A. Senapati

Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM).

The aim of the study was to develop a dedicated colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (CR‐POSSUM) equation for predicting operative mortality, and to compare its performance with the Portsmouth (P)‐POSSUM model.

primary Resection With Anastomosis vs . Hartmann's Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

PurposeThis study compares primary resection with anastomosis and Hartmanns procedure in an adult population with acute colonic diverticulitis.MethodsComparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmanns procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed.ResultsFifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmanns procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome.ConclusionsPatients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmanns procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures.

Objective:To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmanns procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis. Summary Background Data:The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure. Methods:Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patients perspective was used to calculate the optimal operative strategy and sensitivity analysis performed. Results:A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmanns procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively. Conclusion:Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

PROSPER: a randomised comparison of surgical treatments for rectal prolapse

Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures.

The Department of Health’s “two week standard” for bowel cancer: is it working?

Objective: To determine the effectiveness and efficiency of the Department of Health’s new general practitioner referral guidelines for bowel cancer. Design: One year prospective audit. Setting: District general hospital serving a population of 550 000. Subjects: All patients with bowel cancer; all patients referred on the basis of the two week standard and to a routine colorectal surgical outpatient clinic. Main outcome measures: Proportion of cancers referred on the basis of the two week standard and to other colorectal clinics; the proportion with the higher risk criteria and their diagnostic yields; stage of cancers diagnosed in outpatient clinics; and time to treatment. Results: A total of 249 cancers were diagnosed in the index year. Sixty five (26.1%) were referred to two week standard clinics, 40 (16.1%) to routine colorectal surgical outpatient clinics, 54 (22%) to other clinics, and 88 (35.3%) were emergencies. Thirteen patients per week were referred to the two week standard clinics and 85% (54/65) of cancers so referred were seen within two weeks. The diagnostic yield of cancer in the two week standard clinic was 9.4% (65/695) compared with 2.2% (40/1815) in the routine colorectal surgical outpatient clinic (p<0.0001). Eighty five per cent of patients with cancer referred to outpatients matched the guidelines for the two week standard clinics. Only 46% of this group were so referred. Overall, delay to treatment and Dukes’ stage were not improved in patients diagnosed in the two week standard clinics. Conclusions: Most patients with bowel cancer were not referred on the basis of the two week standard although most fulfilled the referral criteria, which had higher diagnostic yields. The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient’s journey.

Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.

Background and Objectives:The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. Methods:Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as ≥80 years, American Society of Anesthesiologists ≥3, preoperative radiotherapy, T4 tumor and BMI ≥30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. Results:A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2–33) versus 10 (1–69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02). Among the 280 (66%) “high risk” patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2–33) days in the laparoscopic group versus 11 (1–69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). Conclusion:Laparoscopic resection of colorectal cancer can achieve excellent results even in “high risk” patients and is associated with significant reductions in length of stay compared with open resection.

Results of Delorme's procedure for rectal prolapse

PURPOSE: This study was designed to examine the results of Delormes procedure. METHODS: Thirty-two patients (24 males and 8 females, mean age, 70 years) underwent Delormes procedure between 1978 and 1990 following symptoms lasting between two weeks and ten years. Thirteen patients had had 21 previous operations for prolapse. RESULTS: The mean operation time was 65 minutes. No blood transfusions were needed, there was no operative mortality, and only two patients had complications (one chest infection and one anastomotic dehiscence). No patients were lost to follow-up. Over a mean follow-up of 24 months (4 months to 4 years), 9 patients died of unrelated conditions. There were four recurrences (12.5 percent), two in patients who had each had two previous procedures. Incontinence improved in 46 percent. No patient became constipated and 50 percent of those constipated preoperatively improved. CONCLUSION: Although abdominal rectopexy is safe and has a low recurrence rate (<5 percent), it involves the hazards of a laparotomy. In addition, up to 40 percent of patients become constipated after rectopexy which may be debilitating. Delormes procedure has a low morbidity, results in good bowel function, and has a low recurrence rate. It can be performed on unfit patients with possible advantages over rectopexy and perhaps should be used more readily.

Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease

The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non‐restorative (Hartmanns procedure, HP) surgery for complicated diverticular disease.

Predictive value of common symptom combinations in diagnosing colorectal cancer

This study compared the diagnostic values of age and single symptoms of colorectal cancer with those of age and symptom combinations.

A prospective randomized controlled trial of simple Bascom's technique versus Bascom's cleft closure for the treatment of chronic pilonidal disease

BACKGROUNDnThe aim of this study was to determine which of Bascoms simple techniques, Bascoms simple surgery or Bascoms cleft closure, is preferred in the management of moderate-severity pilonidal disease.nnnMETHODSnFifty-five patients with chronic pilonidal disease were randomized to receive Bascoms simple surgery (n = 29) or cleft closure (n = 26) under local anesthetic. The primary end point was time to healing. Patients were followed up for a median of 3 years (range, .7-4 y).nnnRESULTSnAfter Bascoms simple surgery, 5 of 29 patients did not heal and proceeded to cleft closure. The remaining patients healed at a median of 4 weeks (range, 3-35 wk). After cleft closure, 21 of 26 wounds healed primarily on removal of sutures at 10 to 13 days. The remaining 5 wounds healed at a median of 4.5 weeks (range, 2-5 wk). Fifty of 55 (91%) patients were contacted for follow-up evaluation, disease recurrence occurred in 2 of 24 after Bascoms simple surgery and in 0 of 26 after cleft closure.nnnCONCLUSIONSnCleft closure offers more predictable healing than Bascoms simple surgery, with less need for re-operation. Disease recurrence is more prevalent after Bascoms simple surgery.