Emergency left colonic resections on an acute surgical unit: does subspecialization improve outcomes?

BACKGROUND: Left-sided colonic pathologies requiring emergency resection are commonly encountered on an acute surgical unit. Subspecialist colorectal (CR) management of these patients may result in decreased morbidity, mortality and stoma rates. This study is the first of its kind comparing outcomes between CR surgeons and general surgeons on an acute surgical unit. METHODS: This is a retrospective review of 196 consecutive patients who underwent emergency left colonic resection on an acute surgical unit between January 2009 and July 2014. Patients were divided into two groups dependent on whether their surgery was managed by a CR specialist or general surgeon. Primary outcome measures were 30-day mortality, rate of primary anastomosis and overall stoma rate. RESULTS: Patients in the two groups were comparable for age, sex, American Society for Anesthesiologists score as well as CR POSSUM scores. Rates of primary anastomosis were significantly higher in the CR group compared with the acute surgical unit group (85.5 versus 28.7%, P ≤ 0.001). Overall stoma rates were significantly lower in the CR group (40.4 versus 88.8%, P = 0.0001). Thirty-day mortality was similar in both groups. Other secondary markers of morbidity including length of stay, return to theatre, anastomotic leak rate, wound problems and systemic complications had no significant difference between the two groups. CONCLUSION: Subspecialist CR management of patients undergoing emergency left-sided colonic resection on an acute surgical unit is associated with a similar level of morbidity and mortality while safely achieving significantly higher rates of primary anastomosis and lower stoma rates.

Performing a colonoscopy 12 months after surgery for colorectal neoplasia.

BACKGROUND: There appears to be acceptance that following up patients after surgery for colorectal neoplasia is of value. However, specific issues relating to which investigations to perform and how often remain unresolved. The aim of this project was to evaluate the clinical utility of performing a colonoscopy 12 months after curative surgery for colorectal neoplasia. METHODS: Patients were selected if they had undergone a curative resection for colorectal neoplasia, and if they had had a completed colonoscopy prior to surgery. Study endpoints included: (i) compliance with follow up; (ii) the prevalence, total number, size, and histology of polyps; and (iii) identification of recurrent or metachronous cancer. RESULTS: The study group included 253 patients of mean age 69.7 years (SD 11.6) and a male : female ratio of 1.4:1.0. Colonoscopies were completed on 90% of patients at a mean of 1.1 years following surgery. A total of 149 polyps were identified in 30% of patients. On histology, 42% were tubular adenomas, 6% tubulo-villous adenomas, 7% were villous adenomas, and 37% were hyperplastic. Advanced adenomas were identified in 7.9% of patients (95% CI 4.8-12.1%). No recurrent or metachronous cancers were identified. CONCLUSION: We have observed a high prevalence of advanced adenomas in patients undergoing a 12-month, follow-up colonoscopy after curative surgery for colorectal neoplasia. The significance of these observations requires further evaluation.

Clinical utility of a de-functioning loop ileostomy.

BACKGROUND: The de-functioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the faecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. The value of de-functioning stomas is currently being challenged. The purpose of the present study was to review the clinical utility of performing a de-functioning loop ileostomy in patients undergoing colorectal surgery. METHODS: A review was undertaken of a prospective colorectal database maintained at Fremantle Hospital. All end-points were defined prior to the collection of data. The study reviewed the indications and type of surgery performed. The main end-points included (i) the prevalence and management of anastomotic leaks at the primary surgery; (ii) unplanned readmissions prior to stoma closure; and (iii) the mortality, reoperation rate, and morbidity associated with closure of the stoma. RESULTS: The study involved 233 patients of mean age 58 years (range 15-89 years) and a male:female ratio of 1.1:1. The majority of patients were undergoing elective surgery (82%) for colorectal neoplasia (71%). The commonest surgical procedure was an ultra-low anterior resection (62%). At the initial surgery, 16 patients (7.0%) developed anastomotic leaks, but only two (0.9%) required reoperation. Eleven patients (4.8%) required 12 unplanned readmissions prior to stoma closure. At closure (n = 230), there were no postoperative deaths, one patient developed an ileal anastomotic leak that was managed with antibiotics, and five patients (2.2%) required reoperation within 30 days of surgery. CONCLUSION: De-functioning loop ileostomy was found to be associated with a relatively low morbidity and no mortality.

Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice.

OBJECTIVE: To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The optimal strategy for dealing with potential stones of the CBD during LC remains controversial. METHODS: The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models. RESULTS: Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods. CONCLUSIONS: The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.