Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer.

AIM: Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT. METHODS: An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak. RESULTS: A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort. CONCLUSION: In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.

Informed Written Consent for Emergency and Elective General Surgery at a Model 4 Hospital: A Closed-Loop Audit.

Introduction The objective of this investigation was to conduct an audit of the consent form standards signed by patients before elective or emergency general surgery at our institution. The investigation involved a comparison of these standards with those outlined in the "HSE National Consent Policy 2022" established by the Health Service Executive (HSE) and the Royal College of Surgeons in Ireland (RCSI). In the event of discrepancies, we intended to complete the audit loop by educating general surgeons on the essential standards for obtaining written consent in both elective and emergency general surgical procedures. Methods To assess the quality of patient consent, a pre-interventional phase was conducted over one week. Information was gathered exclusively through electronic medical record systems. Subsequent to the data analysis, an in-person educational session was conducted to enlighten non-consultant hospital doctors (NCHDs) in surgery about the significance of informed written consent and the criteria for lawful consent according to local guidelines established by the HSE and the RCSI. Three months following the intervention, a follow-up cycle was carried out to evaluate whether there were any improvements in the standards of consent. Results In the initial phase, prior to intervention, a total of 95 consent forms were collected. The patient's name, date of birth (DOB), and hospital board number (BN) were accurately recorded in all consent forms. However, only 66% (n=63) were accurately documented without the use of abbreviations or acronyms. Following the intervention, 145 consent forms were gathered. All appropriately indicated the patient's name, DOB, and BN. However, 84% (n=122) of consent forms were correctly labeled without the use of abbreviations or acronyms (p=0.0017). Conclusion This closed-loop review illustrates that the quality of consent can be notably enhanced through a straightforward educational intervention led by NCHDs in general surgery. Such interventions can be instructive, leading to improved consent form documentation. This, in turn, enhances patient safety and helps prevent potential medico-legal repercussions for both healthcare providers and institutions.

Evaluating the oncological safety of neoadjuvant chemotherapy in locally advanced colon carcinoma: a systematic review and meta-analysis of randomised clinical trials and propensity-matched studies.

PURPOSE: Use of neoadjuvant chemotherapy (NAC) for locally advanced colon cancer (LACC) remains controversial. An integrated analysis of data from high-quality studies may inform the long-term safety of NAC for this cohort. Our aim was to perform a systematic review and meta-analysis of randomised clinical trials (RCTs) and propensity-matched studies to assess the oncological safety of NAC in patients with LACC. METHODS: A systematic review was performed as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Survival was expressed as hazard ratios using time-to-effect generic inverse variance methodology, while surgical outcomes were expressed as odds ratios (ORs) using the Mantel-Haenszel method. Data analysis was performed using Review Manager version 5.4. RESULTS: Eight studies (4 RCTs and 4 retrospective studies) including 31,047 patients with LACC were included. Mean age was 61.0 years (range: 19-93 years) and mean follow-up was 47.6 months (range: 2-133 months). Of those receiving NAC, 4.6% achieved a pathological complete response and 90.6% achieved R0 resection (versus 85.9%, P < 0.001). At 3 years, patients receiving NAC had improved disease-free survival (DFS) (OR: 1.28, 95% confidence interval (CI): 1.02-1.60, P = 0.030) and overall survival (OS) (OR: 1.76, 95% CI: 1.10-2.81, P = 0.020). When using time-to-effect modelling, a non-significant difference was observed for DFS (HR: 0.79, 95% CI: 0.57-1.09, P = 0.150) while a significant difference in favour of NAC was observed for OS (HR: 0.75, 95% CI: 0.58-0.98, P = 0.030). CONCLUSION: This study highlights the oncological safety of NAC for patients being treated with curative intent for LACC using RCT and propensity-matched studies only. These results refute current management guidelines which do not advocate for NAC to improve surgical and oncological outcomes in patients with LACC. TRIAL REGISTRATION: International Prospective Register of Systematic Review (PROSPERO) registration: CRD4202341723.

Impact of the 12-gene recurrence score in influencing adjuvant chemotherapy prescription in mismatch repair proficient stage II/III colonic carcinoma-a systematic review and meta-analysis.

INTRODUCTION: The 12-gene recurrence score (RS) is a clinically validated assay which predicts recurrence risk in patients with stage II/III colon cancer. Decisions regarding adjuvant chemotherapy may be guided using this assay or based on the judgement of tumour board. AIMS: To assess the concordance between the RS and MDT decisions regarding adjuvant chemotherapy in colon cancer. METHODS: A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software. RESULTS: Four studies including 855 patients with a mean age of 68 years (range: 25-90 years) met inclusion criteria. Overall, 79.2% had stage II disease (677/855) and 20.8% had stage III disease (178/855). For the entire cohort, concordant results between the 12-gene assay and MDT were more likely than discordant (odds ratio (OR): 0.38, 95% confidence interval (CI): 0.25-0.56, P < 0.001). Patients were more likely to have chemotherapy omitted than escalated when using the RS (OR: 9.76, 95% CI: 6.72-14.18, P < 0.001). For those with stage II disease, concordant results between the 12-gene assay and MDT were more likely than discordant (OR: 0.30, 95% CI: 0.17-0.53, P < 0.001). In stage II disease, patients were more likely to have chemotherapy omitted than escalated when using the RS (OR: 7.39, 95% CI: 4.85-11.26, P < 0.001). CONCLUSIONS: The use of the 12-gene signature refutes the decision of tumour board in 25% of cases, with 75% of discordant decisions resulting in omission of adjuvant chemotherapy. Therefore, it is possible that a proportion of such patients are being overtreated when relying on tumour board decisions alone.

Survival and morbidity outcomes after pelvic exenteration for pelvic sarcoma: an institutional series.

BACKGROUND: To describe our institutional experience in the management of locally advanced primary, and recurrent pelvic sarcoma through pelvic exenteration (PE). METHODS: Patients undergoing PE for locally advanced primary or recurrent pelvic sarcoma between 2003 and 2017 were identified from a prospectively maintained database at a single quaternary referral hospital in Sydney, Australia were eligible for review. The primary outcomes measured were surgical resection margin and survival. Secondary outcome measures included 30-day morbidity, in hospital length of stay (LOS) and return to theatre. RESULTS: There were 29 patients who underwent PE for pelvic sarcoma during the study period, with 55% (n = 16) having advanced primary tumours and 45% (n = 13) having recurrent disease. The R0 resection rate was 52% (n = 15); and five-year-survival of 38% (n = 11). The R0 resection was noted to be higher in patients having primary advanced tumours (56%) compared to those with recurrent disease (46%), however this failed to reach statistical significance in this cohort. There was no recorded 30-day mortality. Grade 3 or higher Clavien-Dindo complications were uncommon (14%), but more likely in patients undergoing surgery for recurrent disease (75%). CONCLUSION: In our cohort of patients with locally advanced and recurrent disease, more than 50% achieved an R0 resection. Recurrent disease makes R0 resection more difficult and can lead to higher morbidity, need for 30-day re-intervention and longer in hospital LOS. PE surgery remains the only curative option for locally advanced, and recurrent sarcoma in the pelvis, and can be performed with acceptable survival and morbidity outcomes.

Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag?

BACKGROUND: Since the introduction of laparoscopic surgery for gallbladder disease different types of retrieval devices have been used to extract the gallbladder from the peritoneal cavity. These devises infer additional costs and may lead to associated risks and complications. We aimed to evaluate the safety of gallbladder retrieval without the use of a retrieval device. METHODS: A prospective study was conducted across two teaching hospitals in the Republic of Ireland from July 2010-2013. Patients undergoing planed elective day case laparoscopic cholecystectomy in the two institutions were included in the study. Data were collected on patient demographics, the use of a bag, any need for extension of fascial incision, any unexpected over night stay, any 30-day post operative complications and presence of port site hernia within 1 year surgery. RESULTS: There were 373 planned elective day case laparoscopic cholecystectomy performed during the study period. A bag was not used to retrieve the gallbladder in 41 % (n = 152) patients. A retrieval bag was used in the majority of patients (71 %) who required over night stay due to pain. Overall wound infection rate was low (2.4 %), with 57 % of those being in patients where no retrieval bag was used. An increase incision in the fascia was required in 9.7 % of patients. The majority of these were in patients in whom a retrieval bag was used (75 %). At 1 year follow up, there were no recorded cases of port site hernia for the no retrieval bag group and two (0.9 %) cases of umbilical port site hernias in the group where retrieval bag was used. CONCLUSION: In cases of elective uncomplicated laparoscopic cholecystectomy for radiologically confirmed benign disease there was no benefit in using a retrieval bag. Furthermore, not using a bag was associated with less need for increasing the size of the fascial incision thereby reducing post operative pain and risk of port site hernia.

Patients attitude towards surgeons attire in Our Lady of Lourdes Hospital Drogheda.

BACKGROUND: A doctor's competence and professionalism is often judged on the basis of attire. Our Lady of Lourdes (OLOL) is a leading Irish hospital in the implementation of Bare Below the Elbows (BBTE) policy, however surgical attire is not standardised and there is great variability in attire worn on wards. We aimed to evaluate patients attitude towards surgeons attire in OLOL. METHODS: A prospective survey of adult surgical in-patients was conducted from October 2013 to February 2014. A twelve-question questionnaire was used as data collection tool, using a five point Likert scale to assess patients response to each question. Data were collected on patient demographics, patients level of trust and confidence based on different surgical attire, and patients perception of different attire worn by surgical teams. RESULTS: There were 150 completed surveys during the study period with a male to female ratio of 44% to 56% respectively. The mean patient length of in-hospital stay (LOS) was 4.7 days (range 1-22). The most commonly represented age group was 30-40 years (18%), with a comparable spread among all age groups. The majority of patients found the attire worn by surgeons on the ward to be very appropriate (93%). Majority of responders believed scrubs to be the most appropriate attire for surgeons on wards (39%), followed by shirt and tie with white coat (38%) followed by short sleeved shirt and no tie (18%). Shirt and tie with white coat had a positive effect on patients trust in 63% of responders, a negative effect in 10% and no effect in 26%. Scrubs had a positive effect on patients trust in 63%, negative effect in 11% and no effect in 25%. Short sleeved shirt and no tie had a positive effect in 44%, negative effect in 25% and no effect in 30% of patients. CONCLUSION: Patients in OLOL find attire worn by surgeons to be appropriate. Shirt and tie with white coat or scrubs remains the patient's choice attire for surgeons. Shirt and tie with white coat or scrubs has a more positive effect on trust of patients compared to short sleeved shirt and no tie.

Diagnostic laparoscopy in a twelve year old girl with right iliac fossa pain: A life changing diagnosis of complete androgen insensitivity syndrome.

INTRODUCTION: Right iliac fossa (RIF) pain is one of the most common presenting complaints faced by general surgeons in the emergency department. Correct diagnosis and appropriate surgical intervention can often pose a challenge. PRESENTATION OF CASE: A 12-year-old girl presented to the emergency department with a four day history of initially central acute abdominal pain, now localised in the RIF. During laparoscopy, the following findings were made: macroscopically dilated appendix, right and left gonads at the internal opening of the inguinal canal, empty pelvis with a rudimentary uterus on the right side. No evidence of fallopian tubes or connection of uterus to the vagina and broad based, non-inflamed Meckel's diverticulum. An incidental diagnosis of complete androgen insensitivity syndrome was made. DISCUSSION: Androgen insensitivity syndrome (AIS) is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. CONCLUSION: This case report highlights the advantage of laparoscopy as a diagnostic and treatment tool in a twelve year old girl with multiple intra-abdominal findings. While the ultimate diagnosis responsible for her symptom of RIF pain was acute appendicitis, the additional diagnosis of CAIS and incidental Meckel's would have otherwise likely gone undetected.