Hugh Paterson

Waist Circumference and Waist/Hip Ratio Are Better Predictive Risk Factors for Mortality and Morbidity after Colorectal Surgery Than Body Mass Index and Body Surface Area

Objectives:To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mortality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA). Background:Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI. Methods:A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes. Results:A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complications (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoperative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome. Conclusions:The WHR is predictive of adverse events after elective colorectal surgery. It should be used in routine clinical practice and in future risk-estimating systems.

Diverticular disease in Scotland: 2000–2010

Symptomatic diverticular disease (DD) may be increasing in incidence in western society particularly in younger age groups. This study aimed to describe hospital admission rates and management for DD in Scotland between 2000 and 2010.

Synchronous gist, colon and breast adenocarcinoma with double colonic polyp metastases.

INTRODUCTION Long term survivors of breast cancer are at risk of developing distant metastasis years after the initial treatment. We report a case of breast adenocarcinoma with colonic polyp metastases, as well as synchronous primary colonic adenocarcinoma and a gastric GIST. PRESENTATION OF CASE An 83 year old female underwent colonoscopy for rectal bleeding. This showed a primary colonic adenocarcinoma, a pedunculated polyp in the ascending colon and two polyps in the sigmoid colon. A staging CT scan did not show distant metastasis, but revealed a small gastric GIST which was managed conservatively. A right hemicolectomy showed a T3N0 colonic adenocarcinoma and a polyp contained metastatic adenocarcinoma from a breast primary. The patient had undergone surgery 30 years ago for an invasive lobular carcinoma. Further clinical assessment demonstrated an impalpable grade II Invasive ductal carcinoma in the contralateral breast. She was started on hormonal treatment and at 18 months follow-up, she was well with stable disease. DISCUSSION Invasive lobular cancer is the most common histological type of breast cancer that metastasizes to the colon. There is no consensus on the management of breast cancer metastasis to the gastrointestinal tract. Co-existence of a GIST and an adenocarcinoma at two separate locations is uncommon. These are two different cancer entities and it is unclear whether these two are related by as causal relationship. CONCLUSION This is a rare case of three distinct tumours; association between them is unlikely. However, the case highlights the importance of a multidisciplinary approach to cancer treatment.

Enhanced recovery after surgery: Pain management

Effective pain management is fundamental to enhanced recovery after surgery. Selection of strategies should be tailored to patient and operation. As well as improving the quality of recovery, effective analgesia reduces the host stress response, facilitates mobilization and allows resumption of oral intake. Multi‐modal regimens combining paracetamol, non‐steroidal anti‐inflammatory agents where indicated, a potent opioid and a local anaesthetic technique achieve effective analgesia while limiting the dose and thereby side effects of any one agent.

Total perineal reconstruction after abdominoperineal excision for rectal cancer : long-term results of dynamic graciloplasty with Malone appendicostomy.

Aim  This study aimed to assess long‐term function after total perineal reconstruction (TPR) with dynamic graciloplasty (DG) and systematic Malone appendicostomy (MA) adjunction after abdominoperineal excision (APR) for rectal cancer.

Deprivation and access to treatment for colorectal cancer in southeast Scotland 2003–2009

Socioeconomic deprivation is associated with poorer survival from colorectal cancer. We examined the association of deprivation with access to treatment, disease stage at presentation and choice of treatment for colorectal cancer within a regional managed clinical network.

The "lost anvil": an original technique for laparoscopic colorectal anastomosis.

Aim: During laparoscopic colorectal anastomosis, the rectal introduction of the circular stapler is achieved without hand assistance, increasing the risk of rectal injury. Therefore, we describe a technical adjustment facilitating rectal advancement of the stapler. Materials and Methods: Two hundred consecutive patients with benign condition underwent laparoscopic sigmoidectomy. Before any stapling, the complete circular stapler is introduced into the anus. The anvil is released in the lumen of the colon to be resected. After cross-stapling the rectum, the anvil is retrieved in the resected specimen before the final steps of the anastomosis. Feasibility, safety, and long-term results were evaluated. Results: In 194 patients, the anastomosis was successfully performed at upper rectal level. Only, 1 rectal wall injury was observed. At a median follow-up of 44 months, 3 patients presented anastomotic stenosis and 2 small-bowel obstructions. Conclusions: “Lost anvil” technique allows easy and safe circular stapler rectal advancement for laparoscopic colorectal anastomosis in benign diseases.

Adult colo-colonic intussusception.

A 68-year-old man with no significant medical history was admitted to the emergency department, with abdominal pain and vomiting. Examination revealed severe abdominal distension and rebound tenderness. Abdominal radiography showed distension of the small bowel and colon (Fig. 1). CT scan showed typical images of left colonic intussusception with pericolic infiltration, distension of the small bowel and no evidence of ischaemic changes in the proximal colon (Figs. 2, 3). Surgical exploration revealed left colonic obstruction caused by an intussuscepting tumour (Figs. 4, 5, 6). Oncological resection was performed, with the removal of the inferior mesenteric nodes and primary colorectal anastomosis. The patient made an uncomplicated recovery. Histopathological analysis identified a well-differentiated pT3N0 adenocarcinoma of the colon. Colo-colonic intussusception is rare in adults. In contrast to children with the condition, a large number of adult patients have an underlying organic lesion. Since many of these lesions are potentially malignant tumours, optimal treatment is to proceed directly to oncological resection without attempting mechanical reduction, in order to avoid perforation and cancer cell seeding.

Adverse obstetric history is not a risk factor for poor outcome after ventral rectopexy for obstructive defaecation syndrome

Ventral rectopexy (VR) has gained popularity in the management of obstructive defaecation syndrome (ODS) due to a symptomatic rectocele ± intussusception. Data on the efficacy and safety of VR are variable and there are few predictors of successful outcome. This study aimed to examine whether or not an adverse obstetric history influenced the functional outcome following VR for ODS.

PWE-309 Intravenous lidocaine infusions for abdominal surgery

Introduction The Western General Hospital in Edinburgh currently performs several hundred major abdominal surgeries per year. We have adopted perioperative intravenous lidocaine infusions (PILI) as a routine analgesic adjunct for its ease of use and safety profile and have experienced improved analgesic requirements and return of gut function. Lidocaine is a sodium channel blocking amide local anaesthetic but also has secondary analgesic effects and anti-inflammatory effects. For these reasons peri-operative intravenous lidocaine infusions have been investigated for their potential to improve outcomes for patients undergoing major surgery. A recent meta-analysis of 1,754 patients found benefit from the use of PILI especially for patients undergoing abdominal surgery.1We report the introduction of PILI according to a local protocol. The primary objective was to compare our safety data with that expected from the meta-analysis. Our secondary objective was to compare return of bowel function data to that reported by the Early Recovery after Surgery (ERAS) database, which collected data for all patients undergoing major colonic surgery independently of our audit. Method The trust scientific officer waived the requirement for ethical approval as this was considered a change in clinical practice. A local protocol for the administration of PILI was suggested to local clinicians based on the available evidence. Training was delivered to recovery and high dependency unit staff who would be caring for patients receiving PILI. Data were collected prospectively using a standard anonymised paper pro forma. Results Over a period of 24 months data on 127 uses of PILI were collected prospectively, which included 73 patients undergoing colonic resection. Lidocaine infusion was stopped early on nine (7%) occasions; three (2.4%) due to tracking up the vein and three (2.4%) patients reported parasthesiae. Three (2.4%) stoppages were for reasons later deemed to be unrelated. No other adverse events or reactions were reported. Data were available for the assessment of bowel function in 53 patients and patients in the PILI cohort who underwent colonic resection experienced a more rapid return of bowel function (return of flatus, mean days (SD): 2.84 (1.2) v 3.55 (1.7), p < 0.0001; return of bowel opening: 4.17 (2.0) v 4.81 (2.3), p = 0.014). Conclusion PILI is a safe and easily administered peri-operative adjunct which may promote return of gut function after colorectal resection. A multicentre RCT is suggested; powered to address gut function, length of stay, opiate use and perioperative dysrhythmia following colonic resection. The forthcoming Delphi Games may be an opportunity to address this since perioperative ileus is an identified objective. Disclosure of interest None Declared. Reference Vigneault L, et al. Can. J. Anaesth. 2011;58:22–37