A 10-year review on older patients undergoing colorectal cancer surgery: surgeon-led geriatric service and good quality surgery are drivers of good outcomes.

BACKGROUND: Older age and frailty are associated with worse postoperative outcomes and prolonged length of stay (LOS). In this study, we aimed to analyze the long-term outcomes after the implementation of our geriatric surgical service (GSS). METHODS: This was a single-center retrospective study from July 2010 to December 2021 on patients aged ≥75 years or patients aged ≥65 years with frailty. Our GSS includes multidisciplinary assessment and optimization by specialized nurses, physiotherapists, anesthetists, dietitians, and geriatricians. Cumulative sum (CUSUM) analysis was used to assess the performance of our GSS. Our primary outcome was defined as the presence of 30-day mortality, prolonged LOS ≥ 14 days, and/or >10% decrease in the modified Barthel Index at 6 weeks, which depicts the failure of GSS. A downsloping CUSUM curve implies consecutive cases of success. RESULTS: There were 233 patients with a mean age of 79.0 ± 4.9 years; of these, 73 patients (31.3%) were frail. The overall 30-day mortality (1.7%), Clavien-Dindo ≥ grade IIIA complications (12.0%), and LOS (median, 7.0 days) were low. The CUSUM analysis showed 3 phases with overall sustained improvement in outcomes. Transient inconsistency in the second phase (during midimplementation of GSS) may be due to the early adoption of laparoscopic surgery (44.6% vs 24.1%; adjusted P =.031) and expansion of service to include patients with higher perioperative risks (weighted Charlson Comorbidity Index score ≥4: 64.9% vs 38.0%; adjusted P =.002) in the second period compared with the first period. The outcomes subsequently improved in the third phase after overcoming the learning curve. CONCLUSION: Our GSS showed sustained performance over the past decade. Good quality surgery and surgeon-led geriatric service are paramount for good postoperative outcomes.

Impact of nationwide COVID-19 lockdown on workload and injury patterns of major trauma cases in a regional trauma centre in Singapore.

Introduction: Singapore instituted lockdown measures from 7 February 2020 to 1 June 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic. Methods: A retrospective analysis of cases from the national trauma registry was carried out comparing the lockdown period (from 7 February 2020 to 1 June 2020) to the pre-lockdown period (from 7 February 2019 to 1 June 2019). Data extracted included the volume of Tier 1 (injury severity score [ISS] >15) and Tier 2 (ISS 9-15) cases and epidemiology. Subgroup analysis was performed for Tier 1 patient outcomes. Results: Trauma volume decreased by 19.5%, with a 32% drop in Tier 1 cases. Road traffic and workplace accidents decreased by 50% (P < 0.01), while interpersonal violence showed an increase of 37.5% (P = 0.34). There was an 18.1% decrease in usage of trauma workflows (P = 0.01), with an increase in time to intervention for Tier 1 patients from 88 to 124 min (P = 0.22). Discharge to community facilities decreased from 31.4% to 17.1% (P < 0.05). There was no increase in inpatient mortality, length of stay in critical care or length of stay overall. Conclusion: There was an overall decrease in major trauma cases during the lockdown period, particularly road traffic accidents and worksite injuries, and a relative increase in interpersonal violence. Redeployment of manpower and hospital resources may have contributed to decreased usage of trauma workflows and community facilities. In the event of further lockdowns, it is necessary to plan for trauma coverage and maintain the use of workflows to facilitate early intervention.

Meta-analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

BACKGROUND: Primary repair or resection with anastomosis (PR/A) has been gaining increasing recognition for traumatic colonic injuries, with the need for faecal diversion (FD) especially those of penetrating etiology being questioned. However, the role of PR/A in critically ill patients is still controversial with concerns pertaining to safety and anastomotic leak. AIMS AND METHODS: We performed a systemic review of studies comparing outcomes of FD versus PR/A in traumatic colonic injuries. A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed, EMBASE, and Cochrane Library resources. Mortality and anastomotic leak rates are identified as the primary and secondary outcomes, respectively. Data extracted include mortality rates, type of surgical intervention, surgical complications, and need for DC (damage control) surgery. RESULTS: Fourteen studies were identified comprising 11 retrospective, 2 prospective cohort and 1 randomized trial with a total of 2071 patients. Six studies included patients that underwent DC surgery. The overall mortality rate was 3.77% and was higher in the FD group compared to PR/A group (5.38% vs 2.49%, p = 0.07). 71.3% of patients underwent PR/A with an overall leak rate of 4.63%. There was no difference in intra-abdominal collections between the PR/A and FD groups. In the subgroup analysis, anastomotic leak rate was significantly higher in the DC group compared to non-DC group (16.7% vs 3.2%, p = 0.003). CONCLUSIONS: This meta-analysis supports PR/A in stable patients with traumatic colonic injuries. FD should be considered in critically ill patients who require DC surgery as leak rates are significantly higher.

A Comprehensive Analysis of Traumatic Rib Fractures in an Acute General Hospital in Singapore.

BACKGROUND: Rib fractures are common sequelae after blunt chest wall trauma. They can occur in isolation or association with life-threatening injuries to the head, thorax, and abdomen and may be complicated by hemothorax, pneumothorax, or lung contusions. Contiguous rib fractures can result in flail chest, which is associated with increased morbidity and mortality. This study aims to compare the risk factors, treatment modalities, and outcomes between patients with flail chest and nonflail chest postblunt trauma. PATIENTS AND METHODS: Data were retrospectively collected from all patients admitted with rib fractures from January 2016 to December 2016 to the Department of General Surgery, Khoo Teck Puat Hospital, Singapore. The outcomes identified were mortality, pain scores on injury day 1, 3, 5, and 7, injury severity score, duration of mechanical ventilation, worst partial pressure arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, length of intensive care unit (ICU) stay, and pulmonary complications. RESULTS: Motor vehicle accident was the most common cause of rib fractures (63.1%, n = 123). Patients with flail chest had more associated pneumothorax (53.8% vs. 35.2%) and lung contusions (53.8% vs. 30.2%) compared to those without flail chest and underwent more investigations such as inpatient-computed tomography scans (76.9% vs. 59.3%), interventions such as chest tube insertion (61.5% vs. 19.8%), and ICU admission (46.1 vs. 13.7%). Patients also had higher pain scores, used more analgesic modalities, and had increased inpatient mortality (30.8% vs. 4.4%). CONCLUSION: Flail chest is associated with higher morbidity and mortality. Proactive management from a multidisciplinary team such as identification of high-risk patients in particular patients with flail chest, early admission to critical care, and protocols including multimodal pain management, respiratory support, and rehabilitation should be instituted.

S1 Sacrectomy for Re-recurrent Rectal Cancer: Our Experience with Reconstruction Using an Expandable Vertebral Body Replacement Device.

INTRODUCTION: R0 resection is achieved by high sacrectomy for local recurrence of colorectal cancer, but significant rates of perioperative complications and long-term patient morbidity are associated with this procedure. In this report, we outline our unique experience of using an expandable cage for vertebral body reconstruction following S1 sacrectomy in a 66-year-old patient with re-recurrent rectal cancer. We aim to highlight several key steps, with a view to improving postoperative outcomes. TECHNIQUE: A midline laparotomy was performed with the patient in supine Lloyd-Davies position, demonstrating recurrence of tumor at the S1 vertebral body. Subtotal vertebral body excision of S1 with sparing of the posterior wall and ventral foramina was completed by using an ultrasonic bone aspirator. Reconstruction was performed using an expandable corpectomy spacer system. The system was assembled and expanded in situ to optimally bridge the corpectomy. The device was secured into the L5 and S2 vertebrae by means of angled end plate screws superiorly and inferiorly. Bone grafts were positioned adjacent to the implant after this. RESULTS: Total operating time was 266 minutes with 350 mL of intraoperative blood loss. There were no immediate postoperative complications. The patient did not report any back pain at the time of discharge, and no neurological deficit was reported or identified. Postoperative CT scan showed excellent vertebral alignment and preservation of S1 height. CONCLUSION: We conclude that high sacrectomy with an expandable metal cage is feasible in the context of re-recurrent rectal cancer when consideration is given to the method of osteotomy and vertebral body replacement.

Transanal minimally invasive full-thickness anterior middle rectum polyp resection - video vignette.

Rectal preservation is gaining popularity in the surgical treatment of degenerated rectal polyps or early rectal cancer (1,2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment by transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report a 60 year-old woman who underwent TAMIS for a large polyp located anteriorly in the middle 1/3 of the rectum, 7 cm from the dentate line and staged preoperatively as uTisN0M0. This article is protected by copyright. All rights reserved.

Advances in surgical management for locally recurrent rectal cancer: How far have we come?

Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.

Laparoscopic versus Open Omental Patch Repair for Early Presentation of Perforated Peptic Ulcer: Matched Retrospective Cohort Study.

Introduction. The aim of this study was to compare the outcomes between laparoscopic and open omental patch repair (LOPR versus OR) in patients with similar presentation of perforated peptic ulcer (PPU). The secondary aim was to evaluate the outcomes according to the severity of peritonitis. Methods. All patients who underwent omental patch repair at two university-affiliated institutes between January 2010 and December 2014 were reviewed. Matched cohort between LOPR and OR groups was achieved by only including patients that had ulcer perforation <2 cm in size and symptoms occurring <48 hours. Outcome measures were defined in accordance with length of stay (LOS), postoperative complications, and mortality. Results. 148 patients met the predefined inclusion criteria with LOPR performed in 40 patients. Outcome measures consistently support laparoscopic approach but only length of hospital stay (LOS) achieved statistical significance (LOPR 4 days versus OR 5 days, p < 0.01). In a subgroup analysis of patients with MPI score >21, LOPR is also shown to benefit, particularly resulting in significant shorter LOS (4 days versus 11 days, p < 0.01). Conclusion. LOPR offers improved short-term outcomes in patients who present within 48 hours and with perforation size <2 cm. LOPR also proved to be more beneficial in high MPI cases.

Endoscopic surgery - exploring the modalities.

The adoption of endoscopic surgery continues to expand in clinical situations with the recent natural orifice transluminal endoscopic surgery technique enabling abdominal organ resection to be performed without necessitating any skin incision. In recent years, the development of numerous devices and platforms have allowed for such procedures to be carried out in a safer and more efficient manner, and in some ways to better simulate triangulation and surgical tasks (e.g., suturing and dissection). Furthermore, new novel techniques such as submucosal tunneling, endoscopic full-thickness resection and hybrid endo-laparoscopic approaches have further widened its use in more advanced diseases. Nevertheless, many of these new innovations are still at their pre-clinical stage. This review focuses on the various innovations in endoscopic surgery, with emphasis on devices and techniques that are currently in human use.