Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland

BACKGROUND

In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs).

METHODS

All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis.

RESULTS

A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002).

CONCLUSION

Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

Do we need a co-pilot in the operating theatre? A cross-sectional study on surgeons' perceptions

OBJECTIVE

The aim of this original study was to investigate general surgeons' perceptions on the role of dual surgeon operating for high-risk, elective complex surgical procedures.

MATERIAL AND METHODS

A 21-part cross-sectional online survey was self-completed by 85 general surgeons across hospitals in the UK. The survey assessed the perception of dual surgeon operating on patient morbidity and mortality, surgeons' burnout rates, complaints, patient waiting times and overall trainee experience. Statistical analysis was performed using R version 3.6.1.

RESULTS

Overall 78.8% believed that dual surgeon operating could help to overcome these human factors. Sub-analysis includes improve surgeon fatigue (89.4%), improve confidence (83.5%), improve decision-making (76.5%), minimise technical error (69.4%), improve communication, team work and leadership skills (65.9%). 65.9% believed it would reduce surgeons' burnout. There was a statistically significant relationship between the participants believing it would reduce surgeons' burnout and those who felt it would reduce complaints, Chi-squared(4) = [30.8], p = [0.00000342]. A statistically significant relationship was noted between participants believing it would reduce surgeons' burnout and those who felt it would reduce patient mortality/morbidity, Chi-squared(4) = [19.9], p = [0.000517].

CONCLUSION

The survey has highlighted positive surgeons' perceptions regarding dual surgeon operating.

Safety of curative-intent lung cancer surgery in older patients (octogenarians): A contemporary multicentre cohort study

INTRODUCTION

Despite octogenarians representing an ever-increasing proportion of patients with lung cancer, there is a paucity of evidence describing outcomes after lung resection for these patients. We aimed to evaluate short and mid-term outcomes for octogenarians after lung resection.

MATERIALS AND METHODS

A total of 5,470 consecutive patients undergoing lung resection for primary lung cancer from 2012-2019 in two UK centres were included. Primary outcomes were perioperative, 90-day, and one-year mortality in the octogenarian vs. non-octogenarian cohort. Appropriate statistical tests were used to compare outcomes between octogenarian and non-octogenarian patients. Secondary outcomes were post-operative complications and to validate the performance of the Thoracoscore model in the octogenarian cohort.

RESULTS

Overall, 9.4% (n=513) of patients were aged ≥80. The rates of 90-day mortality, one-year mortality, and post-operative atrial fibrillation were significantly higher for octogenarians. The one-year mortality rate for octogenarians fell significantly over time (2012-2015: 16.5% vs 2016-2019: 10.2%, p=0.034). Subgroup analysis (2016-2019 only) demonstrated no significant difference in peri-operative, 90-day, or one-year mortality between octogenarian and non-octogenarian patients. Validation of the Thoracoscore model demonstrated modest discrimination and acceptable calibration.

DISCUSSION

Mortality for octogenarians fell significantly over time in this study. Indeed, when confined to the most recent time period, comparable rates of both 90-day and one-year mortality for octogenarian and non-octogenarian patients were seen. Whilst preventative strategies to reduce the incidence of post-operative atrial fibrillation in octogenarians should be considered, these findings demonstrate that following appropriate patient selection, octogenarians can safely undergo lung resection for lung cancer.

Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach

Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi-disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41-56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi-arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re-exploration. Follow-up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.

Postoperative outcomes of cancer surgery in patients with and without kidney failure with dialysis therapy: A matched-pair cohort study

Background

The difference in outcomes of cancer surgery between patients with and without kidney failure with dialysis therapy (KFDT) remains uncertain.

Methods

Using 2010–18 data in a national inpatient database in Japan, we identified patients who had undergone resection of colorectal, lung, gastric or breast cancer. We matched selected patient characteristics, type of cancer, surgical procedure and hospital of up to four patients without KFDT to each patient with KFDT. We assessed 30-day mortality and postoperative complications.

Results

Through matching, we identified 2248 patients with KFDT (807 with colorectal, 579 with lung, 500 with gastric and 362 with breast cancer) and 8210 patients without KFDT (2851 with colorectal, 2216 with lung, 1756 with gastric and 1387 with breast cancer). Postoperative complications occurred in a higher proportion of patients with KFDT than of those without KFDT after colorectal {20.3% versus 14.6%; risk difference (RD): 5.7% [95% confidence interval (95% CI) 2.6%–8.8%]}, lung [18.0% versus 12.9%; RD: 5.1% (95% CI 1.6%–8.4%)], gastric [25.0% versus 13.2%; RD: 11.8% (95% CI 7.6%–16.2%)] and breast cancer surgery [7.5% versus 3.5%; RD: 3.9% (95% CI 1.1%–6.9%)]. Patients with KFDT had a higher 30-day mortality than those without KFDT after gastric cancer surgery [1.6% versus 0.3%; RD: 1.3% (95% CI 0.1%–2.3%)]. Heart failure and ischemic heart disease occurred more frequently in patients with KFDT.

Conclusions

Patients with KFDT had higher rates of postoperative complications and 30-day mortality; however, RDs varied between cancer types. The higher rates of postoperative complications in patients with KFDT were mainly attributable to cardiovascular complications.

Improved outcomes for patients undergoing colectomy for acute severe inflammatory colitis by adopting a multi-disciplinary care bundle

PURPOSE

Severe inflammatory colitis as a consequence of inflammatory bowel disease (IBD) may not be amenable to medical management, and surgery is often required. The optimal timing of surgery and perioperative therapeutic care requires a formal link between surgical department and gastroenterology which is often lacking. In this study, we assess the impact of adopting a multidisciplinary care bundle on complication rates of subtotal colectomy in IBD patients.

METHODS

This is a single-centre retrospective observational study. Patients were identified through clinical discharge ICD10 codes. Clinical notes of patients who underwent subtotal colectomies from 1 January 2006 to 31 December 2019 were analysed. Socio-demographics, diagnosis, and medical and surgical management data were collected. A multimodule bundle, including weekly MDT discussions, was started in our unit on 1 April 2014. Multivariable logistic regression analysis was performed on these data.

RESULTS

A total of 296 patients were identified with 113 patients of these (38.2%) experiencing a complication post operation. The overall complication rate improved over time (p = 0.023). Those patients treated after the initiation of the MDT bundle had reduced complication rates (44.6% versus 33.7%, p = 0.045). On multivariate analysis, increasing age (1.023 OR; 95% CI 1.004, 1.041) and procedure performed before MDT bundle (3.1 OR; 95% CI 1.689, 5.723) were independent predictors for post-operative complications.

CONCLUSIONS

Closer links between gastroenterology and colorectal specialties have improved patient outcomes in our unit. Whilst IBD MDTs have previously been shown to improve outcomes for patients managed medically, we demonstrate that this interaction, implemented as a multidisciplinary care bundle, also improves surgical outcomes.

Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists

Purpose of review

The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume.

Recent findings

Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes.

Summary

Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.