Right and Transverse Colonic Multi-Visceral Resections for Locally Advanced Cancers-a Single-Center Experience.

Locally advanced colorectal tumors constitute to about 5-22% of all colorectal cancers at the time of presentation. Multi-visceral resection is usually required for such cases in order to achieve curative resection (R0). We aim to present our experience of right and transverse colonic en bloc resections and their outcomes. Retrospective review of a prospective database between February 2008 and December 2014. Case notes, operative findings, histopathology results, and follow-up records were analyzed. A total of 23 patients underwent en bloc multi-visceral resections for locally advanced right-sided or transverse colonic cancers. There were 11 males and 12 females. The mean age was 75 years. Fifteen patients were operated electively and eight were done as emergency. Median follow-up was 36 months. Eleven out of 23 (47%) had more than one organ resected. 78.3% had R0 resections, 17.4% were R1, and 4.3% were indeterminate. The average lymph node yield was 22 [range 5-45]. Senior trainees under supervision did 65% of procedures. Twelve-month disease-free survival was 90% and the 5-year survival was 65%. Right-sided and transverse colonic tumors have a propensity to become locally advanced making curative resections challenging. This is especially relevant when these patients present as an emergency or if the surgeon is less experienced and may opt for a palliative procedure, thus leading to suboptimal outcomes. Multi-visceral resections for locally advanced tumors can be feasible in the district general hospital setting with acceptable outcomes. Multi-disciplinary meeting (MDM) process, adequate training, and experience are vital.

Patient-related factors influence the risk of developing intestinal stoma complications in early post-operative period.

BACKGROUND: Few studies have investigated the risk factors associated with developing intestinal stoma complications using appropriate multivariable methods. We aimed to determine the prevalence of, and risk factors for, stomal complications. METHODS: A retrospective, case-control methodology was used to investigate 12 explanatory variables and four outcome variables in 202 consecutive patients receiving stomas in a district general hospital in the United Kingdom between January 2013 and December 2014. Univariable and multivariable logistic regression were used to calculate odds ratios (ORs). RESULTS: There were 69 complications (69/202; 34.2%) in the early post-operative period (median 12 months) in total, the most common being retraction (30.4%). Performance status (World Health Organization score 1 or more; OR 2.67; 95% confidence intervals (CIs) 1.33-5.33; P = 0.006) and body mass index (>30 kg/m2 ; OR 3.30; 95% CIs 1.61-6.78; P = 0.001) were significantly associated with developing complications in multivariable analysis. Surgery-related risk factors, such as time of day or week of operation and grade of surgeon, were not associated with the development of stoma complications. Thirty-eight patients (18.8%) died over the follow-up period, but mortality was not related to the development of stoma complications (1.01; 0.48-2.13, P = 0.98). CONCLUSION: Patient-related risk factors influence the risk of developing a stoma complication more than surgery-related risk factors. Preoperative and post-operative interventions, planning, vigilance and management should be focussed to at-risk groups, particularly obese patients.

A review of risk scoring systems utilised in patients undergoing gastrointestinal surgery.

INTRODUCTION: Adequate stratification and scoring of risk is essential to optimise clinical practice; the ability to predict operative mortality and morbidity is important. This review aims to outline the essential elements of available risk scoring systems in patients undergoing gastrointestinal surgery and their differences in order to enable effective utilisation. METHODS: The English literature was searched over the last 50 years to provide an overview of systems pertaining to the adult surgical patient. DISCUSSION: Scoring systems can provide objectivity and mortality prediction enabling communication and understanding of severity of illness. Incorporating subjective factors within scoring systems can allow clinicians to apply their experience and understanding of the situation to an individual but are not reproducible. Limitations relating to obtaining variables, calculating predicted mortality and applicability were present in most systems. Over time scoring systems have become out-dated which may reflect continuing improvement in care. APACHE II shows the importance of reproducibility and comparability particularly when assessing critically ill patients. Both NSQIP in the USA and P-POSSUM in the UK seem to have many benefits which derive from their comprehensive dataset. The "Surgical Apgar" score offers relatively objective criteria which contrasts against the subjective nature of the ASA score. CONCLUSION: P-POSSUM and NSQIP are comprehensive but are difficult to calculate. In the search for a simple and easy to calculate score, the "Surgical Apgar" score may be a potential answer. However, more studies need to be performed before it becomes as widely taken up as APACHE II, NSQIP and P-POSSUM.

Sinus excision, release of coccycutaneous attachments and dermal-subcuticular closure (XRD procedure): a novel technique in flattening the natal cleft in pilonidal sinus treatment.

INTRODUCTION: The objective of this study was to analyse, prospectively, the outcome of a new technique - excision of pilonidal sinus and flattening the natal cleft by division of the coccycutaneous attachments at the lower end of the incision. PATIENTS AND METHODS: Sixty-six consecutive patients with chronic pilonidal sinuses were treated between 1995 and 2001. The procedure consisted of an elliptical, wide, local excision, release of the coccycutaneous attachments and primary closure using dermal-subcuticular closure (XRD). Suction drains were used until drainage was minimal. The height of skin level at the lower angle of the wound from the coccyx was measured intra-operatively before and after division of the coccycutaneous attachments. Postoperatively, patients were assessed for hospital stay, return to normal activity, complications and recurrence. RESULTS: Sixty-four patients (97%) were males, median age 27 years. The height of skin level rose from a mean of 1.8 cm (95% CI, 1.78-1.85) to a mean of 3.8 cm (95% CI, 3.77-3.88; P < 0.001). Morbidity affected 12 patients (18%), epidermal separation of the lower wound angles (6 patients), seromas (5 patients) and 1 wound dehiscence at 2 weeks. All other wounds healed primarily without dehiscence. There were no recurrences after a median follow-up of 22.5 months (range, 12-38 months). CONCLUSIONS: Release of the coccycutaneous attachments is an easy technique to learn, which seems to be an effective way of flattening the natal cleft and may result in lower recurrence rate. This technique should be tried in uncomplicated pilonidal sinus disease before more complex procedures are attempted.

Digital assessment of lower rectum fixity in rectal prolapse (DALR): a simple clinical anatomical test to determine the most suitable approach (abdominal versus perineal) for repair.

Selection of an appropriate approach to treat full thickness rectal prolapse remains problematic and controversial. We propose that rectal prolapse may be classified as 'low type' (true rectal prolapse) or 'high type' (intussusception of the sigmoid with a fixed lower rectum). This assessment can be made via a simple clinical test of digital rectal assessment of lower rectal fixity ('the hook test') based on anatomic changes in rectal prolapse to guide the selection process. In cases with the low-type prolapse, a perineal approach is appropriate (either Delorme's procedure, or rectosigmoidectomy with or without pelvic floor repair). For the high type, an abdominal rectopexy with or without high anterior resection is needed. Retrospective analysis of our cases treated over the last 6 years showed a recurrence rate of 6% in perineal procedures and 0% in abdominal rectopexy combined with resection to date. We believe that employing our simple test and classification can contribute to better patient selection for either approach, minimize anaesthetic and surgical risks and also result in lower recurrence rates.

Colorectal cancer in Egypt.

PURPOSE: The aim of this study was to review the age distribution and pathology features of colorectal cancer in Egypt. METHODS: A seven-year review (retrospective in first six years, prospective in the seventh) of all colorectal adenocarcinoma patients (N = 177; 104 males; mean age, 46; range, 19-74 years) presented to the Department of Surgery, Ain Shams University, was performed. Data from three other major hospitals throughout the country were retrieved and compared with Ain Shams data. Retrospective data were retrieved from patients' files and surgery and pathology records. Family history of colorectal cancer and other characteristic hereditary nonpolyposis colorectal cancer tumors was obtained prospectively in all patients. RESULTS: According to Ain Shams data, the disease had no predilection to a specific age group. Thirty-eight percent of the tumors occurred in patients aged less than 40 years, and only 15 percent of patients were aged above 60 years. None of the young patients fulfilled the Amsterdam criteria for hereditary nonpolyposis colorectal cancer. Seventy-five percent of tumors occurred in the left side, 3 percent were Dukes A, and 58 percent were Dukes C. Synchronous and metachronous tumors occurred in 2.8 and 4.5 percent of patients, respectively. Adenomas were present in 5.6 percent of patients and bilharziasis in 3.4 percent of resection specimens. Data from different centers were remarkably similar to Ain Shams results. CONCLUSION: Colorectal cancer in Egypt has no age predilection and more than one-third of tumors affects a young population. The high prevalence in young people can neither be explained on a hereditary basis nor can it be attributed to bilharziasis. The disease usually presents at an advanced stage, and predisposing adenomas are rare. Similarity of the data from different centers suggests that this is the picture of colorectal cancer typical of Egypt.