Major low anterior resection syndrome has equivalent health-related quality of life implications as having a permanent colostomy.

BACKGROUND: The literature is inconclusive when comparing health-related quality of life following restorative anterior resection (AR) compared with abdominoperineal resection (APR). Consideration of functional outcomes may explain this inconsistency. The aim of this study was to compare health-related quality of life in patients post-anterior resection, stratified by low anterior resection syndrome score, and post-abdominoperineal resection patients. METHODS: A cross-sectional study of consecutive patients post APR and AR for rectal or sigmoid adenocarcinoma at a tertiary centre in Sydney, Australia (Jan 2012- Dec 2021) was performed. HRQoL outcomes (SF36v2 physical [PCS] and mental component summary [MCS] scores) were compared between APR and AR patients, with subgroup analyses stratifying AR patients according to LARS score (no/minor/major). Age- and gender-adjusted comparisons were performed by linear regression. RESULTS: Overall, 248 post-AR patients (57.3% male, mean age 70.8 years, SD 11.6) and 64 post-APR patients (62.5% male, mean age 68.1 years, SD 13.1) participated. When stratified by LARS, 'major LARS' had a similar negative effect on age-and sex-adjusted PCS scores as APR. 'No LARS' (p < 0.001) and 'minor LARS' (p < 0.001) patients had higher PCS scores compared to post-APR patients. 'Major LARS' had a similarly negative effect on MCS scores compared with post-APR patients. MCS scores were higher in 'no LARS' (p = 0.006) compared with APR patients. CONCLUSIONS: Postoperative bowel dysfunction significantly impacts health-related quality of life. Patients with 'major LARS' have health-related quality of life as poor as those following APR. This requires consideration when counselling patients on postoperative health-related quality of life, especially where poor postoperative bowel function is anticipated following restorative surgery.

Relative effects of direct spread, lymph node metastasis and venous invasion in relation to blood borne distant metastasis present at the time of resection of colorectal cancer.

Conventionally, lymphatic spread is regarded as the principal mechanism by which haematogenous metastasis occurs in colorectal cancer. The aim of this cross sectional study was to determine the relative strengths of direct tumour spread, the presence of lymph node metastasis and histologically demonstrated venous invasion as drivers of haematogenous metastasis diagnosed at the time of resection of colorectal cancer. The data were drawn from a hospital database of consecutive bowel cancer resections between 1995 and 2017 inclusive. The presence of haematogenous metastasis was determined at the time of surgery by imaging or other investigations or operative findings. Where possible, histological confirmation was obtained. Specimen dissection and reporting followed a standardised procedure. Tumour staging was according to the 7th edition of the UICC/AJCC pTNM system. Analysis was by multivariable logistic regression. After exclusions 3133 patients remained, among whom 380 (12.1%) had one or more haematogenous metastases. In bivariate analyses, the frequency of haematogenous metastasis was directly associated with increasing T status (p<0.001), increasing N status (p<0.001) and increasing extent of venous invasion (p<0.001) and with some other patient and tumour features. In a multivariable model, after adjustment for other features, associations with the occurrence of haematogenous metastasis were as follows: T3 odds ratio (OR) 4.41 (95% confidence interval 2.40-8.10), p<0.001; T4a OR 6.29 (3.27-12.10), p<0.001; T4b OR 5.50 (2.71-11.15), p<0.001; N1 OR 3.39 (2.47-4.64), p<0.001; N2 OR 4.59 (3.21-6.54), p<0.001; mural venous invasion OR 2.18 (1.14-4.16), p=0.018; extramural venous invasion OR 2.91 (2.21-3.83), p<0.001. Only three other features had significant, though weak effects in the model. These results led to the conclusion that venous invasion, demonstrated histologically and also inferred independently by the extent of direct tumour spread, made a greater contribution to the occurrence of haematogenous metastasis than did spread through lymphatics. Our approach and findings may have implications for other cancer sites apart from colorectal cancer.

Randomized clinical trial of the effect of intraoperative humidified carbon dioxide insufflation in open laparotomy for colorectal resection.

BACKGROUND: Animal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas. METHODS: A single-blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO2  group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3-chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T0 ) and end (Tend ) of the operation. Postoperative clinical outcomes were compared between the groups. RESULTS: Of 40 patients enrolled, 20 in the WHCO2 group and 19 in the control group were available for analysis. A significant log(Tend /T0 ) difference between control and WHCO2 groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL-4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3-chlorotyrosine/tyrosine ratio had increased at Tend by 1·1-fold in the WHCO2 group and by 3·1-fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO2 group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008). CONCLUSION: The use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( www.ClinicalTrials.gov/).

ANTECEDENTES: Los estudios en animales han demostrado que la lesión peritoneal se puede minimizar insuflando gas de dióxido de carbono caliente y humidificado (warm, humidified carbon dioxide gas,WHCO2(g) ) en la cavidad abdominal. El objetivo de este ensayo fue investigar los marcadores de inflamación peritoneal y de daño oxidativo en pacientes sometidos a cirugía colorrectal y abdominal tratados dióxido de carbono calentado humidificado en comparación con controles. El objetivo secundario fue evaluar los resultados clínicos perioperatorios. MÉTODOS: Se llevó a cabo un ensayo aleatorizado, controlado y simple ciego en una unidad colorrectal terciaria. Se incluyeron pacientes de > 18 años de edad sometidos operaciones electivas por vía abierta. El grupo de intervención recibió CO2(g) calentado (37°C) y humidificado (98% humedad relativa). Para la comparación de los grupos, se determinaron múltiples marcadores de inflamación peritoneal y daño oxidativo, incluyendo citocinas y quimiocinas, apoptosis (actividad Caspasas -3 y -7 y DeadEndTM TUNEl sistema fluorométrico), la tasa 3-clorotirosina/tirosina nativa (HPLC-MS) y microscopía electrónica de biopsias peritoneales al inicio (T0 ) y al término (Tfinal ) de la operación. Los resultados clínicos postoperatorios se compararon entre los grupos. RESULTADOS: De los 40 pacientes incluidos en el estudio, se dispuso de datos para el análisis en 20 pacientes asignados al grupo de CO2 y en 19 asignados al grupo control. Se observó una diferencia significativa Log(Tend/T0) entre los grupos respecto a IL-2 (grupo control: 5,34, grupo CO2: 2,78, P = 0,028) y IL-4 (grupo control: 3,53, grupo CO2: 2,00, P = 0,04), en tanto que los análisis relativos a la apoptosis no pusieron de manifiesto cambios significativos en la actividad de la caspasa, y se observaron tasas de apoptosis similares a lo largo del borde peritoneal en ambos grupos. La tasa 3-clorotirosina/tirosina nativa aumentó en 1,05 veces en el grupo del CO2 y en 3,1 veces en el grupo control. Por microscopía óptica el peritoneo era visible en el 57,9% de los sujetos del grupo control y en el 95% de los que recibieron tratamiento con WHCO2(g) (P = 0,006). La única diferencia en los resultados clínicos entre los grupos de intervención y control fue el número de días para el paso de gases (2,5 en el grupo de CO2 versus 5,0 días en el grupo control, P = 0,008). CONCLUSIÓN: El uso de WHCO2(g) parece disminuir algunos de los marcadores relacionados con el daño peritoneal por estrés oxidativo durante la laparotomía. Aunque no se observaron diferencias en los resultados clínicos, el estudio no tenía la suficiente potencia para analizar los resultados quirúrgicos.

Competing risks analysis of the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer.

AIM: Despite numerous reports over three decades, the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer remains controversial. This cohort study used competing risks statistical methods to examine the association between transfusion and recurrence and colorectal cancer-specific death after potentially curative and noncurative resection. METHOD: A hospital database provided prospectively recorded clinical, operative and follow-up information. All surviving patients were followed for at least 5 years. Data were analysed by multivariable competing risks regression. RESULTS: From 2575 patients in the period 1995-2010 inclusive, after exclusions, 2334 remained for analysis. Among 1941 who had a potentially curative resection and 393 who had a noncurative resection the transfusion rates were 24.9% and 33.6%, respectively. After potentially curative resection there was no significant bivariate association between transfusion and recurrence (HR 0.93, CI 0.74-1.16, P = 0.499) or between transfusion and colorectal cancer-specific death (HR 1.04, CI 0.82-1.33, P = 0.753). After noncurative resection there was no significant association between transfusion and cancer-specific death (HR 0.93, CI 0.73-1.19, P = 0.560). Multivariable models showed no material effect of potential confounder variables on these results. CONCLUSION: The competing risks findings in this study showed no significant association between perioperative transfusion and recurrence or colorectal cancer-specific death.

Recurrence and cancer-specific death after adjuvant chemotherapy for Stage III colon cancer.

AIM: The recommended standard of care for patients after resection of Stage III colon cancer is adjuvant 5-fluorouracil based chemotherapy - FOLFOX (fluorouracil, leucovorin with oxaliplatin) - or CAPOX (capecitabine, oxaliplatin). This may be modified in older patients or depending on comorbidity. This has been challenged recently as the apparent benefit of adjuvant chemotherapy may arise from improvements in surgery or preoperative imaging or pathology staging. This study compares recurrence and colon-cancer-specific death between patients who received postoperative adjuvant chemotherapy and those who did not. METHOD: Prospectively recorded data from 363 consecutive patients who had a resection for Stage III colonic adenocarcinoma between 1995 and 2010 inclusive were analysed. Surviving patients were followed for at least 5 years. The suitability of patients for chemotherapy was discussed routinely at multidisciplinary team meetings. The incidence of recurrence and colon-cancer-specific death was evaluated by competing risk methods. RESULTS: After adjustment for the competing risk of non-colorectal cancer death, there was no significant difference in recurrence between the 204 patients who received chemotherapy and the 159 who did not [hazard ratio (HR) 0.94, 95% CI 0.66-1.32, P = 0.700) and no significant difference in colon-cancer-specific death (HR 0.73, 95% CI 0.50-1.04, P = 0.084; HR 0.88, 95% CI 0.57-1.36, P = 0.577 after adjustment for relevant covariates). CONCLUSION: These findings question the routine use of chemotherapy after complete mesocolic excision for Stage III colon cancer. Recurrence and cancer-specific death, assessed by competing risk methods, should be the standard outcomes for evaluating the effectiveness of adjuvant chemotherapy after potentially curative resection.

Three steps and a join: a simple guide to right- and left-sided medial to lateral laparoscopic colorectal surgery.

BACKGROUND: To provide a standardised 'medial to lateral' approach to laparoscopic colorectal surgery. METHODS: Both right- and left- sided laparoscopic colorectal procedures were simplified into three well-defined steps and a join. An instructional video and procedural guide provides the important pearls and pitfalls in performing laparoscopic colorectal surgery. RESULTS: During a 10-year period (2006-2016) at a single institution, 20 senior colorectal trainee surgeons and 20 general surgery registrars were trained in the 'three steps and a join' technique. Five hundred and sixty-eight laparoscopic anterior resections using this technique were performed. There were 5 (0.9%) leaks. Five hundred and forty-three laparoscopic right-sided resections were performed. There were 3 (0.6%) anastomotic leaks requiring reoperation and loop ileostomy. CONCLUSIONS: This step-by-step instructional video and procedural guide provides a simple and standardised approach which may be incorporated into a training pathway for laparoscopic right- and left-sided colorectal surgery.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review.

AIM: To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication. METHOD: Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis. RESULTS: The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%). CONCLUSION: Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.

Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision.

AIM: Complete mesocolic excision (CME) has been advocated as likely to improve the long-term oncological outcome of colon cancer resection, although there is a paucity of long-term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long-term results with those of recent European studies of CME. METHOD: Data were drawn from a prospective hospital registry of consecutive resections for colon cancer between 1996 and 2007, including follow-up to the end of 2012. The principal outcomes from potentially curative resections were 5-year Kaplan-Meier rates of local recurrence, systemic recurrence, overall survival and cancer-specific survival. Secondary outcomes for all resections were postoperative complications, number of lymph nodes retrieved and R0 status. RESULTS: For 779 potentially curative resections the local recurrence rate was 2.1% (95% CI 1.3-3.4), the systemic recurrence rate was 10.2% (95% CI 8.1-12.7), the 5-year overall survival rate was 76.2% (95% CI 73.0-79.0) and the cancer-specific survival rate was 89.8% (95% CI 87.3-91.9). For all 905 resections, rates of 14 surgical complications were low and not dissimilar to those in a comparable study. The median lymph node count was 15 (range 0-113). R0 status was confirmed in 883/905 patients (97.6%; 95% CI 96.4-98.5). CONCLUSION: For colon cancer, meticulous dissection along anatomical planes together with high vascular ligation results in few complications, a high R0 rate, low recurrence and high survival.

A historical comparison of single incision and conventional multiport laparoscopic right hemicolectomy.

AIM: Single incision laparoscopic surgery (SILS) is specially suited for surgery of the right colon. This study presents the results of a historical controlled trial comparing single incision and multiport laparoscopic surgery (MLS) for right hemicolectomy. METHOD: A review of outcome data from 149 patients who underwent laparoscopic right hemicolectomy was performed from the Concord Hospital laparoscopic colorectal database. RESULTS: Between July 2006 and December 2011, 149 consecutive laparoscopic right hemicolectomies were performed. The first 74 were performed by MLS and from February 2009 all cases were performed by SILS (n = 75).The median ages in the MLS and SILS groups were 74 and 68 years. The median body mass index was 27 kg/m(2) in both groups. Patients were hospitalized for a median of 8 days in the MLS group compared with 5 days in the SILS group. The median length of the extraction wound was 50 mm in the MLS group compared with 43 mm in the SILS group. The indications for surgery were similar in both groups, being 67% and 68%. One patient in each group required conversion to open laparotomy, and no patient in the SILS group required conversion to a conventional multiport technique. Postoperative morbidity was similar in both groups. CONCLUSION: SILS offers a safe minimally invasive approach to right colon resection. In our series SILS patients had a shorter extraction wound size and shorter length of stay in hospital.

Supervised surgical training and its effect on the short-term outcome in laparoscopic colorectal surgery.

AIM: Laparoscopic colorectal surgery requires supervised training. In this paper we examine the short-term outcome following a component-based training in laparoscopic colorectal surgery. METHOD: Surgical outcome following laparoscopic colorectal resection was recorded on a prospective database. Patients were divided into three groups, including those performed by the fellows, those completed by the consultant and those completed by a combination of both. Analysis of data was carried out for all colorectal resections and the subgroup with colorectal cancer. RESULTS: 511 operations were examined between June 2006 and January 2011. There was no statistically significant difference in operating time between fellows and consultants but it was significantly longer for procedures where consultants and fellows performed components. Conversion rate, postoperative morbidity, recovery and length of stay were similar for all three groups for the whole patient cohort and also the subgroup of cancer patients. In the cancer subgroup, there was no difference in the pathological stage in the three groups. CONCLUSION: Closely supervised training in laparoscopic colorectal surgery is not associated with any adverse effect on the short-term outcome.

A comparison of published rates of resection margin involvement and intra-operative perforation between standard and 'cylindrical' abdominoperineal excision for low rectal cancer.

AIM: The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra-operative bowel perforation. METHOD: Data on rates of margin involvement and perforation were obtained from eight recently published reports and also from a prospective registry of resections at Concord Hospital. Rates of these outcomes and their 95% confidence intervals were evaluated. RESULTS: There was no evidence that extralevator abdominoperineal excision yielded significantly lower rates of resection margin involvement or intra-operative bowel perforation compared with standard abdominoperineal excision in six independent hospital- and population-based patient series. Abdominosacral resection of the rectum, on the other hand, did show significantly lower rates of these endpoints, albeit in selected patients. CONCLUSION: The role of extralevator abdominoperineal excision and abdominosacral resection of the rectum should be investigated further in randomized controlled trials.