Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis.

BACKGROUND: Turnbull-Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull-Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis. METHODS: We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality. RESULTS: Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred. CONCLUSION: Salvage Turnbull-Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon's armamentarium as an alternative to the creation of a permanent stoma.

CONTEXTE: La résection colique abdominale avec extraction trans-anale et anastomose colo-anale différée (CAD) fut décrite initialement par Turnbull et Cutait en 1961. Cette intervention a récemment été rapportée pour le traitement des conditions colorectales complexes. Nous avons revu notre expérience avec la CAD comme chirurgie de sauvetage dans le traitement des complications complexes de l'anastomose colo-anale de première intention. MÉTHODES: Nous avons effectué une étude de cohorte rétrospective entre octobre 2010 et septembre 2011, en analysant la morbidité et la mortalité postopératoires. RÉSULTATS: Sept CAD ont été réalisées en raison de complications anastomotiques (3 fuites anastomotiques chroniques, 2 fistules rectovaginales, 1 fistule colovésicale, 1 ischémie colique) résultant du traitement chirurgical d'un cancer rectal. Six patients avaient subi une iléostomie de dérivation pour fuite anastomotique, dans la période précédant la CAD de sauvetage. À l'exception d'un patient, toutes les procédures se sont soldées en succès. Aucune fuite anastomotique n'a été observée après CAD. Un patient a dû subir une résection abdominopérinéale avec colostomie terminale permanente en raison d'ischémie colique aigue du colon distal après CAD. Aucun décès n'est survenu dans les 30 jours suivant la CAD. CONCLUSION: La CAD de sauvetage apparait comme une intervention sécuritaire qui représente une option thérapeutique valable pour les patients souffrant de complications complexes de fuites anastomotiques colorectales. Cette intervention pourrait s'ajouter à l'arsenal du chirurgien comme alternative à la création d'une stomie permanente.

Postural and dynamic balance while walking in adults with incomplete spinal cord injury.

The purpose of this study was to characterize balance in individuals with and without an incomplete spinal cord injury (ISCI) during the single support phase of gait. Thirty-four individuals (17 with a ISCI, 17 able-bodied) walked at their self-selected walking speed. Among those, eighteen individuals (9 with ISCI, 9 able-bodied) with a similar walking speed were also analyzed. Stabilizing and destabilizing forces quantified balance during the single support phase of gait. The biomechanical factors included in the equation of the stabilizing and destabilizing forces served as explanatory factors. Individuals with ISCI had a lower stabilizing force and a higher destabilizing force compared to able-bodied individuals. The main explanatory factors of the forces extracted from the equations were the speed of the center of mass (maximal stabilizing force) and the distance between the center of pressure and the base of support (minimal destabilizing force). Only the minimal destabilizing force was significantly different among subgroups with a similar walking speed. The stabilizing and destabilizing forces suggest that individuals with ISCI were more stable than able-bodied, which was achieved by walking more slowly - which decrease the speed of the center of mass - and keeping the center of pressure away from the margin of the base of support in order to maintain balance within their range of physical ability.

Gait adaptation during walking on an inclined pathway following spinal cord injury.

BACKGROUND: Individuals with incomplete spinal cord injury need to be assessed in different environments. The objective of this study was to compare lower-limb power generation in subjects with spinal cord injury and healthy subjects while walking on an inclined pathway. METHODS: Eleven subjects with spinal cord injury and eleven healthy subjects walked on an inclined pathway at their natural gait speed and at slow gait speed (healthy subjects only). Ground reaction forces were recorded by force plates embedded in the inclined pathway and a 3-D motion analysis system recorded lower-limb motions. Data analysis included gait cycle parameters and joint peak powers. Differences were identified by student t-tests. FINDINGS: Gait cycle parameters were lower in spinal cord injury subjects compared to healthy subjects at natural speed but similar at slow gait speed. Subjects with spinal cord injury presented lower power at the ankle, knee and hip compared to healthy subjects at natural gait speed while only the power generation at push-off remained lower when the two groups performed at similar speed. INTERPRETATION: The most important differences are associated with the fact that individuals with spinal cord injury walk at a slower speed, except for the ankle power generation. This study demonstrated that, even with a good motor recovery, distal deficits remain and may limit the ability to adapt to uphill and downhill walking. Inclined pathways are indicated to train patients with spinal cord injury. Clinicians should focus on the speed of uphill and downhill walking and on the use of plantar flexors.

Using field notes to evaluate competencies in family medicine training: a study of predictors of intention.

BACKGROUND: Documenting feedback during clinical supervision using field notes (FN) is a recommended competency-based evaluation strategy that will require changes in the culture of medical education. This study identified factors influencing the intention to adopt FN in family medicine training, using the theory of planned behaviour. METHODS: This mixed-methods study involved clinical teachers (CT) and residents from two family medicine units. Main outcomes were: 1) intention (and its predictors: attitude, perceived behavioural control (PBC) and normative belief) to use FN, assessed using a 7-item Likert scale questionnaire (1: strongly disagree to 7: strongly agree) and 2) related salient beliefs, explored in focus groups three and six months after FN implementation. RESULTS: 27 CT and 28 residents participated. Intention to use FN was 6.20±1.20 and 5.74±1.03 in CT and residents respectively. Predictors of this intention were attitude and PBC (mutually influential: p < 0.05), and normative belief (p < 0.01). Focus groups identified underlying beliefs regarding their use (perceived advantages/disadvantages and facilitators/barriers). CONCLUSION: Intention to adopt field notes to document competency is influenced by attitude, perceived behavioural control and normative belief. Implementation of field notes should be preceded by interventions that target the identified salient beliefs to improve this competency-based evaluation strategy.