Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution's Experience.

PURPOSE: We report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years. METHODS: Data including clinical characteristics, preoperative medical therapy, and surgical outcomes were collected. We divided eligible patients into 3 period arms (period 1, 1990 to 1999; period 2, 2000 to 2009; period 3, 2010 to 2016). Outcomes of interest were IPAA leak and pouch failure. RESULTS: A total of 212 patients were included. Median follow-up was 50 (interquartile range, 17 to 120) months. Rates of early and late complications were 34.9% and 52.0%, respectively. Early complications included wound infection (9.4%), pelvic sepsis (8.0%), and small bowel obstruction (6.6%) while late complications included small bowel obstruction (18.9%), anal stenosis (16.8%), and pouch fistula (13.3%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty-three patients (42.3%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (P=0.0025), cyclosporin (P=0.0002), and anti-tumor necrosis factor (P<0.00001) coupled with a shift to laparoscopic technique (P<0.00001), stapled IPAA (P<0.00001), J pouch configuration (P<0.00001), a modified 2-stage procedure (P=0.00012), and a decline in defunctioning ileostomy rate at time of IPAA (P=0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time. CONCLUSION: Despite greater patient exposure to immunomodulatory and biologic therapy before surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.

Predictors of postoperative mortality, morbidity, and long-term survival after palliative resection in patients with colorectal cancer.

BACKGROUND: Limited information is available on predictors of postoperative mortality, morbidity, and long-term survival in patients with stage IV colorectal cancer. OBJECTIVE: This study aimed to identify independent predictors of postoperative mortality and morbidity as well as independent predictors of long-term survival. DESIGN: This study was planned as a retrospective single-institution review. SETTING: This study took place at the Department of Surgery, The Royal Brisbane and Women's Hospital, Australia, between 1984 and 2004. PARTICIPANTS: Prospectively collected data were extracted from the records of 1867 patients undergoing treatment for colorectal cancer. The outcomes for 379 patients undergoing surgical resection of their primary colon or rectal tumor in the presence of unresectable synchronous metastases were analyzed. MAIN OUTCOME MEASURES: Independent predictive factors for postoperative mortality and morbidity as well as long-term survival were assessed by use of logistic regression and Cox regression analysis. RESULTS: Thirty-five (9.2%) patients died in the postoperative period and morbidity was 48.3%. Median survival was 11 months. Thirty-day postoperative mortality was independently associated with medical complications (P < .001), emergency operations (P = .001), female sex (P = .002), and age (≥ 70; P = .007) on regression analysis. Elderly (≥ 70) patients with either advanced local disease or extrahepatic metastases were at a particularly high risk. Preoperative predictors of surgical morbidity included male sex (P = .028) and advanced local disease (P = .036). Preoperative predictors of medical complications included repeat operations (P < .001), elevated urea levels (P = .017), and emergency operations (P = .003). Independent factors associated with poor overall survival included medical complications (P < .001), nodal stage (N2) (P = .004), poor tumor differentiation (P = .006), and apical lymph node involvement (P = .042). A subgroup of patients with advanced nodal disease (N2) and a poor tumor differentiation had a significantly poorer prognosis. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Elderly patients with advanced local disease or extrahepatic metastases are at high risk of 30-day postoperative mortality. Significant nodal disease and poor tumor differentiation are important predictors of long-term survival.

Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients.

BACKGROUND: Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking. METHODS: Data of 1576 patients who underwent primary resection and anastomosis for colorectal adenocarcinoma at a single institution from 1984 to 2004 were prospectively collected. Anastomotic leaks (LEK) were classified as radiological (RAD), local (LOC), or generalised (GEN). Logistic regression analysis of 21 variables was undertaken. Overall survival, cancer-related survival, and disease-free survival were analysed using the Kaplan-Meier method. RESULTS: Mean age of the patients was 67 years (SD = 12.5) and 834 (52.9%) were male. An LEK was more likely when relatively major gynaecological (tubo-oophorectomy, P = 0.004; hysterectomy, P = 0.006) or urological (total cystectomy, P = 0.014) procedures were performed during the same operative session. Other significant factors were anterior resection (P < 0.001), anastomosis using an intraluminal stapling device (P = 0.005), abdominal drain via laparoscopic port (P = 0.024), postoperative blood transfusion (P < 0.001), primary cancer site at the rectum (P = 0.016), and TNM stage of T2 or higher (P = 0.026). Having an LEK showed significant impact on overall (P = 0.021), cancer-related (P = 0.006), and disease-free (P = 0.001) survival. CONCLUSION: In this prospective study, advanced tumour stage, distal site, and need for postoperative blood transfusion were associated with increased rates of anastomotic leakage. In addition to their high risk of immediate postoperative morbidity and mortality, both localized and generalized leaks had similarly negative impacts on overall, cancer-related, and disease-free survival.

Laparoscopic restorative proctectomy - hybrid approach or totally laparoscopic?

BACKGROUND: Laparoscopic rectal resection is now a technique that is emerging from experience with laparoscopic colonic resection. We review and present our experience with restorative proctectomy for cancer and compare those performed with a hybrid technique with those performed totally laparoscopically. METHODS: A total of 177 patients have undergone laparoscopic restorative proctectomy. All of the patients were planned to have the abdominal portion of their surgery performed laparoscopically and to convert to open for the rectal dissection as required. They were then stratified into those that had their surgery performed completely laparoscopically (laparoscopic group - LG), and to those who had their rectal dissection and or transection performed with an open incision (hybrid group - HG). RESULTS: Short-term outcomes were compared between the LG (n=103) and the HG (n=74). The overall complication rate was higher in the HG (12% versus 35% P<0.001), mainly with a significantly higher pelvic abscess rate and higher rate of post-operative ileus. There were no intraoperative or post-operative deaths. Length of stay was equivalent in both groups (five days). To date, distal recurrence has occurred in 7.7% of the patients, eight in the LG and four in the HG (NS). Two patients, one in each group, have had local recurrence only. CONCLUSIONS: Laparoscopic open or laparoscopic hybrid approaches are techniques that can be used in suitable patients. Both have acceptable morbidity and mortality.

Laparoscopic resection for diverticular disease: follow-up of 500 consecutive patients.

OBJECTIVE: To examine morbidity, mortality, conversion rates, and disease recurrence after laparoscopic resection of complicated and uncomplicated diverticular disease in a single center. SUMMARY BACKGROUND DATA: In contrast to colorectal cancer, there are few large studies of laparoscopic or open resection for diverticular disease. METHODS: This study represents a retrospective analysis of a prospectively collected database of all laparoscopic resections for uncomplicated and complicated diverticulitis from a single center. RESULTS: Five hundred patients (305 female) were identified (median age 58; range, 26-89). Recurrent diverticulitis was the most common indication for surgery (77%), followed by perforation (10%) and fistulation (9%). Median operating time was 120 minutes (range, 45-285) and median length of hospital stay was 4 (2-33) days. The splenic flexure was routinely mobilized. There was 1 (0.2%) 30-day and in-hospital death and 55 (11%) patients had major morbidity after the procedure. Conversion to an open operation was performed in 14 (2.8%) cases. Dense adhesions were the most common cause for conversion (6 patients). Among patients with complicated diverticulitis, the conversion rate was 5.3%, whereas for those with uncomplicated disease, it was 2.1% (P = ns). Operating time and length of hospital stay do not differ significantly between patients with complicated and uncomplicated diverticulitis. The conversion rate has come down from 8% for the first 100 cases to 1.5% for the last 400 cases (P = 0.002). To our knowledge, there have been no cases of recurrent diverticulitis. CONCLUSIONS: Laparoscopic resection even in complicated cases of diverticulitis is safe and effective. It can be achieved with short operating times and length of stay in conjunction with very low rates of morbidity and mortality. Adherence to surgical principles including routine mobilization of the splenic flexure and anastomosis onto the rectum may explain the absence of disease recurrence in our experience.

A new surgical education and training programme.

Educating and training tomorrow's surgeons has evolved to become a sophisticated and expensive exercise involving a wide range of learning methods, opportunities and stakeholders. Several factors influence this process, prompting those who provide such programmes to identify these important considerations and develop and implement appropriate responses. The Royal Australasian College of Surgeons embarked on this course of action in 2005, the outcome of which is the new Surgical Education and Training programme with the first intake to be selected in 2007 and commence training in 2008. The new programme is competency based and shorter than any designed previously. Implicitly, it recognizes in the curriculum and assessment development and processes, the nine roles and their underpinning competencies identified as essential for a surgeon. It is an evolution of the previous programme retaining that which has been found to be satisfactory. There will be one episode of selection directly into the candidate's specialty of choice and those accepted will progress in an integrated and seamless fashion, provided they meet the clinical and educational requirements of each year. The curriculum and assessment in the basic sciences include both generic and specially aligned components from the commencement of training in each of the nine surgical specialties. Born of necessity and developed through extensive research, discussion and consensus, the implementation of this programme will involve many challenges, particularly during the transition period. Through cooperation, commitment and partnerships, a more efficient and better outcome will be achieved for trainees, their trainers and their patients.

Functional results of laparoscopic resection rectopexy for symptomatic rectal intussusception.

PURPOSE: This study was designed to assess the role of laparoscopic resection rectopexy for symptomatic rectal intussusception in patients who failed medical treatment. The functional outcomes of laparoscopic resection rectopexy were evaluated. METHODS: Patients who underwent laparoscopic resection rectopexy for rectal intussusception between July 1998 and November 2004 were identified. All patients with obstructed defecation failing medical treatment were included. Data were prospectively collected for the perioperative period. A follow-up questionnaire was used to assess functional outcome. RESULTS: Between 1998 and 2004, a total of 56 patients (53 females (95 percent); age range, 23-83 years) underwent laparoscopic resection rectopexy for rectal intussusception. The median operative time was 123 minutes. Morbidity was 7 percent, and there was no mortality. Fifty-two patients were available for follow-up, and of these 33 (63 percent) reported an overall improvement in their function after surgery. Of 28 patients suffering constipation, 15 (53 percent) reported an improvement in bowel frequency. Sixty-seven percent of patients incontinent before surgery improved. Symptoms of incomplete evacuation resolved in 38 percent of affected patients. Thirty-six percent of patients needing to strain at stool did not have this problem after surgery. Median follow-up was 44 (range, 15-92) months. CONCLUSIONS: The management of patients with rectal intussusception and obstructed defecation failing medical treatment is challenging. Laparoscopic resection rectopexy is an option that might offer symptomatic relief and improved function. Further studies are required to define the selection criteria to optimize the outcome in this patient group.

Task transfer: the view of the Royal Australasian College of Surgeons.

The Royal Australasian College of Surgeons (RACS) supports the evolution of appropriate task transfer in a team environment led by the most experienced clinician - in our case, the surgeon. A clear requirement needs to be identified for task transfer; it should not be used to avoid redressing the current inefficient use of existing surgeons resulting from ongoing underfunding. Maintenance of standards, defined curricula, professional titles and monitored outcomes are essential.

Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience.

PURPOSE: This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated. METHODS: The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test. RESULTS: Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients. CONCLUSIONS: Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

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.