Using animated visualization to improve postoperative mobilization: A randomized controlled trial.

OBJECTIVE: Enhanced recovery after surgery (ERAS) programs fast-track recovery for surgical procedures, including colorectal and gynecological oncology surgery. Early mobilization is a postoperative ERAS module that can be self-managed by patients, but poor adherence is common. Visualization is increasingly being used to improve patient understanding and adherence to health behaviors. This study tested whether an animated visualization intervention could improve adherence to postoperative mobilization. METHOD: Ninety six colorectal and gynecological oncology surgery patients were randomized to intervention, active control, or standard care groups. Intervention participants saw an animated intervention on a computer tablet at Day 1 postsurgery. All participants wore fitness trackers from day of discharge to 7 days postdischarge, and completed psychological measures at baseline, Day 1 postsurgery, and 7 days postdischarge. RESULTS: Step count data was available for 57 colorectal surgery participants. A main effect of group demonstrated that intervention participants had a significantly higher average daily step count from discharge across the week following discharge (Madj = 2,294.60, 95% confidence interval [CI] [1,746.11, 2,744.89]) compared with control participants (Madj = 1,347.25, 95% CI [826.51, 1,871.20]; p = .05). At postsurgery, intervention participants reported significantly greater perceived quality of recovery and less difficulty in being mobile compared with control participants. There were no between-group differences in self-reported exercise or perceptions of surgery and recovery. CONCLUSION: This brief intervention appears effective in improving perceptions of early mobilization, and initial evidence suggests improvements in adherence to postsurgical mobilization. This intervention has high clinical applicability and could be incorporated into postoperative standard care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Great expectations: use of molecular tests and computerised prognostic tools in New Zealand cancer care.

BACKGROUND: Use of molecular tests and computerised prognostic tools designed to individualise cancer care appears to be rapidly increasing in New Zealand. These tests have important clinical and health economic implications, but their impact on cancer care has not been fully assessed. AIM: To determine cancer clinicians' use of and expectations for molecular tests and computerised prognostic tools. METHOD: Online survey of clinicians managing cancer in New Zealand. RESULTS: 137 clinicians participated, 31% used molecular tests and 57% used computerised prognostic tools. These technologies affected clinical decisions made by a quarter of participants. Over 85% of participants believed that the impact of molecular tests and computerised prognostic tools would increase over the next decade and that a stronger evidence base would support their use. CONCLUSIONS: Molecular tests and computerised prognostic tools already influence treatment provided to many New Zealand cancer patients. Clinicians who participated in this survey overwhelmingly expect the use of these tests to increase, which has important clinical implications since there is little high quality prospective data assessing the ability of these tests to improve patient outcomes. Expanded use of these often-expensive tests also has economic implications. The role of these technologies needs to be considered in the context of a wide-ranging cancer control strategy.

Complex anal fistulas: plug or flap?

BACKGROUND: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. METHODS: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. RESULTS: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. CONCLUSIONS: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.

Design and validation of a comprehensive fecal incontinence questionnaire.

PURPOSE: Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise. METHODS: Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion. RESULTS: The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35-1). CONCLUSIONS: This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.

Multiple gene expression classifiers from different array platforms predict poor prognosis of colorectal cancer.

PURPOSE: This study aimed to develop gene classifiers to predict colorectal cancer recurrence. We investigated whether gene classifiers derived from two tumor series using different array platforms could be independently validated by application to the alternate series of patients. EXPERIMENTAL DESIGN: Colorectal tumors from New Zealand (n = 149) and Germany (n = 55) patients had a minimum follow-up of 5 years. RNA was profiled using oligonucleotide printed microarrays (New Zealand samples) and Affymetrix arrays (German samples). Classifiers based on clinical data, gene expression data, and a combination of the two were produced and used to predict recurrence. The use of gene expression information was found to improve the predictive ability in both data sets. The New Zealand and German gene classifiers were cross-validated on the German and New Zealand data sets, respectively, to validate their predictive power. Survival analyses were done to evaluate the ability of the classifiers to predict patient survival. RESULTS: The prediction rates for the New Zealand and German gene-based classifiers were 77% and 84%, respectively. Despite significant differences in study design and technologies used, both classifiers retained prognostic power when applied to the alternate series of patients. Survival analyses showed that both classifiers gave a better stratification of patients than the traditional clinical staging. One classifier contained genes associated with cancer progression, whereas the other had a large immune response gene cluster concordant with the role of a host immune response in modulating colorectal cancer outcome. CONCLUSIONS: The successful reciprocal validation of gene-based classifiers on different patient cohorts and technology platforms supports the power of microarray technology for individualized outcome prediction of colorectal cancer patients. Furthermore, many of the genes identified have known biological functions congruent with the predicted outcomes.

Stapled hemorrhoidectomy.

The procedure of stapled hemorrhoidectomy has been established as a safe and effective method for treating symptomatic hemorrhoids not responsive to more conservative measures. This chapter discusses the issues of safety, efficacy, durability, and cost of this procedure. In addition, we outline techniques for performing the procedure safely and effectively.

Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk.

BACKGROUND: Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis. METHODS: A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated. RESULTS: The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn's disease (OR = 3.3), rectal cancer < or =12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01). CONCLUSIONS: Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision-making regarding defunctioning stoma formation.

The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature.

PURPOSE: Reported prevalence estimates for fecal incontinence among community-dwelling adults vary widely. A systematic review was undertaken to investigate the studied prevalence of fecal incontinence in the community and explore the heterogeneity of study designs and sources of bias that may explain variability in estimates. METHODS: A predetermined search strategy was used to locate all studies published that reported the prevalence of fecal incontinence in a community-based sample of adults. Data were extracted onto a proforma for sampling frame and method, sample size, response rate, definition of fecal incontinence used, data-collection method, and prevalence rates. Included studies were critically appraised for possible sources of selection bias, information bias, and imprecision. RESULTS: A total of 16 studies met the inclusion criteria. These could be grouped into definitions of incontinence that included or excluded incontinence of flatus. The estimated prevalence of anal incontinence (including flatus incontinence) varied from 2 to 24 percent, and the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4 to 18 percent. Only three studies were found to have a study design that minimized significant sources of bias, and only one of these used a validated instrument for data collection. The prevalence estimate of fecal incontinence from these studies was 11 to 15 percent. No pooling of estimates was undertaken because there was wide variation in study design. CONCLUSIONS: A consensus definition of fecal incontinence is needed that accounts for alterations in quality of life. Further cross-sectional studies are required that minimize bias in their design and use validated self-administered questionnaires.

Prognostic significance of occult metastases in colon cancer.

PURPOSE: The purpose of this study was to determine the prognostic significance of occult lymph node metastases in colon cancer detected by cytokeratin 20 reverse transcription polymerase chain reaction. METHODS: Two hundred patients undergoing elective colonic resections were enrolled in the study. Lymph nodes from resected specimens were dissected fresh and assessed by both reverse transcription polymerase chain reaction and histopathology. Follow-up was undertaken for up to five years, and the major end point of death was recorded. Univariate survival analysis was performed by the log-rank method and the change-in-estimate method was used to construct multivariate analysis models for the effect of cytokeratin 20 reverse transcription polymerase chain reaction lymph node status on overall survival. RESULTS: A total of 2,317 lymph nodes from 200 patients were assessed by both histopathology and cytokeratin 20 reverse transcription polymerase chain reaction. Forty-eight of 141 (34 percent) histologically lymph node-negative patients had evidence of occult metastases by cytokeratin 20 reverse transcription polymerase chain reaction. An interim analysis was performed at a median of 42 (range, 23-75) months. Cytokeratin 20 reverse transcription polymerase chain reaction lymph node status was a highly significant predictor of overall survival (P < 0.0001) on univariate analysis. In addition, the number of reverse transcription polymerase chain reaction-positive lymph nodes was a significant predictor of survival in the histologically lymph node-negative group (P < 0.0001) on univariate analysis. On multivariate analysis cytokeratin 20 reverse transcription polymerase chain reaction lymph node status had independent prognostic significance for overall survival (P = 0.021; hazard ratio = 2.7) and the number of cytokeratin 20 reverse transcription polymerase chain reaction-positive lymph nodes was a significant predictor of overall survival in the histologically lymph node-negative group (P = 0.005; hazard ratio = 1.1-11.1). CONCLUSION: Cytokeratin 20 reverse transcription polymerase chain reaction has potential as a clinically useful marker for staging colorectal cancer. Further follow-up is required, but if the current trends continue, a study of the effect of adjuvant therapy in patients with occult metastases detected by cytokeratin 20 reverse transcription polymerase chain reaction is indicated.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy.

BACKGROUND: The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP. METHODS: All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones. RESULTS: A total of 112 patients had successful preoperative ERCP. Sixty-one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin > or = 3 days (P = 0.002), serum alkaline phosphatase > or = 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter > or = 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for > or = 3 days and CBD diameter > or = 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%. CONCLUSIONS: The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.