Cost analysis of a watch-and-wait approach in patients with a complete clinical response to chemoradiotherapy for rectal cancer.

BACKGROUND: There is increasing interest in the watch-and-wait approach for patients with rectal cancer who have had a complete clinical response following neoadjuvant long course chemoradiotherapy. This study is a cost analysis of expenditure on patients in the watch-and-wait program versus patients who underwent standard rectal resection followed by routine surveillance. METHODS: Data were prospectively collated and retrospectively analysed in all patients who presented with rectal cancer from January 2016 to January 2018 at Sir Charles Gairdner Hospital, Perth, Western Australia. Software developed by the North Metropolitan Health Service was used to capture comprehensive data to calculate the in-hospital expenditure for an individual patient throughout their treatment journey. RESULTS: For a patient enrolled in the watch-and-wait pathway, the total cost of surveillance over a 5-year period was $45 246. This was compared with the cost of an ultra-low anterior resection/loop ileostomy/closure of loop and routine postoperative surveillance which came to a total of $87 473. While a patient who had an abdominoperineal resection followed by routine 5-year surveillance had an expenditure of $82 290. CONCLUSION: There is growing evidence that the watch-and-wait strategy is a valid management option. In the cost-conscious environment of the current health care system, the watch-and-wait pathway is a cost-effective and economically advantage treatment.

Occult Para-Psoas Hernia during Routine Endoscopic Totally Extraperitoneal Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: Advantage of the total extraperitoneal (TEP) technique over open inguinal hernia repair allows for exploration of other anatomical regions in search for occult hernias (OH). METHODS: Our institutional practice is to routinely explore the obturator and femoral regions for occult hernias. In addition to this technique, we routinely expose the psoas muscle extensively to perfect mesh placement followed by fibrin glue fixation on both 'triangles of doom and pain'. The use of this technique has led to the identification of three incidental occult para-psoas hernias (PPH) out of a total of 800 TEP repairs performed in a high-volume specialist hernia center. CONCLUSIONS: The purpose of this article is to demonstrate that occult parapsoas hernias (PPH) can be easily identified and safely repaired with mesh glue fixation, using the standard TEP technique during inguinal hernia repair.

Outcomes of patients with metastatic cutaneous squamous cell carcinoma to the axilla: a multicentre cohort study.

BACKGROUND: Metastatic cutaneous squamous cell carcinoma to the axilla is uncommon, with limited data to guide management. We sought to assess the outcomes of patients with this condition after surgery and radiotherapy. METHODS: A retrospective cohort study of patients treated at two Australian hospitals from 1994 through 2016 was performed. RESULTS: A total of 74 patients were identified, including 48 treated curatively with surgery-plus-radiotherapy and 15 with surgery alone. Compared with patients treated with surgery alone, a higher proportion of patients treated with surgery-plus-radiotherapy had lymph nodes larger than 6 cm (53% versus 8%, P = 0.012) and multiple adverse histopathological features (75% versus 47%, P = 0.04). The groups had similar 5-year disease-free survival (45% versus 46%) and overall survival (51% versus 48%). Presence of multiple positive lymph nodes was associated with reduced disease-free survival (hazard ratio 4.57, P = 0.01) and overall survival (hazard ratio 3.53, P = 0.02). Regional recurrence was higher in patients treated with surgery alone (38% versus 22%, P = 0.22) and patients with lymph nodes larger than 6 cm (34% versus 10%, P = 0.03). All recurrences occurred within 2 years following treatment. CONCLUSION: Combined-modality therapy for metastatic cutaneous squamous cell carcinoma to the axilla is recommended for high-risk patients, although outcomes remain modest. The key period for recurrence is within 2 years following treatment.

Emphysematous cholecystitis following routine colonoscopy.

Cholecystitis is a rare sequela of colonoscopy, the relationship between which has not yet been defined. This case study reviews a rural elderly patient who developed right upper quadrant pain following routine colonoscopy. He developed emphysematous cholecystitis, which required laparoscopy with conversion to open via Kocher's incision and underwent a subtotal cholecystectomy due to the severity of necrosis and inflammation. He had an uncomplicated recovery. Colonoscopy is an important diagnostic procedure, the most common complications of which are haemorrhage and perforation. There are less than 10 cases of associated cholecystitis and no reports of emphysematous cholecystitis. The hypothesized pathogenesis is dehydration and lithogenesis associated with traumatic translocation of organisms, however, no definitive correlation has been determined. Due to the potential health impact, cholecystitis cannot be excluded regarding post-colonoscopy abdominal pain, however, the correlation between procedure and pathology remains unclear.

How to use a fan retractor in laparoscopic total mesorectal excision.

Obtaining exposure of the total mesorectal excision plane via a laparoscopic approach is technically challenging due to instrument limitations. Use of an articulating fan retractor is a relatively simple, cost-effective and easily accessible instrument that allows the surgeon to gain improved retraction and exposure in what is an otherwise technically challenging dissection.

Retrospective analysis of a Bi-National Colorectal Cancer Audit to characterize stage II colon cancer patients who were offered adjuvant chemotherapy.

BACKGROUND: Adjuvant chemotherapy for stage II colon cancer is a controversial area with treatment often reserved for patients with high-risk clinicopathological features. The aim of this study was to characterize which patients with stage II disease were offered adjuvant chemotherapy in an Australian and New Zealand setting. METHODS: Data was retrospectively collected from the prospectively maintained Bi-National Colorectal Cancer Audit. Data from all patients with their first episode of stage II colon cancer from January 2007 to January 2019 were included. RESULTS: A total of 3763 patients were identified in the Bi-National Colorectal Cancer Audit database with stage II colon cancer, of which 715 were offered chemotherapy (19%). Patients were at significant greater odds of being offered chemotherapy for stage II disease if they were <55 years old, from an urban area, discussed in a multidisciplinary team (MDT) meeting, had a greater operative urgency, a lower American Society of Anesthesiologists score, had a T4 tumour or had less than 12 lymph nodes harvested. CONCLUSION: In Australia and New Zealand the appropriate patients with high-risk features are more likely to be offered chemotherapy in line with current guideline recommendations; however, this may not be the case for regional patients. A large proportion of patients were not discussed at MDT meeting- given the decision to provide adjuvant chemotherapy for stage II disease remains a controversial area, and the likely small survival benefit offered by adjuvant chemotherapy, appropriate patient selection is critical and best discussed in an MDT setting.