The National Aeronautics and Space Administration-task load index: NASA-TLX: evaluation of its use in surgery.

BACKGROUND: The technical difficulty an operation creates for a surgeon is difficult to measure. Current measures are poor surrogates. In both research and teaching settings it would be valuable to be able to accurately measure this degree of difficulty. The National Aeronautics and Space Administration Task Load Index (NASA TLX) is a multi-dimensional scale designed to obtain workload estimates relating to a task. This study aimed to evaluate the NASA TLX as an objective measure of technical difficulty of an operation. METHODS: Seven surgeons performed 127 pre-defined operations (minimally invasive right hemicolectomy & re-do bariatric surgery) and recorded a NASA TLX score after each operation. These scores were compared to numerous clinical parameters and the score was correlated with the subjective measure of whether the surgeon categorized the operation as "easy", "moderate" or "difficult". RESULTS: The NASA TLX score was significantly correlated with operative duration, blood loss, previous abdominal surgery and the surgeons' assessment of difficulty. It did not correlate with intra-operative or post-operative complications, conversion to open surgery or length of stay. CONCLUSIONS: The NASA TLX score provides a graded numerical score that that correlated significantly with the surgeon's assessment of the technical difficulty, and with operative duration, intra-operative blood loss and previous abdominal surgery. This novel application of this tool could be employed in both research and teaching settings to score surgical difficulty and monitor a trainee's proficiency over time.

Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre.

BACKGROUND: Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital. METHODS: A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period. RESULTS: A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months. CONCLUSION: Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.

Colorectal cancer screening in Australia: An update

Background: Colorectal cancer is the second most common cancer in Australia. The National Health and Medical Research Council (NHMRC) has introduced new recommendations for the prevention, early detection and management of colorectal cancer. General practitioners play a key part in the advocacy, risk stratification and implementation of colorectal cancer screening on the basis of a patient's individual risk. Objective: The aim of this paper is to summarise the NHMRC recommendations pertaining to screening so that they may be applied in general practice. Discussion: The recommended strategy for population screening in Australia remains the immunochemical faecal occult blood test, commencing at age 50 years in asymptomatic individuals with no family history of colorectal cancer. This test is to be performed every two years to age 74 years. Individuals with a family history of colorectal cancer will need appropriate risk stratification. Aspirin should now be considered for all patients aged 50­70 years in the prevention of colorectal cancer.

Colonic transit: what is the impact of a diverting loop ileostomy?

BACKGROUND: Diverting loop ileostomy (DLI) is used following low anterior resections (LAR) or ultra-low anterior resections (ULAR) to reduce anastomotic leak (AL). Preoperative mechanical bowel preparation (MBP) is traditionally used with DLI. However, clearance of the left colon can be achieved with a fleet enema without the physiological compromise of MBP. We aimed to assess colonic transit following DLI in this context. METHODS: A prospective, observational study was performed with patients with rectal cancer undergoing LAR or ULAR in a tertiary colorectal unit with preoperative fleet enema. Radiopaque markers were inserted into the caecum following rectal resection and formation of a DLI with placement confirmed by image intensifier and endoscopy. X-rays were performed at days 1, 3, 5 and 14 post-operation with data collected prospectively. RESULTS: Ten patients (mean age 57, nine males) were enrolled. Mean time to functioning stoma was 1.9 days (range 1-3). There was no movement in the majority of markers in all patients at Day 5 post-operation. In all seven patients with Day 14 X-rays, the majority of markers remained in the right colon. Two patients had delayed AL, with markers found within the pelvis in both of these patients. CONCLUSIONS: This is the first study to assess colonic transit following DLI using fleet enema only, with results suggesting colonic motility is abolished in this setting. The use of a fleet enema without MBP may be sufficient prior to rectal resection surgery when DLI is employed. AL may actually increase colonic transit. Further research is warranted.

Predictors of spermatogenesis in orchiectomy specimens.

OBJECTIVE: To evaluate the presence of spermatogenesis in orchiectomy specimens of patients with testicular cancer to determine possible predictors of success with oncologic testicular sperm extraction of the cancerous testis at orchiectomy. MATERIALS AND METHODS: We retrospectively reviewed the pathology reports and slides from 83 men who underwent radical orchiectomy for testicular cancer at 2 institutions from 1999 to 2010. The presence or absence of spermatogenesis in each specimen was determined. Data on tumor histopathologic type, serum tumor markers, and tumor size were also obtained and analyzed to detect any associations with the presence of spermatogenesis. RESULTS: The 83 specimens included 41 pure seminomas, 36 nonseminomatous and mixed germ cell tumors, and 6 benign lesions. Overall, spermatogenesis was detected in 48 of 77 (62%) cancerous specimens. Spermatogenesis was present in 22 of 41 (54%) pure seminomas and 26 of 36 (72%) nonseminomatous and mixed germ cell tumors, with no significant difference found between the 2 subtypes (P = .11). No association was found between tumor marker levels and the presence of spermatogenesis. A logistic regression model revealed a statistically significant inverse relationship between tumor size and spermatogenesis presence (P = .004). CONCLUSION: At orchiectomy, most cancerous testes contained active spermatogenesis and, thus, represent a viable source for sperm cryopreservation with oncologic testicular sperm extraction. A small tumor size proved to be a positive prognostic indicator for the presence of spermatogenesis, although a larger tumor size did not preclude the presence of spermatogenesis.

Implantation of ethylene vinyl alcohol copolymer for faecal incontinence management.

PURPOSE: The primary objectives of this trial were to evaluate the safety and feasibility of treatment and to gain a preliminary indication of the effectiveness of ethylene vinyl alcohol injections into the anal sphincters of faecally incontinent patients. METHODS: Between April 2004 and February 2006, we conducted a prospective, single-arm, procedure optimization study of ethylene vinyl alcohol injections in 21 subjects with well-characterized faecal incontinence and an intact external anal sphincter at two Australian hospitals. RESULTS: There was a significant decrease in the Cleveland Clinic Florida Faecal Incontinence Score (CCFFIS) (P= 0.0005) and the Faecal Incontinence Severity Index score (P= 0.005) after treatment. At 12 months post-treatment, the mean CCFFIS had decreased by 37% (P= 0.0021), and 47% of subjects had a > or =50% improvement in CCFFIS. There were significant improvements in embarrassment (P= 0.0455) and coping/behaviour (P= 0.0056) domains of the Faecal Incontinence Quality of Life. At 12 months, the mean anal canal length had increased by 29% (P= 0.066), with 40% of patients demonstrating increases of 50% or more. There were no further improvements following retreatment. CONCLUSIONS: Ethylene vinyl alcohol injection into the anal intersphincteric plane is feasible and well tolerated. Improvement in faecal incontinence compared with baseline was seen. Retreating initial non-responders was not successful.

Primary Hodgkin lymphoma of the adrenal gland: a unique case presentation.

Adrenal "incidentalomas" are commonly found on body imaging, and treatment of these lesions 4 cm-6 cm in size is controversial. Most of these lesions are benign adrenal cortical adenomas. Lymphoma is a rare disease manifestation in the adrenal gland, and the overwhelming majority are metastatic lesions. Hodgkin lymphoma has never been reported as a primary adrenal lesion. We present a very unique case report of a 5 cm adrenal "incidentaloma" that represents the first reported case of primary Hodgkin lymphoma in the adrenal gland.

Deficiencies in pathological reporting of colorectal cancer in Victoria.

BACKGROUND: Colorectal cancer (CRC) pathological reporting deficiencies have been shown to be common, with deviations from the suggested minimum dataset. Information from both surgeon and pathologist is necessary for a complete report. These deficiencies have been shown to be correctable with the use of synoptic reporting. We carried out an audit on a random sample of CRC pathological reports from the first 6 months of 2004 in Victoria, Australia, with the aim of documenting current CRC pathological reporting deficiencies. METHODS: A random sample of pathological reports for CRC was obtained from the Cancer Council of Victoria. One hundred and sixteen of these reports were reviewed by a team of surgical and pathology trainees. Presence or absence of the various fields of the 1999 National Health and Medical Research Council minimum dataset for CRC reporting was recorded. RESULTS: There were deviations from the minimal dataset. Most notable was the absence of the information on the apical node, the presence of distant metastasis and perineural invasion. CONCLUSIONS: The opportunity exists for improvement in the pathological reporting of CRC in Victoria through the uniform introduction of synoptic reporting.

Ex vivo sentinel lymph node mapping in colorectal cancer.

INTRODUCTION: Sentinel lymph node mapping has been used in clinical work in malignant melanoma and breast cancer and shown an advantage over routine regional lymphadenectomy. The technique has been applied to colorectal cancer, but concerns over accuracy and high false-negative rates have restricted its use in the routine clinical setting. Most published series have used the in vivo technique and only three studies have been published in which the ex vivo technique was used. The aim of this study was to report the results of a larger study of ex vivo sentinel node mapping. METHODS: All patients with colorectal cancer were considered for the trial, except patients who received preoperative radiotherapy for rectal cancer. All specimens were examined in the operating room within 30 minutes of resection. After opening the bowel, 0.5 ml of patent blue dye was injected submucosally at four sites immediately adjacent to the tumor (2 ml). The pathologic examination of the sentinel nodes and of an equal number of nonsentinel nodes consisted of standard hematoxylin and eosin sectioning, followed by multiple sectioning for further hematoxylin and eosin staining and immunohistochemistry if initial samples did not show tumor metastases. RESULTS: A total of 58 tumors in 57 patients were studied. One or more sentinel nodes were found in relation to 56 tumors, with one of the two failures being attributed to gross mesenteric metastases obstructing lymphatic flow. A mean of 2.93 (0-8) sentinel nodes were found per patient. There was concordance between the sentinel nodes and nonsentinel nodes in 43 patients (76.8 percent). There were nine false-negative sentinel nodes (16 percent). Two patients were upstaged by detailed pathologic examination of the sentinel nodes (micrometastases), and in a further two patients the sentinel node was the only positive node on simple hematoxylin and eosin sectioning. CONCLUSIONS: The technique of ex vivo sentinel node mapping is feasible and accurate in defining sentinel nodes in colorectal cancer. There is, however, a significant false-negative rate making the sentinel nodes not representative of the lymph node basin. This precludes the use of this technique in routine clinical practice. There may be a role in a research setting to help define the prognostic significance of micrometastases.

Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer.

OBJECTIVE: The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival. SUMMARY BACKGROUND DATA: There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed. METHODS: Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level. RESULTS: From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1-6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5-54.6%) compared to 64.0% (CI 61.5-66.3%) in those without leak. In proportional hazards regression-after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement-anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2-2.0) and cancer-specific survival (HR 1.8, CI 1.2-2.6). CONCLUSION: Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival.

Adenocarcinoma in the anal transitional zone after ileal pouch for ulcerative colitis: report of a case.

This article reports the seventh known case of adenocarcinoma arising in or adjacent to an ileal pouch after proctocolectomy for ulcerative colitis. It is the second reported case of adenocarcinoma in the anal transitional zone in this setting. A literature review is presented of the six previous cases published, and on the wider subject of how to best manage the anal transitional zone. It is concluded that this is a rare, but catastrophic, event with a potentially poor prognosis and can occur late (more than a decade) after the original surgery. All ileal pouches performed for ulcerative colitis should be followed for extended periods. The development of dysplasia necessitates close follow-up, including regular biopsies, and local excision and pouch advancement can manage persistent dysplasia. When operating for dysplasia or cancer, biopsies of the anal transitional zone should be performed or consideration given to mandatory mucosectomy.