The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

The impact of preoperative sarcopenia on postoperative ileus following colorectal cancer surgery

PURPOSE

Sarcopenia is associated with poor short- and long-term patient outcomes following colorectal surgery. Despite postoperative ileus (POI) being a major complication following colorectal surgery, the predictive value of sarcopenia for POI is unclear. We assessed the association between sarcopenia and POI in patients with colorectal cancer.

METHODS

Elective colorectal cancer surgery patients were retrospectively included (2018-2022). The cross-sectional psoas area was calculated using preoperative staging imaging at the level of the 3rd lumbar vertebrae. Sarcopenia was determined using gender-specific cut-offs. The primary outcome POI was defined as not achieving GI-2 by day 4. Demographics, operative characteristics, and complications were compared via univariate and multivariate analyses.

RESULTS

Of 297 patients, 67 (22.6%) were sarcopenic. Patients with sarcopenia were older (median 74 (IQR 67-82) vs. 69 (58-76) years, p < 0.001) and had lower body mass index (median 24.4 (IQR 22.2-28.6) vs. 28.8 (24.9-31.9) kg/m2, p < 0.001). POI was significantly more prevalent in patients with sarcopenia (41.8% vs. 26.5%, p = 0.016). Overall rate of complications (85.1% vs. 68.3%, p = 0.007), Calvien-Dindo grade > 3 (13.4% vs. 10.0%, p = 0.026) and length of stay were increased in patients with sarcopenia (median 7 (IQR 5-12) vs. 6 (4-8) days, p = 0.013). Anastomotic leak rate was higher in patients with sarcopenia although the difference was not statistically significant (7.5% vs. 2.6%, p = 0.064). Multivariate analysis demonstrated sarcopenia (OR 2.0, 95% CI 1.1-3.8), male sex (OR 1.9, 95% CI 1.0-3.5), postoperative hypokalemia (OR 3.2, 95% CI 1.6-6.5) and increased opioid use (OR 2.4, 95% CI 1.3-4.3) were predictive of POI.

CONCLUSION

Sarcopenia demonstrates an association with POI. Future research towards truly identifying the predictive value of sarcopenia for postoperative complications could improve informed consent and operative planning for surgical patients.

Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Impact of STIMUlant and osmotic LAXatives (STIMULAX trial) on gastrointestinal recovery after colorectal surgery: randomized clinical trial

BACKGROUND

Recovery of gastrointestinal (GI) function is often delayed after colorectal surgery. Enhanced recovery protocols (ERPs) recommend routine laxative use, but evidence of benefit is unclear. This study aimed to investigate whether the addition of multimodal laxatives to an ERP improves return of GI function in patients undergoing colorectal surgery.

METHODS

This was a single-centre, parallel, open-label RCT. All adult patients undergoing elective colorectal resection or having stoma formation or reversal at the Royal Adelaide Hospital between August 2018 and May 2020 were recruited into the study. The STIMULAX group received oral Coloxyl® with senna and macrogol, with a sodium phosphate enema in addition for right-sided operations. The control group received standard ERP postoperative care. The primary outcome was GI-2, a validated composite measure defined as the interval from surgery until first passage of stool and tolerance of solid intake for 24 h in the absence of vomiting. Secondary outcomes were the incidence of prolonged postoperative ileus (POI), duration of hospital stay, and postoperative complications. The analysis was performed on an intention-to-treat basis.

RESULTS

Of a total of 170 participants, 85 were randomized to each group. Median GI-2 was 1 day shorter in the STIMULAX compared with the control group (median 2  (i.q.r. 1.5-4) versus 3 (2-5.5) days; 95 per cent c.i. -1 to 0 days; P = 0.029). The incidence of prolonged POI was lower in the STIMULAX group (22 versus 38 per cent; relative risk reduction 42 per cent; P = 0.030). There was no difference in duration of hospital day or 30-day postoperative complications (including anastomotic leak) between the STIMULAX and control groups.

CONCLUSION

Routine postoperative use of multimodal laxatives after elective colorectal surgery results in earlier recovery of gastrointestinal function and reduces the incidence of prolonged POI. Registration number: ACTRN12618001261202 (www.anzctr.org.au).

Rectal cancer lateral lymph nodes: multicentre study of the impact of obturator and internal iliac nodes on oncological outcomes

BACKGROUND

In patients with rectal cancer, enlarged lateral lymph nodes (LLNs) result in increased lateral local recurrence (LLR) and lower cancer-specific survival (CSS) rates, which can be improved with (chemo)radiotherapy ((C)RT) and LLN dissection (LLND). This study investigated whether different LLN locations affect oncological outcomes.

METHODS

Patients with low cT3-4 rectal cancer without synchronous distant metastases were included in this multicentre retrospective cohort study. All MRI was re-evaluated, with special attention to LLN involvement and response.

RESULTS

More advanced cT and cN category were associated with the occurrence of enlarged obturator nodes. Multivariable analyses showed that a node in the internal iliac compartment with a short-axis (SA) size of at least 7 mm on baseline MRI and over 4 mm after (C)RT was predictive of LLR, compared with a post-(C)RT SA of 4 mm or less (hazard ratio (HR) 5.74, 95 per cent c.i. 2.98 to 11.05 vs HR 1.40, 0.19 to 10.20; P < 0.001). Obturator LLNs with a SA larger than 6 mm after (C)RT were associated with a higher 5-year distant metastasis rate and lowered CSS in patients who did not undergo LLND. The survival difference was not present after LLND. Multivariable analyses found that only cT category (HR 2.22, 1.07 to 4.64; P = 0.033) and margin involvement (HR 2.95, 1.18 to 7.37; P = 0.021) independently predicted the development of metastatic disease.

CONCLUSION

Internal iliac LLN enlargement is associated with an increased LLR rate, whereas obturator nodes are associated with more advanced disease with increased distant metastasis and reduced CSS rates. LLND improves local control in persistent internal iliac nodes, and might have a role in controlling systemic spread in persistent obturator nodes.Members of the Lateral Node Study Consortium are co-authors of this study and are listed under the heading Collaborators.

Factors predictive of an advanced stage of colorectal cancer at presentation - a bi-national study

AIM

Identifying elements associated with advanced colorectal cancer (CRC) stage may inform understanding of whether advanced disease is a corollary of access to healthcare or tumour biology and in turn allow the use of targeted screening and awareness programmes. The aim of this study was to identify factors that predict advanced stage of CRC at presentation in Australia and New Zealand.

METHOD

This was a cross-sectional registry study sourced from the prospectively maintained Binational Colorectal Cancer Audit database of Australia and New Zealand. The primary outcome was stage as defined by the TNM system with associations drawn to demographic and perioperative variables.

RESULTS

In total, 25 282 separate cancers were included. Univariate analysis found younger age, treatment at a public facility, increasing American Society of Anesthesiologists (ASA) grade, more distal tumours, and less recent year of surgery to all be associated with more advanced disease; sex and presentation at a rural vs urban hospital had no bearing on this outcome. Logistic regression identified younger age (< 60 years vs > 80 years: OR 1.96; 95% CI 1.80-2.14; P = 0.002), treatment at a public vs private hospital (OR 1.21; 95% CI 1.14-1.28; P < 0.001), increasing ASA grade (ASA4 vs ASA1: OR 1.37; 95% CI 1.17-1.59, P < 0.001) and more distal tumours (mid-low rectal vs right colon tumours: OR 1.52; 95% CI 1.41-1.64; P < 0.001) to be independent predictors of nodal or metastatic disease at presentation.

CONCLUSION

Younger age, increasing ASA grade, more distal tumours, and treatment at a public rather than private facility are independently associated with the presence of nodal or distant CRC metastases at diagnosis.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Safety and efficacy of laxatives after major abdominal surgery: systematic review and meta-analysis

Background

Recovery of gastrointestinal function is often delayed after major abdominal surgery, leading to postoperative ileus (POI). Enhanced recovery protocols recommend laxatives to reduce the duration of POI, but evidence is unclear. This systematic review aimed to assess the safety and efficacy of laxative use after major abdominal surgery.

Methods

Ovid MEDLINE, Embase, Cochrane Library and PubMed databases were searched from inception to May 2019 to identify eligible RCTs focused on elective open or minimally invasive major abdominal surgery. The primary outcome was time taken to passage of stool. Secondary outcomes were time taken to tolerance of diet, time taken to flatus, length of hospital stay, postoperative complications and readmission to hospital.

Results

Five RCTs with a total of 416 patients were included. Laxatives reduced the time to passage of stool (mean difference (MD) −0·83 (95 per cent c.i. −1·39 to −0·26) days; P = 0·004), but there was significant heterogeneity between studies for this outcome measure. There was no difference in time to passage of flatus (MD −0·17 (−0·59 to 0·25) days; P = 0·432), time to tolerance of diet (MD −0·01 (−0·12 to 0·10) days; P = 0·865) or length of hospital stay (MD 0·01(−1·36 to 1·38) days; P = 0·992). There were insufficient data available on postoperative complications for meta‐analysis.

Conclusion

Routine postoperative laxative use after major abdominal surgery may result in earlier passage of stool but does not influence other postoperative recovery parameters. Better data are required for postoperative complications and validated outcome measures.

Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study

INTRODUCTION

Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction.

METHOD

An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized.

DISSEMINATION AND IMPLEMENTATION

The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.

Risk factors associated with unplanned readmission following excisional haemorrhoidectomy

AIM

Excisional haemorrhoidectomy is the gold standard for management of advanced symptomatic haemorrhoids. Although an effective treatment, it is associated with significant postoperative morbidity with pain, bleeding and a high readmission rate. This study seeks to investigate potential risk factors that may predict unplanned 30-day readmissions following excisional haemorrhoidectomy.

METHOD

A retrospective cohort review of all haemorrhoidectomies performed at Counties Manukau District Health Board, Auckland, New Zealand, between January 2012 and December 2017 was performed. Baseline demographic data, readmission data and potential variables for readmission were recorded. Univariate and multivariate logistic regression analyses were performed to determine significant variables for readmission within 30 days.

RESULTS

In total, 485 cases of excisional haemorrhoidectomy were included in the final analysis with 62 (12.8%) unplanned readmissions. The demographics between the no readmission and unplanned readmission groups were similar. Multivariate logistic regression analysis demonstrated that male gender (P = 0.018) and the use of non-diathermy devices (P = 0.017) were significant risk factors for readmission. Initial dispensing of opioid analgesia did not decrease the risk of readmission.

CONCLUSION

This study suggests that male gender and surgical technique are associated with increased risk of readmission.

Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk-benefit equation

AIM

Complete mesocolic excision (CME) with central vascular ligation (CVL) has been advocated for right colon adenocarcinoma (RC), but the radicality of vascular dissection remains controversial. Our aim is to report outcomes of selective CVL (D3 lymphadenectomy) during minimally invasive CME for RC.

METHOD

A prospective database identified patients who were treated for RC between 2009 and 2016. Minimally invasive CME was standard. The radicality of lymphadenectomy was defined as high ligation (HL) versus CVL based on operative reports and videos. Two blinded radiologists independently evaluated the pre- and postoperative CT scans for radiographically abnormal nodes.

RESULTS

Of 197 patients who underwent CME, HL was performed in 56 (28%) and CVL in 141 (72%). There were no baseline differences in age, sex, body mass index, American Society of Anesthesiologists score or pathological staging, and there were no major intra-operative complications in either group (including no major vascular injuries). The median total number of nodes retrieved was 27 and 31 (P = 0.011) in HL and CVL groups, resepctively, with pathologically positive nodes identified in 33.9% and 39.8% (P = 0.704), respectively. Preoperative imaging identified abnormal cN3 nodes in 1.5% of patients; all of whom underwent CVL. No abnormal cN2 or cN3 nodes remained on postoperative imaging. The 60-day mortality was 0.5%, and major morbidity was 4%. One patient (0.5%) had an anastomotic recurrence after a median follow-up of 22 months.

CONCLUSION

With imperfect preoperative clinical nodal staging, and in the absence of randomized data, the low morbidity and oncological outcomes observed support the approach of CME with HL as a minimum standard, with CVL (D3 lymphadenectomy) in selected cases.

Closing the audit cycle: improving short-term outcomes of oesophagectomy in a provincial hospital

A previously published study regarding the outcomes of oesophagectomy at a provincial hospital identified issues with perioperative care (Al-Herz et al 2012). The aim of this study was to evaluate the effect of changes in management at the institution concerned. This was a cohort study which compared the outcomes of 30 patients undergoing oesophagectomy before the unit audit and 30 patients after it. Demographics, operative details, recovery parameters, and oncological data were collected retrospectively. There was a significant reduction in the use of intravenous fluid, both intraoperatively (6.6 vs 3.3L, P < 0.0001) and during the first 24 hours (9.2 vs 5.5L, P < 0.0001). Patients were extubated three days earlier (P < 0.001) after the audit, and the percentage of patients requiring tracheostomy was smaller (26.7% vs 0%, P = 0.003). The length of total hospital stay was shorter (15 vs 13 days, P = 0.035). We conclude that the publication of a unit audit changed perioperative practice and resulted in a significant improvement in the short term outcomes after oesophagectomy.

Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: Analysis of a large prospective clinical database

BACKGROUND

Oncological outcomes of laparoscopic colon cancer surgery have been shown to be equivalent to those of open surgery, but only in the setting of randomized controlled trials on highly selected patients. The aim of this study is to investigate whether this finding is generalizable to real world practice.

METHODS

Analysis of prospectively collected data from the BioGrid Australia database was undertaken. Overall and cancer specific survival rates were compared with cox regression analysis controlling for the confounders of age, sex, BMI, ASA score, hospital site, year surgery performed, procedure, tumor stage, and adjuvant chemotherapy.

RESULTS

Between 2003 and 2009, 1,106 patients underwent elective colon cancer resection. There were differences between the laparoscopic and open cohorts in BMI, procedure, post-operative complication rate, and tumor stage. When baseline confounders were accounted for using cox regression analysis, there was no difference in 5 year overall survival (χ(2) test 1.302, P = 0.254), or cancer specific survival (χ(2) test 0.028, P = 0.866).

CONCLUSION

This large prospective clinical study validates previous trial results, and confirms that there is no difference in oncological outcome between laparoscopic and open surgery for colon cancer.

Perioperative care: a survey of New Zealand and Australian colorectal surgeons

AIM

Recent surveys in Europe and North America have demonstrated significant challenges in the implementation of evidence-based surgical practice.

METHOD

A survey of New Zealand and Australian colorectal surgeons was conducted to help understand current practice and perceived barriers to interventions in this region. Questions were based around elective colorectal resection care.

RESULTS

There were 152 eligible participants identified. Over a 60-day period, 82 (54%) surgeons responded but only 76 (50%) of the questionnaires were complete; they were used for data analysis. The majority of surgeons indicated a preference for laparoscopic techniques. Barriers to laparoscopy include lack of operating time, lack of adequate training and institutional pressures. Only 28 (37%) indicated that they cared for patients in a formalized enhanced recovery programme (ERAS). Barriers to implementing ERAS included lack of support from institutions and other specialities. Routine oral 'mechanical' bowel preparation for colon and rectal resection was preferred by 28% and 63%, respectively. Drainage after routine colon and rectal resection was not used by 62 (83%) and 39 (53%). Prophylactic nasogastric intubation afterwards was not used by 66 (87%) responders. The preferred mode of analgesia was patient-controlled opioid analgesia (PCA) for 52%. A 'restrictive' intravenous fluid therapy was preferred by 34 (49%) while 33 (48%) preferred no fluid restriction. A prolonged 'nil by mouth' status was preferred by 28%.

CONCLUSION

There appears to be a high rate of evidence in agreement with some interventions but not others. The systemic barriers to implementing evidence-based perioperative care need attention.

Influences on length of stay in an enhanced recovery programme after colonic surgery

AIM

Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution.

METHOD

Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥ 4 were excluded. Statistical analyses were performed using the Mann-Whitney U-test and Cox regression modelling.

RESULTS

A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right-sided, 41 left-sided and two total colectomies. The median age of the patients was 67.5 (range 31-92) years and the median day stay was 4 (range 3-46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high-dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did.

CONCLUSION

Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.

Systematic review and meta-analysis of intraperitoneal local anaesthetic for pain reduction after laparoscopic gastric procedures

BACKGROUND

With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta-analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures.

METHODS

Comprehensive searches were conducted independently without language restriction. Studies were identified from the following databases from inception to February 2010: Cochrane Central Register of Controlled Trials, the Cochrane Library, MEDLINE, PubMed, Embase and CINAHL. Relevant meeting abstracts and reference lists were searched manually. Appropriate methodology according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adhered to.

RESULTS

Five randomized controlled trials in laparoscopic gastric procedures were identified for review. There was no significant heterogeneity between the trials (χ(2) = 10·27, 10 d.f., P = 0·42, I(2) = 3 per cent). Based on meta-analysis of trials, there appeared to be reduced abdominal pain intensity (overall mean difference in pain score -1·64, 95 per cent confidence interval (c.i.) -2·09 to -1·19; P < 0·001), incidence of shoulder tip pain (overall odds ratio 0·15, 95 per cent c.i. 0·05 to 0·44; P < 0·001) and opioid use (overall mean difference -3·23, -4·81 to -1·66; P < 0·001).

CONCLUSION

There is evidence in favour of IPLA in laparoscopic gastric procedures for reduction of abdominal pain intensity, incidence of shoulder pain and postoperative opioid consumption.

Oesophageal Doppler-guided fluid administration in colorectal surgery: critical appraisal of published clinical trials

The evidence underpinning oesophageal Doppler monitoring (ODM)-guided fluid administration in colorectal surgery has not been critically appraised despite quantitative meta-analyses. A qualitative systematic review of the methodology and findings of all published randomised-controlled trials (RCTs) exploring ODM-guided fluid administration in major abdominal surgery was conducted. Four, well-designed single-centre trials inclusive of 393 patients in total have primarily demonstrated that ODM-guided intraoperative fluid administration decreases hospital length of stay (LOS) and complications by optimising intraoperative cardiac parameters. One subsequently published RCT shows that ODM-guided fluid administration predisposes to a greater LOS and significantly increased complications. However, all the trials have been hampered by imprecise definitions with heterogeneity in patient selection, intraoperative fluid administration strategies and methods of outcome assessment. ODM-guided fluid administration has only been investigated in the setting of laparoscopic colonic surgery and within an optimised perioperative care protocol in one trial, where it was not shown to be beneficial. Nevertheless, it was recommended for use in this context before the trial was even published. ODM-guided fluid administration has not been compared with intraoperative fluid restriction. Current evidence regarding the use of Doppler-guided fluid administration is limited by heterogeneity in the trial design, and the initial clinical benefits observed may be largely offset by recent advances in surgical techniques and perioperative care.

Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

There is a lack of cohesive reports on the systemic levels of local anaesthetic after intraperitoneal application. A comprehensive systematic review with no language restriction was conducted. Eighteen suitable articles were identified. Data were compiled and presented according to local anaesthetic agent. Intraperitoneal local anaesthetic has been studied in many different procedures, including open and laparoscopic surgery. A total of 415 patients were included for analysis. There were no cases of clinical toxicity. There were 11 (2.7%) cases with a systemic level above or close to a safe threshold (as determined by the report authors) in three trials utilising intraperitoneal local anaesthetic after laparoscopic cholecystectomy. Intraperitoneal lignocaine doses varied from 100 to 1000 mg, mean Cmax ranged from 1.01 to 4.32 μg/ml and mean Tmax ranged from 15 to 40 minutes. Intraperitoneal bupivacaine doses varied from 50 to 150 mg (weight based doses also reported), mean Cmax ranged from 0.29 to 1.14 μg/ml and mean Tmax ranged from 15 to 60 minutes. Intraperitoneal ropivacaine doses varied from 100 to 300 mg, mean Cmax ranged from 0.66 to 3.76 μg/ml and mean Tmax ranged from 15 to 35 minutes. The addition of adrenaline to intraperitoneal local anaesthetic almost halves systemic levels and prolongs Tmax. Intraperitoneal local anaesthetic results in detectable systemic levels in the perioperative setting. Despite a lack of clinical toxicity, careful attention to dose is still required to prevent potential systemic toxic levels. Clinicians should also consider the addition of adrenaline to intraperitoneal local anaesthetic solutions to further add to the systemic safety profile.

Ethnic disparity in colonic cancer outcomes in New Zealand--biology or an access issue?

BACKGROUND

There is an ethnic variation in outcomes for colonic cancer in New Zealand. Whether this disparity is caused by cancer biology or inequitable provision of treatment services after diagnosis has not been elucidated.

METHOD

National cancer registry data from 1996 to 2003 were obtained. Incidence and mortality rates for the four major ethnic groups were age-adjusted to the new WHO world population. The impact of age, sex, AJCC stage and site of cancer at diagnosis was compared between ethnic groups using a Cox regression analysis.

RESULTS

A total of 11 987 colonic cancer registrations were identified. The overall raw 5-year mortality was 53.7%. The age-adjusted incidence in Europeans was more than double that of the Maori, Asian and Pacific populations at 33.0 per 100,000 population/year. Europeans presented at a greater age, with more right sided cancers, and at an earlier stage of disease. The opposite was true for the Maori population. Pacific Islanders and Asians presented at a younger age, but with a similar site, stage and sex distribution to the rest of the population. There were no significant differences in 5 year mortality after diagnosis when age, sex, stage, and site at presentation were controlled for by cox regression analysis.

CONCLUSION

These results suggest that age, sex, stage and site at presentation may be more important than inequality in treatment provision after diagnosis in explaining differences in outcomes between the ethnicities. Efforts need to be focused on identifying reasons for the increased risk of colonic neoplasia in Europeans and the later stage disease presentation in the Maori population.

Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy

Background

Recent data have suggested a relationship between postoperative fatigue and the peritoneal cytokine response after surgery. The aim of this study was to test the hypothesis that preoperative administration of glucocorticoids before surgery would decrease fatigue and enhance recovery, by reducing the peritoneal production of cytokines.

Methods

In a double-blind randomized controlled study, patients undergoing elective, open colonic resection were administered 8 mg dexamethasone or normal saline. Patients were treated within an enhanced recovery after surgery programme. Primary outcomes were cytokine levels in peritoneal drain fluid and fatigue as measured by the Identity–Consequence Fatigue Scale (ICFS).

Results

Baseline parameters were similar for 29 patients in the dexamethasone group and 31 in the placebo group. Patients who received dexamethasone had lower ICFS scores on days 3 and 7. Dexamethasone was associated with significantly lower peritoneal fluid interleukin (IL) 6 and IL-13 concentrations on day 1, and these correlated with changes in the ICFS score. There was no significant increase in adverse events in the dexamethasone group.

Conclusion

Preoperative administration of dexamethasone resulted in a significant reduction in early postoperative fatigue, associated with an attenuated early peritoneal cytokine response. Peritoneal production of cytokines may therefore be important in postoperative recovery. Registration number: ACTRN12607000066482 (http://www.anzctr.org.au/).

Systematic review of oxidative stress associated with pneumoperitoneum

Background

There have been several reports of ischaemic complications after routine laparoscopy. The aim of this review was to investigate the relationship between this oxidative stress and pneumoperitoneum.

Methods

Medline, Medline in-process, The Cochrane Library, PubMed and EMBASE were searched for papers on oxidative stress and pneumoperitoneum, from 1947 to March 2008 with no language restriction or restriction on trial design. Papers that did not investigate pneumoperitoneum as a causative factor, or did not report outcome measures related to oxidative stress, were excluded.

Results

A total of 73 relevant papers were identified: 36 animal studies, 21 human clinical trials, nine case reports, five review articles and two comments. Pneumoperitoneum causes a reduction in splanchnic blood flow, resulting in biochemical evidence of oxidative stress in a pressure- and time-dependent manner. There is evidence that the use of carbon dioxide for insufflation is contributory. Several measures proposed to minimize the oxidative stress have shown promise in animal studies, but few have been evaluated in the clinical setting.

Conclusion

There is an increasing body of evidence, mainly from animal studies, that pneumoperitoneum decreases splanchnic perfusion with resulting oxidative stress. It is now appropriate to investigate the clinical significance of pneumoperitoneum-associated oxidative stress.

Meta-analysis of the effect of warm humidified insufflation on pain after laparoscopy

Background

Studies on the use of warmed and humidified insufflation (WHI) in laparoscopic abdominal procedures to reduce pain have been inconclusive owing to small sample sizes.

Methods

An electronic database search identified all randomized controlled trials (RCTs) on adults undergoing elective laparoscopic abdominal surgery under general anaesthesia in which the exposure group had WHI and the control group had standard cold and dry carbon dioxide. The outcome measure was pain by visual analogue score or morphine usage.

Results

Seven RCTs were included. Patients in the WHI group experienced a significant reduction in pain score at 6 h (P = 0·006), 1 day (P = 0·010) and 3 days (P &lt; 0·001) after operation, and in morphine usage on day 2 (P = 0·040).

Conclusion

WHI reduces pain after laparoscopy.