Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial.

BACKGROUND AND OBJECTIVES: To investigate the feasibility of delivering a functional exercise-based prehabilitation intervention and its effects on postoperative length of hospital stay, preoperative physical functioning and health-related quality of life in elective colorectal surgery. MATERIALS AND METHODS: In this randomised controlled feasibility trial, 22 elective colorectal surgery patients were randomly assigned to exercise prehabilitation (n = 11) or standard care (n = 11). Feasibility of delivering the intervention was assessed based on recruitment and compliance to the intervention. Impact on postoperative length of hospital stay and complications, preoperative physical functioning (timed up and go test, five times sit to stand, stair climb test, handgrip dynamometry and 6-min walk test) and health-related quality of life were also assessed. RESULTS: Over 42% of patients (84/198) screened were deemed ineligible for prehabilitation due to insufficient time existing prior to scheduled surgery. Of those who were eligible, approximately 18% consented to the trial. Median length of hospital stay was 8 [range 6-27] and 10 [range 5-12] days respectively for the standard care and prehabilitation groups. Patterns towards preoperative improvements for the timed up and go test, stair climb test and 6-min walk test were observed for all participants receiving prehabilitation but not standard care. CONCLUSIONS: Despite prehabilitation appearing to convey positive benefits on physical functioning, short surgical wait times and patient engagement represent major obstacles to implementing exercise prehabilitation programmes in colorectal cancer patients.

Is sarcopenia a useful predictor of outcome in patients after emergency laparotomy? A study using the NELA database.

Introduction Studies have reported on the use of frailty as a prognostic indicator in patients undergoing elective surgery. Similar data do not exist for patients undergoing emergency surgery. The aim of this study was to evaluate the effect of preoperative sarcopenia measured by computed tomography (CT) on outcome following emergency laparotomy. Materials and methods Data from the National Emergency Laparotomy Audit database were retrieved for patients who had undergone an emergency laparotomy over 12 months at York NHS Foundation Trust. Sarcopenia was assessed by psoas density and area on preoperative CT. Mortality rates at 30 days and 1 year were recorded. Secondary outcomes included discharge rates to non-independent living. Results A total of 259 patients were included. Overall cohort 30-day and 1-year mortality was 13.9% (36/259) and 28.2% (73/259), respectively. Sarcopenia measured by psoas density was associated with increased mortality compared with patients who did not develop sarcopenia at 30 days (29.7%, 19/64, vs. 8.7%, 17/195; P < 0.001; odds ratio, OR, 4.42; 95% confidence interval, CI 2.13-9.26) and at 1 year (57.8%, 37/64, vs. 18.5%, (36/195; P < 0.001; OR 6.05; 95%CI 3.28-11.18). An increase in mortality was seen in patients with sarcopenia measured by psoas area at 30 days (21.3%, 13/61, vs. 9.1%, 17/187; OR 2.71; 95%CI 1.23-5.96, P = 0.013) and at 1 year (42.6%, 26/61, vs. 20.9%, 39/187; OR 2.82; 95% CI 1.52-5.23, P < 0.001). Conclusions Sarcopenia assessed by measurement of psoas density and area on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool merits further attention and may be useful in patients undergoing emergency surgery.

A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition.

BACKGROUND & AIMS: The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). METHODS: This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. RESULTS: Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p = 0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p = 0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p = 0.016). CONCLUSION: Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. TRIAL REGISTRATION: NCT01154179 TRIAL REGISTRY: http://clinicaltrials.gov/ct2/show/NCT01154179.

Impact of probiotics on colonic microflora in patients with colitis: a prospective double blind randomised crossover study.

BACKGROUND & AIMS: The aim of this study was to investigate the spectrum of colonic microflora in patients with colitis and if this could be altered with one month's treatment with synbiotics. METHODS: This was a pilot study in which patients were randomised to either receive a synbiotics preparation for a month and then "crossed over" to receive a placebo, or alternatively to receive the placebo first followed in the second month by synbiotic. Stool samples were collected on entry into the study and then at the end of first and second months respectively. Colonic microflora was measured by terminal restriction fragment length polymorphism technique. Quantitative PCR was used to determine the concentration of individual species. RESULTS: Sixteen patients completed the study of whom 8 had Crohn's colitis and 8 had ulcerative colitis. Their median age was 62 (IQR 50-65) years. An average of 22 terminal restriction fragments (T-RF's) was identified in each patient. Dice cluster analysis showed that each patient had a unique microbial composition which did not change significantly at different time points in the study, irrespective of whether they had probiotics or the placebo. Probiotic organisms were identified in stool samples but did not alter overall spectrum of microflora. In this pilot study we were unable to identify any specific characteristics related to nature of colitis. CONCLUSIONS: This study suggests that there is no difference in colonic microflora between patients with Crohn's or Ulcerative colitis and that the spectrum of bacteria was not altered by synbiotic administration.

Perioperative multimodal optimisation in patients undergoing surgery for fractured neck of femur.

INTRODUCTION: Enhanced Recovery after Surgery protocols are associated with reduced length of stay and morbidity in patients undergoing major surgery. The aim of this audit was to assess the impact of a multimodal optimisation protocol in patients admitted with fractured neck of femur. PATIENTS AND METHODS: A multimodal optimisation protocol was introduced for the care of patients with proximal femoral fractures. The short-term effects of the optimised perioperative care programme was assessed and compared with the conventional perioperative care before the intervention. RESULTS: A total of 232 patients were included in this audit, 117 optimised care and 115 conventional care. Patients were similar with regards to age, gender, domicile, mental status and the type of operation. The optimised group suffered from fewer post-operative complications (36 out of 117 vs 48 out of 115, P = 0.04, Chi square test). There was no significant difference between two groups with regards to the length of hospital stay and 30-day mortality. CONCLUSION: Multimodal optimisation may be associated with a decline in post-operative morbidity in patients with proximal hip fracture. It does not have any significant impact on the length of hospital stay and 30-day mortality.

Avoiding radical surgery after pre-operative chemoradiotherapy: a possible therapeutic option in rectal cancer?

BACKGROUND: In this modern era of multi-modality treatment there is increasing interest in the possibility of avoiding radical surgery in complete responders after neo-adjuvant long-course chemoradiotherapy (LCPRT). In this article, we present a systematic review of such treatments and discuss their therapeutic applicability for the future. METHODS: We searched the PubMed online libraries to identify studies that reported on the long-term surgical and pathological outcomes after local excision together with those that explored the possibility of clinical observation only in patients achieving a complete clinical response after LCPRT. RESULTS: Several retrospective (n = 10), one single-arm prospective, and one small randomised series have reported on the use of local excision after LCPRT and demonstrated acceptably low levels of local recurrence with survival comparable to patients progressing to conventional surgery. One prospective series allocated patients to observation or radical surgery based on histological parameters after local excision (ypT0 and ypT1) and showed no differences in outcomes. Two retrospective series from the same group on a Brazilian cohort of patients reported excellent long-term outcomes after "wait and watch" in complete clinical responders. However, other reports have shown no direct correlation between clinical and pathological response. CONCLUSION: Local excision may be an appropriate option for selected patients developing good clinical response after LCPRT. In our opinion, a policy of clinical observation in complete clinical responders after LCPRT may not be a safe strategy, unless we had robust predictive models for accurate identification of pathological complete response. In order to identify patients that may be potentially appropriate for such an approach we propose a clinical algorithm incorporating important clinical, radiological, and pathological parameters. The proposed model will require validation in a prospective study. Finally, we need randomised data for demonstrating the non-inferiority of clinical observation compared to conventional surgery before this can be considered as standard possible therapeutic option.

Colonoscopy in the octogenarian population: diagnostic and survival outcomes from a large series of patients.

OBJECTIVE: Our aim was to audit the diagnostic and survival outcomes of colonoscopy in octogenarians and to determine if it confers any survival benefit. METHODS: A review of a prospectively maintained database over a two year period between October 2005 and September 2007 was undertaken. Data on numerous outcome variables and survival were collected and analysed. Categorical variables were compared using the Chi-square test. Kaplan-Meier survival curves were constructed and log rank test were used to compare survival curves. RESULTS: There were 1905 patients, of which 289 (15%) were over the age of 80 years. Caecal intubation was significantly lower in octogenarians when compared with young patients (239/289, (82%) vs. 1411/1616 (88%), p = 0.025). The most common reason for failure to intubate the caecum was presence of stenosing pathology in distal bowel (octogenarians 46% (23 out of 50 failed intubations) vs. young 23% (49 out of 205 failed intubations), p = 0.002). A greater proportion of octogenarians had poor bowel preparation when compared with the young (20% vs. 13%, p = 0.001). Significantly more pathology was detected in octogenarians (72% vs. 59%, p = 0.001). Forty-four (15.2%) octogenarians were found to have malignancy. Of these, only 23 (52%) underwent subsequent surgery. Median survival of octogenarians who had surgery was not statistically better (31 (IQR 12-38) months vs. 16 (IQR 5-31) months, p = 0.10) than those who did not. CONCLUSION: Colonoscopy is safe in octogenarians and provides a high yield. Our results suggest that it does not appear to result in any survival benefit. However, to establish this, further research with larger cohorts and longer follow-up periods would be required.

Oxidative stress in laparoscopic versus open abdominal surgery: a systematic review.

BACKGROUND: Any form of trauma, including surgery, is known to result in oxidative stress. Increased intra-abdominal pressure during pneumoperitoneum and inflation-deflation may cause ischemia reperfusion and, hence, oxidative stress may be greater during laparoscopic surgery. The aim of this study was to systemically review the literature to compare oxidative stress in laparoscopic and open procedures. METHODS: A systematic search of the Medline, Pub Med, EMBASE, and Cochrane databases was performed with the following keywords: pneumoperitoneum AND surger $ OR laparoscop $ AND oxida $. The search was limited to articles published between 1980 and August 2010. RESULTS: The initial search identified 197 papers. After review of the abstracts, 17 papers met the inclusion criteria. Six more papers were identified through the reference lists. It was not possible to perform a meta-analysis due to heterogeneity of patient data, patient selection criteria, and diversity of biomarkers used. The majority of studies demonstrated greater immediate oxidative stress after open surgery. There was, however, a paucity of studies comparing open versus laparoscopic surgery with regards to tissue oxidative stress. CONCLUSION: Laparoscopic surgery seems to produce less systemic oxidative stress. However the effect of pneumoperitoneum on local oxidative stress and tissue hypoxia and its clinical significance need further investigation.

Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways has been shown to minimize the duration of hospital stay. The aim of this study was to identify which factors have the greatest impact at reducing the length of stay within an enhanced recovery programme. METHODS: A retrospective case note review of patients undergoing open elective colorectal resections between August 2007 and May 2009 was performed. Data on numerous pre, peri and postoperative variables were collected. Postoperative complications, readmissions, length of stay and fitness for discharge were recorded. Using logistic regression analysis, univariate and multivariate analysis of predictors for a shorter hospital stay was performed. Odd ratios and ninety-five percent confidence intervals were calculated and a p-value of less than 0.05 was significant. RESULTS: There were 231 patients, of which 130 were female. Median age was 68 (IQR 56-76) years. Median length of stay was 6 (IQR 5-9) days. On multivariate analysis, ASA grade (OR 2.85 (95%CI 1.17-6.89), p = 0.040), the avoidance of oral opiates in the postoperative period (OR 0.39 (95%CI 0.18-0.84), p = 0.016) and the duration of use of epidurals for postoperative analgesia (OR 0.44 (95%CI 0.12-0.94), p = 0.023) were found to be significant predictors of reduced hospital stay. CONCLUSION: Lower ASA grade, use of epidurals and avoidance of regular oral opiates are associated with an earlier discharge in an ERAS programme.

Early restoration of intestinal continuity in acute mesenteric ischaemia using Bishop-Koop stoma.

INTRODUCTION: Acute mesenteric ischaemia frequently requires extensive bowel resection. Primary anastomosis is unsafe necessitating exteriorisation of proximal small bowel and distal colon. Inevitably, therefore, patients are left with high output stomas with concomitant fluid and nutritional problems. SUBJECTS: We present two cases of acute mesenteric ischaemia both of which required extensive bowel resection. In both patients, we re-established intestinal continuity early by fashioning a Bishop-Koop type of reconstruction. RESULTS: Both patients had uneventful postoperative recoveries with no stoma-related complication or anastomosis problems. Neither patient required prolonged parenteral therapy. CONCLUSIONS: Bishop-Koop procedure may be used safely in a selected group of patients, with potential advantages of early restoration of intestinal continuity and easier closure.

Could pre-mortem computerised tomography scans reduce the need for coroner's post-mortem examinations?

INTRODUCTION: Post-mortem examinations may result in considerable distress to the bereaved family. This audit was undertaken to examine whether computerised tomography (CT) scanning prior to death might reduce the need for post-mortems without compromising the accuracy of recording the cause of death. SUBJECTS AND METHODS: The case notes of 100 consecutive patients who had a coroner's post-mortem, because the cause of death was unknown, were reviewed by four senior clinicians. Along with the likely cause of death, the clinicians gave their opinion as to whether a CT scan would have enabled certification of death without the need for a post-mortem. Concordance between the post-mortem findings and the clinical events surrounding death was explored. RESULTS: It would have been possible to perform a pre-mortem CT scan on 90 of the 100 patients. A pre-mortem CT scan would have given the cause of death in 59 (66%) of these. In 30 patients, the cause of death established by the post-mortem was at variance with the clinical events surrounding death and clinically relevant information, such as recent surgery, was not recorded on the death certificates of 26 patients. CONCLUSIONS: The use of a pre-mortem CT scan and involvement of senior clinicians in the process of establishing cause of death will improve the accuracy and may obviate the need for a post-mortem in some patients. However, if a post-mortem is needed, the clinical notes should always be available for the pathologists and a senior member of the patient's team should attend the post-mortem to help accurate death certification.

Current pattern of perioperative practice in elective colorectal surgery; a questionnaire survey of ACPGBI members.

INTRODUCTION: Enhanced recovery programmes (ERAS) are safe and have been shown to decrease the length of the hospital stay and complications following colorectal surgery. However implementation of ERAS requires dedicated resources. In addition, the practice of ERAS still varies between different surgeons and in different centres. AIM: The aim of this paper is to investigate the prevailing perioperative practice among members of the Association of Coloproctology of Great Britain and Ireland (APGBI). METHODS: A questionnaire was developed based on the principles of ERAS. The questionnaire was emailed to all members of the ACPGBI as extracted from the membership directory of the association of the year 2008. A postal questionnaire was subsequently sent to those who did not reply to the initial email. RESULTS: The response rate was 64%. Certain aspects of ERAS such as pre-operative information and assessment, intra-operative warming, avoidance of nasogastric tubes and drains and early initiation of fluid and solid food was in practice by majority of the surgeons. The routine use of bowel preparation for left sided colonic resections is in practice by nearly 60% of the surgeons. The use of carbohydrate loading prior to surgery has not been adopted by more than half of the surgeons. There was no difference between type of hospital and adherence to ERAS. Some surgeons tend to have a slightly different approach to perioperative care in open and laparoscopic surgery. CONCLUSION: Adherence to ERAS among colorectal surgeons is relatively high. Certain aspects of perioperative practice have potential for improvement. Practice of ERAS should be encouraged in both laparoscopic and open surgery.

ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications).

When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or - for limited period of time and with limitation in the osmolarity and composition of the solution - through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or - if planned for an extended or unlimited time - long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.