Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia.

BACKGROUND: Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. METHODS: All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. RESULTS: Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). CONCLUSION: The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.

Transanal haemorrhoidal dearterialization for the treatment of grade III and IV haemorrhoids: a 3-year experience.

BACKGROUND: Transanal haemorrhoidal dearterialization (THD) is increasingly perceived as an effective and better tolerated alternative to excisional haemorrhoidectomy. The aim of this study was to evaluate outcomes and the patient experience of THD in an Australian population with grade III or IV haemorrhoids. METHODS: A retrospective review of prospectively maintained database on patients who had undergone THD over a 3-year period was performed. Data were collected on demographics, operative data, complications, recurrences and readmissions, postoperative pain and further interventions. Patient perceptions and satisfaction with the procedure were assessed with a telephone survey. RESULTS: A total of 85 patients with a mean age of 55 (±14) years with grade III (85%) or grade IV (15%) haemorrhoids underwent THD. Indications for surgery were predominantly bleeding (87%) and prolapse (41%). Median outpatients follow-up was 42 days and median telephone follow-up was 802 days. Median operating time was 25 min (±12). Twenty-four per cent of patients suffered complications, including postoperative bleeding (7%), constipation (7%), local sepsis (6%), anal fissure (5%) and temporary incontinence (2%). Severe postoperative pain occurred in 16% of the patients. The symptom recurrence rate was 19% and reintervention rate was 14%. About 98.8% of patients reported good or excellent overall satisfaction with the procedure. CONCLUSION: THD is a relatively new technique for the treatment of haemorrhoids, which is increasingly being used as an alternative to excisional haemorrhoidectomy. This study shows that patients' satisfaction with THD is high despite a moderate complication and recurrence rate and significant incidence of postoperative pain.

Carbon dioxide insufflation during colonoscopy in deeply sedated patients.

AIM: To compare the impact of carbon dioxide (CO2) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy. METHODS: Patients referred for colonoscopy were randomized to receive either CO2 or air insufflation during the procedure. Both the colonoscopist and patient were blinded to the type of gas used. During the procedure, insertion and withdrawal times, caecal intubation rates, total sedation given and capnography readings were recorded. The level of sedation and magnitude of patient discomfort during the procedure was assessed by a nurse using a visual analogue scale (VAS) (0-3). Patients then graded their level of discomfort and abdominal bloating using a similar VAS. Complications during and after the procedure were recorded. RESULTS: A total of 142 patients were randomized with 72 in the air arm and 70 in the CO2 arm. Mean age between the two study groups were similar. Insertion time to the caecum was quicker in the CO2 group at 7.3 min vs 9.9 min with air (P = 0.0083). The average withdrawal times were not significantly different between the two groups. Caecal intubation rates were 94.4% and 100% in the air and CO2 groups respectively (P = 0.012). The level of discomfort assessed by the nurse was 0.69 (air) and 0.39 (CO2) (P = 0.0155) and by the patient 0.82 (air) and 0.46 (CO2) (P = 0.0228). The level of abdominal bloating was 0.97 (air) and 0.36 (CO2) (P = 0.001). Capnography readings trended to be higher in the CO2 group at the commencement, caecal intubation, and conclusion of the procedure, even though this was not significantly different when compared to readings obtained during air insufflation. There were no complications in both arms. CONCLUSION: CO2 insufflation during colonoscopy is more efficacious than air, allowing quicker and better cecal intubation rates. Abdominal discomfort and bloating were significantly less with CO2 insufflation.

Laparoscopic colorectal surgery for cancer: intermediate to long-term outcomes.

PURPOSE: Since 1991, a laparoscopic-assisted resection has been used at the Royal Brisbane Hospital selectively for patients with colorectal cancer. This article audits the intermediate to long-term postoperative complications and cancer follow-up data. METHODS: All patients undergoing a laparoscopic resection for cancer were prospectively followed up with regard to long-term outcomes. RESULTS: One hundred eighty-one patients have been studied. One hundred fifty-four patients had potentially curative procedures performed in the study period. Median follow up was 71 (range, 7-108) months. The overall recurrence rate in this group was 6 percent (21 recurrences). There was one port site recurrence after a potentially curative procedure (0.6 percent) and one port site recurrence after a palliative resection. Perioperative mortality was 1 percent (2 patients). Only six patients suffered an adhesive small-bowel obstruction postoperatively. There was one incisional hernia. Unadjusted five-year median survival data for Australian Clinico-pathological Staging A was 91 percent (3.5 percent recurrence); for Australian Clinico-pathological Staging B, 83 percent (15 percent recurrence); and for Australian Clinico-pathological Staging C, 74 percent (26 percent recurrence). CONCLUSION: In selected patients a laparoscopic resection for colorectal cancer produces acceptable intermediate to long-term oncologic outcomes and a low long-term complication rate.