Open compared with laparoscopic complete mesocolic excision with central lymphadenectomy for colon cancer: a systematic review and meta-analysis.

AIM: Several studies report improved survival in colon cancer with use of extended lymphadenectomy techniques (ELTs), such as D3 lymphadenectomy or complete mesocolic excision. The noninferiority of laparoscopic versus open techniques has already been established in D2 resections. The aim of this study was to compare the safety and efficacy of open and laparoscopic approaches for ELTs in colon cancer. METHOD: Major databases, including PubMed, Scopus and the Cochrane library, were searched using defined inclusion and exclusion criteria, and relevant data were extracted. The Cochrane and Newcastle-Ottawa tools were used for critical appraisal and quality assessment. Meta-analysis with various subgroup analyses were undertaken, and clinical and statistical heterogeneity, along with publication bias, were also assessed. RESULTS: One randomized and seven case-control trials were included. All studies were found to be of low methodological quality with some external validity issues. There was no difference in short-term mortality [OR = 2.16 (95% CI: 0.73-6.41); P = 0.16], anastomotic leakage, ileus or deep-sited infection/abscess. There was a trend for longer operative time [weighted mean difference (WMD) = -30.88 (95% CI: -62.38 to 0.61); P = 0.05] and shorter length of hospital stay [WMD = 2.29 (95% CI: -0.39 to 4.98); P = 0.09] with the laparoscopic approach. Laparoscopic right hemicolectomy had a lower wound-infection rate [OR = 2.87 (95% CI: 1.38-5.98); P = 0.005] compared with the relevant open group. No statistically significant difference was found in overall survival [hazard ratio (HR) = 0.85 (95% CI: 0.69-1.06); P = 0.15], disease-free survival, local recurrence and distant metastases. CONCLUSION: Based on the current evidence, the laparoscopic technique appears to be at least as safe as the open technique when used in performing ELTs for colonic cancer, with similar morbidity and oncological outcomes.

Reversal of loop ileostomy under an Enhanced Recovery Programme - Is the stapled anastomosis technique still better than the handsewn technique?

INTRODUCTION: Recent literature suggests that stapled anastomotic (SA) technique for the reversal of loop ileostomy (LI) may be beneficial in terms of early recovery and reduced incidence of small bowel obstruction when compared to the handsewn anastomosis (HA). Enhanced Recovery Programme (ERP) after colorectal procedures has demonstrated a reduction in some aspects of surgical morbidity. The aim of this study was to investigate the outcomes of patients undergoing reversal of LI within an ERP programme and compare the HA to the SA in relation to clinical outcomes. MATERIAL AND METHODS: All adult patients undergoing elective reversal of loop ileostomy between January 2008 and December 2012 without any additional procedures, were included in our study. Adherence to ERP modules and 30 day postoperative complications were assessed via retrospective review of patient case notes. RESULTS: One hundred and eight patients had an ileostomy reversal; 61 in the SA and 47 in the HA group. There were no demographic differences between the two groups. ERP module compliance was satisfactory (>80%) in 11 of the 14 modules with no difference in individual module compliance between the two groups. The operating times were found to be comparable (p = 0.35). Overall mortality (p = 0.44), anastomotic leak rates (p = 1.00), intra-abdominal collections (p = 0.65), small bowel obstruction (p = 1.00), reoperation rates (p = 0.65), ileus (p = 0.14) and other significant complications (Clavien-Dindo > 2) (p = 0.08) were similar between the two groups. A significantly longer total length of hospital stay (TLOS) was found in the SA group (median 3 Vs 4 days, p = 0.009). CONCLUSION: Reversal of LI under an ERP appears to potentially neutralise the suggested SA benefits in terms of postoperative complications without any additional negative implications. Other non-operative factors may have a potential effect on outcomes such as the TLOS.

Medical malpractice claims in relation to colorectal malignancy in the national health service.

AIM: Under the current increased financial constraints affecting the National Health Service (NHS), clinical negligence claims and associated compensations are constantly rising. Our aim was to identify the magnitude, trends and causes of malpractice claims in relation to a common pathology such as colorectal malignancy in the NHS. METHOD: Data requests were submitted to the NHS Litigation Authority (NHSLA) and to the Medical Defence Union (MDU) and Medical Protection Society (MPS). Data were reviewed, categorized clinically and analysed in terms of causes and costs behind claims. RESULTS: Data from the MPS and MDU were unavailable. In all, 169 claims were identified from the NHSLA database between 2003 and 2012; 123 (73%) cases had been closed, 80 (65%) of which were successful. An increasing overall claim frequency and success rate were found over the last few years. Total litigation expenses were £8.6 million, with 39% paid out as legal expenses. The commonest cause of complaint in successful claims was in relation to diagnostic delays or failures (58%, £5.1 million), with a delay or failure by the clinician to take action in response to an abnormal investigation result being a major factor. The occurrence of peri-operative complications (20%, £1.6 million) was the second commonest cause. CONCLUSION: Average frequency and success rates of malpractice claims in secondary care in the NHS are rising, leading to significant overall payouts. The failure or delay in diagnosing colorectal malignancy or its postoperative complications is a common cause behind malpractice claims. Improvement in these areas could enhance patient care and reduce future claims.

Nutritional access routes following oesophagectomy--a systematic review.

Nutritional support in patients undergoing oesophagectomy is of paramount importance in this usually malnourished patient group, but encountering significant clinical practice variation between units. Our aim was therefore to assess the strength of evidence behind nutritional support routes post-oesophagectomy. The Cochrane Library and Controlled Trials Registry, MEDLINE (Ovid) (1966-April 2009), PubMed, EMBASE (1966-April 2009), CINAHL, Web of knowledge and SCOPUS databases, were electronically searched for the highest level of evidence, with English language as a limit. Reference follow-up was also used. Studies were critically reviewed based on The NHS Public Health Resource Unit Critical Appraisal Skills Programme Tools. Five randomised control trials (RCTs) and one case-control trial, with 344 patients, were included in the review. There was a significant variation in the routes assessed (including intravenous fluid therapy, peripheral and central line nutrition, feeding jejunostomy, nasojejunal and nasoduodenal tubes) and the methodological quality of each study, with small patient numbers. No route was found to be superior over another in the RCTs. In the case-control trial, the combination of enteral parenteral nutrition led to shorter hospital stay compared with parenteral feeding alone. Nasojejunal and nasoduodenal tubes are associated with a significant rate of dislodgement. There is absence of strong direct evidence supporting a single feeding access route in oesophagectomy patients. Clinical decisions should be made based on available evidence from other types of gastrointestinal surgery, currently favouring enteral nutrition. If enteral feeding is chosen, feeding jejunostomy may be superior to nasojejunal or duodenal tubes.

Litigation claims in vascular surgery in the United Kingdom's NHS.

OBJECTIVES: To establish the incidence, costs and causes of medical negligence claims in relation to vascular surgery in the UK's NHS. METHODS: All claims related to vascular surgery reported to the NHS Litigation Authority from April 1995 to April 2007 were included in the study. Data was subsequently reviewed, coded and analysed. RESULTS: 395 claims were identified (mean: 49/year over last 5 years) of which 303 had been settled. Damage compensation was given in 160 cases, with overall litigation costs of approximately 17 million pounds (21 million euros). The main complaint reasons in successful claims were intra-operative problems (50%), failure/delay of treatment (14%) and failure/delay of diagnosis (11%). Varicose vein (VV) surgery was involved in 48% of successful claims, with intra-operative nerve and vessel damage being the major causes. Peripheral vascular disease (PVD) and abdominal aortic aneurysm (AAA) disease were the next two types of disease/procedures involved in successful claims with 21% and 6% respectively. CONCLUSIONS: The number of claims related to vascular surgery has remained stable over the past 5 years. Improved consenting and higher surgical skill levels especially in relation to VV surgery and increased diagnostic vigilance in PVD, AAA disease and infections are potential areas for future improvement.

Evaluation of a wireless ingestible temperature probe in cardiac surgery.

OBJECTIVES: CorTemp is a wireless intestinal temperature monitoring system in the form of an ingestible pill and an external receiver. The aim of the study was to evaluate the system's accuracy and practicality during cardiac surgery. METHODS: A repeat measures design using simultaneous temperature readings from the pulmonary artery (T (pa)), a nasopharyngeal thermometer (T (np)), skin thermometers (T (sk)) and the CorTemp system (T (in)), was conducted in 15 patients undergoing elective cardiac surgery under hypothermic conditions. RESULTS: Only 67 % of patients' data was analysed and the statistical analysis of a total of 264 sets of readings showed a clinically significant temperature difference of T (in) compared to the other thermometers with limits of agreement between T (in) and T (pa), T (np) and T (sk) (+/- 0.35 to +/- 1.53 degrees C), (+/- 0.72 to +/- 1.63 degrees C) (+/- 0.40 to +/- 1.84 degrees C), respectively. The T (in) bias was significantly different from that of T (pa) ( P = 0.0023), T (np) ( P = 0.018) and T (sk) ( P = 0.0005) during rewarming. The T (in) rate of temperature change was also found to be significantly slower during the rewarming period. CONCLUSIONS: The significant temperature differences detected during rewarming urge caution regarding CorTemp use as an accurate estimator of brain temperature in cardiac surgery. Further studies are required to assess its potentially useful role as a body core and intestinal temperature monitoring system and as a useful adjunct in investigating bowel ischaemia aetiology in cardiac surgery.

Vitamin D deficiency: prevention or treatment?

BACKGROUND: Vitamin D deficiency is a chronic condition which contributes to general ill health and seems to be re-emerging in our catchment area since funding of vitamin D supplementation by Primary Care Trusts ceased. This study aims to verify this situation and to assess the cost effectiveness of reintroducing vitamin D supplementation in the Burnley Health Care NHS Trust. METHODS: Vitamin D deficient patients presenting between January 1994 and May 2005 were identified and data retrospectively collected from their case notes. The cost of treatment and the theoretical cost of primary prevention for the Trust population were calculated using previous and current DoH guidelines. RESULTS: Fourteen patients were identified, of whom 86% presented in the last 5 years and 93% were of Asian origin. The incidence of vitamin D deficiency for our population is 1 in 923 children overall and 1 in 117 in children of Asian origin. The average cost of treatment for each such child is pound2500, while the theoretical cost of prevention of vitamin D deficiency in the Asian population through primary prevention according to COMA guidance is pound2400 per case. CONCLUSIONS: Vitamin D deficiency is re-emerging in our Trust. The overwhelming majority of our patients are of Asian origin. The cost of primary prevention for this high risk population compares favourably both medically and financially with treatment of established disease. We suggest that Primary Care Trusts provide funds for vitamin D supplementation of Asian children for at least the first 2 years of life.