COVID-19 and the impact on urology service provision at Capital & Coast District Health Board.

AIM: To determine the impact on the Capital & Coast District Health Board (CCDHB) urology service of the implementation of nationwide healthcare restrictions in response to the COVID-19 pandemic. METHODS: This is an observational retrospective study over a 21 working day period during the implementation of National Hospital Response Framework Alert (NHRFA) level 2. We obtained patient data during this period and a corresponding control period prior to the pandemic. The data was focussed on the volume of operating theatre cases, outpatient consultations, procedural clinic appointments and the estimated avoided outpatient travel. RESULTS: Total urology admissions decreased by 27% during the 21-day NHRFA level 2 period. However, acute surgical procedures increased by 30% whereas elective surgical procedures decreased by 32%. Outpatient consultations overall decreased by 32% during NHRFA level 2 despite virtual phone consultations increasing by 274%. Procedural clinic appointments decreased by 85%. The virtual platform also saved each patient an estimated 22.7km of average travel. CONCLUSION: The data demonstrate the effects of restrictions in response to a crisis and set a precedent for future management in such scenarios. The data also show how service efficiency can be optimised while providing an environmentally friendly alternative for routine clinical practice.

Risk factors for readmission with dehydration after ileostomy formation: A systematic review and meta-analysis.

AIM: Ileostomy formation is a commonly performed procedure with substantial associated morbidity. Patients with an ileostomy experience high rates of unplanned hospital readmission with dehydration, and such events have a long-term health and economic impact. Reports of the significant risk factors associated with these readmissions have been inconsistent. This study aimed to identify the significant risk factors for readmission with dehydration following ileostomy formation. METHOD: A systematic search was conducted using the Medline, Embase, Cochrane and CINAHL databases. All original research articles reporting risk factors for readmission with dehydration following ileostomy formation in adults were included. The primary outcome was the pooled risk ratio of clinically relevant variables potentially associated with dehydration-related readmission following ileostomy formation. The secondary outcome was the incidence of dehydration-related readmission. RESULTS: Ten studies (27 089 patients) were included. The incidences of 30- and 60-day readmission with dehydration were 5.0% (range 2.1%-13.2%) and 10.3% (range 7.3%-14.1%), respectively. Eight variables were found to be significantly associated with dehydration-related readmission: age ≥65 years, body mass index ≥30 kg/m2 , diabetes mellitus, hypertension, renal comorbidity, regular diuretic use, ileal pouch-anal anastomosis procedure and length of stay after index admission. A preoperative diagnosis of colorectal cancer was less likely to result in readmission with dehydration. CONCLUSION: Readmission with dehydration following ileostomy formation is a significant issue with several risk factors. Awareness of these risk factors will help inform the design of future studies addressing risk prediction, allow risk stratification of ileostomates and aid in the development of personalized prevention strategies.

Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis.

BACKGROUND: Defunctioning ileostomy is widely used to protect a low colorectal anastomosis. However, the use of an ileostomy may have an impact on long-term bowel function and quality of life after anterior resection. The objectives were to compare bowel function and quality of life outcomes between patients undergoing an anterior resection for rectal cancer, with and without the formation of a diverting ileostomy, and to compare outcomes for early versus late closure of diverting ileostomy. METHOD: A systematic literature review was performed to identify studies published between 2007 and 2018 comparing bowel function and quality of life outcomes after an anterior resection for rectal cancer in those with and without formation of a diverting ileostomy. RESULTS: Four studies (three randomized controlled trials) reported bowel function and quality of life outcomes. Pooled analysis for 227 participants showed that having an ileostomy is associated with twice the risk of suffering from low anterior resection syndrome (odds ratio (major low anterior resection syndrome) 1.96, 95% confidence interval 1.1, 3.5; P = 0.02). There were no consistent differences in quality of life. Based on single studies there is limited evidence of some improvements in bowel function but no difference in quality of life after early compared to late closure of ileostomy. CONCLUSION: There is some evidence for an association between low anterior resection syndrome and the use of a diverting ileostomy to protect a rectal anastomosis. Potential confounders include height of the anastomosis. Further research into the mechanisms underlying this potential association may inform methods to mitigate the harms of an ileostomy.

Oesophagectomy at a New Zealand regional centre: where to now?

BACKGROUND: This study aims to define contemporary trends in characteristics, costs and management of patients diagnosed with oesophageal adenocarcinoma in New Zealand. METHODS: Clinical, pathological and management data of the 135 patients presenting with histologically proven adenocarcinoma to our institution over a 5-year period (January 2010 to December 2014) was collected. Primary analysis reviewed patient demographics, co-morbidities, treatment strategy and survival. Secondary analysis defined operative outcomes including complications, mortality rates and overall survival to December 2016. RESULTS: Thirty-eight patients underwent oesophago-gastrectomy (resection rate 28%) with curative intent following neoadjuvant chemotherapy with Clavien-Dindo ≥3 complications in 17 patients (46%). Actuarial survivals from surgery at 1, 3 and 5 years were (79, 55 and 50%), with 19 patients (54%) alive and disease free at a median follow-up of 26.5 months (range 1-82 months). Overall, this represented one sixth of the national volume of oesophagectomy. Ninety-seven patients were managed non-surgically due to metastatic or advanced local disease (n = 64), co-morbid status (n = 27), patients choice (n = 2) and unknown (n = 4). Median survival from diagnosis in non-resected patients was 9 months (range 1-40 months). CONCLUSION: Oesophagectomy remains a challenging procedure for any institution, although good results can be achieved. Foci for referral are emerging in New Zealand for the surgical management of oesophageal cancer.

Predictors of surgical intervention following initial surveillance for acute ureteric colic.

PURPOSE: To identify clinical and stone-related factors predicting the need for surgical intervention in patients who were clinically considered appropriate for non-surgical intervention. PATIENTS AND METHODS: We conducted a retrospective review of a contemporary cohort of patients who were selected for surveillance following presentation with acute ureteric colic. Data on patient demographic and stone variables, inpatient management and long-term outcomes were evaluated. Multivariate logistic regression was used to generate a nomogram predicting need for surgical intervention. The accuracy of the nomogram was subsequently validated with an independent cohort of patients presenting with ureteric colic. RESULTS: Of 870 study eligible patients presenting with acute ureteric colic, 527 were initially treated non-surgically and included in the analysis. 113 of these eventually required surgical intervention. Median time from first presentation to acute surgery was 11 (IQR 4-82) days. In our final MVA analysis, duration of symptoms more than 3 days, not receiving alpha-blockers, positive history of previous renal calculi and stone location, burden and density were independent predictors of need for surgical intervention. Patients who required opioid analgesia were more likely to have surgical intervention; however, this did not reach statistical significance. The area under the curve (AUC) of the final model was 0.802. The nomogram was validated with a cohort of 210 consecutive colic patients with AUC of 0.833 (SE 0.041, p < 0.001). CONCLUSIONS: We have identified independent predictors of the need for surgical intervention during an episode of renal colic and formulated a nomogram. Combined with the diligent use of acute ureteroscopy at our centre, this nomogram may have clinical utility when making decisions regarding treatment options with potential healthcare cost savings.

Prospective comparison of return of bowel function after left versus right colectomy.

BACKGROUND: Passage of flatus and stool represents a key milestone in recovery after colonic resections. Colorectal surgeons may hold varied expectations regarding recovery rates after left- versus right-sided colectomies, but there is currently little evidence to inform post-operative care. This study prospectively compared gut function recovery after left- versus right-sided resections. METHODS: Prospective data were analysed from 94 consecutive patients undergoing elective colorectal resections with primary anastomosis at Auckland City Hospital. Patients having ileostomies were excluded. Primary analysis compared time to first bowel motion between left- versus right-sided resections, excluding patients who developed prolonged post-operative ileus, while secondary analyses compared length of stay, rates of prolonged ileus and other complications. RESULTS: Analysis included 42 patients with left-sided and 52 with right-sided resections. No significant differences were observed for complications (P = 0.1), length of stay (P = 0.9) or development of prolonged ileus (P = 0.2). Rate of return of bowel function was faster in patients after left-sided resections (median 2.5 versus 4 days; P = 0.03 by Log-rank (Mantel-Cox) test), when patients with prolonged post-operative ileus were excluded. An association was also identified between length of bowel resected and time to recovery of bowel function for right-sided (P = 0.02) but not left-sided resections (P = 0.9). CONCLUSION: This study shows that for patients who do not progress to prolonged ileus, those with left-sided resections experience faster return of bowel function when compared with those having right-sided resections. The reason for this finding is currently unknown and deserves further attention.