Patient education about recovery after colorectal surgery: systematic scoping review.

AIM: Enhanced recovery after surgery (ERAS) protocols aim to optimize recovery through a series of evidence-based recommendations. A key component of ERAS is the provision of patient education. Whilst the recommendation for this is strong, the evidence to inform its format, timing and delivery is unclear. The aim of this review was to describe previous educational interventions used to improve recovery after colorectal surgery and to explore opportunities for future research. METHODS: A systematic scoping review was performed. MEDLINE and Embase databases were searched between 1 January 1990 and 12 February 2020. Studies which described or assessed the effectiveness of a patient education or information resource to improve recovery after colorectal surgery were eligible. Outcomes of interest included the format, timing and delivery of interventions, as well as key features of intervention and study design. A narrative synthesis of data was produced through a process of charting and summarizing key results. RESULTS: A total of 1298 papers were inspected, and 11 were eligible for inclusion. Five papers were reports of randomized controlled trials, and others reported a mix of non-randomized and qualitative studies. The design of educational interventions included audio-visual resources (n = 3), smartphone device applications (n = 3) and approaches to facilitate person-to-person counselling (n = 5). Most of the counselling interventions reported positive outcomes (mainly in length of hospital stay), whereas the other types reported mixed results. Patients and the public were seldom involved as collaborators in the design of interventions. CONCLUSIONS: Patient education is generally advantageous, but there is insufficient evidence to optimize its design and delivery in the setting of colorectal surgery.

Systematic review and meta-analysis of cytokeratin 19-based one-step nucleic acid amplification versus histopathology for sentinel lymph node assessment in breast cancer.

BACKGROUND: One-step nucleic acid amplification (OSNA) is a new rapid assay for detecting breast cancer metastases during surgery, saving a second procedure for patients requiring an axillary clearance. Many centres in the UK and abroad have adopted OSNA in place of routine histopathology, despite no published meta-analysis. The aim of this systematic review and meta-analysis was to determine whether intraoperative OSNA for lymph node assessment is comparable to routine histopathology in the detection of clinically relevant metastases. METHODS: PubMed, Embase, Web of Knowledge and regional databases were searched for relevant studies published before December 2012. Included studies compared OSNA and standard histology using fresh lymph nodes that were assessed in a clearly defined systematic manner in accordance with the index study. RESULTS: Twelve eligible studies were identified that included 5057 lymph nodes from 2192 patients. Although meta-analysis using a random-effects model showed a similar overall proportion of macrometastases detected (429 of 3234 versus 432 of 3234; odds ratio 0·99, 95 per cent confidence interval 0·86 to 1·15), analysis of concordance showed that the pooled positive predictive value for detecting macrometastases was 0·79. This suggests that up to 21 per cent of patients found to have macrometastases using OSNA would have an axillary clearance when histology would have classified the deposits as non-macrometastases. Furthermore, analysis of data from the index publication showed that the range of cytokeratin 19 titres for tumours of a given volume is too wide to predict tumour size. CONCLUSION: OSNA has an unacceptably low positive predictive value, leading to axillary clearances that would not be recommended if standard histology had been used to assess the sentinel node.

Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery.

AIM: Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage. METHOD: A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing. RESULTS: Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications. CONCLUSION: Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.

Carcinoembryonic antigen is the preferred biomarker for in vivo colorectal cancer targeting.

BACKGROUND: Colorectal cancer-specific biomarkers have been used as molecular targets for fluorescent intra-operative imaging, targeted PET/MRI, and selective cytotoxic drug delivery yet the selection of biomarkers used is rarely evidence-based. We evaluated sensitivities and specificites of four of the most commonly used markers: carcinoembryonic antigen (CEA), tumour-associated glycoprotein-72 (TAG-72), folate receptor-α (FRα) and Epithelial growth factor receptor (EGFR). METHODS: Marker expression was evaluated semi-quantitatively in matched mucosal and colorectal cancer tissues from 280 patients using immunohistochemistry (scores of 0-15). Matched positive and negative lymph nodes from 18 patients were also examined. RESULTS: Markers were more highly expressed in tumour tissue than in matched normal tissue in 98.8%, 79.0%, 37.1% and 32.8% of cases for CEA, TAG-72, FRα and EGFR, respectively. Carcinoembryonic antigen showed the greatest differential expression, with tumours scoring a mean of 10.8 points higher than normal tissues (95% CI 10.31-11.21, P<0.001). Similarly, CEA showed the greatest differential expression between positive and negative lymph nodes. Receiver operating characteristic analyses showed CEA to have the best sensitivity (93.7%) and specificity (96.1%) for colorectal cancer detection. CONCLUSION: Carcinoembryonic antigen has the greatest potential to allow highly specific tumour imaging and drug delivery; future translational research should aim to exploit this.

Intra-operative tumour detection and staging in colorectal cancer surgery.

AIM: Surgical resection for colorectal cancer involves segmental resection and regional lymphadenectomy. The appropriateness of this 'one-size-fits-all' strategy is questioned as bowel cancer screening programmes result in a shift to earlier stage disease. Currently, the nodal status of a colorectal cancer can only be reliably determined by histopathological examination of the resected specimen. New methods of intra-operative staging are required to allow surgical resection to be tailored to the stage of the disease. METHOD: A literature search was performed of PubMed and Embase databases using the terms 'colon' OR 'colorectal' AND 'intra-operative detection' OR 'intra-operative staging' OR 'intra-operative detection' OR 'radioimmunoguided surgery'. Articles published between January 1980 and January 2012 were included. Technologies that have the potential to allow intra-operative staging and treatment stratification were identified and further searches performed. RESULTS: Established techniques such as sentinel lymph node mapping and radioimmunoguided surgery have benefited from combination with other technologies to allow real-time intra-operative staging. Intra-operative fluorescence, using naturally fluorescent biomarkers or fluorescent tumour probes, probably offers the most practical means of intra-operative lymph node staging and may be facilitated using nanotechnology. Optical coherence tomography and real-time elastography have the potential to provide an in vivo'virtual biopsy'. CONCLUSION: Technological advances may allow accurate intra-operative lymph node staging to facilitate tailored surgical resection. This may become the next paradigm shift in colorectal cancer surgery.

Excellent outcomes after emergency groin hernia repair.

PURPOSE: Emergency repair of incarcerated inguinal and femoral hernias has traditionally been regarded as carrying an increased risk of morbidity and mortality in a patient population that tends to be elderly with significant co-morbidities. Excessive waiting times for elective repair and delays in diagnosis and treatment increase the risk of strangulation, bowel resection and overall mortality. This study examined the management of emergency surgery for groin hernias for a 3 year period in a large teaching hospital. METHOD: The notes of all patients undergoing emergency groin hernia repair in our hospital between 1 January 2005 and 31 December 2007 were examined. Patient demographics and details of perioperative course and outcome were analysed. RESULTS: Seventy-nine (50 males) patients had emergency groin hernia repair in the 3 year study period. Inguinal hernias predominated (61 vs 18); 12/79 (15%) had previously been assessed as outpatients prior to emergency presentation-all had inguinal hernias and nine (11.4 %) were on the waiting list for elective repair at the time of emergency surgery (mean wait 59 days). Complications were observed in 24% of patients. Two patients (2.5%) required small bowel resection, both performed without recourse to formal laparotomy, and two patients died within 30 days of surgery (2.5%). CONCLUSIONS: It is possible to achieve excellent complication, bowel resection and 30-day mortality rates in emergency groin hernia repair even in patients who have previously declined surgery due to perceived anaesthetic risks. As NHS waiting times for surgery decrease, the number of hernias repaired emergently whilst awaiting elective surgery will also fall.

Nicorandil induced perianal ulceration.

Nicorandil is a cardioprotective drug which is used in the prophylaxis and long-term treatment of angina pectoris. Debilitating perianal ulcer is a rare complication of Nicorandil therapy which can cause diagnostic and management dilemmas. We describe the management of a case of Nicorandil-induced perianal ulcer and review pertinent contemporary literature.

EBRA-Digital release 2003 versus 1998: A comparison of instrument repeatability for measuring implant migration and wear.

EBRA-Digital is an established method for measuring implant migration after total hip arthroplasty using digitized radiographs that has recently undergone a change in the software platform that may influence its precision. We assessed the precision of EBRA-Digital 2003 release and compared it to the previous 1998 release using consecutive, standardized, plain radiographic examinations made on the same day after repositioning in 29 patients. The precision of implant migration and wear measurements was similar between the two software releases, although analysis times were quicker using the 2003 release (p<0.01). Image file compression at a ratio of 30 resulted in poorer measurement precision for some variables. The EBRA 2003 software platform has similar precision to the previous release and allows faster measurement of implant migration and wear. The level of image file compression that is used affects the precision of these measurements. (Hip International 2005; 15: 226-9).