Wah-Siew Tan

Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer

A defunctioning stoma is frequently created to minimize the impact of any subsequent anastomotic leak after a low rectal anastomosis. This review evaluates the need for routine stoma formation.

Risk prediction score in laparoscopic colorectal surgery training: experience from the English National Training Program.

OBJECTIVE The overall aim was to develop and validate a risk prediction score for laparoscopic colorectal surgery training cases. BACKGROUND Published risk prediction scores are not transferable between hospitals because they are derived from a single institutions data and are not designed for use in training situations. METHODS Cases from the prospectively collected database of the National Training Programme in Laparoscopic Colorectal Surgery, between July 2008 and July 2012, were analyzed. Independent risk factors for conversion were identified by the logistic regression. Converting the odds ratios into integers created a risk prediction score for conversion. The clinical impact of this score was investigated by comparing postoperative complications and the level of trainer input in high- and low-risk cases. To study whether adverse outcomes in predicted high-risk cases occur outside the National Training Programme in Laparoscopic Colorectal Surgery, 2 external data sets were examined. RESULTS A total of 2341 cases carried out in 42 hospitals were analyzed. Significant risk factors for conversion were body mass index, American Society of Anesthesiology classification, male sex, prior abdominal surgery, and resection type. At a risk score of more than 6, complication rates increased, including mortality (2.9% vs 0.5%, P < 0.001), anastomotic leak (4.3% vs 1.4%, P = 0.002), and a higher level of trainer input (32.2% vs 19.9% of cases, P < 0.001). Analysis of 786 external cases showed that high-risk cases had higher conversion (18.8% vs 7.1%, P < 0.001), overall complication (36.4% vs 15.0%, P < 0.001), and leak rates (4.0% vs 1.3%, P = 0.015). CONCLUSIONS A risk predication score to facilitate case selection in laparoscopic colorectal surgery training was developed and validated.

The Use of CEEA 34 in Stapled Hemorrhoidectomy: Suggested Modifications in Technique

Stapled hemorrhoidectomy has been shown to be superior to conventional hemorrhoidectomy in numerous randomized, controlled trials and systemic reviews, with less postoperative pain and faster recovery. Premium Plus CEEA 34 has been recently introduced for use in stapled hemorrhoidectomy. The use of this stapler requires some modifications in technique.

Salvaging a linear staple line defect in ultra-low anterior resection

The challenge of performing an ultra-low anterior resection has become technically possible with advances in surgical technique and equipment. The double stapled technique is frequently favored. Malfunction of equipment, however, can jeopardize an already difficult surgical procedure. Stapling across unhealthy tissue, such as irradiated rectal tissue, may also contribute. Two patients who underwent ultra-low anterior resections were noted to have a linear staple defect after linear stapling was performed. In these cases, an alternative to refashioning the anastomosis is to close the defect with handsewn sutures, incorporating the closed defect into the circular stapler. This was performed in both patients with good outcome. This technique can be used to salvage a defective staple line, as an alternative to refashioning the anastomosis.

Authors' reply: Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer (Br J Surg 2009; 96: 462–472)

Sir If only surgery was as easy as the conclusion of this meta-analysis, that stomas are recommended after low anterior resection for rectal cancer. In reality there are countless factors to take into consideration, not least the patient’s wishes on the issue. One could also argue that a defunctioning stoma does not decrease the reoperation rate as this paper concludes, as it necessitates a further operation for closure, with the morbidity and mortality associated 1. G. Nash Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB, UK DOI: 10.1002/bjs.6794