Judith L. Trudel

Epidural Analgesia Enhances Functional Exercise Capacity and Health-related Quality of Life after Colonic Surgery: Results of a Randomized Trial

BACKGROUND Multimodal analgesia programs have been shown to decrease hospital stay, but it not clear which functions are restored after surgery. The objective of this study is to evaluate the impact of epidural anesthesia and analgesia on functional exercise capacity and health-related quality of life. METHODS Sixty-four patients undergoing elective colonic resection were randomized to either patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl (epidural group). All patients in both groups received similar perioperative care and were offered the same amount of postoperative oral nutrition and assistance with mobilization. Primary outcome was functional exercise capacity as measured by the 6-min walking test, and secondary outcome was health-related quality of life, as measured by the SF-36 health survey. These were assessed before surgery and at 3 and 6 weeks after hospital discharge. Other variables measured in hospital included pain and fatigue visual analogue scale, bowel function, time out of bed, nutritional intake, complication rate, readiness for discharge, and length of hospital stay. RESULTS Although the 6-min walking test and the SF-36 physical health component decreased in both groups at 3 and 6 weeks after surgery, the patient-controlled analgesia group experienced a significantly greater decrease at both times (P < 0.01). Patients in the epidural group had lower postoperative pain and fatigue scores, which allowed them to mobilize to a greater extent (P < 0.05) and eat more (P < 0.05). Length of hospital stay and incidence of complications were similar in both groups, although patients in the epidural group were ready to be discharged earlier. CONCLUSIONS The superior quality of pain relief provided by epidural analgesia had a positive impact on out-of-bed mobilization, bowel function, and intake of food, with long-lasting effects on exercise capacity and health-related quality of life.

Toxic megacolon complicating pseudomembranous enterocolitis

PURPOSE: Toxic megacolon is a rare complication of pseudomembranous enterocolitis. We reviewed our recent experience with this complication. METHODS: The first five patients of the series were studied retrospectively, and six others were followed prospectively. RESULTS: Between June 1992 and May 1994, 11 patients (8 male, 3 female) developed toxic megacolon secondary to pseudomembranous enterocolitis. Mean age was 60.7 ±11.8 (range, 40–79) years. Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; white blood cell count greater than 10.5, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; tachycardia greater than 100, 55 percent; fever greater than 38.5‡ Celsius, 45 percent; shock or hypotension, 45 percent. Predisposing factors included antibiotics, 64 percent; immunosuppressants or chemotherapy, 36 percent; antidiarrheals, 27 percent; and barium enema in one patient. Five patients (45 percent) had more than one predisposing factor. X-rays showed transverse colon dilation and loss of haustrations in eight patients (72 percent), with a mean diameter of 99 ±3.4 cm. Flexible proctosigmoidoscopy showed pseudomembranes in all scoped patients, and toxin assay forClostridium difficile was positive in all patients. One patient had emergency surgery. Ten patients were initially treated medically with nasogastric suction and intravenous resuscitation (90 percent) and antibiotics (100 percent), usually in the intensive care unit (80 percent). Four patients did not respond and underwent surgery; two others improved, then deteriorated, and also underwent surgery. Altogether, 7 of 11 patients (64 percent) underwent surgery. Three patients (27 percent) responded well to medical treatment. One patient was deemed too ill to undergo surgery and died. Mean delay to surgery was 3.0 ±1.3 days. No sealed or overt perforation was found at laparotomy. All patients who underwent surgery had a subtotal colectomy, with either a Hartmanns stump (71 percent) or a mucous fistula (29 percent). Eventually, five of seven patients who were operated on and two of four medically treated patients died (overall mortality, 64 percent). Only one patient underwent closure of ileostomy and anastomosis. CONCLUSION: Toxic megacolon complicating pseudomembranous enterocolitis is a serious problem that carries a high morbidity and mortality rate, regardless of treatment.

Outcome of Local Excision of Rectal Carcinoma

PURPOSEThis study was designed to determine the results of patients with rectal adenocarcinoma treated with local excision.METHODSA retrospective, chart review was conducted for all patients treated with local excision for rectal adenocarcinoma from 1984 to 1998.RESULTSSixty-four patients were retained for analysis. The median follow-up was 37 (range, 9–125) months. There were 15 local failures with a median time to local failure of 12 months. Seven patients were salvaged with further operation (4 by repeat local excision, 4 by abdominoperineal resection, and 1 by low anterior resection). The incidence of local recurrence increased with advancing stage of the carcinoma (T1, 13 percent; T2, 24 percent; T3, 71 percent), histologic grade of differentiation, (well, 12 percent; moderately, 24 percent; poorly, 44 percent), and margin status (negative, 16 percent; close (within 2 mm), 33 percent; positive, 50 percent). Sixteen percent of carcinomas ≤ 3 cm failed compared with 47 percent for carcinomas > 3 cm. Nine percent (1/11) of T2 patients treated with adjuvant radiation therapy recurred locally compared with 36 percent (5/14) without radiation therapy. Three of four T3 patients who received radiation therapy failed locally compared with two of three who did not. Using the Kaplan-Meier method, the overall survival at five years was 71 percent, and disease-free survival was 83 percent. Actuarial local failure was 27 percent and freedom from distant metastasis was 86 percent. The sphincter preservation rate was 90 percent at five years.CONCLUSIONSLocal excision alone is an acceptable option for well-differentiated, T1 carcinomas, ≤ 3 cm. Adjuvant radiation is recommended for T2 lesions. The high local recurrence rate in patients after local excision of T3 lesions with or without adjuvant radiotherapy would mandate a radical resection.

Do surgical residents rated as better teachers perform better on in-training examinations?

BACKGROUND There have been no attempts to objectively compare resident teaching ability with resident knowledge level. METHODS Resident teaching ability, as rated by medical students and junior surgical residents, was compared with resident knowledge level, estimated by in-training examination results, for 18 PGY5 and PGY4 surgical residents at McGill University (September 1996 to July 1997). RESULTS There was a trend to suggest that greater teaching ability is associated with higher in-training examination scores; this did not achieve statistical significance. PGY4 residents were rated as better teachers than PGY5 residents. Resident self-evaluation revealed a high degree of interest in teaching; inadequate time was the principal deterrent to resident teaching; enjoyment and learning during teaching were found to be the most common incentives. CONCLUSIONS Our results suggest an association between resident level of knowledge and teaching ability. The principal deterrent to teaching--inadequate time--must be addressed to effectively assist surgical resident teaching.

Postoperative hypocalcemic tetany caused by fleet® Phospho®-Soda preparation in a patient taking alendronate sodium

This case report describes a patient who was previously prescribed alendronate (Fosamax®) and presented with postoperative hypophosphatemia and hypocalcemic tetany after bowel preparation with Fleet® Phospho®-Soda. This report suggests that patients taking bone metabolism regulators may not be able to respond appropriately to hypocalcemic stressors.

Substance P increases in vitro lymphokine-activated-killer (LAK) cell cytotoxicity against fresh colorectal cancer cells.

Gut-associated lymphoid cells are modulated by several gut hormones. We postulated that lymphokine-associated-killer (LAK) cell cytotoxicity of lymphocytes isolated from the gut mucosa may be increased by substance P (SP). Intestinal lamina propria mononuclear cells (LPMC) and colonic cancer cells were isolated from operative specimens by successive mechanical and enzymatic dissociation methods. Effector LAK cells were induced by culturing LPMC with recombinant interleukin-2 at a concentration of 250 U/ml. Substance P (10(-5) M) was added to the culture medium. Targets consisted of fresh colon cancer cells, HT-29 (cultured human colon cancer cell line), and control cell lines. After 4 days of incubation, cytotoxicity was measured using a 4-h 51Cr release assay. LAK cells alone showed moderate cytotoxicity against HT-29 and none against fresh colon cancer cells. LAK cells generated in the presence of substance P showed moderate cytotoxicity against HT-29 and strong cytotoxicity against fresh colorectal cancer cells. The percentage of cytotoxicity +/- SEM at various effector to target ratios was [(*) denotes P < 0.05 compared with above]: [table: see text] We conclude that substance P significantly increases LAK cell cytotoxicity against fresh colon cancer cells, but not against cultured cells.

The value of specialization--is there an outcome difference in the management of fistulas complicating diverticulitis.

PURPOSE: The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to determine whether there were any outcome differences in the management of fistulas complicating diverticulitis. METHODS: We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticulitis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully trained colorectal surgeons and 85 under the care of general surgeons. RESULTS: There were no significant differences in patient demographics, preoperative comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperative ureteral stenting (Colorectal Surgery 55.5 percentvs. General Surgery 24.4 percent,P=0.001). The general surgeons performed more initial diverting Hartmanns and colostomy procedures (Colorectal Surgery 5.4 percentvs. General Surgery 27 percent,P=0.013). The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1–28) daysvs. General Surgery 8 (range, 0–29) days;P<0.001), longer postoperative lengths of stay (median Colorectal Surgery 11 (range, 5–40) daysvs. General Surgery 14 (range, 2–80) days;P=0.001), and longer total lengths of stay (median Colorectal Surgery 14 (range, 6–62) daysvs. General Surgery 24 (range, 6–100) days;P<0.001). The patients in the General Surgery group experienced a higher rate of wound infections (Colorectal Surgery 5.4 percentvs. General Surgery 12.9 percent), and a larger proportion of them experienced complications (Colorectal Surgery 27 percentvs. General Surgery 41.2 percent). CONCLUSIONS: We conclude that specialization in colon and rectal surgery contributed to an improved outcome, with a lower rate of diverting procedures, a shorter hospital stay, and a lower rate of complications.

Predicting residual rectal adenocarcinoma in the surgical specimen after preoperative brachytherapy with endoscopic ultrasound

BACKGROUND AND STUDY AIMS A novel brachytherapy (BT) protocol evaluated at McGill University has shown promise in terms of downstaging and achieving high tumour sterilization rates in rectal cancer. Endoscopic ultrasound (EUS) has emerged as the imaging modality of choice for local staging of rectal cancer. However, external beam radiotherapy appears to decrease the accuracy of EUS from 85% to 40%. The aim of the present study was to prospectively evaluate the accuracy of EUS in assessing the response of rectal cancer to BT. PATIENTS AND METHODS Thirty-three patients with locally advanced (stage T2 or T3) operable rectal carcinomas were included in an experimental protocol involving a novel conformal technique, using three-dimensional planning, to administer high-dose rate preoperative BT. The 18 patients who were able to have a post-BT EUS exam arranged within two weeks before surgery (eg, four to eight weeks post-BT) were included in this study. Tumour (T)- and lymph node (N)-staging on radial EUS, as well as interpretation of the residual tumour, were assessed prospectively. Pathologists were blinded to the post-BT EUS results. RESULTS The mean age was 70 years (SD +/- 11; range, 52 to 93 years) and 78% of the patients were male. Pre-BT EUS indicated that 16 patients (89%) were stage T3, and two were stage T2. Five patients (28%) had positive nodes (N1) by ultrasound. With BT, the mean maximal wall thickness on EUS decreased from 14 mm to 9.4 mm (P<0.001). At the time of surgery, seven of the 18 patients (39%) had no detectable tumour in the resected specimen; one had carcinoma in situ, one was stage T1, one was stage T2, and eight were stage T3. Eleven patients (61%) underwent an abdominoperineal resection, including four of the 11 (36%) with no ultimate evidence of residual carcinoma. Eight patients (44%) were node-positive. The sensitivity, specificity, and positive and negative predictive values of post-BT EUS in predicting residual tumour were 82%, 29%, 64% and 50%, respectively. The post-BT EUS accurately predicted the T-stage in eight (44%) patients; most errors were due to overstaging. CONCLUSIONS Rectal cancer T-staging by EUS post-BT is inaccurate, and although it appears sensitive in predicting the presence or absence of residual tumor in rectal adenocarcinoma after preoperative BT, the low predictive values in this setting limit its utility at this time.