John Frye

Stents or open operation for palliation of colorectal cancer: a retrospective, cohort study of perioperative outcome and long-term survival.

PURPOSE:Expandable, metallic stents provide a new modality of palliation for patients with noncurable metastatic colorectal adenocarcinoma. This study was designed to compare the use of expandable metallic stents as a palliative measure to traditional open surgical management, with particular reference to length of stay, and survival.METHODS:Patients admitted between 1997 and 2002 with left-sided (splenic flexure and distal), colorectal adenocarcinoma and nonresectable metastatic disease (Stage 4) were treated with expandable metal stents or open surgery (resection, bypass, or stoma). The group of patients having stents inserted were compared with regard to perioperative outcome and survival to those having open surgical procedures.RESULTS:Twenty-two of 25 patients had colonic stents successfully inserted and 19 patients underwent open surgery. The two groups were comparable: stent: median age, 66 (range, 37–88) years; 13 males; and open operation: median age, 68 (range, 51–85) years; 12 males. The tumors were primary in 22 stents procedures and 18 open operations. The site of obstruction was: splenic flexure, 2 stent vs. 0 open operation; descending colon, 2 stent vs. 2 open operation; sigmoid colon, 12 stent vs. 6 open operation; rectum, 9 stent vs. 11 open operation. The American Society of Anesthesiologists (ASA) class was: ASA 1, 0 stent vs. 0 open operation; ASA 2, 6 stent vs. 9 open operation; ASA 3, 15 stent vs. 7 open operation; ASA 4, 4 stent vs. 3 open operation. The open operations were laparotomy only (n = 2), bypass (n = 1), stoma (n = 7), resection with anastomosis (n = 4), resection without anastomosis (n = 5). The complications after open operation were urinary (n = 2), stroke (n = 1), cardiac (n = 2), respiratory (n = 2), deep vein thrombosis (n = 1), anastomotic leak (n = 1). There were no stent-related complications. The mean length of stay was significantly shorter in the stent group (4 vs. 10.4 days; P < 0.0001). There was no difference in survival between the two groups (median survival: stent group, 7.5 months; open operation, 3.9 months; log-rank P value = 0.2156).CONCLUSIONS:Patients treated with stents are discharged earlier than after open surgery. Stents do not affect survival. Expandable metal stents provide an acceptable alternative and may be better than traditional open surgical techniques.

Local Invasion of the Bladder With Colorectal Cancers: Surgical Management and Patterns of Local Recurrence

PURPOSE: Colorectal cancers may be adherent to the urinary bladder. To achieve oncologic clearance of the cancer, en bloc bladder resection should be performed. This study describes the multicenter experiences of en bloc bladder resection for colorectal cancer in the major New Zealand public hospitals. METHODS: A retrospective database of patients undergoing surgery for colorectal cancer adherent to the bladder between 1984 and 1999 was constructed. Data was analyzed for age, gender, disease stage, and outcome (local recurrence and survival). RESULTS: Fifty-three patients were identified: International Union Against Cancer and American Joint Committee on Cancer Stage 1 = 0; Stage 2 = 23; Stage 3 = 22; Stage 4 = 6; unknown = 2. Forty-five had en bloc partial cystectomy performed, four en bloc total cystectomy, and four had the adhesions disrupted and no bladder resection. The most common site of the primary colorectal cancer is sigmoid colon, with local invasion into the dome of the bladder. All patients who did not have en bloc resection developed local recurrence and died from their disease. Mean follow-up was 62 months. The extent of bladder resection did not seem important in determining local recurrence. CONCLUSIONS: En bloc resection of the urinary bladder should be performed if the patient is to be offered an optimal oncologic resection for adherent colorectal cancer. The decision to perform total rather than partial cystectomy should be based on the anatomic location of the tumor. Because the sigmoid is usually the primary site, most patients will not have received preoperative radiation. Therefore, postoperative radiotherapy may reduce local recurrence in these patients.

Parastomal hernia following minimally invasive stoma formation

Background:  Minimally invasive intestinal stoma formation using a laparoscopic approach or through a trephine, is widely described in published literature. The incidence of parastomal hernia (PH) following a stoma formed without formal laparotomy is not well reported. The present review aims to assess the current data available on minimally invasive stoma formation, with particular reference to the incidence of PH.

Abdominoperineal resection or low Hartmann's procedure.

Aim:  To compare patients having low Hartmanns resection (LHP) with abdominoperineal resection (APR) by investigating postoperative complications.

Accuracy of visual prediction of pathology of colorectal polyps: how accurate are we?

Small and diminutive polyps seen at colonoscopy could be left unresected because of a balance of risks between perceived low malignant potential and complications of removing the polyp. This relies on a high accuracy in prediction of the pathology of the polyp. This study was undertaken to determine if experienced endoscopists could determine the histological types of polyps found at colonoscopy.

Response to Re: Accuracy of visual prediction of pathology of colorectal polyps: how accurate are we?

It has recently come to my attention that the outpatient department at most public hospitals is under great stress. The number of new referrals and review patients has significantly increased in the last decade. For example, at our institution, new referrals per month have increased from an average of 27 per month in 2004 to 137 per month this year. Although the numbers have significantly increased, staffing has not. With the ageing population, this logarithmic increase will ultimately be unmanageable. In orthopaedic and plastic surgery, the majority of review patients can adequately be managed by a general practitioner. However in my experience, general practitioners are not happy in managing these cases due to lack of experience. An option to help alleviate the burden on public outpatients, particularly orthopaedic and plastic outpatients, would be to incorporate an outpatient rotation for training general practitioners. General practice trainees often undertake numerous resident rotations in surgery, but rarely attend the outpatient department due to time constraints. By incorporating a dedicated outpatient rotation for trainee general practitioners, we will add a helping hand to clinic; train future general practitioners to be more confident at managing simple fractures, wounds and post-operative patients; and help prevent delayed referrals for time-critical conditions.

Response to Re: Accuracy of visual prediction of pathology of colorectal polyps: how accurate are we?: Letters to the Editor

It has recently come to my attention that the outpatient department at most public hospitals is under great stress. The number of new referrals and review patients has significantly increased in the last decade. For example, at our institution, new referrals per month have increased from an average of 27 per month in 2004 to 137 per month this year. Although the numbers have significantly increased, staffing has not. With the ageing population, this logarithmic increase will ultimately be unmanageable. In orthopaedic and plastic surgery, the majority of review patients can adequately be managed by a general practitioner. However in my experience, general practitioners are not happy in managing these cases due to lack of experience. An option to help alleviate the burden on public outpatients, particularly orthopaedic and plastic outpatients, would be to incorporate an outpatient rotation for training general practitioners. General practice trainees often undertake numerous resident rotations in surgery, but rarely attend the outpatient department due to time constraints. By incorporating a dedicated outpatient rotation for trainee general practitioners, we will add a helping hand to clinic; train future general practitioners to be more confident at managing simple fractures, wounds and post-operative patients; and help prevent delayed referrals for time-critical conditions.

Traumatic splenic injury managed with arterial embolisation in a patient with idiopathic thrombocytopenic pupura.

Angioembolisation is rapidly becoming a standard part of the algorithm for nonoperative management of blunt traumatic splenic injuries. However, its utility in haematological disease states, such as idiopathic thrombocytopenic purpura (ITP), has not been previously confirmed. We present a case of blunt traumatic splenic injury in a patient with newly diagnosed ITP that was successfully managed with angioembolisation.