Standardizing process in acute biliary disease.

INTRODUCTION: The perioperative management of biliary disease (BD) is variable across institutions with suboptimal outcomes for patients and health care systems. This results in inefficient utilization of limited resources. The aim of the current study was to identify modifiable factors impacting patients' time to theater, intraoperative time, and time to discharge as the constituents of length of stay to guide creation of a perioperative management protocol to address this variability. METHODS: Data were prospectively captured at Christchurch Hospital for all adult patients presenting for cholecystectomy between May 2015 and May 2022. Pre, post, and intraoperative factors were assessed for their impact on time to theater, operative time, and postoperative hours to discharge. RESULTS: Four thousand five hundred seventy-seven patients underwent cholecystectomy during the study period, of which 2807 (61%) were acute presentations and made up the cohort for analysis. Time to theater was significantly impacted by preoperative imaging type, while operative grade and the procedure type had the most clinically significant impact on operative time. Postoperatively time to discharge was significantly impacted by drain placement. CONCLUSIONS: Standardizing management of BD would likely result in significant savings for the health care system and improved outcomes for patients. The data seen here evidence the importance of appropriate imaging selection, intraoperative difficulty operative grade identification, and low suction drain selection. These data have been incorporated in a perioperative management protocol as standardization of care across the patient workflow in BD is a sensible approach for ensuring optimal use of scarce resources.

The utility of synoptic operation reports in colorectal surgery: a systematic review.

PURPOSE: Accurate documentation is crucial in surgical patient care. Synoptic reports (SR) are structured checklist-based reports that offer a standardised alternative to traditional narrative reports (NR). This systematic review aims to assess the completeness of SR compared to NR in colorectal cancer (CRC) surgery. Secondary outcomes include the time to completion, surgeon satisfaction, educational value, research value, and barriers to implementation. METHODS: Prospective or retrospective studies that assessed SR compared to NR in colorectal cancer surgery procedures were identified through a systematic search of Ovid MEDLINE, Embase (Ovid), CIHNAL Plus with Full Text (EBSCOhost), and Cochrane. One thousand two articles were screened, and eight studies met the inclusion criteria after full-text review of 17 papers. RESULTS: Analysis included 1797 operative reports (NR, 729; SR, 1068). Across studies reporting this outcome, the completeness of documentation was significantly higher in SR (P < 0.001). Reporting of secondary outcomes was limited, with a predominant focus on research value. Several studies demonstrated significantly reduced data extraction times when utilising SR. Surgeon satisfaction with SR was high, and these reports were seen as valuable tools for research and education. Barriers to implementation included integrating SR into existing electronic medical records (EMR) and surgeon concerns regarding increased administrative burden. CONCLUSIONS: SR offer advantages in completeness, data extraction, and communication compared to NR. Surgeons perceive them as beneficial for research, quality improvement, and teaching. This review supports the necessity for development of user-friendly SR that seamlessly integrate into pre-existing EMRs, optimising patient care and enhancing the quality of CRC surgical documentation.

A longitudinal study examining the relationship between prioritization scores and changes in impact on life scores in elective surgery patients.

BACKGROUND: Healthcare systems globally face the issue of resource constraints and need for prioritization of elective surgery. Inclusive, explicit prioritization tools are important in improving consistency and equity of access to surgery across health systems. The General Surgical Prioritization Tool developed by New Zealand's Ministry of Health scores patients for elective non-cancer surgery based on surgeon's clinical judgement and patient derived Impact on Life (IoL) scores. This study aims to measure the changes in patient derived IoL scores after common general surgical procedures to enable direct comparison and inform future prioritization. METHOD: This longitudinal observational study enrolled 322 participants who had undergone elective general surgical procedures. Participants were contacted 3 to 9 months after their procedures and requested to complete the IoL questionnaire. The primary endpoint was the change in IoL scores after surgery among the different procedures. RESULTS: Overall, 229/304 (75%) participants responded to the questionnaire and there were no significant baseline differences between responders and non-responders. Patients in the gallbladder treatment group had the greatest improvement in IoL scores. Patients across all ethnic groups had similar changes in IoL scores. Multivariate analysis showed that gallbladder surgery (relative to hernia surgery) and pre-surgery IoL scores significantly predicted improvement. CONCLUSION: The patient reported IoL score recorded at prioritization for surgery all reduced, albeit to varying amounts, after common general surgical procedures. This, combined with the fact that IoL scores predicted post-operative improvement support their inclusion in prioritization tools in addition to surgeon derived components.

Use of artificial intelligence for the prediction of lymph node metastases in early-stage colorectal cancer: systematic review.

BACKGROUND: Risk evaluation of lymph node metastasis for early-stage (T1 and T2) colorectal cancers is critical for determining therapeutic strategies. Traditional methods of lymph node metastasis prediction have limited accuracy. This systematic review aimed to review the potential of artificial intelligence in predicting lymph node metastasis in early-stage colorectal cancers. METHODS: A comprehensive search was performed of papers that evaluated the potential of artificial intelligence in predicting lymph node metastasis in early-stage colorectal cancers. Studies were appraised using the Joanna Briggs Institute tools. The primary outcome was summarizing artificial intelligence models and their accuracy. Secondary outcomes included influential variables and strategies to address challenges. RESULTS: Of 3190 screened manuscripts, 11 were included, involving 8648 patients from 1996 to 2023. Due to diverse artificial intelligence models and varied metrics, no data synthesis was performed. Models included random forest algorithms, support vector machine, deep learning, artificial neural network, convolutional neural network and least absolute shrinkage and selection operator regression. Artificial intelligence models' area under the curve values ranged from 0.74 to 0.9993 (slide level) and 0.9476 to 0.9956 (single-node level), outperforming traditional clinical guidelines. CONCLUSION: Artificial intelligence models show promise in predicting lymph node metastasis in early-stage colorectal cancers, potentially refining clinical decisions and improving outcomes. PROSPERO REGISTRATION NUMBER: CRD42023409094.

Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy.

BACKGROUND: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. METHODS: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. RESULTS: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. CONCLUSION: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Digital spatial profiling identifies molecular changes involved in development of colitis-associated colorectal cancer.

Objective: Chronic colonic inflammation seen in inflammatory bowel disease (IBD) is a risk factor for colorectal cancer (CRC). Colitis-associated cancers (CAC) are molecularly different from sporadic CRC. This study aimed to evaluate spatially defined molecular changes associated with neoplastic progression to identify mechanisms of action and potential biomarkers for prognostication. Design: IBD patients who had undergone colectomy for treatment of their IBD or dysplasia were identified from an institutional database. Formalin-fixed paraffin embedded samples from areas of normal, inflamed, dysplastic and adenocarcinoma tissue were identified for digital spatial profiling using the Nanostring GeoMx™ Cancer Transcriptome Atlas. RNA expression and quantification of 1812 genes was measured and analysed in a spatial context to compare differences in gene expression. Results: Sixteen patients were included, nine patients had CAC, two had dysplasia only and five had colitis only. Significant, step-wise differences in gene expression were seen between tissue types, mainly involving progressive over-expression of collagen genes associated with stromal remodelling. Similarly, MYC over-expression was associated with neoplastic progression. Comparison of normal and inflamed tissue from patients who progressed to those who did not also showed significant differences in immune-related genes, including under-expression of thte chemokines CCL18, CCL25 and IL-R7, as well as CD3, CD6 and lysozyme. The known oncogene CD24 was significantly overexpressed. Conclusion: Both tissue types and patient groups are molecularly distinguishable on the basis of their gene expression patterns. Further prospective work is necessary to confirm these differences and establish their clinical significance and potential utility as biomarkers.

What are heads of department looking for in new general surgeons in Aotearoa New Zealand?

BACKGROUND: Training pathways vary significantly after completion of the general surgery surgical education and training (SET) program due to increasing sub-specialization. Aotearoa New Zealand requires a diverse range of general surgeons. Appointment of new consultant surgeons can be an opaque process; trainees are often uncertain how to tailor their training to that required by potential employers. Heads of departments (HODs) are influential in new appointments, and their opinions on desirable candidate attributes are valuable. METHODS: An online survey was conducted in March 2023. All public hospital general surgery HODs were invited to participate. The survey sought opinions on the importance of attributes, skills and experience when appointing a new consultant general surgeon. RESULTS: The response rate was 70% (14/20) including 6 of 7 HODs from tertiary hospitals and 8 of 13 from secondary hospitals. The top three desirable factors were all personal attributes (being a team player, having a strong work ethic, and good interpersonal skills). 10 of 14 respondents disagreed that SET completion alone is sufficient without the need for further training. Most respondents preferred at least 2 years of fellowship training, except for trauma and endocrine surgery, where 1 year was frequently considered sufficient. Only one respondent agreed formal research training is highly valued. CONCLUSION: Trainees would be wise to obtain training desired by the majority of HODs while building an individualized profile of attributes, skills and experience tailored to hospitals they may wish to work in. The findings should be considered by organizations responsible for general surgical training and workforce planning.

Influence of the type of anatomic resection on anastomotic leak after surgery for colon cancer.

INTRODUCTION: Anastomotic leak (AL) after colon cancer resection is feared by surgeons because of its associated morbidity and mortality. Considerable research has been directed at predictive factors for AL, but not the anatomic type of colonic resection. Anecdotally, certain types of resection are associated with higher leak rates although there remains a paucity of data on this. This study aimed to determine the AL rate for different types of colon cancer resection to inform decisions regarding the choice of operation. METHODOLOGY: Retrospective analysis of Bowel Cancer Outcome Registry (BCOR) for all colonic cancer resections with anastomosis between January 2007 and December 2020. Demographic, patient, tumour and outcome data were analysed. AL rates were compared among the different colonic procedures with both univariate and multivariate analysis. RESULTS: 20 191 patients who underwent resection with anastomosis for cancer were included in this study. Of these 535 (2.6%) suffered ALs. While the univariate analysis found male sex, procedure type, symptomatic cancers, emergency surgery, unsupervised registrars, conversion to open surgery, medical complications and higher TNM staging were associated with AL, multivariate analysis, found only procedure type remained a significant predictor of AL (total colectomy (OR 4.049, P<0.001), subtotal colectomy (OR 2.477, P<0.001) and extended right hemicolectomy (OR 2.171, P < 0.001)). CONCLUSION: AL is more common in extended colonic resections. With growing evidence of similar oncological outcomes between subtotal colectomy and left hemicolectomy for splenic flexure cancers, more limited resections should be considered. The type of colonic resection should be integrated into prediction tools for AL.

Weekend effect in emergency laparotomy: a propensity score-matched analysis.

BACKGROUND: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. METHODS: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics. RESULTS: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). CONCLUSIONS: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy.

INTRODUCTION: Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy. METHODS: Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol. RESULTS: A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005). CONCLUSIONS: The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.

Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy.

BACKGROUND: An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process. METHODS: Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process. RESULTS: 317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n = 225) were annotated. Single ICC of operative grade was 0.760 (0.663-0.842 p < 0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade. CONCLUSION: Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.

Evaluation of the inflammatory profile following uncomplicated elective colectomy.

BACKGROUND: Attenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches. METHODS: A multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3-year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL-6, IL-1ß, TNFα, IL-10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software. RESULTS: A total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL-6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL-10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m2 had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers. CONCLUSION: The postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak.

Improving operative documentation in colorectal cancer surgery: synoptic notes pave the way forward.

BACKGROUND: Synoptic operative reports may improve reporting of key operative information. This study aimed to compare information included in synoptic reports with narrative notes following the introduction of a synoptic reporting system at a tertiary colorectal cancer referral centre. METHODS: A standardized synoptic template incorporating the operative fields in the Australasian Bi-National Colorectal Cancer Audit (BCCA) was introduced for colorectal cancer surgery at the host institution in 2017. Colorectal cancer patients were identified from a prospectively collected database to collate samples of synoptic and narrative operative reports for comparison. The primary outcome was reporting of colon and rectal cancer-specific quality measures. Synoptic reporting of quality measures by clinician grade and uptake of synoptic reporting were also measured. RESULTS: Five hundred and ninety-five operative reports were reviewed; 84% of all quality measures were included in synoptic reports and 43% in narrative reports describing colon cancer surgery (P <0.001). Synoptic reports describing rectal cancer surgery included 84% of quality measures with 40% reported in narrative reports (P <0.001). Reporting for most individual quality measures did not change depending on clinician experience. Synoptic reporting methods were used to document 80% of all colon cancer surgery and 84% of rectal cancer surgery. CONCLUSION: Synoptic operative reports were superior to narrative reports in documenting quality measures. Synoptic reporting facilitates simultaneous data capture and bulk upload for audits including the BCCA. Development of synoptic operative reports standardized across Australasian colorectal cancer centres should be further investigated as a tool to facilitate collaborative audit and research.

Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study.

BACKGROUND: Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. METHODS: A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1ß, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. RESULTS: Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P = 0.02) and POD 1 (area under the curve 0.69; P = 0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD 4. CONCLUSIONS: Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.

Functional Outcome of Laparoscopic-Assisted Resection Versus Open Resection of Rectal Cancer: A Secondary Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial.

BACKGROUND: Low anterior resection syndrome has a significant impact on the quality of life in rectal cancer survivors. Previous studies comparing laparoscopic to open rectal resection have neglected bowel function outcomes. OBJECTIVE: This study aimed to assess whether there is a difference in the functional outcome between patients undergoing laparoscopic versus open resection for rectal adenocarcinoma. DESIGN: Cross-sectional prevalence of low anterior resection syndrome was assessed in a secondary analysis of the multicenter phase 3 randomized clinical trial, Australasian Laparoscopic Cancer of the Rectum Trial (ACTRN12609000663257). SETTING: There were 7 study subsites across New Zealand and Australia. PATIENTS: Participants were adults with rectal cancer who underwent anterior resection and had bowel continuity. MAIN OUTCOME MEASURES: Postoperative bowel function was evaluated using the validated low anterior resection syndrome score and Bowel Function Instrument. RESULTS: The Australasian Laparoscopic Cancer of the Rectum Trial randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. A total of 257 participants were eligible for, and invited to, participate in additional follow-up; 163 (63%) completed functional follow-up. Overall cross-sectional prevalence of major low anterior resection syndrome was 49% (minor low anterior resection syndrome 27%). There were no differences in median overall Bowel Function Instrument score nor low anterior resection syndrome score between participants undergoing laparoscopic versus open surgery (66 vs 67, p = 0.52; 31 vs 27, p = 0.24) at a median follow-up of 69 months. LIMITATIONS: The major limitations are a result of conducting a secondary analysis; the likelihood of an insufficient sample size to detect a difference in prevalence between the groups and the possibility of selection bias as a subset of the randomized population was analyzed. CONCLUSIONS: Bowel dysfunction affects a majority of rectal cancer patients for a significant time after the operation. In this secondary analysis of a randomized trial, surgical approach does not appear to influence the likelihood or severity of low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B794. RESULTADO FUNCIONAL DE LA RESECCIN ASISTIDA POR LAPAROSCOPIA VERSUS RESECCIN ABIERTA EN CNCER DE RECTO ANLISIS SECUNDARIO DEL ESTUDIO DE CNCER DE RECTO LAPAROSCPICO DE AUSTRALASIA: ANTECEDENTES:El síndrome de resección anterior baja tiene un impacto significativo en la calidad de vida de los supervivientes de cáncer de recto. Los estudios anteriores que compararon la resección rectal laparoscópica con la abierta no han presentado resultados de la función intestinal.OBJETIVO:Evaluar si existe una diferencia en el resultado funcional entre los pacientes sometidos a resección laparoscópica versus resección abierta por adenocarcinoma de recto.DISEÑO:La prevalencia transversal del síndrome de resección anterior baja se evaluó en un análisis secundario del ensayo clínico aleatorizado multicéntrico de fase 3, Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia (Australasian Laparoscopic Cancer of the Rectum Trial, ACTRN12609000663257).AJUSTE:Siete subsitios de estudio en Nueva Zelanda y Australia.PACIENTES:Los participantes eran adultos con cáncer de recto que se sometieron a resección anterior con anastomosis.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal posoperatoria se evaluó utilizando el previamente validado puntaje LARS y el Instrumento de Función Intestinal.RESULTADOS:El Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia asignó al azar a 475 pacientes con adenocarcinoma rectal T1-T3 a menos de 15 cm del borde anal. 257 participantes fueron elegibles e invitados a participar en un seguimiento adicional. 163 (63%) completaron el seguimiento funcional. La prevalencia transversal general de LARS mayor fue del 49% (LARS menor 27%). No hubo diferencias en la puntuación media general del Instrumento de Función Intestinal ni en la puntuación LARS entre los participantes sometidos a cirugía laparoscópica versus cirugía abierta (66 frente a 67, p = 0,52; 31 frente a 27, p = 0,24) en una mediana de seguimiento de 69 meses.LIMITACIONES:Las principales limitaciones son el resultado de realizar un análisis secundario; se analizó la probabilidad de un tamaño de muestra insuficiente para detectar una diferencia en la prevalencia entre los grupos y la posibilidad de sesgo de selección como un subconjunto de la población aleatorizada.CONCLUSIONES:La disfunción intestinal afecta a la mayoría de los pacientes con cáncer de recto durante un tiempo significativo después de la operación. En este análisis secundario de un ensayo aleatorizado, el abordaje quirúrgico no parece influir en la probabilidad o gravedad del síndrome de resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B794. (Traducción-Dr. Felipe Bellolio).

Multicentre study of appendicitis management comparing a large South Island metropolitan hospital, to its referring regional and rural centres.

BACKGROUND: Globally, patients presenting with acute surgical disease in rural areas have poorer outcomes when compared to urban areas; little data are available regarding outcomes for New Zealand (NZ) rural patients. This study aimed to compare the surgical management of appendicitis in a large metropolitan centre with its regional referral centres. METHODS: In this retrospective cohort study, patient data were collated from the studied centres between November 2014 and October 2019. In addition to patient demographics, patterns of referral and presentation, the primary outcome was time to the theatre; secondary outcomes were perforation rates, length of stay and complications. Data are presented as medians (interquartile range). RESULTS: A total of 3533 patients underwent appendicectomy over the period studied. For those presenting directly to the metropolitan centre, the median wait-time to the theatre was 16 h (9.2-23.2); if patients were transferred, they waited for 20.8 h (13.6-27). Patients presenting to regional centres waited for 7.6 h (4.5-15.4, P < 0.001). Perforation rates for transferred patients were 31% which was greater than for those presenting to the metropolitan (20%) or regional centres (17%, P = 0.014). Complications were also highest in transferred patients (20%) when compared to the metropolitan (17%) or regional centres (10%, P < 0.001). CONCLUSION: Patients who were transferred to Christchurch Hospital from rural centres without surgical services had a longer wait-time than those who presented to Christchurch Hospital directly or were treated in regional centres. This was associated with higher rates of perforated appendicitis.

RNAscope compatibility with image analysis platforms for the quantification of tissue-based colorectal cancer biomarkers in archival formalin-fixed paraffin-embedded tissue.

RNAscope®, has emerged as an important in-situ hybridisation method to validate mRNA expression within single cells whilst preserving tissue morphology in histological samples. The aim of this research was to compare the utility of various open-source and commercial image analysis methods, to quantify mRNA transcripts identified by RNAscope within formalin fixed paraffin embedded (FFPE) histological samples and cell monolayer preparations. Examination of MLH1 expression from 10 histological FFPE colorectal cancer specimens using four image analysis tools (Colour Deconvolution, SpotStudio, WEKA and the LEICA RNA-ISH algorithm) showed the WEKA tool as having the greatest level of agreement with manual quantification. Comparing image analysis methods to qRT-PCR for quantifying MLH1, GFI1 and TNFRSF11A expression within two colorectal cell lines results suggest that these image analysis methods perform at a similar level to qRT-PCR. Furthermore, we describe the strengths and limitations for each image analysis method when used in combination with RNAscope assays. Our study concludes that there are several freely available and commercial image analysis tools that enable reliable RNA in situ expression analysis, however operators need to consider factors, such as expected expression levels of target genes, software usability and functionality.

The long-term incidence of dysplasia and colorectal cancer in a Crohn's colitis population-based cohort.

AIM: The risk of developing colorectal cancer (CRC) in Crohn's disease (CD) has been variably reported. Chronic inflammation is associated with an increased risk of neoplasia; variable outcomes in CD possibly reflect the heterogeneous nature of the disease. The aim of this work was to characterize the risk of CRC in a New Zealand population-based cohort of CD patients with colonic inflammation. METHOD: A review of all participants with CD in the population-based Canterbury Inflammatory Bowel Disease Study was conducted. Data on demographics, endoscopic surveillance, presence of dysplasia/neoplasia and oncological outcome were extracted. The age-adjusted standardized incidence ratio (SIR) was used to compare the incidence of CRC in the cohort with the incidence of CRC in the New Zealand population in 2006. RESULTS: Data on 649 patients with CD were collected. Four hundred and thirty-six participants (58% female) with ileocolonic or colonic CD were included for analysis. CRC was diagnosed in 13 patients (62% female). The median age at CRC diagnosis was 58.5 years, and the mean duration of CD prior to diagnosis of CRC was 20.4 years. When compared with the New Zealand population (using census data), the overall age-adjusted SIR was 4.1 (95% CI 2.4-7.1). CONCLUSION: This population-based cohort of patients with colonic CD shows a significantly increased risk of CRC compared with the general population. This is consistent with the colonic location of inflammation increasing the risk of neoplasia. Inclusion of patients with isolated upper gastrointestinal/ileal CD in similar studies may mask the truly increased risk for patients with long-standing colonic inflammation.

New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review.

BACKGROUND: Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. RESULTS: Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. CONCLUSION: There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.