Arman Kahokehr

Lymph Node Evaluation and Long-Term Survival in Stage II and Stage III Colon Cancer: A National Study

The most important prognostic factor in colonic cancer is the presence or absence of regional lymph nodes metastases. The aim of this study was to evaluate the relationship between 5-year mortality in the New Zealand population, and the number of nodes examined in Stage II and III colon cancers. New Zealand Cancer Registry data were retrieved for patients with colonic cancer from January 1995 to July 2003. Patients with incomplete entries, Stage I tumors, and distant metastases were excluded from analysis. Univariate and Cox regression models were used with 5-year mortality as the primary endpoint. The study identified 4309 patients. Younger age, female gender, Pacific Island descent, and right-sided tumors were associated with significantly higher lymph node retrieval. Cox regression analysis showed that the number of nodes examined was a significant predictor of 5-year mortality when age, sex, ethnicity, and site were controlled for. Five-year survival consistently improved between nodal strata until the 16-node mark, above which survival advantage was minimal. For Stage III cancers, a higher lymph node ratio was associated with a significant increase in mortality. Increased rates of nodal examination are associated with a significantly lower 5-year mortality for Stage II and III colonic cancer, but this survival advantage appears to be minimal after the 16-node mark. The lymph node ratio has been validated as a powerful predictor of survival in Stage III cancer. Our results support the current practice of harvesting and examining as many nodes as possible during attempted curative resection.BackgroundThe most important prognostic factor in colonic cancer is the presence or absence of regional lymph nodes metastases. The aim of this study was to evaluate the relationship between 5-year mortality in the New Zealand population, and the number of nodes examined in Stage II and III colon cancers.MethodsNew Zealand Cancer Registry data were retrieved for patients with colonic cancer from January 1995 to July 2003. Patients with incomplete entries, Stage I tumors, and distant metastases were excluded from analysis. Univariate and Cox regression models were used with 5-year mortality as the primary endpoint.ResultsThe study identified 4309 patients. Younger age, female gender, Pacific Island descent, and right-sided tumors were associated with significantly higher lymph node retrieval. Cox regression analysis showed that the number of nodes examined was a significant predictor of 5-year mortality when age, sex, ethnicity, and site were controlled for. Five-year survival consistently improved between nodal strata until the 16-node mark, above which survival advantage was minimal. For Stage III cancers, a higher lymph node ratio was associated with a significant increase in mortality.ConclusionsIncreased rates of nodal examination are associated with a significantly lower 5-year mortality for Stage II and III colonic cancer, but this survival advantage appears to be minimal after the 16-node mark. The lymph node ratio has been validated as a powerful predictor of survival in Stage III cancer. Our results support the current practice of harvesting and examining as many nodes as possible during attempted curative resection.

Implementation of ERAS and how to overcome the barriers

BACKGROUND Multimodal care or Enhanced Recovery after Surgery (ERAS) protocols are gaining popularity in order to modify surgical stress responses after colonic resection. However, these protocols are not straightforward to implement as peri-operative care is varied. We aimed to identify areas that may need attention in order to successfully change practice. METHOD The literature was reviewed for current practice, methods and issues in implementing ERAS. Based on this and our own experience we discuss several important areas that need particular attention in developing and sustaining an ERAS program. RESULTS International surveys have shown that current peri-operative care in colorectal resection is not evidence based. Important aspects of the ERAS philosophy including patient counselling, teamwork and attitude change are identified and discussed. CONCLUSION Implementing evidence-based peri-operative care into practice is challenging. Barriers to multimodal recovery pathways should be addressed.

Systematic review of oxidative stress associated with pneumoperitoneum

There have been several reports of ischaemic complications after routine laparoscopy. The aim of this review was to investigate the relationship between this oxidative stress and pneumoperitoneum.

Laparoscopic Colorectal Surgery Is Associated With a Higher Intraoperative Complication Rate Than Open Surgery

Objectives:Laparoscopic colorectal resection is equivalent to open resection in a number of important areas. However, recent data have raised concern that intraoperative complications may be increased. We conducted a meta-analysis comparing intraoperative complication rates of laparoscopic and equivalent open colorectal resection. Data Sources:Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases were searched, as were relevant scientific meeting abstracts and reference lists of included articles. Review Methods:Randomized controlled trials (RCTs) evaluating laparoscopic versus open surgery for any colorectal indication were included. Exclusion criteria were: trials assessing hand-assisted resection, and trials that excluded conversions to open surgery. There were no restrictions on language. Data were entered on an intention-to-treat basis in prospectively designed tables with complications categorized per event as: total complications, haemorrhage, bowel injury, and solid organ injury. Corresponding authors were contacted if information was missing. The Cochrane Collaboration tool was used for assessing risk of bias, the PETO odds ratio method was used for meta-analysis. Results:Complete intraoperative complication data were obtained for 10 out of 30 included RCTs. Four thousand and fifty-five patients were analyzed; 2159 in the Laparoscopic Group and 1896 in the Open Group. There was a higher total intraoperative complication rate (OR 1.37, P = 0.010) and a higher rate of bowel injury in the Laparoscopic Group (OR 1.88, P = 0.020). There was no difference in the rate of intraoperative haemorrhage or solid organ injury. Conclusion:Laparoscopic colorectal resection is associated with a significantly higher intraoperative complication rate than equivalent open surgery.

A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial.

Psychological stress has been shown to impair wound healing, but experimental research in surgical patients is lacking. This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients. This randomised controlled trial was conducted at a surgical centre. Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy; exclusion criteria were cancellation of surgery, medical complications, and refusal of consent. Seventy five patients were randomised and 15 patients were excluded; 60 patients completed the study (15 male, 45 female). Participants were randomised to receive standard care or standard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery. In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing. Change in perceived stress from before surgery to 7-day follow-up was assessed using questionnaires. Intervention group patients showed a reduction in perceived stress compared with the control group, controlling for age. Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients (difference in means 0.35, 95% CI 0.66-0.03; t(43)=2.23, p=0.03). Changes in perceived stress were not associated with hydroxyproline deposition. A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients. The intervention may have particular clinical application for those at risk of poor healing following surgery.

Preoperative Glucocorticoid Use in Major Abdominal Surgery Systematic Review and Meta-Analysis of Randomized Trials

Objective: To determine the clinical safety and efficacy of preoperative glucocorticoid (GC) administration in major abdominal surgery with regards to short term outcomes. Background: Previous randomized controlled trials (RCTs) in major abdominal surgery have displayed conflicting results regarding the short-term benefits of preoperative GC administration. Importantly, the safety of this intervention has not been conclusively determined. Methods: A systematic review and quantitative meta-analysis was conducted of all RCTs exploring preoperative GC administration in major abdominal surgery for the endpoints of complications, hospital length of stay (LOS) and serum IL-6 on postoperative day one. Subset analyses by procedure were planned “a priori.” Results: Eleven RCTs of moderate quality, comprising 439 patients in total, were included in the final analysis. Preoperative GC use decreased complications (OR = 0.37; 95% CI, 0.21–0.64; P < 0.01), LOS (mean = 1.97 days; 95% CI, −3.33 to −0.61; P = 0.01), and serum IL-6 (mean: −55 pg/mL; 95% CI, −82.30 to −27.91; P < 0.01). Preoperative GCs decreased complications in hepatic resection (OR = 0.28; 95% CI, 0.14–0.55; P < 0.01) and mean LOS (mean LOS: −2.66; 95% CI, −5.01 to −0.32; P = 0.03). GCs reduced mean LOS in patients undergoing colorectal surgery (mean LOS: −0.98; 95% CI, −1.67 to −0.27; P = 0.01). There was no difference in complication rates (OR: 0.45; 95% CI, 0.16–1.32; P = 0.15) or anastomotic leaks specifically. Conclusions: Preoperative administration of GCs decreases complications and LOS after major abdominal surgery as a likely consequence of attenuating the postsurgical inflammatory response. There is no evidence of increased complications in colorectal surgery.

Systematic review and meta-analysis of intraperitoneal local anaesthetic for pain reduction after laparoscopic gastric procedures.

With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta‐analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures.

Meta-analysis of the effect of warm humidified insufflation on pain after laparoscopy

Studies on the use of warmed and humidified insufflation (WHI) in laparoscopic abdominal procedures to reduce pain have been inconclusive owing to small sample sizes.

Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial.

Background:Two wounds are created after abdominal surgery. The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions. In animal models vagotomy blunts the intraperitoneal response to induced inflammation. This is not feasible in humans. However a transient chemical afferentectomy after colectomy by using neuraxial blockade (epidural) and intraperitoneal blockade may be possible. We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic (IPLA) on recovery parameters after colectomy, in the setting of an established enhanced recovery after surgery (ERAS) program. Methods:Double blinded, randomized, placebo controlled design. The study group (IPLA) received instillation of intraperitoneal ropivacaine (75 mg) before dissection and postoperative infusion of 0.2% solution at 4 mL/hour for 3 days continuously. The placebo group (NS) was treated as above with 0.9% saline solution. All patients were cared for under ERAS standardized perioperative care. Epidural infusion was stopped on day 2. Patients were discharged from day 3 onwards once criteria met. Perioperative data, surgical recovery score (SRS), complications, and length of stay were recorded. Systemic cytokines response, neuroendocrine parameters, pain measures and opioid use data were collected. Patients were followed up for 60 days. Results:Sixty patients were recruited. Patients were equivalently matched at baseline. There were no local anesthetic related adverse events. The complication rate, including anastomotic leak rate, was equivalent between groups. IPLA group had better SRS scores for the duration of intraperitoneal infusion. Pain and opioid use was reduced in the IPLA group. Systemic cytokine and cortisol response was diminished in the IPLA group. IPLA group had consistently higher systemic ropivacaine levels than placebo group. Conclusion:Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery. This was associated with a blunting of postsurgical systemic cytokines and cortisol. Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion. Therefore a transient chemical afferentectomy with clinical benefit is possible with this method. A longer IPLA infusion duration needs to be studied. This study is registered at clinicaltrials.gov and carries the ID number NCT00722709.

The Humoral Response After Laparoscopic Versus Open Colorectal Surgery: A Meta-Analysis

BACKGROUND The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery. MATERIALS AND METHODS A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0. RESULTS Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis. CONCLUSION Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.