P. Terry Phang

Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer

BACKGROUND Short-course preoperative radiotherapy and total mesorectal excision have decreased local recurrence rates from rectal cancer. However, the effect of this radiotherapy on bowel function and quality of life in these patients is not well understood. METHODS Between 1999 and 2004, 34 patients underwent low anterior resection and either short-course preoperative radiation (N = 24) or surgery alone (N = 10). Quality of life and bowel function were assessed using validated instruments: European Organization of Research and Treatment of Cancer Quality of Life questionnaires, Fecal Incontinence Quality of Life Scale, and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument. RESULTS Patients treated with preoperative radiation had higher rates of fecal incontinence and showed a strong trend toward lower global quality-of-life scores. In addition, there was a trend toward worse bowel function in these patients. CONCLUSIONS Patients treated with short-course preoperative radiotherapy had worse continence-related quality of life than patients treated with surgery alone for rectal cancer. Fecal incontinence has a negative effect on quality of life in these patients, causing difficulty with coping, lifestyle, and depression, and limiting daily activities. Validated instruments provide standardized assessment of bowel function and quality of life.

Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes

PURPOSE Rectal cancer outcome depends on stage, technical aspects of surgical excision, and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific survival and recurrence. METHODS We reviewed all 495 rectal cancer patients registered in British Columbia in 1996. RESULTS There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers, P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened survival, P = 0.0007, and overall recurrence, P =0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19. CONCLUSIONS Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome.

Outcomes of anal fistula surgery in patients with inflammatory bowel disease.

BACKGROUND Anal fistulas in patients with Crohns disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion. METHODS This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively. RESULTS Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Pauls Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures. CONCLUSIONS Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.

Effect of subcutaneous carbon dioxide insufflation on arterial pCO2

PURPOSE Subcutaneous emphysema following laparoscopy could result in postoperative respiratory acidosis from prolonged CO2 absorption. We studied the magnitude and duration of alterations in PaCO2 coincident with direct CO2 insufflation into the subcutaneous fat of the anterior abdominal wall of 5 anesthetized juvenile pigs. METHODS First, each pig was insufflated with 6 L of CO2 to produce moderate emphysema over the trunk. Following return to baseline PaCO2, each pig was re-insufflated with 12 L of CO2 to produce severe emphysema over lower limbs, neck, head, and trunk. Measurements of arterial blood gases were performed every 5 or 10 min. Minute ventilation was held constant to represent the worst case scenario. RESULTS From baseline PaCO2 of 41.8 +/- 2.3 mm Hg, PaCO2 peaked at 68.3 +/- 8.6 (P < 0.02) and 92.9 +/- 10.7 (P < 0.01) mm Hg for the 6- and 12-L volumes, respectively, 20 to 25 minutes following insufflation. From baseline arterial pH of 7.40 +/- 0.02, respective nadirs of pH were 7.21 +/- 0.06 (P < 0.02) and 7.08 +/- 0.05 (P < 0.01). PaCO2 and arterial pH took approximately 100 minutes to return to baseline after insufflation with both 6 and 12 L volumes. CONCLUSIONS When minute ventilation is fixed, subcutaneous CO2 insufflation causes increased PaCO2 and decreased pH that may persist for a prolonged period of time. Therefore, patients with subcutaneous emphysema after laparoscopy should be observed in postanesthetic recovery until PaCO2 and pH approach baseline.

The effects of retroperitoneal carbon dioxide insufflation on hemodynamics and arterial carbon dioxide

BACKGROUND Laparoscopic techniques are being increasingly used for retroperitoneal surgery. However, hemodynamic and ventilatory efforts of retroperitoneal carbon dioxide (CO2) insufflation have not been studied. We hypothesized that differences in absorptive surface, anatomy, and compartment compliance could result in different hemodynamic and ventilatory effects between retroperitoneal and intraperitoneal insufflation. METHODS Pigs (n = 7) were anesthetized and stabilized. The peritoneal cavity was incrementally insufflated with CO2 to a maximum pressure of 25 cm H2O and the gas released. Hemodynamics and arterial blood gas values were recorded initially, at each level of insufflation, and following the pneumoperitoneum release until baseline values were reached. This insufflation protocol was repeated in the retroperitoneum. RESULTS Mean arterial pressure (111 mm Hg, 95% confidence interval 99 to 156) and cardiac output (3.7 L/min, 2.8 to 5.2) did not change with increasing insufflation pressure of either intraperitoneum or retroperitoneum. PaCO2 was directly related to insufflation pressure in both spaces, increasing from 41.2 mm Hg (37.3 to 43.4) at baseline to 57.7 mm Hg (47.6 to 82.1) at insufflation pressure of 25 cm H2O. After release of the insufflation gas, time to return to baseline PaCO2 was slightly less from the retroperitoneal space (73 minutes, 45 to 105) than the intraperitoneal (107 minutes, 35 to 175). CONCLUSIONS The effects of CO2 insufflation on hemodynamics and PaCO2 are the same in the retroperitoneal and intraperitoneal spaces.

Effect of emergent presentation on outcome from rectal cancer management

BACKGROUND We have previously reported outcomes for all rectal cancers in BC in 1996. We found that our local recurrence rates and survival were suboptimal relative to current standards in recent literature. METHODS In this retrospective, population-based study, we report the influence of emergent presentation (obstruction, perforation, massive hemorrhage) on outcomes, types of surgical procedures and use of staging investigations, and use of adjuvant radiation and chemotherapy. RESULTS There were 452 invasive adenocarcinomas of the rectum of which 45 were emergent and 407 nonemergent. Disease-specific survival at 4 years for emergent and nonemergent stage II cancers were 66% versus 80%, respectively, and for stage III cancers, 60% versus 73%, respectively (P <0.04). Local recurrence rates at 4 years for emergent and nonemergent stage II cancers were 20% versus 15%, respectively, and for stage III cancers, 70% and 20%, respectively (P <0.05). Surgical resection more frequently involved a stoma for emergent (60%) than for nonemergent (35%) cases (P <0.01). Percent of patients having complete staging investigations were similar between emergent (42%) and nonemergent patients (39%). Adjuvant radiation was given in similar proportion to emergent (61%) and nonemergent (55%) patients. Adjuvant chemotherapy was given to a slightly higher proportion of emergent patients (63%) than nonemergent patients (43%). CONCLUSIONS We conclude that outcome from rectal cancer management is worse for emergent than nonemergent presentation. Since there is no difference in use of staging investigations or adjuvant therapy, the difference in outcome is likely due to difference in surgical technique between emergent and nonemergent cases.

Effects of radiation and surgery on function and quality of life (QOL) in rectal cancer patients

Pre-operative radiotherapy (PRT) and total mesorectal excision surgery (TME) for rectal cancer yield the lowest risk for local recurrence. However, both treatments negatively impact quality of life (QOL). To understand individual treatment effects, we ask whether PRT affects function and quality of life before TME. Function and QOL were prospectively assessed in 26 patients using EORTC QLQ-C30/-CR38, and Wexner scale at three time points: before PRT, 6 weeks after PRT and before TME, and one year after stoma closure. Wexner score did not change post-PRT but did increase post-TME (p < .01). Micturition score did not change with PRT or TME (p = .29). Sexual function score improved post-PRT (p = .03) but did not change post-TME. Global health status did not change post-treatments (p = .45). Future perspective improved post-surgery (p = .04). PRT did not affect micturition, bowel function, or QOL. Future perspective improved despite increased bowel problems and fecal incontinence. QOL was maintained after curative rectal cancer treatments, radiation and TME surgery. This information may help patients and physicians better understand effects of PRT and TME treatments for rectal cancer.

Tattooing or not? A review of current practice and outcomes for laparoscopic colonic resection following endoscopy at a tertiary care centre

Background Because small colonic tumours may not be visualized or palpated during laparoscopy, location of the lesion must be identified before surgery. The aim of this study was to evaluate the effectiveness of the current recommendation of endoscopic tattooing of lesions prior to laparoscopic colonic resections. Methods All consecutive patients who underwent elective laparoscopic resection for a colonic lesion at a single tertiary institution between 2013 and 2015 were identified for chart review. Results In total, 224 patients underwent laparoscopic resection for a benign or malignant colonic lesion during the study period. All patients had a complete colonoscopy preoperatively. In all, 148 patients (66%) had their lesion tattooed at endoscopy. Most lesions were tattooed distally, but 15% were tattooed either proximally, both proximally and distally, or tattooed without specifying location as proximal or distal. Tattoo localization was accurate in 69% of cases. Tattooed lesions were not visible during surgery 21.5% of time; 2 cases were converted to open surgery to identify the lesion. Inaccuracy in endoscopic localization led to change in surgical plan in 16% of surgeries. In the nontattooed group, 1 case was converted to open surgery to localize the lesion, 3 required intraoperative colonoscopy and 1 had positive margins on final pathology. Conclusion To improve surgical planning, we recommend the practice of endoscopic tattooing of all colon lesions at a location just distal to the lesion using multiple injections to cover the circumference of the bowel wall.