Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

285 ‘Smart Phrase’ Ward Rounds: Do They Improve Documentation and Efficiency?

Aim

Accurate ward round documentation plays a crucial role in patient management. In the last two years, UCLH has introduced EPIC software. This gives opportunity to create templates for repetitive processes (‘smart phrases’). The aim of this project was to assess if the introduction of ‘smart phrase’ templates can improve the quality of ward round documentation.

Method

Following consultation, 5 fundamental domains were agreed to be included in the template, namely: Procedure and postoperative day, current clinical issues, physical examination, objective assessment (including vital signs, fluid balance/drains, blood tests, DVT prophylaxis, antibiotic status), and 24h treatment plan. A baseline audit was performed, then the new template was introduced. Two PDSA cycles were performed, for 3 weeks after introduction, and repeated two months later. Chi-square tests was used to assess statistical significance of change (p<0.05).

Results

A statistically significant improvement in documentation for all domains - apart from ‘current clinical issues’ and ‘24h planning', which were well documented to start - was observed after the introduction of smart phrases; with an average improvement of 34.8% (range 0–65.6%). The improvement was maintained at 2 months (improvement from baseline 35.1%, range 0–59%). A small decrement in documentation occurred between introduction and the 2-month PDSA assessments in some domains (mean change 0.7%, range -12.3 to 23%), although this was not statistically significant.

Conclusions

The introduction of smart phrases significantly improved ward round documentation of important parameters. Evolution of additional smart phrase is expected to further improve the accuracy leading to more efficient decisions and safer clinical practice.

Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial

BACKGROUND

Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site.

METHODS

In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

FINDINGS

Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events.

INTERPRETATION

Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias.

FUNDING

National Institute for Health Research Research for Patient Benefit and Allergan.

Impact of anaemia at discharge following colorectal cancer surgery

OBJECTIVES

Preoperative anaemia is common in patients with colorectal cancer and increasingly optimised prior to surgery. Comparably little attention is given to the prevalence and consequences of postoperative anaemia. We aimed to investigate the frequency and short- or long-term impact of anaemia at discharge following colorectal cancer resection.

METHODS

A dedicated, prospectively populated database of elective laparoscopic colorectal cancer procedures undertaken with curative intent within a fully implemented ERAS protocol was utilised. The primary endpoint was anaemia at time of discharge (haemoglobin (Hb) < 120 g/L for women and < 135 g/L for men). Patient demographics, tumour characteristics, operative details and postoperative outcomes were captured. Median follow-up was 61 months with overall survival calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at time of hospital discharge.

RESULTS

A total of 532 patients with median 61-month follow-up were included. 46.4% were anaemic preoperatively (cohort mean Hb 129.4 g/L ± 18.7). Median surgical blood loss was 100 mL (IQR 0-200 mL). Upon discharge, most patients were anaemic (76.6%, Hb 116.3 g/L ± 14, mean 19 g/L ± 11 below lower limit of normal, p < 0.001). 16.7% experienced postoperative complications which were associated with lower discharge Hb (112 g/L ± 12 vs. 117 g/L ± 14, p = 0.001). Patients discharged anaemic had longer hospital stays (7 [5-11] vs. 6 [5-8], p = 0.037). Anaemia at discharge was independently associated with reduced overall survival (82% vs. 70%, p = 0.018; HR 1.6 (95% CI 1.04-2.5), p = 0.034).

CONCLUSION

Anaemia at time of discharge following elective laparoscopic colorectal cancer surgery and ERAS care is common with associated negative impacts upon short-term clinical outcomes and long-term overall survival.

Bulking for stress urinary incontinence in men: A systematic review

AIMS

An updated literature review on outcomes in men treated with currently commercially available bulking agents was performed to determine whether this is a reasonable option in selected patients.

METHODS

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework of systematic reviews. A comprehensive search of PubMed, Medline, and Embase was undertaken. Abstracts were independently screened by two investigators to include men with stress urinary incontinence treated with a peri-urethral injection of bulking agents currently available in the market.

RESULTS

Only eight original articles met the inclusion criteria. The bulking agents used were Macroplastique in five studies (total 123 patients), Opsys, Durasphere, and Urolastic in one study each (10, 7, and 2 patients, respectively). Only one study was randomized; Macroplastique vs AUS in men with mild or total incontinence. The included populations were heterogeneous and encompassed endoscopic, perineal, abdominal and laparoscopic prostate surgery as well as spinal cord injuries and urethral sphincter insufficiency. Significant dissimilarity was evident for the duration of incontinence (9-108 months), mean volume of bulking agent used (2.3-13.5 mL), number of cushions (1-5), depth and position of the cushions. The outcomes varied significantly, with reported dry rates between 0% and 83%. Outcomes were limited by relatively short follow-up in most studies.

CONCLUSION

Following initial enthusiasm and then dismay with collagen-based compounds, sparse and heterogeneous literature data were produced on newer non-migrating and nonabsorbable bulking agents. Some studies have suggested encouraging, if short term outcomes, however, future studies are needed in this field to support recommendations for widespread use.

Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation?

BACKGROUND

There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes.

METHODS

An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method.

RESULTS

Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2-3.1], p = 0.008), age ≤ 65 (OR 1.9 [1.2-3], p = 0.01), higher ASA scores (p = 0.01) stoma formation (OR 6.9 [4.1-11], p < 0.001) and neoadjuvant treatment (OR 5.06 [3.1-8.3], p < 0.001). There was no association between time to surgery and BMI (p = 0.36), conversion (16.3%, p = 0.5), length of stay (p = 0.33) and readmission or reoperation (p = 0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p = 0.397, p = 0.962 and p = 0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p = 0.52).

CONCLUSION

Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.

Does the number of operating specialists influence the conversion rate and outcomes after laparoscopic colorectal cancer surgery?

BACKGROUND

Laparoscopic techniques in colorectal surgery have been widely utilised due to short-term patient benefits but conversion to open surgery is associated with adverse short- and long-term patient outcomes. The aim of this study was to investigate the influence of dual specialist operating on the conversion rate and patient outcomes following laparoscopic colorectal surgery.

METHODS

A prospectively populated colorectal cancer surgery database was reviewed. Cases were grouped into single or dual consultant procedures. Cluster analysis and odds ratio (OR) were used to identify risk factors for conversion. Primary outcome measures were conversion to open and five year overall survival (OS) calculated using the Kaplan-Meier log-rank method.

RESULTS

750 patients underwent laparoscopic colorectal cancer resection between 2002 and 2015 (median age 73, 319 (42.5%) female, 282 (37.6%) rectal malignancies, 135 patients (18%) had two consultants). The single surgeon conversion rate was 20.4% compared to 5.5% for dual operating (OR 4.4, 95% CI 1.87-10.2, p < 0.001). There were no demographic or tumour differences between the laparoscopic/converted and number of surgeon groups. Two-step cluster analysis identified cluster I (lower risk) 406 patients, 8% converted and cluster II (higher risk) 261 patients, conversion rate 30%. Median follow-up was 48 months (range 0-168). Five-year OS was significantly inferior for both converted and single surgeon cases (63% vs. 77%, p < 0.001 and 61% vs. 70%, p = 0.033, respectively).

CONCLUSION

In selected colorectal cancer patients operated by fully trained laparoscopic surgeons, we observed a reduction in conversion with associated long-term survival benefit from dual operating specialists.

Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival?

AIM

Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes.

METHOD

A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission.

RESULTS

A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P = 0.092), but OS was worse in patients with longer total LoS (20 vs 14 days, P = 0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission.

CONCLUSION

Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.

Application of objective clinical human reliability analysis (OCHRA) in assessment of technical performance in laparoscopic rectal cancer surgery

BACKGROUND

Laparoscopic rectal resection is technically challenging, with outcomes dependent upon technical performance. No robust objective assessment tool exists for laparoscopic rectal resection surgery. This study aimed to investigate the application of the objective clinical human reliability analysis (OCHRA) technique for assessing technical performance of laparoscopic rectal surgery and explore the validity and reliability of this technique.

METHODS

Laparoscopic rectal cancer resection operations were described in the format of a hierarchical task analysis. Potential technical errors were defined. The OCHRA technique was used to identify technical errors enacted in videos of twenty consecutive laparoscopic rectal cancer resection operations from a single site. The procedural task, spatial location, and circumstances of all identified errors were logged. Clinical validity was assessed through correlation with clinical outcomes; reliability was assessed by test-retest.

RESULTS

A total of 335 execution errors identified, with a median 15 per operation. More errors were observed during pelvic tasks compared with abdominal tasks (p < 0.001). Within the pelvis, more errors were observed during dissection on the right side than the left (p = 0.03). Test-retest confirmed reliability (r = 0.97, p < 0.001). A significant correlation was observed between error frequency and mesorectal specimen quality (r s = 0.52, p = 0.02) and with blood loss (r s = 0.609, p = 0.004).

CONCLUSIONS

OCHRA offers a valid and reliable method for evaluating technical performance of laparoscopic rectal surgery.

Is early laparoscopic cholecystectomy safe after the "safe period"?

BACKGROUND

Early laparoscopic cholecystectomy (ELC) in acute cholecystitis improves hospital stay and outcome. Operative difficulty is said to increase with delay, and surgery is usually advised within 3 days of presentation. It can be difficult to accommodate all these patients within 3 days; this study evaluates results within and after this "safe period."

MATERIALS AND METHODS

In total, 137 patients (male:female 45:92) presenting as an emergency due to acute cholecystitis over 45 months from August 1, 2003, who then underwent ELC with an on-table cholangiogram (OTC) or laparoscopic ultrasound were prospectively studied. Outcome was compared between those who underwent surgery within 72 hours (group 1) or after 72 hours (group 2).

RESULTS

There were 87 patients in group 1 versus 50 in group 2. There was no significant difference with reference to ASA grading, length of operation (median 90 vs. 90 minutes; P = 1.000), conversion rates (7 vs. 10%; P = 0.523), median postoperative stay (2 vs. 3 days; P = 0.203), or 30-day readmission rates [5/87 [6%] vs. 3/50 [6%]; P = 1.000] between groups, respectively. There was no mortality. One patient had a biliary leak from a duct of Lushka in group 2, which settled after endoscopic stenting.

CONCLUSION

In experienced hands, ELC is safe even after 72 hours.

Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction

The left thoraco-abdominal (LTA) esophago-gastrectomy is rarely performed and yet provides excellent exposure of the esophageal hiatus. The aim of this study was to review the outcome of LTA esophago-gastrectomy within a single unit. Patients were selected for an LTA esophago-gastrectomy (January 2000 - June 2003) based upon the presence of locally advanced tumors of the distal esophagus and cardia. These patients were identified from a prospective consultant database. LTA esophagogastrectomy was technically possible in all 38 patients (34 males; median age = 63 years). In-hospital mortality was 2.6% (1 patient). Four patients (10.5%) were admitted to the intensive care unit and three (7.9%) returned to theatre. Two patients developed clinically apparent anastomotic leaks (5.3%). A potentially curative resection was performed in 34 patients (89%) but 22 (57.8%) of these patients were subsequently found to have tumor cells at or within 2 mm from the circumferential resection margin. The 1-year and 2-year overall survival rates were 70% and 52%, respectively. Long-term complications included benign anastomotic stricture (24%), delayed gastric emptying (26%) and a persistent thoracic wound sinus (15%). LTA esophagogastrectomy remains a viable approach with an acceptably low incidence of short and long-term complications.

Collecting duct carcinoma of the renal medulla presenting with paraplegia

We report an interesting case of a patient with collecting duct carcinoma arising from the left kidney who presented with paraplegia secondary to metastases. The diagnosis was based on CT and histology. To our knowledge this is the first case of collecting duct carcinoma to present with paraplegia. The literature review also highlights the rarity of this disease with less than a hundred cases reported to date and the aggressive nature and poor prognosis despite prompt interventions.