Rectal trauma injuries: outcomes from the U.S. National Trauma Data Bank.

BACKGROUND: There is a  lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. METHODS: Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. RESULTS: Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality. CONCLUSIONS: Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.

Potentiating the effects of radiotherapy in rectal cancer: the role of aspirin, statins and metformin as adjuncts to therapy.

BACKGROUND: Complete tumour response (pCR) to neo-adjuvant chemo-radiotherapy for rectal cancer is associated with a reduction in local recurrence and improved disease-free and overall survival, but is achieved in only 20-30% of patients. Drug repurposing for anti-cancer treatments is gaining momentum, but the potential of such drugs as adjuncts, to increase tumour response to chemo-radiotherapy in rectal cancer, is only just beginning to be recognised. METHODS: A systematic literature search was conducted and all studies investigating the use of drugs to enhance response to neo-adjuvant radiation in rectal cancer were included. 2137 studies were identified and following review 12 studies were extracted for full text review, 9 studies were included in the final analysis. RESULTS: The use of statins or aspirin during neo-adjuvant therapy was associated with a significantly higher rate of tumour downstaging. Statins were identified as a significant predictor of pCR and aspirin users had a greater 5-year progression-free survival and overall survival. Metformin use was associated with a significantly higher overall and disease-free survival, in a subset of diabetic patients. CONCLUSIONS: Aspirin, metformin and statins are associated with increased downstaging of rectal tumours and thus may have a role as adjuncts to neoadjuvant treatment, highlighting a clear need for prospective randomised controlled trials to determine their true impact on tumour response and overall survival.

Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme.

AIM: The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision. METHOD: Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score (GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire. RESULTS: Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC. CONCLUSION: Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure.

Comparison of single-incision laparoscopic high anterior resection with standard laparoscopic high anterior resection.

AIM: Single-incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS). METHOD: Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS. RESULTS: Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three-port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2-24) h for SILS vs 18 (2-96) h for StdLS] and were discharged faster [1 (1-8) days for SILS vs 3 (1-24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30-day mortality. CONCLUSION: SILS for high anterior resection is feasible, safe and quicker to perform than standard three-port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.

Enhanced recovery after laparoscopic colorectal resection with primary anastomosis: accelerated discharge is safe and does not give rise to increased readmission rates.

AIMS: Enhanced recovery programmes after colorectal surgery are promoted to minimize complications and expedite recovery, thus reducing length of hospital stay where appropriate and improving the overall standard of patient care. There are few published trials of enhanced recovery programmes in the context of laparoscopic colorectal surgery. METHODS: Data were prospectively collected on all laparoscopic colorectal resections carried out in our institution from May 2004 to November 2009. An informal move to 48-h discharge was introduced in May 2004 and the official enhanced recovery programme was launched in November 2008. We identified all patients with a primary anastomosis discharged within 3 days of surgery. Early outcomes - leaks, complications, readmission rates and returns to theatre - were analysed. RESULTS: In all, 606 resections were performed in this period. Median length of stay was 4 (0-52) days. Of these patients, 279 (46%) met the criteria of accelerated discharge by day 3: 2 (0.7%) were discharged on the day of surgery, 70 (25.1%) within 24 h, 116 (41.6%) within 48 h and 91 (32.6%) by 72h. Age was not a significant factor in determining length of stay. Patients undergoing right hemicolectomy were more likely to be discharged by 24 h than those with left-sided anastomoses, and patients having total mesorectal excision resections were more likely to stay 3 days. The readmission rate was 4%, regardless of day of discharge. CONCLUSION: Accelerated discharge is feasible and safe. High readmission rates reported in enhanced recovery programmes after open colorectal surgery have not occurred in our laparoscopic experience.

Laparoendoscopic single-site surgery is feasible in complex colorectal resections and could enable day case colectomy.

BACKGROUND: Fast-track surgery accelerates recovery, reduces morbidity, and shortens hospital stay. However, the benefits of laparoscopic versus open surgery remain unproven within a fast-track program. Case reports of laparoendoscopic single-site (LESS) colectomies are appearing with claims of cosmetic advantage and decreased parietal trauma. This report describes the largest case series of LESS colorectal surgery and its effects on recovery. METHODS: In this series, 20 consecutive unselected patients underwent LESS colorectal surgery including right hemicolectomy (n = 3), extended right hemicolectomy, high anterior resection (n = 2), low anterior resection involving total mesorectal excision (TME; n = 3), ileocolic anastomosis (n = 2, including 1 redo surgery), colectomy and ileorectal anastomosis (n = 4, including 1 with ventral mesh rectopexy), panproctocolectomy (n = 2), proctocolectomy and ileoanal pouch (n = 2) and an abdominoperineal excision of rectum. Single-port conventional instrumentation and transversus abdominus plane (TAP) block analgesia were used. The indications included cancer (n = 8), Crohn's disease (n = 4), ulcerative colitis (n = 3) complicated diverticulosis (n = 2), and slow-transit constipation (n = 3). Eight of the patients had undergone previous surgery. RESULTS: Most of the cases (90%) were managed successfully using the LESS technique and conventional instrumentation. Two operations (10%) were converted to standard laparoscopy, due to insufficient theater time and an unstable port. The operative time ranged from 45 to 240 min (median, 110 min). A normal diet was tolerated within 6 h by 7 patients and in 12 to 16 h (overnight) by 11 patients. Complications included anastomotic bleed (n = 1), ileus (n = 2), acute renal failure secondary to hyperphosphatemia and hypocalcemia (n = 1), urine retention (n = 1), and wound infection (n = 1). The median hospital stay was 46 h (range, 7-384 h). Eight patients were discharged within 24 h. There was one readmission (5%). CONCLUSION: Laparoendoscopic single-site colorectal resection using conventional instrumentation is feasible and safe when performed by an experienced team. The LESS approach may have advantages in terms of minimal pain, cosmesis, lower costs, and faster recovery. A randomized trial is required to confirm whether LESS offers a true patient benefit over standard laparoscopic resection.

Single incision laparoscopic (SILS) restorative proctocolectomy with ileal pouch-anal anastomosis.

BACKGROUND: Restorative proctocolectomy with ileoanal pouch is the definitive procedure in ulcerative colitis. The potential benefits afforded by a single incision laparoscopic (SILS) approach make it appropriate to consider. METHODS: Electronic data were prospectively collected from all patients who underwent SILS restorative proctocolectomy (SILS-RPC) between June 2009 and June 2010. RESULTS: Ten consecutive patients (4 male), with median BMI = 22 (range = 20-28 kg/m(2)) underwent SILS-LRPC over a 1-year period. Three had undergone a previous emergency laparoscopic colectomy. A single-port device (Covidien SILS™ or Olympus TriPort™) was positioned at the site of the existing or proposed temporary ileostomy (2.5-cm incision). The colon and rectum were extracted through the SILS site (n = 8) or transanally following a mucosectomy (n = 2). A 20-cm J pouch was constructed extracorporeally and returned via the ileostomy site. Pouch-anal anastomosis was performed intracorporeally (n = 8) or hand-sutured (n = 2) and a diverting loop ileostomy was created at the SILS port site. The median operation time was 185 min (range = 100-381). There were no conversions or additional ports required. Median time to full diet was 36 h (range = 4-48 h) with a median hospital stay of 3 days (range = 2-8 days). There were no 30-day readmissions. Complications included surgical emphysema with temperature and a panic attack. Nine stomas have been closed. All patients have spontaneity of defecation, with a median pouch frequency of four per day, including once at night. All are fully continent and able to defer during the day. One reported a dry ejaculate for 10 weeks. CONCLUSION: SILS restorative proctocolectomy is safe with good early functional outcomes when performed by an experienced laparoscopic surgeon.

Factors associated with degree of tumour response to neo-adjuvant radiotherapy in rectal cancer and subsequent corresponding outcomes.

BACKGROUND: Tumour response to neo-adjuvant radiotherapy for rectal cancer varies significantly between patients, as classified by Tumour Regression Grade (TRG 0-3), with 0 equating to pathological complete response (pCR) and 3 denoting minimal/no response. pCR is associated with significantly better local recurrence rates and survival, but is achieved in only 20-30% of patients. The literature contains limited data reporting factors predictive of tumour response and corresponding outcomes according to degree of regression. METHODS: All patients with rectal cancer who received neo-adjuvant radiotherapy, entered into the National Cancer Database (NCDB) in 2009-2013, were included. Data were analysed on procedure performed, tumour details, pathological findings, chemo-radiotherapy regimens, patient demographics, outcomes and survival. Multivariate regression analysis was used to identify factors independently associated with pCR. RESULTS: Of 13,742 patients, 32.4% achieved pCR/TRG0 (4452). Factors associated with pCR (vs. TRG3) included adenocarcinoma rather than mucinous adenocarcinoma histology; well/moderately differentiated grade; lower clinical tumour (cT1, cT2, cT3) and nodal (N0 and N1) stage, and the addition of neo-adjuvant chemotherapy. Elevated CEA levels were associated with TRG3. pCR patients had higher rates of local excision, shorter mean length of stay and lower unplanned readmission rates, than TRG3. R0 resection rates and overall survival were significantly higher in all grades of regression, compared to TRG3 (p < 0.0001). CONCLUSION: Tumour regression correlates with outcomes. Identifying factors predictive of response may facilitate higher pCR rates, the tailoring of therapy, and improve outcomes.