Anil Keshava

What do patients want? Patient preferences and surrogate decision making in the treatment of colorectal cancer

AbstractPURPOSE: Clinicians often make decisions for their patients, despite evidence that suggests that correspondence between patient and clinician decision making is poor. The management of colorectal cancer presents difficult decisions because the impact of treatment on quality of life might overshadow its survival efficacy. This study investigated whether patients are able to trade survival for quality of life as a means to express their preference for treatment options and to compare their preferences with those expressed by clinicians. METHODS: Patients undergoing curative surgery for colorectal cancer were interviewed postoperatively to elicit their preferences in four hypothetical treatment scenarios. A questionnaire was mailed to all Australian colorectal surgeons and medical oncologists that asked them to respond as if they themselves were patients. RESULTS: One hundred patients (91 percent), 43 colorectal surgeons (77 percent), and 103 medical oncologists (50 percent) participated. In all four scenarios, patients were able to trade survival for quality of life. Patients’ responses varied between scenarios, both in willingness to trade and the average amount traded. There were significant differences between patients and clinicians. Clinicians were more willing than patients to trade survival to avoid a permanent colostomy in favor of chemoradiotherapy. Patients’ strongest preference was to avoid chemotherapy, more than to avoid a permanent colostomy. CONCLUSIONS: Patients are able to trade survival as a measure of preference for quality of life and can do so differentially between treatment scenarios. Patients’ preferences do not always accord with those of clinicians. Unless patients’ preferences are explicitly sought and incorporated into clinical decision making, patients may not receive the treatment that is best for them.

Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients.

Objective:Prolonged ileus—the failure of postoperative ileus to resolve within a few days after major abdominal surgery—leads to significant medical consequences for the patient and costs to the hospital system. The aim of this retrospective analysis of prospectively collected data was to identify independent preoperative and intraoperative risk factors for prolonged ileus in a large consecutive series of patients who had undergone resection for colorectal cancer. Methods:Patients were drawn from a hospital registry of 2400 consecutive resections over the period 1995–2009. Thirty-four potential predictors of prolonged ileus were analyzed by logistic regression. Results:Prolonged ileus occurred in 14.0% of patients. Statistically significant independent predictors of prolonged ileus were male sex (OR: 1.7, P < 0.001), peripheral vascular disease (OR: 1.8, P < 0.001), respiratory comorbidity (OR: 1.6, P < 0.001), resection at urgent operation (OR: 2.2, P < 0.001), perioperative transfusion (OR: 1.6, P < 0.010), stoma constructed (OR: 1.4, P < 0.001), and operation lasting ≥3 hours (OR: 1.6, P < 0.001). Conclusions:These features can be used to alert medical and nursing staff to patients likely to experience prolonged ileus after bowel resection so that they can be monitored closely in the postoperative period and available treatments targeted toward them. These features may also be useful in the research context to facilitate the more efficient selection of high-risk patients as subjects in clinical trials of prevention or treatment.

Single-incision laparoscopic right hemicolectomy.

The results of a prospective consecutive series of single‐incision laparoscopic right hemicolectomy procedures are presented.

The significance of involvement of a free serosal surface for recurrence and survival following resection of clinicopathological stage B and C rectal cancer

Objective  To determine whether the presence of tumour at a free serosal surface was independently associated with pelvic recurrence or survival in patients who had a resection for clinicopathological stage B or stage C rectal cancer and who had not received adjuvant therapy.

KARYDAKIS FLAP REPAIR FOR SACROCOCCYGEAL PILONIDAL SINUS DISEASE: HOW IMPORTANT IS TECHNIQUE?

Numerous operative and conservative treatments have been described in the published work for the management of sacrococcygeal pilonidal sinus; yet there remains considerable debate over its ideal treatment. This report is an audit of our results using the Karydakis flap repair in the management of this condition. We analysed prospective data on 70 patients who had had a Karydakis procedure. The length of follow up ranged from 1 to 79 months (median 36 months). Seventy‐one operations were carried out in 70 patients. This included 12 patients (17%) who had previously undergone between one and four procedures (median 2) for recurrent disease. Superficial wound breakdown occurred in 27 patients (38%) and complete wound breakdown occurred in six patients (8.4%). These wounds were allowed to heal by secondary intent. The median time to complete healing for superficial and complete wound breakdown was 80 and 84 days, respectively. Disease recurrence occurred in three patients (4.2%) – two of whom had recurrent disease at the time of this presentation. Of the three patients who had a recurrence after our surgery, two had a superficial breakdown and one had a complete wound breakdown. Sacrococcygeal pilonidal disease has a low recurrence rate when treated by the Karydakis operation involving flattening of the midline cleft. This procedure avoids the need for more complicated flap repairs.

A comparison of published rates of resection margin involvement and intra‐operative perforation between standard and ‘cylindrical’ abdominoperineal excision for low rectal cancer

Aim  The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra‐operative bowel perforation.

Plugs unplugged. Anal fistula plug: the Concord experience

Purpose:  The purpose of this study was to analyse preliminary experience and outcomes with the Cook Surgisis AFP™ anal fistula plug (Cook Medical, Bloomington, IN, USA) with respect to the treatment of complex anal fistulae in a specialist colorectal unit.

Single-port laparoscopic right colonic resection

Background:  The laparoscopic approach is a recognized treatment option for colonic resection. We present the first single‐port operation for colonic resection using standard laparoscopic equipment and techniques.

A historical comparison of single incision and conventional multiport laparoscopic right hemicolectomy

Single incision laparoscopic surgery (SILS) is specially suited for surgery of the right colon. This study presents the results of a historical controlled trial comparing single incision and multiport laparoscopic surgery (MLS) for right hemicolectomy.

Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision

Complete mesocolic excision (CME) has been advocated as likely to improve the long‐term oncological outcome of colon cancer resection, although there is a paucity of long‐term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long‐term results with those of recent European studies of CME.