Fallibility of tattooing colonic neoplasia ahead of laparoscopic resection: a retrospective cohort study

INTRODUCTION

Precise geographical localisation of colonic neoplasia is a prerequisite for proper laparoscopic oncological resection. Preoperative endoscopic peri-tumoural tattoo practice is routinely recommended but seldom scrutinised.

METHODS

A retrospective review of recent consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection as identified from our prospectively maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation.

RESULTS

Some 210 patients with 'tattooed' colonic neoplasia were identified, of whom 169 underwent laparoscopic surgery (mean age 68 years, median BMI 27.8kg/m2, male-to-female ratio 95:74). The majority of tumours were malignant (149; 88%), symptomatic (133; 79%) and proximal to the splenic flexure (92; 54%). Inaccurate colonoscopist localisation judgement occurred in 12% of cases, 60% of which were corrected by preoperative staging computed tomography scan. A useful lesional tattoo was absent in 11/169 cases (6.5%) being specifically stated as present in 104 operation notes (61%) and absent in 10 (5.9%). Tumours missing overt peritumoral tattoos intraoperatively were more likely to be smaller, earlier stage and injected longer preoperatively (p=0.006), although half had histological ink staining. Eight lesions missing tattoos were radiologically occult. Four (44%) of these patients had on-table colonoscopy, and five (55%) needed laparotomy (conversion rate 55% vs 23% overall, p<0.005) with one needing a second operation to resect the initially missed target lesion. Mean (range) operative duration and postoperative length of stay of those missing tattoos compared with those with tattoos was 200 (78-300) versus 188 (50-597) min and 15.5 (4-22) versus 12(4-70) days (p>0.05).

CONCLUSIONS

Tattoo in advance of attempting laparoscopic resection is vital for precision cancer surgery especially for radiologically unseen tumours to avoid adverse clinical consequence.

679 Introduction of A Robotic Rectopexy Programme with Benchmarking to International Standards in Published Randomised Controlled Trials

Aim

With the evolution of robotic surgery, the adoption of a robotic approach to perform rectopexy, in particular ventral mesh repair (VMR), is gaining popularity. We aimed to audit clinical outcomes following introduction of a robotic rectopexy (RR) programme and compare outcomes to internationally published randomised controlled trials (RCTs).

Method

Consecutive patients undergoing RR from July to December were included. The daVinci Xi surgical system (Intuitive, California) was used for all procedures using a modified left lower abdominal approach. Where VMR was performed, a 4 x 18cm Permacol mesh was used as standard and posterior fixation using ethibond. We compared operative times and 30-day clinical outcomes to international data.

Results

Over a six-month period, thirteen RR were performed (n = 1 sutured, n = 2 resection sutured, n = 10 VMR). All patients were female with a mean age of 60.4 years (SD 14.12). Mean time from 1st consultation to surgery was 10.7 months. Three patients had an external rectal prolapse and ten patients a rectocoele confirmed on dynamic MRI. Seven patients had co-existing urinary symptoms impacting on quality of life. Median docking time was 23 minutes and median robotic operative time was 194 minutes (156 minutes reported). There were no conversions (2.5% reported). Average length of stay was 5 days (4 days reported) and there were no 30-day morbidities (8.6% reported) or readmissions.

Conclusions

Robotic rectopexy can be performed with appropriate operative times and clinical outcomes and offers a superior operative platform for critical operative steps including rectal mobilisation and VMR mesh placement and suturing.

1057 Outcome Reporting Following Rectopexy Requires Standardisation for Reproducibility and Transparent Outcome Analysis

Aim

Rectopexy is a surgical procedure commonly used to correct rectal prolapse. Several studies have investigated different approaches (abdominal, perineal) and techniques (open, laparoscopic, robotic) in this field however reporting outcomes vary significantly among studies impeding comparison of techniques. We aimed to comprehensively analyse primary outcome reporting methods following rectopexy in published literature.

Method

A systematic search was performed in keeping with PRISMA guidelines and search protocol registered with PROSPERO. Published databases were searched using the following terms: “rectopexy”, “abdominal rectopexy” and “rectopexy outcomes”. Randomised controlled trials, comparative and non-comparative prospective and retrospective studies published between 1992 and 2019 were included for analysis. Review articles, letters, editorials, abstracts, and non-English language studies were excluded. A narrative description of outcomes was reported.

Results

A total of 1089 articles were screened, and 32 articles were identified as suitable for inclusion, reporting on 1780 patients who underwent rectopexy surgery. Over 30 unique methods of reporting outcomes were recorded, with the most common being the rate of recurrence (n = 15), Cleveland Clinic Faecal Incontinence score (CCIS) (n = 11), and customised symptom questionnaires (n = 10). Many studies recognised the impact of symptoms of rectal prolapse on patients’ quality of life (QoL) however, few utilised standardised quality of life scores to evaluate the outcome of the procedures.

Conclusions

As surgical technique evolves in rectopexy, incorporating minimally invasive surgery and robotic surgery, it is important that outcome reporting is standardised to facilitate transparent comparison. Improving patient QoL is the mainstay of surgical intervention and it is important that QoL outcome measures are incorporated.

Haematoma in a hydrocele of the canal of Nuck mimicking a Richter's hernia

We report a haematoma in a hydrocele of the canal of Nuck in a 69-year-old female. She presented with a right-sided groin swelling, the differential for which included an irreducible inguinal hernia or haematoma given her aspirin and clopidegrel use. Successful treatment involved evacuation of the haematoma with excision of the sac. Despite a high index of suspicion for a haematoma, these swellings should ideally be explored given the potential for co-existence of a hernia.

Calf muscle wasting after tibial shaft fracture

OBJECTIVES

To study the long term effect of tibial shaft fractures treated by immobilisation in a long leg cast on the calf muscle bulk.

METHODS

Computed tomography scans were performed at fixed points on the lower legs of 23 non-professional athletes who sustained closed tibial fractures 16 years previously. Length of immobilisation was determined from the hospital records. All the fractures were treated non-operatively. The cross sectional area of the various leg compartments was measured and compared with the non-injured leg.

RESULTS

There was a significant reduction in cross sectional area of the posterior compartment (p<0.001, Student's t test). No such difference was seen in the anterolateral compartment.

CONCLUSION

Tibial fractures treated non-operatively are associated with significant long term calf muscle wasting.

Beyond biology: the social context of prenatal behaviour and birth outcomes

OBJECTIVES

In this study we examine the factors that are associated with adverse birth outcomes using a representative national sample. In our analysis we take into account factors which are related to the mother's behaviour during pregnancy and also consider the socio-economic circumstances of the family.

METHODS

A series of logistic regression models are used to determine the increased risks of low birth weight, preterm, and small for gestational age births associated with maternal smoking, alcohol consumption and high blood pressure in relation to socio-economic factors, such as family dysfunction, social support, income adequacy, age, and education.

RESULTS

All socio-economic factors showed gradients of maternal smoking during pregnancy while only mother's education and socio-economic status demonstrated gradients of alcohol use and high blood pressure. Maternal smoking, high blood pressure, higher levels of family dysfunction, and lower levels of mother's education were found to significantly increase the risk of an adverse birth outcome.

CONCLUSIONS

Interventions designed to mitigate the hazards of adverse birth outcomes should be designed to reflect the gradients of risky prenatal maternal behaviours associated with age, education, income, and family dysfunction.

The clustering of severe behavioural, health and educational deficits in Canadian children: preliminary evidence from the National Longitudinal Survey of Children and Youth

This study identifies a high-risk subpopulation of children with a markedly antisocial behavioural profile in a national sample of Canadian children. We examine a broad array of environmental and child factors that may be associated with this high-risk group. The data are for 18,135 two to eleven year olds in the National Longitudinal Survey of Children and Youth. A cluster analysis was performed to identify children possessing extreme antisocial behaviour across five dimensions: aggression, hyperactivity, prosocial behaviour, emotional difficulties and misconduct. Clusters were compared across structural, family, school, neighbourhood, and health covariates. Membership in this severe cluster is associated with material disadvantage across the range of environmental factors as well as significant deficits in child health and education.

The clustering of severe behavioural, health and educational deficits in Canadian children: preliminary evidence from the National Longitudinal Survey of Children and Youth

This study identifies a high-risk subpopulation of children with a markedly antisocial behavioural profile in a national sample of Canadian children. We examine a broad array of environmental and child factors that may be associated with this high-risk group. The data are for 18,135 two to eleven year olds in the National Longitudinal Survey of Children and Youth. A cluster analysis was performed to identify children possessing extreme antisocial behaviour across five dimensions: aggression, hyperactivity, prosocial behaviour, emotional difficulties and misconduct. Clusters were compared across structural, family, school, neighbourhood, and health covariates. Membership in this severe cluster is associated with material disadvantage across the range of environmental factors as well as significant deficits in child health and education.

Youthful prostitution and child sexual trauma

This paper has examined research that attempts to explain entry to prostitution in terms of the family experiences of young prostitutes. Though there is some evidence of rape, incest, and other kinds of sexual trauma in these backgrounds, this evidence is inconsistent and contradictory. A more plausible approach to the question is based on general control theories. Any traumas or conflicts that unattach children and youth from their families make youngsters highly vulnerable to delinquency. In the case of adolescent females, breach of family attachments appears to heighten the risk of early sexual involvements that, in the context of gender differences in sexual development, expose them to partners significantly older than themselves, and in significantly larger numbers than would otherwise be the case. These factors help explain the role of dysfunctional backgrounds in entry to prostitution without presupposing a role for unobservable traumas and psychiatric disturbances. They likewise recognize a role for the interaction between social control factors and the normal process of sexual development.