palliative group before operation (P < 0.01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P < 0.001). CONCLUSION: Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.

Lloyd-Davies position with Trendelenburg--a disaster waiting to happen?

PURPOSE: Lower limb compartment syndrome has been reported to occur after colorectal, urological, and gynecological procedures during which the patient's lower limbs are elevated for prolonged periods of time. METHOD: We investigated lower limb perfusion in a group of patients undergoing prolonged pelvic surgery both during and immediately after surgery, using intra-arterial blood pressure monitoring, laser doppler flowmetry, and pulse oximetry. RESULTS: Use of the modified lithotomy position was not associated with any demonstrable decrease in lower limb perfusion. The addition of 15 degrees head-down tilt, however, during pelvic dissection, led to an immediate and significant drop in lower limb perfusion (P < 0.05; Mann-Whitney U test). The subgroup of patients analyzed postoperatively showed a ten-fold increase (P < 0.01) in perfusion that was confined to the muscle compartment with no demonstrable increase in skin perfusion or intra-arterial pedal blood pressure. CONCLUSION: The use of the modified lithotomy position during pelvic surgery is not associated with lower limb ischemia. Addition of Trendelenburg position, however, causes profound ischemia of the lower limbs, and this is followed during the recovery period by hyperperfusion that is confined to the muscle compartments, which may put patients at risk of developing lower limb compartment syndrome.

Nerve regeneration across colorectal anastomoses after low anterior resection in a canine model.

The disappearance and subsequent return of the recto-anal inhibitory reflex following low anterior resection was investigated using manometric and histological studies. Ten female greyhound dogs were randomised into 2 groups. All underwent low anterior resection. Five had stapled EEA anastomosis of the rectum and 5 were handsewn. The recto-anal inhibitory reflex was measured before and after surgery using a microtransducer tipped catheter. Six months postoperatively the recto-anal inhibitory response was again measured and the animals sacrificed. The colorectal anastomoses were examined histologically using light microscopy to determine the pattern of innervation at the anastomotic site. Manometric studies showed the recto-anal inhibitory reflex present in all cases pre-operatively, in only 1 case on the tenth postoperative day and was present in eight cases after 6 months. Histological examination of longitudinal sections across the anastomoses showed clear evidence of regenerating nerve trunks at the anastomotic site in both stapled and handsewn groups. We conclude that the return of the recto-anal inhibitory reflex is associated with regeneration of intramural autonomic nerves across the anastomotic scar.

Acute urinary retention. Comparison of suprapubic and urethral catheterisation.

A total of 86 consecutive patients who presented to the accident and emergency department with acute urinary retention due to prostatomegaly required catheterisation; 56 received suprapubic catheters and 30 were catheterised urethrally. Both groups were followed up for 3 years. Of the 30 patients catheterised urethrally, 12 (40%) developed urinary tract infections compared with 10 (18%) urinary tract infections in the 56 patients catheterised suprapubically. Five patients (17%) in the urethral group developed urethral strictures with no strictures in the suprapubic group. Two patients catheterised urethrally developed epididymo-orchitis and 1 developed septicaemia. None of the patients with suprapubic catheters developed these complications. Furthermore, 16 patients catheterised suprapubically underwent successful trial clamping of their catheter, whereas 7 patients required recatheterisation following removal of their urethral catheters. We recommend that the use of suprapubic catheters should become the preferred initial treatment for acute urinary retention.

Atypical diverticular disease: surgical results.

PURPOSE: Patients with diverticular disease may present with chronic symptoms but never develop diverticulitis. The purpose of this research was to review the outcome of surgical intervention in this subgroup of patients with atypical "smoldering" diverticular disease. METHODS: Records of 930 patients who underwent sigmoid resection for diverticular disease during a ten-year period at the Mayo Clinic in Rochester, Minnesota, were reviewed. Forty-seven patients (5 percent) fit our inclusion criteria for smoldering diverticular disease and underwent sigmoid colectomy with primary anastomosis. A minimum of 12 months of follow-up was completed in 68 percent of these patients. RESULTS: Evidence of acute or chronic inflammatory changes was present in 76 percent of resected specimens. Complete resolution of symptoms occurred in 76.5 percent, with 88 percent being pain free. CONCLUSIONS: We conclude that the diagnosis and presentation of atypical smoldering diverticular disease is an uncommon and poorly defined entity. However, sigmoid resection in this subgroup of patients is safe and is associated with resolution of symptoms in the majority of cases.