Douglas Stupart

Surveillance colonoscopy improves survival in a cohort of subjects with a single mismatch repair gene mutation

Objective  Previous studies have shown a benefit for surveillance colonoscopy in heterogeneous groups of subjects with suspected or proven hereditary nonpolyposis colon cancer. The aim of this study was to investigate whether surveillance colonoscopy improves the survival in subjects who all carry a single mismatch repair gene defect.

Long-term results of palliative stenting or surgery for incurable obstructing colon cancer.

Objective  Self‐expanding metal stents are an effective means of relieving left‐sided malignant colonic obstruction, and in the setting of incurable disease may provide palliation while allowing the patients to avoid surgery altogether. With modern chemotherapy regimes, patients may have a long‐life expectancy, even in the presence of metastases. The purpose of this study was to investigate the long‐term results of palliative stent placement, compared with patients undergoing palliative surgery.

Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction.

Gastroduodenal obstruction due to malignancy can be difficult to palliate. Self‐expanding metal stents (SEMS) are gaining acceptance as an effective alternative to surgical bypass.

Does an Acute Surgical Model increase the rate of negative appendicectomy or perforated appendicitis

The clinical outcomes from suspected appendicitis depend on balancing the rate of negative appendicectomy (NA) with perforated appendicitis (PA). An Acute Surgical Model (ASM) was introduced at Geelong Hospital (GH) in 2011 involving a dedicated emergency general surgery theatre list every business day giving greater access to theatre for general surgeons. The aim of this study was to evaluate the effect of the ASM at GH on the management of appendicitis, in particular the NA and PA rates.

Surgery for colonic cancer in HNPCC: total vs segmental colectomy

Aim  The high reported risk of metachronous colon cancer (MCC) in hereditary nonpolyposis colorectal cancer (HNPCC) has led some authors to recommend total colectomy (TC) as the preferred operation for primary colon cancer, but this remains controversial. No previous study has compared survival after TC with segmental colectomy (SC) in HNPCC. The aim of this study was to determine the risk of developing MCC in patients with genetically proven HNPCC after SC or TC for cancer, and to compare their long‐term survival.

Prevalence of Clostridium difficile colonization among healthcare workers

BackgroundClostridium difficile infection (CDI) has increased to epidemic proportions in recent years. The carriage of C. difficile among healthy adults and hospital inpatients has been established. We sought to determine whether C. difficile colonization exists among healthcare workers (HCWs) in our setting.MethodsA point prevalence study of stool colonization with C. difficile among doctors, nurses and allied health staff at a large regional teaching hospital in Geelong, Victoria. All participants completed a short questionnaire and all stool specimens were tested by Techlab® C.diff Quik Check enzyme immunoassay followed by enrichment culture.ResultsAmong 128 healthcare workers, 77% were female, of mean age 43 years, and the majority were nursing staff (73%). Nineteen HCWs (15%) reported diarrhoea, and 12 (9%) had taken antibiotics in the previous six weeks. Over 40% of participants reported having contact with a patient with known or suspected CDI in the 6 weeks before the stool was collected. C. difficile was not isolated from the stool of any participants.ConclusionAlthough HCWs are at risk of asymptomatic carriage and could act as a reservoir for transmission in the hospital environment, with the use of a screening test and culture we were unable to identify C. difficile in the stool of our participants in a non-outbreak setting. This may reflect potential colonization resistance of the gut microbiota, or the success of infection prevention strategies at our institution.

Introduction of laparoscopic colorectal cancer surgery in developing nations

Laparoscopic colorectal cancer surgery (LCRCS) is established in the developed world, with considerable interest growing in developing nations1,2. It has reached the point in the UK where patients are soon to be given the right to insist on LCRCS even if their surgeon prefers open resection (OCRCS)3,4. This enthusiasm results from two recent Cochrane reports. A review of short-term outcomes in 2005 concluded that, if subsequent longterm outcomes of open and laparoscopic resections should prove equivalent, then the laparoscopic approach should be preferred5. These longterm outcomes were the subject of a review in 2008, in which 12 of 33 randomized controlled trials (RCTs), including 2881 patients, were considered suitable for analysis6. It concluded that there was no difference in long-term outcome for colonic cancer between open and laparoscopic surgery. For rectal cancer, the number of available studies and included patients was considered too small to draw reliable conclusions. Only six of these 12 RCTs reported lymph node data. Significantly fewer nodes were harvested by LCRCS than by OCRCS. Only four studies reported hazard ratios for tumour recurrence, of which only one reported hazard ratios for rectal cancer. The authors further acknowledged several factors that could have introduced bias, including inadequate data and disregard of the duration of follow-up. The report included 3-year survival data from the CLASICC trial, but not long-term follow-up of COLOR 800, COLOR II 740 or LAPKON II studies, which collectively involved a further 2000 patients. Since then, the LAPKON II group has published its short-term outcome in 679 patients, reporting that LCRCS is associated with an increased duration of operation and no decrease in morbidity, even in a moderate-risk population7. In 2007, relating to the 3-year results of the CLASICC II trial, Wagman8 asked whether laparoscopy and open surgery for colorectal cancer had reached equipoise. As in many surgical RCTs, the question of generalization of outcomes was raised. Patient selection, surgeon selection, site selection, market forces and investigator bias were all factors that might produce different results if LCRCS was to be widely adopted. Given the demonstration of oncological equivalence (disease-free and overall survival) and near equivalence of quality of life and morbidity between LCRCS and OCRCS, the author asked whether there was a need to incorporate laparoscopic resection into oncological practice. The implication was that surgeons who preferred the open technique could take comfort in knowing that the open procedure was not inferior to LCRCS. In many developing countries there is little structured training in LCRCS. Many private hospitals have no tradition of surgical training, and rarely take responsibility for the ongoing education and career development of their surgical workforce. Even in teaching hospitals, laparoscopic training is often scarce. A review of laparoscopic training in South African academic departments showed that almost no LCRCS training was offered. Many departments did not offer training in general laparoscopic surgery, such as cholecystectomy, hernia repair, fundoplication or appendicectomy9,10. After leaving a training programme, young surgeons teach themselves in private practice, supervised for a few operations by a benevolent, but often inexperienced, colleague. The situation in South Africa is likely to pertain in many developing countries. Most surgeons who carry out abdominal surgery in developing nations are general surgeons and not subspecialized. They have a limited colorectal workload and little oncological training. This is evident from open surgery where total mesorectal excision and neoadjuvant therapies are not commonly used when dealing with rectal cancer. The proposal that these surgeons adopt one of the more complex laparoscopic techniques and apply it to patients with cancer, in the hope that it will give the patient a marked advantage, seems misguided and likely to be dangerous. Data from large centres show only modest short-term benefits, and all stress the importance of expert LCRCS surgeons to achieve these results. The data from large trials are often criticized by laparoscopic enthusiasts for not being better, for example conversion rates above 20 per cent; they also criticize the participating surgeons as

Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection

BACKGROUND Case volume per 100 000 population and perioperative mortality rate (POMR) are key indicators to monitor and strengthen surgical services. However, comparisons of POMR have been restricted by absence of standardised approaches to when it is measured, the ideal denominator, need for risk adjustment, and whether data are available. We aimed to address these issues and recommend a minimum dataset by analysing four large mixed surgical datasets, two from well-resourced settings with sophisticated electronic patient information systems and two from resource-limited settings where clinicians maintain locally developed databases. METHODS We obtained data from the New Zealand (NZ) National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa (PMZ) and Port Moresby, Papua New Guinea (PNG). Information was sought on inclusion and exclusion criteria, coding criteria, and completeness of patient identifiers, admission, procedure, discharge and death dates, operation details, urgency of admission, and American Society of Anesthesiologists (ASA) score. Date-related errors were defined as missing dates and impossible discrepancies. For every site, we then calculated the POMR, the effect of admission episodes or procedures as denominator, and the difference between in-hospital POMR and 30-day POMR. To determine the need for risk adjustment, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site of age, admission urgency, ASA score, and procedure type. FINDINGS 1 365 773 patient admissions involving 1 514 242 procedures were included, among which 8655 deaths were recorded within 30 days. Database inclusion and exclusion criteria differed substantially. NZ and Geelong records had less than 0·1% date-related errors and greater than 99·9% completeness. PMZ databases had 99·9% or greater completeness of all data except date-related items (94·0%). PNG had 99·9% or greater completeness for date of birth or age and admission date and operative procedure, but 80-83% completeness of patient identifiers and date related items. Coding of procedures was not standardised, and only NZ recorded ASA status and complete post-discharge mortality. In-hospital POMR range was 0·38% in NZ to 3·44% in PMZ, and in NZ it underestimated 30-day POMR by roughly a third. The difference in POMR by procedures instead of admission episodes as denominator ranged from 10% to 70%. Age older than 65 years and emergency admission had large independent effects on POMR, but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. INTERPRETATION Hospitals can collect and provide data for case volume and POMR without sophisticated electronic information systems. POMR should initially be defined by in-hospital mortality because post-discharge deaths are not usually recorded, and with procedures as denominator because details allowing linkage of several operations within one patients admission are not always present. Although age and admission urgency are independently associated with POMR, and ASA and case mix were not included, risk adjustment might not be essential because the relative odds between sites persisted. Standardisation of inclusion criteria and definitions is needed, as is attention to accuracy and completeness of dates of procedures, discharge and death. A one-page, paper-based form, or alternatively a simple electronic data collection form, containing a minimum dataset commenced in the operating theatre could facilitate this process. FUNDING None.

Recalibration and validation of a preoperative risk prediction model for mortality in major colorectal surgery.

BACKGROUND: In 2009, Barwon Health designed a risk stratification model for mortality in major colorectal surgery with the use of only preoperative risk factors. The Barwon Health 2009 model was shown to predict mortality reliably, and it was comparable to other models, such as the original, POSSUM. However, the Barwon Health 2009 model was never validated with data other than those used to develop the model. OBJECTIVE: The aim of this study was to perform temporal and external validation of the Barwon Health 2009 model and to compare it with other published models. DESIGN: The temporal validation was a prospective observational study, whereas the external validation was a retrospective observational study. The discrimination and calibration of the models were assessed by using the area under receiver operator characteristic and &khgr;2 test of Hosmer-Lemeshow goodness-of-fi technique. SETTINGS: This is a multi-institutional study. Data were collected from 2008 to 2010. RESULTS: There were 474 major colorectal cases at Geelong Hospital (temporal validation) and 389 cases at Western Hospital (external validation). The overall mortality rate was 5.10% and 1.03%. In the comparison of the 2 demographics, Geelong Hospital had a higher proportion of patients who were older and had higher ASA scores and comorbidity counts, whereas Western Hospital surgeons were operating on a higher number of urgent cases. Despite the differences, the Barwon Health 2009 model was able to discriminate mortality reliably (area under receiver operator characteristic = 0.753) but had poor model calibration (p < 0.001) on temporal validation. Hence, the model was recalibrated to predict mortality accurately(area under receiver operator characteristic = 0.772; p = 0.83), and this was successfully validated at Western Hospital (area under receiver operator characteristic = 0.788; p = 0.24). CONCLUSIONS: We have developed a model that can accurately predict mortality after major colorectal surgery by using only data that are available preoperatively. After recalibration, the model was successfully validated in a second hospital.

Colorectal preOperative Surgical Score (CrOSS) for mortality in major colorectal surgery

Colorectal surgery carries a significant mortality risk, with reported rates of 1–6% for elective surgery and up to 22% in the emergency setting. Both clinicians and patients will benefit from being able to predict the likelihood of death before surgery. Recently, we have described and validated two risk stratification models for colorectal surgery, the Barwon Health 2012 and Association Française de Chirurgie models. However, these models are not suitable for assessment at patients bedside. The purpose of this study is to develop a simplified preoperative model capable of predicting mortality following colorectal surgery.