Irshad Shaikh

Outcome of right‐ and left‐sided colonic and rectal cancer following surgical resection

Aim  To determine the outcome of surgery for colorectal cancer from a single region and to see whether location of the primary cancer influences prognosis.

Use of topical negative pressure in assisted abdominal closure does not lead to high incidence of enteric fistulae.

Aim  Reports suggested an increase in enterocutaneous fistulae with topical negative pressure (TNP) use in the open abdomen. The purpose of this study was to establish if our experience raises similar concerns.

The value of biochemical markers in predicting a perforation in acute appendicitis

Acute appendicitis is the most common surgical diagnosis of abdominal pain. Perforated appendicitis can result in increased morbidity and mortality. Identifying a perforation early can reduce the impact on the patient. Bilirubin, C‐reactive protein (CRP) and white cell count (WCC) have been shown to indicate perforation in appendicitis. This study aimed to identify whether these biochemical markers can be used to identify if patients are suitable for either a conservative or surgical approach.

Gallstone ileus: surgical strategies and clinical outcome.

OBJECTIVE:  Gallstone ileus is a rare cause of intestinal obstruction affecting mainly the elderly. This study aimed to analyze the surgical treatments and outcome of the disease.

Post‐cholecystectomy cystic duct stump leak: a preventable morbidity

OBJECTIVE: While major bile duct injury is the most serious complication following laparoscopic cholecystectomy, bile leak from the cystic duct stump remains the commonest morbidity. This is a retrospective assessment of all patients who had a cholecystectomy over a 5‐year period from April 2003 to March 2008.

Laparoscopic approach and patient length of stay in elective colorectal surgery without an enhanced recovery programme

Laparoscopic colorectal resection was developed in the 1990s as a minimally invasive alternative to open colorectal surgery. The benefits of a laparoscopic approach are well established, resulting in quicker recovery and earlier return to normal activity. Studies have found less parenteral analgesic use, shorter time to first flatus and bowel movement, quicker resumption of an oral liquid and solid diet, and a significantly shorter length of hospitalization in patients undergoing laparoscopic as opposed to open bowel operations. Colorectal resection has traditionally been associated with an unpredictable length of stay (LOS) in hospital. Inadequate pain management, perceived risk of ileus in early feeding and prolonged immobilization were the main factors associated with delayed recovery. This led to the concept of fast track ‘enhanced recovery after surgery’ (ERAS) in 1999, which reduced the length of hospital stay significantly. The median LOS is 7–10 days for laparoscopic surgery, compared with a median LOS of 8–12 days following open surgery. With an ERAS programme, this is further reduced to 4–7 days. Despite this, the role of ERAS combined with laparoscopic colorectal surgery remains unclear. A systematic review concluded that with the implementation of ERAS, the laparoscopic technique did not show any advantage over an open surgical approach with regard to postoperative LOS. Other trials have shown that laparoscopic colorectal resection with ERAS does not reduce the duration of ileus or hospital stay. However, the LAFA Trial (Laparoscopy and/or Fast Track Multimodal Management versus Standard Care) concluded that the optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a fast track programme. The results of EnROL, a multicentre randomized trial comparing laparoscopic versus open surgery for colorectal cancer within an enhanced recovery programme are eagerly awaited. We conducted a retrospective cohort study to assess the impact of laparoscopic approach in elective colorectal cancer surgery on patient LOS and readmission rates prior to introduction of a formal ERAS programme at a district general hospital. During this time, decisions regarding use of bowel preparation, nasogastric tube insertion/removal, surgical drain placement/removal etc., were made by the surgical team on a case-by-case basis. We examined elective resections taking place over 6 years, in two distinct periods. Due to changes in practice, the senior author predominantly performed open colorectal resection between 2005 and 2007 (group 1) and laparoscopic resection between 2008 and 2010 (group 2). Abdomino-perineal resection, Hartmann’s procedure, surgery for recurrent cancer and defunctioning stoma formation were excluded from analysis. Our results showed that four out of 50 patients (8%) underwent laparoscopic surgery in group 1. In group 2, 56 out of 70 patients (80%) underwent laparoscopic surgery. The mean LOS for resection without stoma was 9.63 ± 3.33 days in group 1 and 5.60 ± 3.83 in group 2 (P = 0.0001), and 15.44 ± 10.4 in group 1 and 6.79 ± 5.5 in group 2 when resection was performed with covering ileostomy (P = 0.0031). Overall, patients who had colorectal surgery with or without stoma throughout the whole study period had a mean LOS of 5.12 days ± 3.83 for the laparoscopic group versus 11.07 days ± 6.9 for the open group. This represents a significant reduction in mean LOS of 5.94 days (confidence interval = 3.16 to 8.13) in favour of the laparoscopic surgery group (P = 0.0001). The difference in mean age between the two groups was insignificant (P = 0.4961). The total number of laparoscopic converted to open operations was four out of 60 (6.7%). This was necessary in patients with bulky tumours and post chemoradiotherapy fibrosis, making the pelvic dissection difficult. Only two out of 60 patients who had laparoscopic colorectal resections were readmitted within 28 days of discharge (3.3%). Both were found to have postoperative collections and underwent radiologically guided drainage. One patient required a laparotomy and end colostomy for anastomotic failure 16 days following an open anterior resection and ileostomy. No patients required a laparotomy for an anastomotic leak after laparoscopic surgeries. Two patients undergoing open anterior resections died from unexpected myocardial infarction, while there were no 30-day mortalities in the laparoscopic group. Our results demonstrate that reduction in LOS can be achieved without ERAS, but by the adoption of a laparoscopic technique. We have confirmed a mean reduction of LOS in the laparoscopic surgery group compared with the open surgery group, with low readmission rates (3.3%), low anastomotic complication rates (1.7%) and no 30-day mortalities, despite no formal ERAS programme. We believe that the laparoscopic approach is the single most important variable influencing LOS after elective colorectal cancer surgery and eagerly await the results of further studies assessing the true impact of ERAS.

Extended pelvic side wall excision for locally advanced rectal cancers

Extended pelvic side wall excision is a useful technique for treatment of recurrent or advanced rectal cancer involving sciatic notch and does not compromise the dissection of major pelvic vessels and vascular control.

The effect of a screening programme on the outcome of colorectal cancer

Aim  The study aimed to determine whether the introduction of a screening programme for colorectal cancer influenced resection and recurrence rates and prognosis.

Method of pedicle division during laparoscopic right hemicolectomy affects lymph node yield and short-term outcomes: Right hemicolectomy pedicle division

Several ways of performing laparoscopic right hemicolectomy (RHC) have evolved. The vascular pedicle can be divided into extracorporeal (RHC‐EC) or intracorporeal (RHC‐IC). It is not known whether vessel ligation during RHC‐EC is as central as during RHC‐IC. We compare these approaches in terms of pathological and short‐term clinical outcomes.

Colorectal malignant polyps: the surveillance dilemma

A 61-year-old man presented to our hospital with left-sided abdominal pains and fever. He had a history of primary cutaneous melanomas excised in 2003 and 2005, small bowel melanoma metastases excised in 2011 and radiologically confirmed metastases in the mediastinum, lung and liver. His tumour was BRAF V600 mutation positive. He was taking vemurafanib as part of the COMBI-V trial, resulting in dramatic reduction in volume of a palpable cervical metastasis. Vemurafanib has been shown to prolong progression-free survival in advanced melanoma by inhibiting the BRAF cell signalling pathway. Abdominal computed tomography scan suggested visceral perforation with free fluid and gas in the left upper quadrant (Fig. 1). At laparotomy, an abscess was found adjacent to perforated small bowel segment. The small bowel was resected with primary anastomosis and the patient made a good recovery. Histological findings were of multiple metastatic melanoma deposits with mucosal ulceration and serosal exudate at the area of oversewn perforation. Between melanoma deposits, the small bowel appeared microscopically normal. Small bowel metastases are found in over 25% of advanced melanoma patients undergoing autopsy. However, only 0.8–4.4% of patients with primary melanoma developed symptoms from intestinal metastases before death. Many intestinal metastases are therefore occult. Intestinal melanomas may present with symptoms of partial obstruction or bleeding, but perforation itself is exceptionally rare, with only six previous cases documented in the literature. Colonic perforation secondary to drug-induced colitis has been reported with other new anti-melanoma agents including ipilimumab; however, our case differs as the perforation was at the site of a small bowel metastasis. As far as we are aware, our case is the first example of a perforation that occurred while the patient was taking vemurafanib. We hypothesize that vemurafanib may have contributed to visceral perforation, although drug-induced necrosis was not proven histologically.