Abhiram Sharma

Stress and burnout among colorectal surgeons and colorectal nurse specialists working in the National Health Service

Background  It has been suggested that changes to the organization of the National Health Service (NHS) and clinical practices in dealing with cancer are associated with increased stress and burnout in healthcare professionals. The aim of this study, therefore, was to evaluate stress and burnout in colorectal surgeons (surgeons) and colorectal clinical nurse specialists (nurses) working in the NHS.

Tobacco Smoking and Postoperative Outcomes After Colorectal Surgery.

Objective: The aim of this study was to delineate the impact of smoking on postoperative outcomes after colorectal resection for malignant and benign processes. Background: Studies to date have implicated smoking as a risk factor for increased postoperative complications. However, there is a paucity of data on the effects of smoking after colorectal surgery and in particular for malignant compared with benign processes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (2005–2010) database was queried for patients undergoing elective major colorectal resection for colorectal cancer, diverticular disease, or inflammatory bowel disease. Risk-adjusted 30-day outcomes were assessed and compared between patient cohorts identified as never-smokers, ex-smokers, and current smokers. Primary outcomes of incisional infections, infectious and major complications, and mortality were evaluated using regression modeling adjusting for patient characteristics and comorbidities. Results: A total of 47,574 patients were identified, of which 26,333 had surgery for colorectal cancer, 14,019 for diverticular disease, and 7222 for inflammatory bowel disease. More than 60% of patients had never smoked, 20.4% were current smokers, and 19.2% were ex-smokers. After adjustment, current smokers were at a significantly increased risk of postoperative morbidity [odds ratio (OR), 1.3; 95% confidence interval (CI), 1.21–1.40] and mortality (OR, 1.5; 95% CI, 1.11–1.94) after colorectal surgery. This finding persisted across malignant and benign diagnoses and also demonstrated a significant dose-dependent effect when stratifying by pack-years of smoking. Conclusions: Smoking increases the risk of complications after all types of major colorectal surgery, with the greatest risk apparent for current smokers. A concerted effort should be made toward promoting smoking cessation in all patients scheduled for elective colorectal surgery.

Closure of defunctioning loop ileostomy is associated with considerable morbidity.

Aim  An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients.

Outcomes Associated With Resident Involvement in Partial Colectomy

BACKGROUND: Surgical cases that include trainees are associated with worse outcomes in comparison with those that include attending surgeons alone. OBJECTIVE: This study aimed to identify whether resident involvement in partial colectomy was associated with worse outcomes when evaluated by surgical approach and resident experience. DESIGN: This is a retrospective study using the National Surgical Quality Improvement Program database. SETTINGS: This study evaluates cases included in the National Surgical Quality Improvement Program database. PATIENTS: All patients were included who underwent partial colectomy including both open and laparoscopic approaches. INTERVENTIONS: Residents were involved. MAIN OUTCOME MEASURES: The primary outcome measures were the association of resident involvement and major complication events, minor complication events, unplanned return to operating room, and operative time. RESULTS: Cases with residents were associated with major complications (OR 1.18, CI 1.09–1.27, p < 0.001) on multivariate analysis. However, after including operative time in the model only open cases involving fifth year residents were still associated with major complications (OR 1.13, p = 0.037). Resident involvement was associated with increased likelihood of minor complications (OR 1.3, p < 0.001) and an increased risk of unplanned return to the operating room (OR 1.20, p < 0.001). Operative time was longer for cases with residents on average by 33.7 minutes and 27 minutes for open and laparoscopic cases. LIMITATIONS: This study was limited by its retrospective design and lack of data on teachings status, case complexity, and intraoperative evaluation of technique. CONCLUSIONS: Resident involvement in partial colectomies is associated with an increased major complications, minor complications, likelihood of return to the operating room, and operative time.

Colorectal MDTs: the team's perspective

Objective  Multidisciplinary teams (MDTs) are an integral part of the National Cancer Plan. However, there is surprisingly little empirical research on how these are perceived by colorectal surgeons (CRSs) and colorectal clinical nurse specialists (CNSs). The purpose of this study therefore was to obtain the views of a national cohort of CRSs and CNSs regarding various important aspects of MDT functioning and role of CNS in current setting.

Association between operative approach and complications in patients undergoing Hartmann's reversal.

Complications following reversal of Hartmanns procedure are common, with morbidity rates of up to 50 per cent, and a mortality rate as high as 10 per cent. This is based on case series with heterogeneous data collection and analysis. This study determined risk factors for complications following Hartmanns reversal.

Baseline quality of life factors predict long term survival after elective resection for colorectal cancer.

Background. Studies have shown an association between baseline quality of life (Qol) and survival in advanced cancers. The aim of this study was to investigate their predictive value in long term survival after elective colorectal cancer resection. Methods. A consecutive series of patients undergoing elective colorectal cancer surgery for nonmetastatic disease were recruited in 2003/04. Patients completed standardized quality of life questionnaires (HADS, FACTC, MRS, and PANAS) prior to and 6 weeks after surgery. Univariate (log-rank test) and multivariate analyses (Cox proportional hazards) were performed to predict long term survival. Results. Ninety-seven patients met the inclusion criteria. Sixty-five (67%) were male and the median age of the group was 70 years. Forty-six (47.5%) patients had died and the mean survival was 1,741 days (median 2159, range 9–2923 days). Preoperative mood rating scale and functional assessment of cancer therapy-colorectal FACT C emotional well-being and postoperative FACT C additional concerns were independent predictors of long term survival. Conclusion. Incorporating psychosocial measures in preoperative assessment of cancer patients could help to identify patients who require assessment with a view to implementing psychosocial interventions. These active interventions to maximize mood and well-being should form an integral part of multidisciplinary treatment in these patients.

Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum.

BACKGROUND: Abdominoperineal excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated. OBJECTIVES: This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jackknife position might improve excision margins and oncological outcomes. METHODS: A single-institution review of a prospectively maintained database comparing the quality of excision and oncological outcomes after abdominoperineal excision in conventional and prone position was performed. Consecutive abdominoperineal excisions performed for adenocarcinoma of the rectum between January 1999 and April 2008 were included. RESULTS: Abdominoperineal excision cases were assessed including 63 in the Lloyd-Davies position and 58 in the prone jackknife position. The 5-year local recurrence rate was 5% in the prone jackknife group in comparison with 23% in the Lloyd-Davies group (p = 0.03) by life table analysis. For local recurrence, the most significant and independent risk factors were a favorable effect of having the patient in the prone jackknife position for the perineal phase of abdominoperineal excision (HR 0.2; 95% CI 0.04–0.81) and, unfavorably, a positive circumferential resection margin (HR 7.1; 95% CI 2.4–20). Lymph node involvement (N2) was an independent risk factor for overall survival (HR 4.6; 95% CI 2.1–9.5) and relapse of disease (HR 4.0; 95% CI 0.7–9.4). LIMITATIONS: This study has some limitations because it is a retrospective review of a prospective database. CONCLUSION: These data suggest that the rate of local recurrence after abdominoperineal excision may be lowered by adaptation of the prone jackknife position.

Patient personality predicts postoperative stay after colorectal cancer resection.

Objective  Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS.

Tu1754 Rectal Prolapse Repair: Laparoscopic or Perineal Approach?

Introduction: Primary anastomosis with or without proximal diversion is increasingly applied to pts requiring urgent colectomy for complicated disease of the sigmoid colon. Conversely, the Hartmann procedure (HP) is now often restricted to patients who are unstable or otherwise ill suited to primary anastomosis. As such, pts who are evaluated for Hartmann takedown often have formidable comorbities and considerable judgment is often required in pt selection. We sought to define the complication rate of Hartmann takedown in this setting. Methods: A prospective complication database was searched for consecutive adult patients undergoing colostomy takedown with colorectal anastomosis (HP) at an academic teaching hospital from 1/1/02 to 12/31/10. Demographics, BMI, ASA classification, interval between Hartmann procedure and subsequent takedown, surgical indication, surgeon volume and specialty, length of stay and complications were recorded. Fishers exact test was used to identify risk factors for postoperative complications. Results: 104 pts underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons did 4 or fewer procedures during the study period. 39 pts had their original Hartmann procedure done elsewhere; 38 of these reversals were done by a colorectal surgeon. During the same time period, 334 patients underwent a Hartmann procedure at our institution. 77/104 pts (74%) had their HP for complicated diverticulitis; anastomotic leak was the second most common indication. The median age was 61 years (31-84 yrs) and the interval from Hartmann procedure to reversal ranged from 87-1489 days. Only 8 pts (7.7%) had an ASA of 1 and at least 30 patients required a concomitant ventral hernia repair. 30 pts (29%) had complications and 12 (11%) had two or more complications (Table 1). There were two deaths, four anastomotic leaks, and seven patients had inadvertent enterotomies. Only ASA status predicted postop complications (p=.01) Conclusions: Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than fivefold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are largely restricted to patients who are poor candidates for takedown and that their colostomy is highly likely to be permanent. Table 1: Complications (n=30 pts)