Oncologic outcomes of neoadjuvant chemoradiation for locally advanced rectal cancer: a single-institution experience

<p><b>INTRODUCTION</b>This study reports the outcomes of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by surgery in a local population of Singapore.</p><p><b>MATERIALS AND METHODS</b>The records of 85 patients who underwent neoadjuvant chemoradiation for locally advanced rectal cancer followed by surgery at the Tan Tock Seng Hospital (TTSH) between November 2002 and January 2012 were reviewed. The treatment protocol comprised radiotherapy to a total dose of 50.4 Gy concurrent with 5-fluorouracil-based chemotherapy. Patients underwent total mesorectal excision surgery following the completion of neoadjuvant chemoradiation. Local control, disease-free survival and overall survival were analysed using Kaplan-Meier methods.</p><p><b>RESULTS</b>Median age of the patients was 61 years. All of them completed radiotherapy. One patient did not complete neoadjuvant chemotherapy. The median time to surgery was 52 days. Fifty-five percent (47 of 85) of patients achieved pathological downstaging and 13% (11 of 85) of patients had a pathologic complete response to preoperative treatment. The neoadjuvant chemoradiation was well tolerated. Four percent of patients had grade 3 diarrhoea and 4% of them had grade 3 dermatitis. There were no grade 4 toxicities. With a median follow-up of 41 months, the 5-year actuarial local recurrence, disease-free survival and overall survival rates were 7%, 71.9%, and 83.2% respectively. Univariate analysis showed that patients with positive surgical margins had significantly worse disease-free survival and overall survival (P=0.012 and P<0.001 respectively) and a trend towards a higher rate of local recurrence (P=0.08).</p><p><b>CONCLUSION</b>Our study provides evidence that neoadjuvant chemoradiation is an effective treatment for locally advanced rectal cancer. Our outcomes are comparable with internationally published data and demonstrate the reproducibility of the neoadjuvant approach in an Asian population.</p>

Management plan to reduce risks in perioperative care of patients with obstructive sleep apnoea averts the need for presurgical polysomnography

<p><b>INTRODUCTION</b>Obstructive sleep apnoea (OSA) is associated with increased perioperative morbidity and mortality. Patients at risk of OSA as determined by pre-anaesthesia screening based on the American Society of Anesthesiologists checklist were divided into 2 groups for comparison: (i) those who proceeded to elective surgery under a risk management protocol without undergoing formal polysomnography preoperatively and; (ii) those who underwent polysomnography and any subsequent OSA treatment as required before elective surgery. We hypothesised that it is clinically safe and acceptable for patients identified on screening as OSA at-risk to proceed for elective surgery without delay for polysomnography, with no increase in postoperative complications if managed on a perioperative risk reduction protocol.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of patients presenting to the preanaesthesia clinic over an 18-month period and identified to be OSA at-risk on screening checklist was conducted (n = 463). The incidence of postoperative complications for each category of OSA severity (mild-moderate and severe) in the 2 study groups was compared.</p><p><b>RESULTS</b>There was no statistically significant difference in the incidence of cardiac (3.3% vs 2.3%), respiratory (14.3% vs 12.5%), and neurologic complications (0.6% vs 0%) between the screening-only and polysomnography-confirmed OSA groups respectively (P >0.05). There was good agreement of the OSA risk that is identified by screening checklist with OSA severity as determined on formal polysomnography (kappa coefficient = 0.953).</p><p><b>CONCLUSION</b>Previously undiagnosed OSA is common in the presurgical population. In our study, there was no significant increase in postoperative complications in patients managed on the OSA risk management protocol. With this protocol, it is clinically safe to proceed with elective surgery without delay for formal polysomnography confirmation.</p>

Surgical hand antisepsis-a pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub

<p><b>INTRODUCTION</b>The surgeon uses different methods of surgical hand antisepsis with the aim of reducing surgical site infections. To date, there are no local studies comparing the efficacy of iodine hand scrub against newer alcohol-based hand rubs with active ingredients. Our pilot study compares a traditional aqueous hand scrub using 7.5% Povidone iodine (PVP-I) against a hand rub using Avagard: 61% ethyl alcohol, 1% chlorhexidine gluconate. The outcome measure is the number of Colony Forming Units (CFU) cultured from 10-digit fingertip imprints on agar plates.</p><p><b>MATERIALS AND METHODS</b>Ten volunteers underwent 2 hand preparation protocols, with a 30-minute interval in between-Protocol A (3-minute of aqueous scrub using PVP-I) and Protocol B (3-minute of hand rub, until dry, using Avagard). In each protocol, fingertip imprints were obtained immediately after hand preparation (t(0)). The volunteers proceeded to don sterile gloves and performed specific tasks (suturing). At one hour, the gloves were removed and a second set of imprints was obtained (t(1)).</p><p><b>RESULTS</b>Four sets of fingertip imprints were obtained. All 10 participants complied with the supervised hand preparation procedures for each protocol. CFUs of initial fingertip imprints (t(0)): The median CFU counts for initial imprint was significantly higher in the PVP-I treatment (median = 6, Inter Quartile Range (IQR) = 33) compared to the Avagard treatment (median = 0, IQR = 0, P <0.001). CFUs of fingertip imprint at 1 hour (t(1)): The median CFU counts for second imprint (t(1)) was significantly higher in the PVP-I treatment (median = 0.5, IQR = 11) compared to the Avagard treatment (median = 0, IQR = 0, P = 0.009). Our results suggest that the Avagard was more efficacious than aqueous PVP-I scrub at reducing baseline colony counts and sustaining this antisepsis effect.</p><p><b>CONCLUSION</b>Alcohol hand rub with an active compound, demonstrated superior efficacy in CFU reduction. Based on our results, and those pooled from other authors, we suggest that alcohol-based hand rubs could be included in the operating theatre as an alternative to traditional surgical scrub for surgical hand antisepsis.</p>