Les Bokey

Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients.

Objective:Prolonged ileus—the failure of postoperative ileus to resolve within a few days after major abdominal surgery—leads to significant medical consequences for the patient and costs to the hospital system. The aim of this retrospective analysis of prospectively collected data was to identify independent preoperative and intraoperative risk factors for prolonged ileus in a large consecutive series of patients who had undergone resection for colorectal cancer. Methods:Patients were drawn from a hospital registry of 2400 consecutive resections over the period 1995–2009. Thirty-four potential predictors of prolonged ileus were analyzed by logistic regression. Results:Prolonged ileus occurred in 14.0% of patients. Statistically significant independent predictors of prolonged ileus were male sex (OR: 1.7, P < 0.001), peripheral vascular disease (OR: 1.8, P < 0.001), respiratory comorbidity (OR: 1.6, P < 0.001), resection at urgent operation (OR: 2.2, P < 0.001), perioperative transfusion (OR: 1.6, P < 0.010), stoma constructed (OR: 1.4, P < 0.001), and operation lasting ≥3 hours (OR: 1.6, P < 0.001). Conclusions:These features can be used to alert medical and nursing staff to patients likely to experience prolonged ileus after bowel resection so that they can be monitored closely in the postoperative period and available treatments targeted toward them. These features may also be useful in the research context to facilitate the more efficient selection of high-risk patients as subjects in clinical trials of prevention or treatment.

Mobilization of the Rectum Anatomic Concepts and the Bookshelf Revisited

INTRODUCTION: Sound surgical technique is based on accurate anatomic knowledge. In surgery for cancer, the anatomy of the perirectal fascia and the retrorectal plane is the basis for correct mobilization of the rectum to ensure clear surgical margins and to minimize the risk of local recurrence. METHODS: This review of the literature on the perirectal fascia is based on a translation of the original description by Thoma Jonnesco and a later account by Wilhelm Waldeyer. The Jonnesco description, first published in 1896 in French, is compared with the German account of 1899. These were critically analyzed in the context of our own and other techniques of mobilizing the rectum. CONCLUSIONS: Mobilization of the rectum for cancer can be performed along anatomic planes with minimal blood loss, preservation of the pelvic autonomic nerves and a low prevalence of local recurrence. Different techniques including total mesorectal excision are based on the same anatomic principles, however, popular words have been used to replace accepted, established terminology. In particular, the description of total mesorectal excision has been confusing because of its emphasis on the words “total” and “mesorectum.” The use of the word “mesorectum” anatomically is inaccurate and the implication that total excision of all the perirectal fat contained within the perirectal fascia “en bloc” in all patients with rectal cancer will minimize local recurrence remains contentious.

Correlates and outcomes of tumor adherence in resected colonic and rectal cancers.

Objectives:The aims of this study were to examine the associations between tumor adherence and other operative findings, postoperative complications, recurrence, and survival after resection of colorectal cancer. Summary Background Data:The prognostic importance of tumor adherence to other organs or structures, either by direct invasion (T4) or simply by inflammatory adhesions, is yet to be clearly defined as earlier studies have been limited in size or have not used contemporary multivariable statistical techniques. Methods:Data were drawn from a comprehensive, prospective hospital registry of all resections for colorectal cancer between January 1971 and December 2000 with follow-up to December 2005. Statistical analysis employed the &khgr;2 test, Kaplan-Meier estimation, and proportional hazards regression with a significance level of <0.05 and 95% confidence intervals (CI). Results:Tumor adherence was identified in 268 of 2504 resections (10.7%). Adherent tumors were more likely than nonadherent tumors to be spontaneously or surgically perforated or transected, to have nodal metastases and to be poorly differentiated. Venous invasion was more frequent in adherent colonic but not rectal tumors. Adherence was associated with only 5 of 16 medical and surgical complications considered. In rectal cancer, adherence was independently associated with pelvic recurrence (hazard ratio 1.8, 95% CI 1.2–2.7) and diminished survival (hazard ratio 1.6, 95% CI 1.3–2.0) after adjustment for other variables. Conclusion:In rectal cancer, tumor adherence indicates a poor prognosis after adjustment for other prognostic factors, regardless of whether actual tumor invasion of the adherent structure has occurred. However, adherence is not associated with survival after resection of colonic cancer.

Body image as a predictor of psychopathology in surgical patients with colorectal disease

OBJECTIVE This study aimed to test the relevance of a cognitive behavioural model of body image in a prospective study of colorectal surgery patients and to determine if pre-existing body image disturbance influenced psychological adjustment following surgery. METHODS Sixty-seven adult consecutive colorectal surgery patients completed measures assessing psychopathology, body image related beliefs and health related quality of life during pre-admission for surgery using a questionnaire battery. Each participant was followed up three months after surgery. RESULTS Depression and anxiety were positively correlated with body image disturbance and self evaluation at baseline. Those patients who went on to receive stomas experienced a significant deterioration in their body image that was not observed in those whose surgery did not result in the formation of a stoma. In the regression analysis, body image disturbance was a significant predictor of baseline levels of depression and emotional quality of life. Initial levels of body image disturbance remained a significant predictor of depression and anxiety at follow up assessment after medical variables and baseline levels of depression and anxiety, respectively, had been controlled for. CONCLUSION Our findings support the hypothesis that pre-existing vulnerabilities in body image influence emotional adjustment during the recovery phase following surgery. Further research on screening for body image disturbance in surgical patients in order to promote adjustment is warranted.

Fascin expression predicts survival after potentially curative resection of node-positive colon cancer.

Fascin, an actin-bundling protein, is expressed in many neoplasms including colorectal cancer. It is considered to be a mediator of tumor cell invasion and an indicator of aggressive phenotype; however, there are few reports on the association between fascin and prognosis in colorectal cancer. The aims of this study were to: (a) investigate the expression of fascin in the central part of the tumor and at the invasive front in patients who had a potentially curative resection for node-positive colonic carcinoma; (b) examine the method of scoring fascin expression; and (c) investigate the association between fascin expression and overall survival and other clinicopathologic features. Fascin expression was assessed by immunostaining of microarrays from archived tissue of 470 patients who were followed for a minimum of 5 years after resection. Other clinicopathologic data had been recorded prospectively according to a standardized protocol. Analysis of overall survival was by the Kaplan-Meier method and Cox regression. For both central tumor tissue and the invasive front, it was found that the percentage of stained cells was a sufficient measure of fascin expression in relation to survival, with staining intensity providing no significant additional information. At both levels, there was a significant independent association between high fascin expression and diminished survival, although this association was much stronger in the central region (adjusted hazard ratio 1.6, P<0.001) than at the invasive front (adjusted hazard ratio 1.1, P=0.044). Fascin expression predicted overall survival but did not displace other routinely collected clinicopathologic predictors.

Tumor budding and survival after potentially curative resection of node-positive colon cancer.

PURPOSE: The aim of this study was to investigate the relationship between tumor budding and other pathology features and overall survival after resection of clinicopathological stage III colon cancer. METHODS: The number of buds and other histopathological features were assessed in 477 patients who were operated on between 1971 and 2001, with follow-up to December 2006. Overall survival was analyzed using the Kaplan-Meier method and Cox regression. RESULTS: The number of buds was dichotomized as low (0 to 8) vs high (≥9). High budding was more common in men, in high-grade tumors, in the presence of venous invasion, and where the tumor had involved a free serosal surface, but budding was not associated with 8 other clinical and pathological features. The 5-year survival rate for patients with 0 to 8 buds was 51.0% (95% confidence interval, 44.9–55.1), whereas that for patients with 9 or more buds was 33.9% (95% confidence interval, 25.2–42.8). This association, however, disappeared after adjustment for other variables independently associated with survival (hazard ratio, 1.2; 95% confidence interval, 0.94–1.54; P = .139). CONCLUSION: In stage III colon cancer, tumor budding did not provide additional independent prognostic information beyond that given by routine pathology reporting.

Should there be a national core curriculum for anatomy

Are medical students taught enough anatomy? It is now abundantly clear that there are serious concerns about the level of anatomy taught to medical students. Concerns have been expressed by the students themselves, by those responsible for training procedural specialities and by the community at large. Currently, a sufficient knowledge of Anatomy is assumed by certain medical educationalists. However, Craig et al., in a unique and timely survey detailing issues in teaching anatomy to medical students in Australia and New Zealand, demonstrate convincingly that this is not always the case. Their survey is unique because it sheds light on what is actually taking place at the teaching coal face, and it is timely, given that the theme of the recent annual scientific meeting of the Australian and New Zealand Association of Clinical Anatomists (ANZACA) held at Monash University was anatomy education. The ANZACA meeting included a forum exploring the need for agreed, national core curricula in anatomy for students in professional courses. It is no accident that anatomy education galvanized the establishment of ANZACA in 2004 and that clinical anatomy is the future of anatomy. This is also of direct interest to surgeons with implications for the college and postgraduate surgical training. The findings of a mailed questionnaire sent to all 21 Australian and New Zealand medical schools by staff at the University of Wollongong, Graduate School of Medicine are not altogether surprising, although informative and remindful for they resonate with the concerns previously expressed by contributors to this journal. These were in response to the invited comments made by one of us almost a decade ago lamenting the decline of dissection-based teaching of anatomy in medical curricula. This followed the introduction of graduate medical programmes with shorter courses and a broader mix of students (including some from non-science backgrounds) as well as the adoption of problem-based learning (PBL) to ensure integration and to more adequately deal with the rapid expansion of medical knowledge. The radically changed educational approaches commencing from the mid-1990s resulted in a very significant reduction in total contact teaching time for all preclinical disciplines, especially anatomy, with the consequent loss of cadaver dissection and viva vocé examinations, once the major drivers for learning, teaching and assessing this subject. The ensuing debate as to how, when and what anatomy to teach medical students has generated considerable interest with lively correspondence, often anecdotal, and with little factual information. This is now largely redressed by the findings of the survey by Craig et al. Indeed, despite the use of prosected specimens, models, body painting, innovative computer simulation and radiology imaging, including computerized tomography and ultrasonography, it has to be said that the loss of the opportunity for cadaver dissection was a serious deficit and a concern to many, including the students themselves. The sentiment from both the Craig et al. paper and the ANZACA forum is that anatomy must be reinstated primarily (though not exclusively) as a ‘stand-alone’ subject within the framework of PBL curricula. This could include dissection and not just as an ‘option’. Furthermore, with the dissolution of the Anatomical Society of Australia and New Zealand in 1996 (until resurrected as ANZACA in 2004), the onus seemed to be on the college to set the agenda, to safeguard content and standards and even to fill the gap by providing teachers capable of teaching the subject. What is the state of play now, and what needs to be performed in the short to medium term? These are important considerations in the debate given that many medical students (who are now recent graduates) felt very insecure about their anatomical knowledge, especially those considering future surgical careers; the critical loss of medically qualified teachers from anatomy departments who are capable of teaching clinically relevant anatomy and the alarm this continues to generate in the press. The most important finding of the survey by Craig et al. was the considerable variation in all aspects of the teaching of anatomy throughout Australasian medical schools. Currently, the average time allocated to anatomy according to the survey is 171 h (standard deviation (SD) ~117), mainly delivered in the early years of the course, typically using a combined regional/systemic approach. It seems to us that given a mean contact time of about 170 h throughout the course, if 130 h of that was ‘stand-alone’ anatomy (see Table 1), this would enable time within practical classes to include targeted dissection (and even incorporate the anatomical basis of clinical procedures that can be required of a first port of call doctor). The 40 h not designated as ‘stand alone’ anatomy ideally should be integrated (including within PBL tutorials) and also permeate later years of the course.

Mural and extramural venous invasion and prognosis in colorectal cancer.

BACKGROUND: Extramural venous invasion is a known independent predictor of poor prognosis after resection of colorectal adenocarcinoma, but the prognostic value of mural venous invasion alone and the association between venous invasion and prognosis within tumor stages has received little research attention. OBJECTIVE: This study aimed to determine whether associations between mural and extramural venous invasion and outcome differ among tumor stages after adjustment for other factors known to influence prognosis. DESIGN: This study is a retrospective analysis of prospectively collected data. SETTINGS: Data were drawn from a registry of 3040 consecutive patients undergoing resection between 1980 and 2005 under the care of specialist surgeons in a tertiary referral public hospital and an affiliated private hospital. A standardized protocol was used for the pathological assessment of specimens. MAIN OUTCOME MEASURES: The primary outcomes measured were overall survival, cancer-specific survival, and recurrence. RESULTS: There was no significant association between venous invasion and survival in stages A (n = 544) or B (n = 1078). In stage C (n = 899), overall survival time was significantly shorter in patients with mural invasion alone or extramural invasion (both p < 0.001) than in those without invasion, and this persisted after adjustment for other prognostic variables. Equivalent bivariate associations were found in stage D, but only the effect of extramural invasion persisted after adjustment. LIMITATIONS: Our findings arise from the experience of a single surgical group and may not be generalizable to other settings. Only hematoxylin and eosin staining was used. CONCLUSIONS: The association between venous invasion and prognosis was stage specific. Both mural venous invasion alone and extramural venous invasion independently predicted overall survival in patients with stage C tumors, but not in patients with stages A, B, or D tumors. Although mural invasion alone was rare, the separate reporting of both mural and extramural invasion in patients with stage C tumor is informative and desirable.

Clinicopathological correlates and prognostic significance of maspin expression in 450 patients after potentially curative resection of node‐positive colonic cancer

Fung C L‐S, Chan C, Jankova L, Dent O F, Robertson G, Molloy M, Bokey L, Chapuis P H, Lin B P C & Clarke S J
(2010) Histopathology56, 319–330

Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision

Complete mesocolic excision (CME) has been advocated as likely to improve the long‐term oncological outcome of colon cancer resection, although there is a paucity of long‐term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long‐term results with those of recent European studies of CME.