Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand.

BACKGROUND: Small intestinal Neuroendocrine Neoplasms (SI-NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI-NEN in Auckland, Aotearoa New Zealand (AoNZ). METHODS: A retrospective study of all patients diagnosed with a jejunal or ileal SI-NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data. RESULTS: One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10-year disease-specific survival for all patients was 66.1% (95% CI 56.5-75.7%) and 61.8% (95% CI 51.8-71.8%), respectively. Ten-year disease-specific survival was 100% for stage I and II, 74% (95%CI 61.7-84.4%) for stage III and 33.9% (95%CI 16.9-35.6%) for stage IV SI-NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92-5.5) nor distant resection (HR 1.72, 95% CI 0.63-4.7) were significantly associated with a disease-specific or overall survival benefit. CONCLUSION: This study demonstrates that stage at SI-NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.

Impact of Clinical Data Veracity on Cancer Genomic Research.

Genomic analysis of tumors is transforming our understanding of cancer. However, although a great deal of attention is paid to the accuracy of the cancer genomic data itself, less attention has been paid to the accuracy of the associated clinical information that renders the genomic data useful for research. In this brief communication, we suggest that omissions and errors in clinical annotations have a major impact on the interpretation of cancer genomic data. We describe our discovery of annotation omissions and errors when reviewing an already carefully annotated colorectal cancer gene expression dataset from our laboratory. The potential importance of clinical annotation omissions and errors was then explored using simulation analyses with an independent genomic dataset. We suggest that the completeness and veracity of clinical annotations accompanying cancer genomic data require renewed focus by the oncology research community, when planning new collections and when interpreting existing cancer genomic data.

Stapled versus handsewn methods for ileocolic anastomoses.

BACKGROUND: Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007. OBJECTIVES: To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY: MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS: Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS: After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS: Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

Using animated visualization to improve postoperative mobilization: A randomized controlled trial.

OBJECTIVE: Enhanced recovery after surgery (ERAS) programs fast-track recovery for surgical procedures, including colorectal and gynecological oncology surgery. Early mobilization is a postoperative ERAS module that can be self-managed by patients, but poor adherence is common. Visualization is increasingly being used to improve patient understanding and adherence to health behaviors. This study tested whether an animated visualization intervention could improve adherence to postoperative mobilization. METHOD: Ninety six colorectal and gynecological oncology surgery patients were randomized to intervention, active control, or standard care groups. Intervention participants saw an animated intervention on a computer tablet at Day 1 postsurgery. All participants wore fitness trackers from day of discharge to 7 days postdischarge, and completed psychological measures at baseline, Day 1 postsurgery, and 7 days postdischarge. RESULTS: Step count data was available for 57 colorectal surgery participants. A main effect of group demonstrated that intervention participants had a significantly higher average daily step count from discharge across the week following discharge (Madj = 2,294.60, 95% confidence interval [CI] [1,746.11, 2,744.89]) compared with control participants (Madj = 1,347.25, 95% CI [826.51, 1,871.20]; p = .05). At postsurgery, intervention participants reported significantly greater perceived quality of recovery and less difficulty in being mobile compared with control participants. There were no between-group differences in self-reported exercise or perceptions of surgery and recovery. CONCLUSION: This brief intervention appears effective in improving perceptions of early mobilization, and initial evidence suggests improvements in adherence to postsurgical mobilization. This intervention has high clinical applicability and could be incorporated into postoperative standard care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Design and validation of a comprehensive fecal incontinence questionnaire.

PURPOSE: Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise. METHODS: Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion. RESULTS: The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35-1). CONCLUSIONS: This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.

Multiple gene expression classifiers from different array platforms predict poor prognosis of colorectal cancer.

PURPOSE: This study aimed to develop gene classifiers to predict colorectal cancer recurrence. We investigated whether gene classifiers derived from two tumor series using different array platforms could be independently validated by application to the alternate series of patients. EXPERIMENTAL DESIGN: Colorectal tumors from New Zealand (n = 149) and Germany (n = 55) patients had a minimum follow-up of 5 years. RNA was profiled using oligonucleotide printed microarrays (New Zealand samples) and Affymetrix arrays (German samples). Classifiers based on clinical data, gene expression data, and a combination of the two were produced and used to predict recurrence. The use of gene expression information was found to improve the predictive ability in both data sets. The New Zealand and German gene classifiers were cross-validated on the German and New Zealand data sets, respectively, to validate their predictive power. Survival analyses were done to evaluate the ability of the classifiers to predict patient survival. RESULTS: The prediction rates for the New Zealand and German gene-based classifiers were 77% and 84%, respectively. Despite significant differences in study design and technologies used, both classifiers retained prognostic power when applied to the alternate series of patients. Survival analyses showed that both classifiers gave a better stratification of patients than the traditional clinical staging. One classifier contained genes associated with cancer progression, whereas the other had a large immune response gene cluster concordant with the role of a host immune response in modulating colorectal cancer outcome. CONCLUSIONS: The successful reciprocal validation of gene-based classifiers on different patient cohorts and technology platforms supports the power of microarray technology for individualized outcome prediction of colorectal cancer patients. Furthermore, many of the genes identified have known biological functions congruent with the predicted outcomes.

Resection of peritoneal metastases causing malignant small bowel obstruction.

BACKGROUND: Resection of peritoneal metastases has been shown to improve survival in patients with abdominal metastatic disease from abdominal or extra abdominal malignancy. This study evaluates the benefit of peritoneal metastatic resection in patients with malignant small bowel obstruction and a past history of treated cancer. PATIENTS AND METHODS: Patients undergoing laparotomy for resection of peritoneal metastases from recurrence of previous cancer between 1992-2003 were reviewed retrospectively. Data were collected about type of primary cancer, interval to recurrence, extent of the disease and completeness of resection, morbidity and mortality and long-term survival. RESULTS: Between 1992 and 2003 there were 79 patients (median age 62, range 19-91) who had laparotomy for small bowel obstruction due to recurrent cancer. The primary cancer was colorectal (31), gynaecologic cancer (19), melanoma (16) and others (13). Overall, the rate of complications was 35% and mortality was 10%. Median survival was 5 months; patients with history of colorectal cancer had better survival than other cancer (median survival 7 months vs. 4 months; p = 0.02). Multivariate analysis showed that the extent of recurrent disease was the only factor that affected overall survival. CONCLUSION: Laparotomy for small bowel obstruction is a worthwhile option for patients with malignant small bowel obstruction. Although it is associated with significant morbidity and mortality it offers a reasonable survival benefit in particular for patients with completely resectable disease.

Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk.

BACKGROUND: Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis. METHODS: A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated. RESULTS: The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn's disease (OR = 3.3), rectal cancer < or =12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01). CONCLUSIONS: Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision-making regarding defunctioning stoma formation.

Stapled hemorrhoidectomy.

The procedure of stapled hemorrhoidectomy has been established as a safe and effective method for treating symptomatic hemorrhoids not responsive to more conservative measures. This chapter discusses the issues of safety, efficacy, durability, and cost of this procedure. In addition, we outline techniques for performing the procedure safely and effectively.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy.

BACKGROUND: The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP. METHODS: All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones. RESULTS: A total of 112 patients had successful preoperative ERCP. Sixty-one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin > or = 3 days (P = 0.002), serum alkaline phosphatase > or = 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter > or = 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for > or = 3 days and CBD diameter > or = 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%. CONCLUSIONS: The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.

Pathological reporting of malignant colorectal polyps.

AIM: The pathological reporting of malignant colorectal polyps plays an important role in determining whether definitive surgical resection is required following endoscopic polypectomy. This study aims to assess the adequacy of reporting on malignant polyp specimens at Auckland Hospital and whether synoptic reporting results in an improvement. METHOD: The pathology database at Auckland Hospital was accessed using a search strategy to identify all malignant polyps diagnosed between 1999 and 2011. Pathology reports were reviewed retrospectively. RESULTS: In total 121 malignant polyps were found. Of these, 73 were colonoscopic polypectomies, 41 were colectomy specimens, and seven transanal resections. Of the 41 colectomy specimens, 19 (46%) were reported in synoptic format compared with none of the colonoscopic polypectomies or transanal resections. The status of the margin of excision, differentiation, and presence of lymphovascular invasion were given in 100% of synoptic reports compared with 51% of non-synoptic reports. CONCLUSION: Synoptic reporting does improve the completeness of pathological reporting in malignant colorectal polyps. Currently none of the colonoscopically excised malignant polyps are reported in this format at Auckland Hospital. The development and routine use of a synoptic system for reporting on malignant polyps would give clinicians more information on which to base decisions.

Early ileostomy closure: is there a downside?

BACKGROUND: A loop ileostomy is a common adjunct to formation of a low colorectal anastomosis. However, it is not without significant physical and psychological morbidity, and financial cost. Feasibility of early closure during the index admission has previously been reported. This pilot study examines the safety of early closure compared with traditional timing. METHODS: A retrospective audit of consecutive ileostomy closures performed in a tertiary colorectal unit from January 2008 to January 2010. Demographic data, treatment data and complications were collected by a single investigator from a prospective clinical audit database and hospital records. Patients undergoing early closure (within 10 days of the index operation) were compared with the traditional timing group. RESULTS: A total of 93 patients underwent closure of loop ileostomy during the study period (44 female; 49 male). Median patient age was 61 years. Nineteen patients (20%) underwent early closure. There were six wound infections in the early closure group (32%), and five in the traditional timing group (7%) (P = 0.01). There was no significant difference in other complications between the two groups. There was a significantly shorter overall hospital stay in the early closure group with a median stay of 14 days (range 10-26), and in the traditional timing group a median stay of 17 days (range 7-80) (P = 0.05). Seven patients (9%) in the traditional timing group had ileostomy-related complications. CONCLUSION: Early ileostomy closure appears to be associated with an increased wound infection rate but otherwise appears to be a safe alternative to traditional closure in selected patients and may reduce overall hospital stay.

Great expectations: use of molecular tests and computerised prognostic tools in New Zealand cancer care.

BACKGROUND: Use of molecular tests and computerised prognostic tools designed to individualise cancer care appears to be rapidly increasing in New Zealand. These tests have important clinical and health economic implications, but their impact on cancer care has not been fully assessed. AIM: To determine cancer clinicians' use of and expectations for molecular tests and computerised prognostic tools. METHOD: Online survey of clinicians managing cancer in New Zealand. RESULTS: 137 clinicians participated, 31% used molecular tests and 57% used computerised prognostic tools. These technologies affected clinical decisions made by a quarter of participants. Over 85% of participants believed that the impact of molecular tests and computerised prognostic tools would increase over the next decade and that a stronger evidence base would support their use. CONCLUSIONS: Molecular tests and computerised prognostic tools already influence treatment provided to many New Zealand cancer patients. Clinicians who participated in this survey overwhelmingly expect the use of these tests to increase, which has important clinical implications since there is little high quality prospective data assessing the ability of these tests to improve patient outcomes. Expanded use of these often-expensive tests also has economic implications. The role of these technologies needs to be considered in the context of a wide-ranging cancer control strategy.

Dietary patterns and information needs of colorectal cancer patients post-surgery in Auckland.

AIM: To test the feasibility of collecting dietary data from colorectal cancer (CRC) patients in Auckland, New Zealand and to investigate their dietary information needs post-surgery, in terms of current information sources and satisfaction. METHODS: A food frequency questionnaire was used to collect information on the dietary intake and patterns of patients who had undergone surgical resection of CRC in the Auckland region. Dietary intakes were compared to the Ministry of Health Food and Nutrition Guidelines for Adult New Zealanders (FNG-MoH) along with other publications of dietary patterns in patients with CRC. Participants were also asked to report on what dietary information they received and their satisfaction with this information. RESULTS: Thirty participants completed the survey. Sixty-seven percent and 50% of participants met the recommended daily servings of fruit and vegetables respectively in the FNG-MoH. Four distinct dietary patterns were described for the study population. Over 50% of participants indicated that they did not receive any dietary information after surgery. CONCLUSION: We were able to collect dietary information from this patient group, and this demonstrated that a significant proportion of the study population did not meet the FNG-MoH guidelines for recommended daily fruit and vegetable servings, and that there is an unmet information need in this patient group.

The colorectal cancer patients' journey: the Auckland region.

AIM: To identify the time taken from referral to first treatment of patients with colorectal cancer (CRC) in the Auckland region and benchmark these against available guidelines for timeliness. METHOD: Retrospective study of clinical records of all patients diagnosed with CRC identified from the national registry and Auckland regional databases in the years 2001 and 2005. Data extracted included demographics, dates and types of interventions and the patient journey from referral to initiation of first treatment. RESULTS: Of the 1128 patients diagnosed and treated in these cohorts, 68% were referred through their general practitioner and 58% saw a surgeon at their first specialist appointment. Seventy-nine percent received initial treatment with curative intent. The median time from initial referral to first treatment was 35 days, with only 68% of patients being treated within 62 days of initial referral. CONCLUSION: The colorectal patient journey is complicated by multiple pathways of presentation and treatment and by patient choice. These factors need to be considered when assessing the acceptability of transit times based on summary data. That nearly one-third of patients did not complete the United Kingdom-based target of 62 days from referral to first treatment indicates there is a need for further improvement in service delivery for patients developing CRC in the Auckland region.

Complex anal fistulas: plug or flap?

BACKGROUND: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. METHODS: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. RESULTS: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. CONCLUSIONS: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.

Benchmarking home parenteral nutrition in Scotland and New Zealand: disparities revealed.

AIM: Home parenteral nutrition (HPN) remains the treatment of choice for severe intestinal failure. These patients are few in number but consume significant resource in funding and personnel. Patients receiving HPN in Scotland and New Zealand (NZ) are both tracked through HPN registers which enable clinical audit for identifying important variations in practice. Scotland and NZ have similar demographics, healthcare systems, and populations (Scotland 5.1 million, NZ 4.1 million). METHODS: The HPN registers for Scotland and New Zealand for 2005 were examined for patients who received HPN during 2005 together with the diagnostic category identified (ICD-10) that resulted in provision of HPN. RESULTS: The diagnostic categories for the 2005 HPN patients were similar in both countries but rates of provision were much higher in Scotland (71 patients vs 14 patients). CONCLUSIONS: Despite similar demographics, healthcare systems, and population size, HPN is utilised to a significantly lesser extent in NZ. The reasons for this are not clear. However, it is possible that there is a lack of recognition of the need for HPN and/or under provision of HPN, which may lead to poorer treatment outcomes.

The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature.

PURPOSE: Reported prevalence estimates for fecal incontinence among community-dwelling adults vary widely. A systematic review was undertaken to investigate the studied prevalence of fecal incontinence in the community and explore the heterogeneity of study designs and sources of bias that may explain variability in estimates. METHODS: A predetermined search strategy was used to locate all studies published that reported the prevalence of fecal incontinence in a community-based sample of adults. Data were extracted onto a proforma for sampling frame and method, sample size, response rate, definition of fecal incontinence used, data-collection method, and prevalence rates. Included studies were critically appraised for possible sources of selection bias, information bias, and imprecision. RESULTS: A total of 16 studies met the inclusion criteria. These could be grouped into definitions of incontinence that included or excluded incontinence of flatus. The estimated prevalence of anal incontinence (including flatus incontinence) varied from 2 to 24 percent, and the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4 to 18 percent. Only three studies were found to have a study design that minimized significant sources of bias, and only one of these used a validated instrument for data collection. The prevalence estimate of fecal incontinence from these studies was 11 to 15 percent. No pooling of estimates was undertaken because there was wide variation in study design. CONCLUSIONS: A consensus definition of fecal incontinence is needed that accounts for alterations in quality of life. Further cross-sectional studies are required that minimize bias in their design and use validated self-administered questionnaires.