A review of trauma laparotomy at Christchurch Hospital.

AIM: Trauma is one of the leading causes for years of life lost in New Zealand. Its costs to acute care services alone amount to hundreds of millions per year, and it is the main contributor to years of life lost in patients under 40. Since 2016, the Canterbury Trauma Registry has been actively collecting data on all major traumas presenting to Christchurch hospital. This study will aim to define the demographics of trauma laparotomy patients presenting to Christchurch Hospital, and to assess the relationship between missed injuries (MI) on computed tomography (CT) imaging and time to theatre. METHODS: A retrospective study of trauma patient from June 2016 to February 2019. Data for major trauma patients were supplied from the Canterbury Trauma Registry. Data for minor trauma patients were individually selected from the online operative procedures registry. Non-parametric analysis was undertaken with an independent sample Kruskal-Wallis test alongside pairwise comparisons. RESULTS: Sixty trauma laparotomies were performed over 36 months, predominantly male gender (43/60) and under 40 years of age (39/60). Motor vehicle accident (31/60) and knife injuries (10/60) were the most common mechanisms. Fourty-three out of sixty patients received pre-operative CT scans. Fourty out of sixty patients received a CT scan within 2 hours. Large bowel injuries (four cases) and small bowel (three cases) were the most common missed injuries on pre-operative CT. Small bowel injuries are the predominate injury in blunt trauma while diaphragm and liver injuries predominated in penetrating trauma. Four patients did not undergo laparotomy within 24 hours. There is a statistically significant difference (p<0.001) in time to operating theatre between patients with no pre-operative CT and patients with no MI on CT and patients with MI on CT. There is no statistically significant difference (p<0.231) in time to operating theatre in patients with no MI on CT and patients with MI on CT. CONCLUSION: There is no statistically significant difference in time to operation between trauma laparotomy patients with no MI on pre-operative CT to patients with MI on pre-operative CT. There are recognisable injury patterns in trauma patients. There are delays in trauma patients receiving prompt CT imaging. CT imaging can miss life-threatening injury, close patient observation and further examination, and imaging or operative therapy may be required even if initial imaging is reassuring.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival.

BACKGROUND: Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC. METHODS: A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival. RESULTS: Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01). CONCLUSIONS: OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

Hinchey I and II diverticular abscesses: long-term outcome of conservative treatment.

BACKGROUND: The management of diverticular disease and its complications are an increasing burden to the health system. The natural history of conservatively managed diverticular abscesses (Hinchey I and II) is poorly described and it remains open to debate whether subsequent sigmoid resection is indicated after conservative management. This observational study compares outcomes of patients treated with conservative management (antibiotics +/- percutaneous drainage) and surgery. METHODS: All patients admitted at Christchurch Hospital with diverticulitis between 1 January 1998 and 31 December 2009 were recorded in a database. A retrospective analysis of patients with an abscess due to complicated diverticulitis was undertaken. Initial management, recurrence and subsequent surgery were recorded. The patients were followed until 1 January 2014. RESULTS: Of 1044 patients with diverticulitis, 107 with diverticular abscess were included in this analysis. The median age was 66 ± 16 and 60 were male. All patients had sigmoid diverticulitis and were diagnosed with a computed tomography. The median abscess size was 4.2 ± 2.1 cm. During median follow-up of 110 months, the overall recurrence rate was 20% (21/107). Recurrence varied according to initial treatment; namely antibiotics (30%), percutaneous drainage plus antibiotics (27%) and surgery (5%) (P = 0.004). The median time to recurrence was 4 ± 11.7 months, and most recurrences were treated conservatively; four patients underwent delayed surgery. CONCLUSION: Recurrence after diverticular abscess is higher after initial conservative treatment (antibiotics +/- percutaneous drainage) compared with surgery, however, patients with recurrent disease can be treated conservatively with similar good outcomes and few patients required further surgery.

Management of malignant colorectal polyps in New Zealand.

BACKGROUND: The management of colorectal polyps containing a focus of malignancy is problematic, and the risks of under- and over-treatment must be balanced. The primary aim of this study was to describe the management and outcomes of patients with malignant polyps in the New Zealand population; the secondary aim was to investigate prognostic factors. METHODS: Retrospective review of relevant clinical records at five New Zealand District Health Boards. RESULTS: Out of the 414 patients identified, 51 patients were excluded because of the presence of other relevant colorectal pathology, leaving 363 patients for analysis. Of these, 182 had a polypectomy, and 181 had a bowel resection as definitive treatment. The overall 5-year survival was not altered with resection but was improved with re-excision of any form (repeat polypectomy or bowel resection). There were 110 rectal lesions and 253 colonic lesions. A total of 16% of patients who had resection after polypectomy were found to have residual cancer in the resected specimen. Ischaemic heart disease, chronic obstructive pulmonary disease and metastatic disease were found to negatively impact overall survival (P < 0.001). Resection was more likely to follow polypectomy if polypectomy margins were positive, fragmentation occurred for sessile lesions and for pedunculated lesions with a higher Haggitt level. CONCLUSION: Polypectomy is oncologically safe in selected patients. Re-excision improves overall survival and should be considered in patients with low comorbidity (American Society of Anesthesiologists score 1 and 2) and where there is concern about margins (sessile lesions and positive polypectomy margins). In the majority of patients, however, no residual disease is found.

Giant villous adenoma presenting as McKittrick-Wheelock syndrome and pseudo-obstruction.

McKittrick-Wheelock syndrome is a rare but recognised complication of hypersecretory rectosigmoid villous adenoma. Fluid and electrolyte imbalances require close monitoring because of large-volume losses of water, sodium and potassium. We report an unusual presentation of the syndrome associated with the development of acute pseudo-obstruction of the colon, presumably due to electrolyte dysfunction and acute renal failure.

Pancreatic cancer: management and survival.

AIM: To review the management and survival from all pancreatic cancer over a 5-year period at a tertiary referral hospital in New Zealand and to examine similar outcome data from the national cancer registry. METHODS: A retrospective audit was conducted for the 5-year period 1994-99 of patients discharged from Christchurch Hospital (Christchurch, New Zealand) and all patients in the New Zealand Cancer Registry with a diagnosis of pancreatic cancer. Kaplan- Meier survival curves were used for analysis. RESULTS: From Christchurch Hospital a total of 230 patients were identified with a discharge diagnosis of pancreatic cancer. Medium survival for all groups was 3.9 months. There was a median survival of 1.6 months for the non-interventional group, 3.1 months for the stent group, 6.2 months for the bypass group and 12.6 months for the pancreatico-duodenectomy group. These data are very similar to the New Zealand National Cancer Registry data, where the overall median survival was 3.1 months and median survival for a pancreatico-duodenectomy was 13.9 months. CONCLUSION: A pancreatico-duodenectomy is usually a palliative surgical technique and not a curative procedure. Those selected for resection have been shown to have an advantage over operative bypass in terms of length of survival, however, this most likely reflects selection bias.

Surveillance for dysplasia in patients with inflammatory bowel disease: a national survey of colonoscopic practice in New Zealand.

BACKGROUND: Patients with chronic ulcerative colitis and Crohn's colitis have an increased risk of colorectal cancer. Because of this, surveillance colonoscopy is practiced. AIMS: We aimed to describe the practice of surveillance colonoscopy in New Zealand, with comparison among specialties, and with practice internationally. SUBJECTS: New Zealand colonoscopists (both physicians and surgeons) looking after patients with inflammatory bowel disease were surveyed to evaluate attitudes about surveillance colonoscopy and ways in which colonoscopy results are interpreted. METHODS: A postal survey assessed the colonoscopist's understanding of how and why surveillance colonoscopy is undertaken and their interpretation of the results from such evaluations. RESULTS: Of the 196 physicians and surgeons surveyed, 180 responded (92 percent). Sixty responses were excluded. Only 24 of 120 respondents (20 percent) correctly defined dysplasia. The median number of biopsies taken at colonoscopy was 17. Eighty of 120 (67 percent) and 77 of 120 (64 percent) doctors underestimate the risk of invasive malignancy if low-grade or high-grade dysplasia, respectively, is identified. The colectomy referral rate for dysplasia-associated lesion or mass was 115/120 (96 percent); that for high-grade dysplasia was 110/120 (92 percent); and that for low-grade dysplasia was 26/120 (22 percent). Thirty of 120 (25 percent) doctors offer patients the option of colectomy after 20 years of colitis. Seventy of 120 (58 percent) doctors sought the opinion of a second pathologist if dysplasia was found. There were differences in responses between specialist groups, with colorectal surgeons most likely to correctly define dysplasia and appreciate the significance of low-grade dysplasia. CONCLUSIONS: Many New Zealand colonoscopists have a poor understanding of the definition and importance of dysplasia associated with colitis. Although colectomy referral rates are higher in this study than in similar studies, low-grade dysplasia is often not referred for colectomy. Improved education may improve surveillance practice.