Surgical Site Infection (SSI) Rate after Colorectal surgery at the Philippine General Hospital

OBJECTIVE@#Surgical site infection (SSI) is one of the most common healthcare-associated infections. This study aimed to determine SSI rate and the associated factors among colorectal surgery patients.@*METHODS@#This included adult patients who underwent surgery under the Division of Colorectal Surgery from January to May 2018. Clinico-demographic, operative, and SSI outcome data were reviewed. Occurrence of SSI during admission until discharge, and up to 30 days after the surgery was analyzed. @*RESULTS@#A total of 172 surgeries were performed. Majority were elective procedures (68.0%), and performed via open approach (67.4%). Most were malignant cases (62.6%). Sixty-three colorectal resections were done (41 colon and 22 rectal). SSI rate prior to discharge was 6.4%, and 15.7% at 30 days. Among colorectal resections, 18 (28.6%) patients had SSI at 30 days. SSI rates were significantly higher among patients who were ASA 2 or 3; received chemotherapy 12 weeks prior to surgery; had malignant pathology; underwent emergency surgery; received perioperative transfusion; had stapled skin closure; had low anterior resection for rectal cancer; and had multivisceral resection. @*CONCLUSION@#The Division of Colorectal Surgery at the Philippine General Hospital had a higher SSI rate as compared to literature. Although this could be partly explained by the differences in patient and surgeon population, improving on SSI rates will be the unit's goal. Continued SSI surveillance with more patient accrual may provide better insight to the associated risk factors.

McKittrick-Wheelock Syndrome: A Case Series

McKittrick-Wheelock syndrome is a rare and life-threatening disease characterized by the triad of (1) chronic mucous diarrhea, (2) renal function impairment with hydroelectrolyte imbalance, and (3) a giant colorectal tumor. Often, the tumor is a rectal adenoma. With the mortality being certain, if left untreated, it is important to raise awareness on the presentation, diagnosis, and management of this disease entity. Here, we presented 3 cases of McKittrick-Wheelock syndrome that were successfully managed with surgical resection at the Philippine General Hospital from August 2018 to May 2019. Resolution of their symptoms, reversal of their renal impairment, and correction of their electrolyte depletion were noted after removal of the tumor with a sphincter-saving operation.

Disseminated intravascular coagulation from Intraperitoneal Oxaliplatin for Appendiceal Carcinoma: A case report

@#This is a case of a 65-year-old female diagnosed with appendiceal carcinoma, who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Profuse bleeding through the peritoneal drains, with hemodynamic instability, warranted a re-exploration on the fourth postoperative day. Intraoperatively, there was 500 mL of blood clots mostly on the right upper quadrant, diffuse muscle oozing along the previously-stripped right hemidiaphragm and right paracolic gutter, and a non-expanding hematoma on the right anterior abdominal wall. Bleeding parameters were checked postoperatively, and derangements pointing to a disseminated intravascular coagulation were noted. The patient was managed with multiple blood transfusions of packed red blood cells, fresh frozen plasma, platelet concentrates, and cryoprecipitate. Dexamethasone and tranexamic acid were given intravenously. The patient was discharged well on postoperative day 14 after clinical resolution of the bleeding. Eight days after discharge, however, patient succumbed to myocardial infarction.

Outcomes of surgical management of buschke-lowenstein tumor in a Philippine tertiary hospital

Buschke-Lowenstein tumor (BLT) is a sexually transmitted infection (STI) caused by the human papillomavirus. This study investigated the profile, management, and outcomes of patients who underwent surgery for BLT from 2015 to 2019 at the Philippine General Hospital. Seven patients underwent surgery for BLT. All were male, with ages ranging from 21 to 41 years. Presenting symptoms were anal mass, foul-smelling discharge, pain, bleeding, and pruritus. All were positive for human immunodeficiency virus. All admitted to having engaged in both insertive and receptive anal intercourse, with multiple partners. All underwent excision with healing by secondary intention. Two had recurrence of warts. Four had an anal stricture. Of these, 3 underwent anal dilatation, while 1 had to undergo proximal bowel diversion. One had intraepithelial carcinoma without dermal invasion on histopathologic analysis. BLT is a rare STI characterized by local aggressiveness but with low malignant potential. Wide excision remains to be the mainstay of treatment.

Improved outcomes with implementation of an Enhanced Recovery After Surgery pathway for patients undergoing elective colorectal surgery in the Philippines

Purpose@#This study aims to evaluate surgical outcomes (i.e. length of stay [LOS], 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the Enhanced Recovery After Surgery (ERAS) pathway, and determine its association with the rate of compliance to the different ERAS components. @*Methods@#This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then retrospectively compared to outcomes prior to the implementation of ERAS. @*Results@#A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92.0% (SR, 91.8%; CR, 93.1%; RR, 90.7%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.1±6.7 days vs. 10.0±5.4 days, P=0.002) and RR (19.9±11.4 days vs. 16.9±10.5 days, P=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar. @*Conclusion@#Increased compliance to ERAS protocol is associated with a decrease in morbidity across all surgery types. The implementation of an ERAS protocol significantly decreased mean hospital LOS, without any increase in major surgical complications. Having your own hospital ERAS pathway improves documentation and accuracy of reporting surgical complications.

Modifications to Treatment Plan of Rectal Cancer in Response to COVID-19 at the Philippine General Hospital

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare resources worldwide. Despite the high number of cases, cancer management should remain one of the priorities of healthcare, as any delay would potentially cause disease progression. @*Methods@#This was an observational study that included nonmetastatic rectal cancer patients managed at the Philippine General Hospital from March 16 to May 31, 2020, coinciding with the lockdown. The treatment received and their outcomes were investigated. @*Results@#Of the 52 patients included, the majority were female (57.7%), belonging to the age group of 50 to 69 years (53.8%), and residing outside the capital (59.6%). On follow-up, 23.1% had no disease progression, 17.3% had local progression, 28.8% had metastatic progression, 19.2% have died, and 11.5% were lost to follow up. The initial plan for 47.6% patients was changed. Of the 21 patients with nonmetastatic disease, 2 underwent outright resection. The remaining 19 required neoadjuvant therapy. Eight have completed their neoadjuvant treatment, 8 are undergoing treatment, 2 had their treatment interrupted, and 1 has yet to begin treatment. Among the 9 patients who completed neoadjuvant therapy, only 1 was able to undergo resection on time. The rest were delayed, with a median time of 4 months. One has repeatedly failed to arrive for her surgery due to public transport limitations. There was 1 adjuvant chemotherapy-related mortality. @*Conclusion@#Delays in cancer management resulted in disease progression in several patients. Alternative neoadjuvant treatment options should be considered while taking into account oncologic outcomes, acceptable toxicity, and limitation of potential COVID-19 exposure.

Modifications to Treatment Plan of Rectal Cancer in Response to COVID-19 at the Philippine General Hospital

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare resources worldwide. Despite the high number of cases, cancer management should remain one of the priorities of healthcare, as any delay would potentially cause disease progression. @*Methods@#This was an observational study that included nonmetastatic rectal cancer patients managed at the Philippine General Hospital from March 16 to May 31, 2020, coinciding with the lockdown. The treatment received and their outcomes were investigated. @*Results@#Of the 52 patients included, the majority were female (57.7%), belonging to the age group of 50 to 69 years (53.8%), and residing outside the capital (59.6%). On follow-up, 23.1% had no disease progression, 17.3% had local progression, 28.8% had metastatic progression, 19.2% have died, and 11.5% were lost to follow up. The initial plan for 47.6% patients was changed. Of the 21 patients with nonmetastatic disease, 2 underwent outright resection. The remaining 19 required neoadjuvant therapy. Eight have completed their neoadjuvant treatment, 8 are undergoing treatment, 2 had their treatment interrupted, and 1 has yet to begin treatment. Among the 9 patients who completed neoadjuvant therapy, only 1 was able to undergo resection on time. The rest were delayed, with a median time of 4 months. One has repeatedly failed to arrive for her surgery due to public transport limitations. There was 1 adjuvant chemotherapy-related mortality. @*Conclusion@#Delays in cancer management resulted in disease progression in several patients. Alternative neoadjuvant treatment options should be considered while taking into account oncologic outcomes, acceptable toxicity, and limitation of potential COVID-19 exposure.

Initial Experience With Video-Assisted Anal Fistula Treatment in the Philippines

Purpose@#We determined the outcomes of patients undergoing video-assisted anal fistula treatment (VAAFT) for fistulain-ano at the Philippine General Hospital. @*Methods@#Twenty consecutive adult patients who underwent the VAAFT procedure from 2016–2018 were included in this investigation. Information detailing baseline demographic and clinical data, fistula type and classification, and previous surgeries were retrieved from in-hospital and operative records. Operative time, identification of the internal opening, method of internal opening closure, and occurrence of immediate postoperative complications were determined. The status of the fistula was assessed at one month, 3 months, and 6 months postoperatively based on outpatient follow-up records. The primary outcomes were healing rate and recurrence rate. Secondary outcomes were 30-day morbidity, postoperative complications, and incontinence using the Wexner score. @*Results@#Eighteen patients (90%) had a preoperative diagnosis of complex fistula, and 13 patients (65%) had undergone a previous fistula surgery. Primary healing rate was 55% at 1 month, 63.16% at 3 months, and 78.95% at 6 months postoperatively. Eighteen patients (94.74%) maintained continence (Wexner score = 0) at 6 months. @*Conclusion@#Our study results suggest that VAAFT is a safe, minimally invasive technique for treatment of anal fistula and can preserve anal sphincter function. The technique has an acceptable healing rate with minimal complications.