Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review.

AIM: A literature review was performed to elucidate whether long-course preoperative radiotherapy for patients with rectal cancer affects lymph node yield, and whether this influences prognosis. METHOD: Cochrane Database, PubMed/MEDLINE, Scopus, Web of Knowledge, Embase and CINAHL databases and reference lists from published journal articles published between 1 January 1990 and 30 June 2011 were searched. Studies examining lymph node yield and prognosis were selected for review. RESULTS: One thousand and twenty-nine articles were found, of which 11 met the inclusion criteria. None was a randomized controlled trial and all were cohort studies. Four studies showed that long-course preoperative radiotherapy reduced lymph node yield; however only one demonstrated a statistically significant survival benefit in patients with higher lymph node yields. Five-year survival was 48% in patients with fewer than and 69% in those with more than 11 lymph nodes identified in the operative specimen (P = 0.04). CONCLUSION: Whilst long-course preoperative radiotherapy appears to reduce lymph node yield in patients with rectal cancer, no causal relationship between lymph node yield and survival can be established in this group of patients.

Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection.

BACKGROUND: A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented. METHODS: A total of 592 eligible patients were entered and studied from 1998 to 2005. RESULTS: Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed; 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70.3(11.0) years). Forty-three laparoscopic operations (14.6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0.002), owing primarily to a lower rate in patients aged 70 years or more (P = 0.002). Fewer patients in the laparoscopic group experienced any complication (P = 0.035), especially patients aged 70 years or above (P = 0.019). CONCLUSION: Treatment choices for colonic cancer depend principally upon disease-free survival; however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection. REGISTRATION NUMBER: NCT00202111 (http://www.clinicaltrials.gov).

Laparoscopically assisted colectomy: a study of risk factors and predictors of open conversion.

BACKGROUND: Conversion to an open procedure during laparoscopically assisted colorectal resection may be necessary because of technical, patient, or pathologic factors. Recent literature has indicated that converted patients may have poorer outcomes than those undergoing open or completed laparoscopically assisted procedure. This study aimed to audit the authors' experience with laparoscopically assisted colectomy and to assess the clinical outcomes of patients undergoing conversion. METHODS: All laparoscopic right hemicolectomies or anterior resections performed at seven South Australian hospitals from 1997 to 2006 were reviewed. Data pertaining to patient sex, age, American Society of Anesthesiology (ASA) score, pathology, operative outcomes including operating time, conversion, reason for conversion, length of hospital stay, and intra- and postoperative complications were analyzed. RESULTS: Laparoscopic anterior resection had a higher rate of open conversion than laparoscopic right hemicolectomy (18.7% vs 10.4%; p = 0.028). In the right hemicolectomy group, none of the investigated risk factors for conversion were statistically significant, and the morbidity rates for the two groups were similar. The median hospital stay was significantly longer in the anterior resection group (p < 0.001), and the wound morbidity rate was higher in the converted group (12.8% vs 3.0%; p = 0.022). Age older than 75 years and a high ASA status were independent risk factors for conversion in anterior resection. CONCLUSIONS: Conversion of laparoscopic anterior resection to open procedure is associated with higher wound morbidity and a longer hospital stay. The authors recommend that surgeons carefully consider the selection of patients 75 years of age or older and high ASA status for laparoscopic anterior resection.

Treatment and survival from colorectal cancer: the experience of patients at South Australian teaching hospitals between 1980 and 2002.

AIMS: To evaluate trends in colorectal cancer survival and treatment at South Australian teaching hospitals and degree of adherence to treatment guidelines which recommend adjuvant chemotherapy for Dukes' C colon cancers and combined chemotherapy and radiotherapy for high-risk rectal cancers. MATERIALS AND METHODS: Trends in disease specific survival and primary treatment were analysed, and comparisons drawn between diagnostic epochs, using cancer registry data from South Australian teaching hospitals. Statistical methods included univariate and multivariable disease specific survival analyses. RESULTS: Five-year survival increased from 48% in 1980-1986 to 56% in 1995-2002. Largest gains were for stage C, where survivals were higher when chemotherapy was part of the primary treatment. By comparison, gains in 1-year survival were largest for stage D. Chemotherapy was provided for 4% of patients with colorectal cancers in 1980-1986, increasing to 32% in 1995-2002. Among stage C cases below 70 years at diagnosis, the proportion having chemotherapy increased to 83% in 1995-2002. The most common chemotherapy was fluorouracil (5FU) as a single agent in 1980-1986 and 5FU with leucovorin in 1995-2002. As expected, radiotherapy was used more frequently for rectal than colon cancers, and particularly for stage C. Among stage C rectal cases below 70 years, the proportion having radiotherapy increased from 10% in 1980-1986 to 57% in 1995-2002. Approximately 93% of colorectal cancers were treated surgically. Patients not treated surgically tended to be aged 80 years or more and to present with distant metastases. CONCLUSIONS: Trends in chemotherapy and radiotherapy accord with evidence-based recommendations. There have been reassuring gains in survivals after adjusting for stage, grade and other prognostic indicators. The data show survival gains and treatment patterns that individual hospitals can use as benchmarks when evaluating their own experience.

Short communication: endoanal ultrasound during contraction of the anal sphincter--improved definition and diagnostic accuracy.

Endoanal ultrasound was used in the investigation of 26 patients with faecal incontinence. In each case images of the anal sphincter were taken at rest and during contraction or squeezing (dynamic). Better definition of the normal anal sphincter or anal sphincter defects was obtained in 16 (62%) of the patients with imaging during contraction. In eight of the 13 patients with a sphincter defect there was better definition of the defect and increased separation of the ends of the sphincter during contraction. Imaging during contraction improves diagnostic accuracy and is a useful adjunct with endoanal ultrasound.

Positive proximal resection margins after resection for carcinoma of the oesophagus and stomach: effect on survival and symptom recurrence.

BACKGROUND: Our aim was to determine the frequency, survival and symptomatic local recurrence rate of patients with a positive proximal resection margin in a series of patients having a resection for carcinoma of the oesophagus or stomach. METHODS: A retrospective study of pathology reports and case notes. Survival and data on local recurrence were obtained from the patient or general practitioner. RESULTS: Ten (11.5%) of 87 patients having a gastric or oesophageal resection for carcinoma had a positive proximal resection margin. All 10 patients underwent a palliative resection for late-stage disease. Nine were dead at an average 8.3 months (range 2-20 months) post-resection and one patient remains alive at 9 months. Only one of these 10 patients had evidence of a local recurrence with recurrent dysphagia prior to death at 11 months. CONCLUSION: A high incidence of a positive proximal resection margin was found. This occurred in patients who underwent a palliative resection for late-stage disease, most of whom died before local recurrence became a problem. For patients recognized as having late-stage disease, surgery for symptom palliation need not be aggressive (such as to include a thoracotomy) because achieving microscopic clearance is unlikely to affect the long-term outcome.

Reoperation after failed antireflux surgery.

Between 1978 and 1992, 61 patients were operated on for new or recurrent problems after antireflux surgery. Indications for reoperation were recurrent reflux in 50 patients (associated with dysphagia in 14), dysphagia alone in six and postprandial pain in five. At reoperation the cause of the problem was apparent as anatomical breakdown of the repair in 19 patients, gastric pull-through (slipped Nissen procedure) in 14 and paraoesophageal hernia in six. In 18 patients the cause of the symptoms was not readily apparent. Reoperation consisted of fundoplication alone in 27 patients, fundoplication with pyloroplasty in eight, fundoplication with proximal gastric vagotomy in four, a Collis-Nissen procedure in 11 (four also had pyloroplasty), a Roux-en-Y procedure in four, total gastrectomy in one and reduction of a paraoesophageal hernia in six. Of the 20 patients with some form of destruction of the gastric outlet six experienced troublesome dumping symptoms and in two this was severe. Two patients died from cardiac causes after surgery. Of the remaining 59 patients, 51 rated the procedure as successful. Repeat antireflux procedures can give results almost as good as those of primary antireflux surgery. However, pyloroplasty and gastric resection should be avoided if at all possible.

Postanal repair for faecal incontinence: long-term follow-up.

BACKGROUND: To determine the long-term outcome of postanal repair, and to assess whether the preoperative and physiological tests had any bearing on this outcome. Review included an opportunity for assessment with anal manometry and anal ultrasound. METHOD: Review of all patients (n = 22) over a 10 year period from 1986 to 1996. Comparison was of pre-operative symptoms to symptoms at review. Correlation of outcome with pre-operative manometry and the results of manometry and ultrasound at review (n = 6) was determined. RESULTS: Assessment was possible in 19 of the 22 patients. Follow-up ranged from 2 to 10 years (median, 8 years). Two had stomas created at 6 and 9 months and are considered failures. Seven patients considered the operation a success, in four it improved their symptoms and in six it was considered a failure. Comparison of pre- and postoperative symptoms scores found a statistically significant improvement (P = 0.0093; two-tailed Wilcoxon signed rank sum test). The outcome was not influenced by the results of pre-operative anal manometry. Anal ultrasound found five sphincter defects in six patients. Such defects did not preclude improvement from postanal repair. CONCLUSIONS: Although the results showed improvement or success in only 11 (58%) of the patients this was felt to be important given that these patients may have few alternatives other than complicated procedures or a stoma. Postanal repair has a place in the management of faecal incontinence.

Investigation of fecal incontinence with endoanal ultrasound.

PURPOSE: This study was undertaken to audit the results of endoanal ultrasound in patients with fecal incontinence. METHODS: Endoanal ultrasound was used to investigate 53 patients with fecal incontinence. Data for endoanal ultrasound were collected prospectively. Results were compared with clinical and obstetric history, obtained retrospectively from case notes, and were compared with manometric and operative findings. RESULTS: Sphincter abnormalities were identified in 42 of 53 patients. A total of 28 anterior defects were thought to be obstetric in origin. Fourteen other defects were secondary to anal pathology or surgery. Patients with anterior external sphincter defects either had complete defects (4 patients; mean age, 31 years) or proximal defects (24 patients; mean age, 55 years). For patients with a proximal defect, 38 percent gave a history of obstetric tear, episiotomy, or forceps delivery, and the rest declared having had an apparently normal delivery. Only 50 percent had a sphincter weakness that was evident on clinical examination. Of those studied with manometry, only 21 percent had low squeeze pressures consistent with an external sphincter defect. CONCLUSIONS: Sphincter defects seen on ultrasound may not have a history of obstetric trauma or abnormal clinical and manometric findings. Endoanal ultrasound is recommended in all patients with fecal incontinence to detect occult sphincter defects.

Correlation of pudendal nerve terminal motor latency with the results of anal manometry.

UNLABELLED: Denervation to the external anal sphincter is commonly found in disordered defaecation. AIM: To determine whether a correlation exists between pudendal nerve terminal motor latency (PNTML) and anal manometry and what influence an external sphincter defect (ESD) has on any correlation. METHOD: Sixty seven consecutive patients (23 constipated, 44 incontinent) were analysed. All had results available for PNTML and anal manometry. Anal ultrasound performed in the later part of the study period was available in 46 patients. RESULTS: A significant negative correlation was found between the mean PNTML and squeeze pressures (SP) for incontinent patients (r = -0.32, P = 0.037). No significant correlation was seen in constipated patients. A coexisting ESD was found in 57% of the 46 patients studied. In those without an ESD a significant negative correlation was found between mean PNTML and SP (r = -0.50; P = 0.026). No correlation was found in patients with an ESD. Age did not significantly affect the PNTML or SP results, but was associated with a reduced resting pressure (r = -0.34; P = 0.005). CONCLUSIONS: The PNTML was significantly correlated with SP in patients with incontinence and in the subgroup of patients without an ESD. In the assessment of disordered defaecation PNTML is therefore recommended as an adjunct to anal ultrasound.

Delayed pudendal nerve conduction and endosonographic appearance of the anal sphincter complex.

PURPOSE: The aim of this study was to test the hypothesis that a delay in pudendal nerve conduction as measured by pudendal nerve terminal motor latency should be associated with atrophy of the external anal sphincter as measured using endoanal ultrasound. METHODS: Sixty-two adult females (median age, 58.9 (range, 22-88) years) presenting for evaluation of fecal incontinence with no evidence of an external anal sphincter tear on ultrasound were recruited. Ultrasound was performed with a 7.5-MHz radial rotating axial endoprobe in the left lateral position. Four measurements were made in the transverse plane--the external anal sphincter thickness in the midanal canal at the 6 o'clock and 9 o'clock positions, the internal sphincter at the 9 o'clock position, and the external anal sphincter in the low canal at the 9 o'clock position. Pudendal nerve terminal motor latency was measured using a transrectal nerve stimulation technique with measurement of the evoked muscle response. RESULTS: Although there was a trend toward thinner external sphincter muscles in those with bilateral prolonged pudendal nerve terminal motor latency, independent sample t-tests and Pearson correlation coefficients showed no statistically significant relationship (right pudendal nerve terminal motor latency: P = 0.083, 0.184, 0.128, 0.910; r = 0.228, 0.175, -0.201, -0.015; left pudendal nerve terminal motor latency: P = 0.946, 0.276, 0.510, 0.123; r = -0.009, -0.143, -0.087, -0.201). CONCLUSIONS: No statistically significant relationship between ultrasound-measured anal sphincter muscle thickness and pudendal nerve terminal motor latency was identified. Although a trend was suggested that could be further evaluated by a study with a larger sample size and a control group with asymptomatic patients, the small differences in muscle thickness involved and the difficulties in measurement suggest that the establishment of clinically useful ultrasound criteria for the detection of the neuropathic anal sphincter complex is unlikely.

Prospective study of biofeedback for treatment of constipation.

PURPOSE: This study was designed to evaluate prospectively the results of pelvic floor physiotherapy with the aid of biofeedback in a heterogeneous group of patients with intractable constipation. METHODS: Biofeedback was used to treat 19 patients (age range, 16-78 (median, 63) years) with intractable constipation. Assessment, using visual linear analog scales of symptoms, was performed prospectively by an independent researcher. Biofeedback was performed by a physiotherapist, and patients were required to attend six sessions on an outpatient basis. The cause of constipation was heterogeneous, with no specific disorder being implicated on testing with anal manometry, defecating proctography, and colonic transit time. RESULTS: At six weeks, there was a median 27 percent (range, -8-93 percent) improvement in symptom scores. At six months, there was a median 23 percent (range, -54-64 percent) improvement in symptom scores. These were statistically significant compared with the scores at outset, six weeks (P = 0.0006), and six months (P = 0.012). However, only two (12.5 percent) patients at the six-month follow-up had an improvement of greater than 50 percent in their symptoms. CONCLUSION: Biofeedback is not recommended in the management of constipation.

Prospective trial of pelvic floor retraining in patients with fecal incontinence.

PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29-85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P < 0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.