Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status.

BACKGROUND: Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia. METHODS: A retrospective study was conducted at a regional tertiary care centre (2008-2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed. RESULTS: In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05-3.79), p = 0.036) and rural patients (OR 1.83(1.21-2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13-24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2-3.04), p = 0.007), and rural patients (OR 1.73(1.13-2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18-4.54), p = 0.015) and rural patients (OR 1.92(1.29-2.86), p = 0.001). CONCLUSIONS: This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Surgical Services for Breast Cancer Patients in Australia, is There a Gap for Aboriginal and/or Torres Strait Islander Women?

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women. METHODS: This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians. RESULTS: The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes. CONCLUSIONS: Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.

Emergency to Elective Surgery Ratio as a Disparities Sensitive Surgical Access Metric, A Study of Low Socioeconomic Status in Australia.

BACKGROUND: The emergency to elective surgery ratio is a proposed indicator for global access to surgical care. There is a well-established link between low socioeconomic status and increased morbidity and mortality. This study examined the emergency to elective surgery ratios for low socioeconomic patients utilising both self-reported unemployment and the neighbourhood Index of Economic Resources (IER). METHODS: A retrospective study was conducted at a regional tertiary care centre in Australia, including data over a ten-year period (2008-2018). Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, rurality, and if surgeries were due to trauma or injuries, was performed. RESULTS: 84,014 patients underwent a surgical procedure in the period examined; 29.0% underwent emergency surgery, 5.31% were unemployed, and 26.6% lived in neighbourhoods with the lowest IER. Following multivariable testing, the rate of emergency surgery was higher for unemployed patients (OR 1.42 [1.32-1.52], p < 0.001), and for those from the lowest IER (OR 1.13 [1.08-1.19], p < 0.001). For unemployed patients, this disparity increased during the study period (OR 1.32 [2008-2012], OR 1.48 [2013-2018]). When stratified by specialty, most (7/11) had significant disparities for unemployed patients: Cardiac/Cardiothoracic, Otolaryngology, Maxillofacial/Dental, Obstetrics/Gynaecology, Orthopaedics, Plastics, and Vascular surgery. CONCLUSIONS: Unemployed Australians and those residing in the most disadvantaged IER neighbourhoods had higher emergency to elective surgery rates. The disparity in emergency to elective surgery rates for unemployed patients was found in most surgical specialties and increased over the period examined. This suggests a widespread and potentially increasing disparity in access to surgical care for patients of socioeconomic disadvantage, specifically for those who are unemployed.

Implementation of the World Health Organization Surgical Safety Checklist Correlates with Reduced Surgical Mortality and Length of Hospital Admission in a High-Income Country.

BACKGROUND: The World Health Organization Surgical Safety Checklist (WHO SSC) has been widely implemented in an effort to decrease surgical adverse events. The effects of the checklist on postoperative outcomes have not previously been examined in Australia, and there is limited evidence on the effects of the checklist in the long term. METHODS: A retrospective review was conducted using administrative databases to examine the effects of the implementation of the checklist on postoperative outcomes. Data from 21,306 surgical procedures, performed over a 5-year time period at a tertiary care centre in Australia where the WHO SSC was introduced in the middle of this period, were analysed using multivariate logistic regression. RESULTS: Postoperative mortality rates decreased from 1.2 to 0.92% [p = 0.038, OR 0.74 (0.56-0.98)], and length of admission decreased from 5.2 to 4.7 days (p = 0.014). The reduction in mortality rates reached significance at the 2-3 years post-implementation period [p = 0.017, OR 0.61 (0.41-0.92)]. The observed decrease in mortality rates was independent of the surgical procedure duration. CONCLUSION: Implementation of the WHO SSC was associated with a statistically significant reduction in mortality and length of admission over a 5-year time period. This is the first study demonstrating a reduction in postoperative mortality after the implementation of the checklist in an Australian setting. In this study, a relatively longer period examined, comparative to previous international studies, may have allowed factors like surgical culture change to take effect.

Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies.

BACKGROUND: The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events. METHOD: This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A meta-analysis was not conducted as combining observational studies of heterogeneous quality may be highly biased. RESULTS: The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations. CONCLUSIONS: The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias.

Supplementary home biofeedback improves quality of life in younger patients with fecal incontinence.

BACKGROUND: Biofeedback is a scarce, resource-intensive clinical therapy. It is used to treat patients with bowel problems, including fecal incontinence (FI), who fail to respond to simple dietary advice, medication, or pelvic floor exercises. Populations are aging and younger cohorts use technology in managing their health, affording FI self-management opportunities. AIM: Does supplementary home-based biofeedback improve FI and quality of life (QOL)? METHODS: Seventy-five incontinent participants (12 male), mean age 61.1 years, consented to participate. Thirty-nine patients (5 male) were randomized to the standard biofeedback protocol plus daily home use of a Peritron perineometer (intervention) and 36 patients (7 male) to the standard biofeedback protocol (control). On completion of the study each perineometer exercise session was rated for technique by 2 raters, blinded to the patient and order of sessions. RESULTS: With the exception of Fecal Incontinence Quality of Life Scale lifestyle improvement (intervention--9.1% vs. controls--0.3%, P=0.026) and embarrassment improvement (intervention--50.0% vs. controls--18.3%, P=0.026), supplementary home biofeedback did not result in greater clinical improvement for the intervention group as a whole. However, on stratification around the mean age, continence and QOL of younger people in the intervention group were significantly better than those of their control counterparts. Graphed perineometer sessions demonstrated high compliance and improvement in exercise technique. Perineometers provided reassurance, motivation, and an exercise reminder ensuring that confidence was achieved quickly. CONCLUSIONS: Home biofeedback was acceptable and well tolerated by all users. Younger participants significantly benefited from using this technology.

Regulation of microRNA-1288 in colorectal cancer: altered expression and its clinicopathological significance.

We aim to examine the miR-1288 expression in cancer cell lines and a large cohort of patients with colorectal cancer. Two colon cancer cell lines (SW480 and SW48) and one normal colonic epithelial cell line (FHC) were recruited. The miRNA expressions of miR-1288 were tested on these cell lines by using quantitative real-time polymerase chain reaction (qRT-PCR). An exogenous miR-1288 (mimic) was used to detect cell proliferation and cell cycle changes in SW480 using MTT calorimetric assay and flow cytometry, respectively. In addition, tissues from 122 patients with surgical resection of colorectum (82 adenocarcinomas, 20 adenomas, and 20 non-neoplastic tissues) were tested for miR-1288 expression by qRT-PCR. The colon cancer cell lines showed reduced expression of miR-1288 compared to normal colonic epithelial cell line. Over expression of miR-1288 in SW480 cell line showed increased cell proliferation and increased G2-M phase cells. In tissues, reduced miR-1288 expression was noted in majority of colorectal adenocarcinoma compared to colorectal adenoma and non-neoplastic tissues. Reduced or absent expression of miR-1288 was noted in 76% (n = 62/82) of the cancers. The expression levels of miR-1288 were higher in distal colorectal adenocarcinomas (P = 0.013) and in cancers of lower T staging (P = 0.033). To conclude, alternation of miR-1288 expression is important in the progression of colorectal cancer. The differential regulation of miR-1288 was found to be related to cancer location and pathological staging in colorectal cancers.

Serial Cross-Sectional Observations of Sun-Protective Behaviors at an Annual Outdoor Motorsport Event in Tropical Queensland, Australia.

Skin cancer, the most prevalent cancer in Caucasians residing at low latitudes, can primarily be prevented by avoiding overexposure to sunlight. Serial cross-sectional observations were conducted at an outdoor motorsport event held in Townsville, Queensland each July (Southern winter) to determine whether sun-protection habits changed over time. Most (71.1%) of the 1337 attendees observed (97.6% lightly pigmented skin, 64.0% male) wore a hat (any style shading the face), while few (18.5%) wore three-quarter or full-length sleeves. While hat-wearing rates (any style) were similar in 2009 (326, 72.6%) and 2013 (625, 70.4%), the use of sun-protective styles (wide-brimmed/bucket/legionnaires) decreased from 29.2% to 18.6% over the same period, primarily because the use of sun-protective hats halved (from 28.7% to 14.0%) among females, while decreasing from 29.4% to 21.1% in males. Although relatively few individuals wore sun-protective (three-quarter-length or full-length) sleeves regardless of year (OR = 0.117, P < 0.0001), encouragingly, the use of sun-protective sleeves more than doubled between 2009 (10.5%) and 2013 (22.5%). Interestingly females, albeit the minority, at this sporting event were less likely to wear a hat (OR = 0.473, P < 0.0001) than males. These findings highlight the need for continued momentum toward skin cancer primary prevention through sun protection with a dedicated focus on outdoor sporting settings.

Metachronous carcinomas in colorectum and its clinicopathological significance.

PURPOSE: The study was designed to examine the significance of colorectal metachronous carcinoma in a large cohort of patients. METHODS: Over a mean follow-up period of 10 years, the clinicopathological features, microsatellite instability (MSI) and clinical follow-up of 56 patients with metachronous colorectal carcinoma were analysed. RESULTS: The prevalence of metachronous colorectal carcinoma was 2.1 %. The metachronous colorectal carcinomas appeared between 7 and 246 months (mean = 66 months) after surgical resection of the index colorectal carcinomas. Thirty-six per cent (n = 20) of the metachronous carcinoma occurred more than 5 years after the operation of the index carcinoma. Of the 56 patients, 20 % (n = 11) of the metachronous colorectal carcinomas were mucinous adenocarcinoma. Cancers detected in the secondary operations (metachronous colorectal carcinomas), when compared with the primary index cancers, were smaller, showed higher proportions of mucinous adenocarcinoma and more often located in the proximal colon. Patients with metachronous colorectal cancers had higher prevalence of mucinous adenocarcinoma, loss of staining for MSI markers and better survival rates than other patients with colorectal cancers. CONCLUSIONS: Patients with metachronous colorectal carcinomas have characteristic features, and attention to these features is important for better management of this group of cancer.

Socioeconomic disparities in rates of facial fracture surgeries for women and men at a regional tertiary care centre in Australia.

BACKGROUND: Assault is the most common mechanism of injury in patients presenting with facial trauma in Australia. For women, there is a propensity for maxillofacial injuries to stem from intimate partner violence (IPV). Those with a low socioeconomic status have higher rates of IPV. This study examines variations in the proportion of surgical procedures that are due to facial trauma for Australian women and men by employment status and residential socioeconomic status. METHODS: A single centre retrospective study was conducted (2008-2018). The proportion of operative patients presenting with facial fractures was examined. Multivariable logistic regression adjusting for year and age, was performed for women and men. RESULTS: Facial fractures comprised 1.51% (1602) of all surgeries, patients had a mean age of 32, and 81.3% were male. Unemployed patients were more likely to require surgery for a facial fracture (OR 2.36 (2.09-2.68), P <0.001), and there were no significant variations by index of economic resources (IER). Unemployed males had higher rates of facial fractures (OR 2.09 (1.82-2.39), P <0.001). Unemployed and disadvantaged IER females had higher rates of facial fractures (OR 5.02 (3.73-6.75), P <0.001 and OR 2.31(1.63-3.29), P <0.001). CONCLUSIONS: This study found disparities in rates of surgery for facial fractures; unemployment increased the rates for men and women, whereas disadvantaged IER increased rates for women. Studies have demonstrated higher rates of IPV for unemployed and low socioeconomic status women. Further research ascertaining the aetiology of these disparities is important both for primary prevention initiatives and to enable treating clinicians to better understand and address the role of IPV and alcohol consumption in these injuries.

Disparities in surgical outcomes for low socioeconomic status patients in Australia.

BACKGROUND: There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self-reported unemployment and neighbourhood level socioeconomic status in Australia. METHODS: A retrospective administrative data review was conducted at a tertiary care centre over a 10-year period (2008-2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed. RESULTS: 106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50-2.82), OR 1.37 (1.15-1.64)), all complications (OR 1.43 (1.31-1.56), OR 1.21 (1.14-1.28)), failure to rescue (OR 2.03 (1.39-2.95), OR 1.38 (1.11-1.72)) and return to theatre (OR 1.42 (1.27-1.59), OR 1.24 (1.14-1.36)) (P < 0.005 for all). CONCLUSIONS: Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

Biofeedback for fecal incontinence: a randomized study comparing exercise regimens.

BACKGROUND: Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes. OBJECTIVE: This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants. DESIGN: This was a randomized clinical study. SETTINGS: This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia. PATIENTS: Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later. INTERVENTION: Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises). MAIN OUTCOME MEASURES: The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool. RESULTS: No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises. LIMITATIONS: This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population. CONCLUSIONS: Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.

Predictors of postoperative mortality, morbidity, and long-term survival after palliative resection in patients with colorectal cancer.

BACKGROUND: Limited information is available on predictors of postoperative mortality, morbidity, and long-term survival in patients with stage IV colorectal cancer. OBJECTIVE: This study aimed to identify independent predictors of postoperative mortality and morbidity as well as independent predictors of long-term survival. DESIGN: This study was planned as a retrospective single-institution review. SETTING: This study took place at the Department of Surgery, The Royal Brisbane and Women's Hospital, Australia, between 1984 and 2004. PARTICIPANTS: Prospectively collected data were extracted from the records of 1867 patients undergoing treatment for colorectal cancer. The outcomes for 379 patients undergoing surgical resection of their primary colon or rectal tumor in the presence of unresectable synchronous metastases were analyzed. MAIN OUTCOME MEASURES: Independent predictive factors for postoperative mortality and morbidity as well as long-term survival were assessed by use of logistic regression and Cox regression analysis. RESULTS: Thirty-five (9.2%) patients died in the postoperative period and morbidity was 48.3%. Median survival was 11 months. Thirty-day postoperative mortality was independently associated with medical complications (P < .001), emergency operations (P = .001), female sex (P = .002), and age (≥ 70; P = .007) on regression analysis. Elderly (≥ 70) patients with either advanced local disease or extrahepatic metastases were at a particularly high risk. Preoperative predictors of surgical morbidity included male sex (P = .028) and advanced local disease (P = .036). Preoperative predictors of medical complications included repeat operations (P < .001), elevated urea levels (P = .017), and emergency operations (P = .003). Independent factors associated with poor overall survival included medical complications (P < .001), nodal stage (N2) (P = .004), poor tumor differentiation (P = .006), and apical lymph node involvement (P = .042). A subgroup of patients with advanced nodal disease (N2) and a poor tumor differentiation had a significantly poorer prognosis. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Elderly patients with advanced local disease or extrahepatic metastases are at high risk of 30-day postoperative mortality. Significant nodal disease and poor tumor differentiation are important predictors of long-term survival.

Signet-ring cell carcinoma of colorectum--current perspectives and molecular biology.

PURPOSE: Colorectal signet-ring cell carcinoma (SRCC) is rare, and very little detailed information on the molecular biology of the disease is available. METHODS: The literature on the clinical, pathological and, in particular, the molecular biology of this rare entity was critically reviewed. The reviewed articles take into account a total of 1,817 cases of SRCC, but only 143 cases have molecular data available. The characteristics of two patients with colorectal SRCC were also discussed. RESULTS: Colorectal SRCC mostly occurs in younger patients, is larger and has different site predilection compared with conventional colorectal adenocarcinoma. It can occur as one of the synchronous cancers in the colorectum. The cancer is usually diagnosed at advanced stages because of the late manifestation of symptoms, and aggressive treatment strategy is required. Limited reports in the literature have shown that the variant of colorectal cancer demonstrated a different pattern of genetic alterations of common growth kinase-related oncogenes (K-ras, BRAF), tumour suppressor genes (p53, p16), gene methylation and cell adhesion-related genes related to the Wingless signalling pathway (E-cadherin and beta-catenin) from conventional colorectal adenocarcinoma. Colorectal SRCC also showed high expression of mucin-related genes and genes related to the gastrointestinal system. There was also a higher prevalence of microsatellite instability-high tumours and low Cox-2 expression in colorectal SRCC as opposed to conventional adenocarcinoma. CONCLUSIONS: Colorectal SRCC has unique molecular pathological features. The unique molecular profiles in SRCC may provide molecular-based improvements to patient management in colorectal SRCC.

Systematic review of prognostic factors related to overall survival in patients with stage IV colorectal cancer and unresectable metastases.

BACKGROUND: With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision. METHOD: A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review. RESULTS: Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases. CONCLUSION: Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.

Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients.

BACKGROUND: Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking. METHODS: Data of 1576 patients who underwent primary resection and anastomosis for colorectal adenocarcinoma at a single institution from 1984 to 2004 were prospectively collected. Anastomotic leaks (LEK) were classified as radiological (RAD), local (LOC), or generalised (GEN). Logistic regression analysis of 21 variables was undertaken. Overall survival, cancer-related survival, and disease-free survival were analysed using the Kaplan-Meier method. RESULTS: Mean age of the patients was 67 years (SD = 12.5) and 834 (52.9%) were male. An LEK was more likely when relatively major gynaecological (tubo-oophorectomy, P = 0.004; hysterectomy, P = 0.006) or urological (total cystectomy, P = 0.014) procedures were performed during the same operative session. Other significant factors were anterior resection (P < 0.001), anastomosis using an intraluminal stapling device (P = 0.005), abdominal drain via laparoscopic port (P = 0.024), postoperative blood transfusion (P < 0.001), primary cancer site at the rectum (P = 0.016), and TNM stage of T2 or higher (P = 0.026). Having an LEK showed significant impact on overall (P = 0.021), cancer-related (P = 0.006), and disease-free (P = 0.001) survival. CONCLUSION: In this prospective study, advanced tumour stage, distal site, and need for postoperative blood transfusion were associated with increased rates of anastomotic leakage. In addition to their high risk of immediate postoperative morbidity and mortality, both localized and generalized leaks had similarly negative impacts on overall, cancer-related, and disease-free survival.

Surgical treatment for colorectal cancer.

The rapid in development of surgical technology has had a major effect in surgical treatment of colorectal cancer. Laparoscopic colon cancer surgery has been proven to provide better short-term clinical and oncologic outcomes. However this quickly accepted surgical approach is still performed by a minority of colorectal surgeons. The more technically challenging procedure of laparoscopic rectal cancer surgery is also on its way to demonstrating perhaps similar short-term benefits. This article reviews current evidences of both short-term and long-term outcomes of laparoscopic colorectal cancer surgery, including the overall costs comparison between laparoscopic surgery and conventional open surgery. In addition, different surgical techniques for laparoscopic colon and rectal cancer are compared. Also the relevant future challenge of colorectal cancer robotic surgery is reviewed.

Laparoscopic parastomal hernia repair.

Parastomal hernia is a common complication after stoma formation. Its reported incidence varies from 30% to 50%. Loop ileostomy has the lowest risk (0%-6.2%), followed by end ileostomy, and loop colostomy with a similar risk of 28% to 30%. End colostomy carries the highest risk for parastomal hernia of 48%. Even though most hernias occur within the first 2 years after stoma construction, the risk of herniation extends up to 20 years. Theoretically, parastomal hernia occurs as a result of mechanical factors, an intrinsic defect in collagen metabolism, and wound repair. Parastomal hernia is asymptomatic most of the time, but it may be associated with serious complications such as strangulation and perforation; hence, elective repair is mandatory for carefully selected cases and surgical approaches. Primary closure of the aponeurosis at the hernia site, either via peristomal approach or through midline incision, is a simple procedure, but it carries a recurrence rate of 38% to 100%. Stoma relocation may result in a zero recurrence rate at the same hernia site, but the risk of a parastomal hernia after new stoma formation is still expected. In addition, an incisional hernia at the previous colostomy site closure may also occur. Similar to other sites of hernia repair, prosthetic mesh has been used to reinforce the hernia defect intraperitoneally through open incision and recently via the laparoscopic approach. Mesh repair has demonstrated the lowest risk of recurrence for parastomal hernia of 0% to 33%.

The effect of obstruction and perforation on colorectal cancer disease-free survival.

BACKGROUND: Obstruction (OBSTR) and perforation (PERF) in colorectal cancer impact adversely upon outcomes, and cancer-related survival may also be affected. However, data are sparse, particularly on disease-free survival (DFS) where the cancer is both obstructed and perforated (OBS-PERF). METHODS: Data were extracted from a prospectively collected database of 1876 colorectal cancer patients managed and followed up at the Royal Brisbane Hospital from 1984 to 2004. The patients who had curative surgery (n = 1426) were classified as OBSTR (n = 153), PERF (n = 53), OBS-PERF (n = 19), and uncomplicated (UNCOM; n = 1201). Kaplan-Meier survival and Cox proportional hazard analyses were performed. RESULTS: Postoperative mortality within 30 days of surgery was 1.5% (n = 22) and the overall complication rate was 40.8% (n = 582). However, only 7.2% (n = 102) required reoperations. The median survival time was 71 (IQR = 64.9-77.1) months and the median follow-up for DFS was 37.5 (IQR 14-68) months. The overall recurrence rate was 32.7% (n = 466), the local recurrence rate was 9.4% (n = 135), and local and distant recurrences occurred in the same patient in 4.7% (n = 67). Male gender, OBSTR, PERF, OBS-PERF, emergency operation, major medical and surgical complications, reoperation, TNM staging, tumor grading, and tumor venous invasion adversely affected DFS (p < 0.05). Multivariate analysis showed that OBS-PERF (p = 0.008), major medical complications (p = 0.011), reoperation (p = 0.018), TNM staging (p < 0.001), grading (p = 0.018), and venous invasion (p = 0.002) were independently associated with a poorer DFS. CONCLUSIONS: OBS-PERF colorectal cancer is associated with a poorer DFS, which may be worse than either OBSTR or PERF alone.