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.

Human factors in pelvic exenteration: themes in high-performing teams

AIM

The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and postoperative phases.

METHOD

Qualitative analysis of focus groups was used to capture authentic human interactions that reflect real-world multiprofessional performance. Theatre teams were treated as clusters, with a particular focus group containing participants who worked together regularly.

RESULTS

Three focus groups were conducted. Four themes emerged - driving force, technical skills, nontechnical skills and operational aspects - with a total of 16 subthemes. Saturation was reached by group 2, with no new subthemes emerging after this. There was some interaction between the themes and the subthemes. Broadly speaking, driving force led to the development of specialised technical skills and nontechnical skills, which were operationalized into successful service through operational aspects.

CONCLUSION

This study of teams performing pelvic exenteration is the first in the field using this methodology. It has generated rich qualitative data with authentic insights into the pragmatic aspects of developing and delivering a service. In addition, it shows how the themes are connected or 'coupled' in a network, for example technical and non-technical skills. In a complex system, 'tight coupling' leads to both high performance and adverse events. In this paper, we report the qualitative aspects of high performance by pelvic exenteration teams in a complex sociotechnical system, which depends on tight coupling of several themes.

Bacterial lipopolysaccharide modulates immune response in the colorectal tumor microenvironment

Immune responses can have opposing effects in colorectal cancer (CRC), the balance of which may determine whether a cancer regresses, progresses, or potentially metastasizes. These effects are evident in CRC consensus molecular subtypes (CMS) where both CMS1 and CMS4 contain immune infiltrates yet have opposing prognoses. The microbiome has previously been associated with CRC and immune response in CRC but has largely been ignored in the CRC subtype discussion. We used CMS subtyping on surgical resections from patients and aimed to determine the contributions of the microbiome to the pleiotropic effects evident in immune-infiltrated subtypes. We integrated host gene-expression and meta-transcriptomic data to determine the link between immune characteristics and microbiome contributions in these subtypes and identified lipopolysaccharide (LPS) binding as a potential functional mechanism. We identified candidate bacteria with LPS properties that could affect immune response, and tested the effects of their LPS on cytokine production of peripheral blood mononuclear cells (PBMCs). We focused on Fusobacterium periodonticum and Bacteroides fragilis in CMS1, and Porphyromonas asaccharolytica in CMS4. Treatment of PBMCs with LPS isolated from these bacteria showed that F. periodonticum stimulates cytokine production in PBMCs while both B. fragilis and P. asaccharolytica had an inhibitory effect. Furthermore, LPS from the latter two species can inhibit the immunogenic properties of F. periodonticum LPS when co-incubated with PBMCs. We propose that different microbes in the CRC tumor microenvironment can alter the local immune activity, with important implications for prognosis and treatment response.

Could Microplastics Be a Driver for Early Onset Colorectal Cancer?

Introduction: The incidence of colorectal cancer in those under 50 years of age (early onset colorectal cancer (EOCRC)) is increasing throughout the world. This has predominantly been an increase in distal colonic and rectal cancers, which are biologically similar to late onset colorectal cancer (LOCRC) but with higher rates of mucinous or signet ring histology, or poorly differentiated cancers. The epidemiology of this change suggests that it is a cohort effect since 1960, and is most likely driven by an environmental cause. We explore the possible role of microplastics as a driver for this change. Review: The development of sporadic colorectal cancer is likely facilitated by the interaction of gut bacteria and the intestinal wall. Normally, a complex layer of luminal mucus provides colonocytes with a level of protection from the effects of these bacteria and their toxins. Plastics were first developed in the early 1900s. After 1945 they became more widely used, with a resultant dramatic increase in plastic pollution and their breakdown to microplastics. Microplastics (MPs) are consumed by humans from an early age and in increasingly large quantities. As MPs pass through the gastrointestinal tract they interact with the normal physiological mechanism of the body, particularly in the colon and rectum, where they may interact with the protective colonic mucus layer. We describe several possible mechanisms of how microplastics may disrupt this mucus layer, thus reducing its protective effect and increasing the likelihood of colorectal cancer. Conclusions: The epidemiology of increase in EOCRC suggests an environmental driver. This increase in EOCRC matches the time sequence in which we could expect to see an effect of rapid increase of MPs in the environment and, as such, we have explored possible mechanisms for this effect. We suggest that it is possible that the MPs damage the barrier integrity of the colonic mucus layer, thus reducing its protective effect. MPs in CRC pathogenesis warrants further investigation. Future directions: Further clarification needs to be sought regarding the interaction between MPs, gut microbiota and the mucus layer. This will need to be modelled in long-term animal studies to better understand how chronic consumption of environmentally-acquired MPs may contribute to an increased risk of colorectal carcinogenesis.

An epigenetic signature of advanced colorectal cancer metastasis

Colorectal cancer (CRC) is a leading cause of morbidity and mortality worldwide. The majority of CRC deaths are caused by tumor metastasis, even following treatment. There is strong evidence for epigenetic changes, such as DNA methylation, accompanying CRC metastasis and poorer patient survival. Earlier detection and a better understanding of molecular drivers for CRC metastasis are of critical clinical importance. Here, we identify a signature of advanced CRC metastasis by performing whole genome-scale DNA methylation and full transcriptome analyses of paired primary cancers and liver metastases from CRC patients. We observed striking methylation differences between primary and metastatic pairs. A subset of loci showed coordinated methylation-expression changes, suggesting these are potentially epigenetic drivers that control the expression of critical genes in the metastatic cascade. The identification of CRC epigenomic markers of metastasis has the potential to enable better outcome prediction and lead to the discovery of new therapeutic targets.

Distinct changes in the colonic microbiome associated with acute diverticulitis

AIM

The pathogenesis of acute diverticulitis (AD) remains incompletely understood, despite it being one of the most common gastrointestinal conditions worldwide. The aim of this study was to investigate the role of the colonic microbiome in the pathogenesis of AD.

METHOD

A prospective case-control study was performed, comparing the microbiome of AD patients with that of controls, using 16S rRNA sequencing of rectal swab samples.

RESULTS

The microbiome of individuals with AD showed lower diversity than that of controls. There were significant compositional differences observed, with a lower abundance of commensal bacterial families and genera such as Lachnospiraceae, Ruminococcus and Faecalibacterium in AD patients compared with controls, and there was an increase in several genera with known pathogenic roles including Fusobacteria, Prevotella and Paraprevotella.

CONCLUSION

This is the largest study to date to examine the microbiota of AD patients, and adds evidence to the proposed hypothesis that alterations in the colonic microbiome play a role in the pathogenesis of AD.

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.

Detection of Fusobacterium nucleatum DNA in primary care patient stool samples does not predict progression of colorectal neoplasia

Background

Carriage of certain bacterial species may represent potential biomarkers of colorectal cancer (CRC). Prominent among these is Fusobacterium nucleatum. We explored the association of F. nucleatum DNA in stool samples with the presence of colonic neoplastic lesions in a cohort of primary care patients, and compared our findings with those from an unrelated cohort of colonoscopy patients followed clinically over time.

Methods

Carriage rates of F. nucleatum in stool samples were assessed in 185 patients referred for a faecal immunochemical test (FIT) by their general practitioners (GPs). Comparisons were made with stool samples from 57 patients diagnosed with CRC and 57 age-matched healthy controls, and with tissue samples taken at colonoscopy from 150 patients with a decade of subsequent clinical follow-up.

Findings

F. nucleatum DNA was found at a high rate (47.0%) in stool samples from primary care patients, and more often in stool samples from CRC patients (47.4%) than in healthy controls (7.0%), (P = 7.66E-7). No association was found between carriage of F. nucleatum and FIT positivity (P = 0.588). While evidence of stool-associated F. nucleatum DNA was significantly more likely to indicate a lesion in those primary care patients progressed to colonoscopy (P = 0.023), this finding did not extend to the progression of neoplastic lesions in the 150 patients with a decade of follow up.

Conclusion

The finding of F. nucleatum DNA at similar rates in stool samples from patients diagnosed with CRC and in primary care patients with pre-cancerous lesions supports growing awareness that the presence of these bacteria may be a biomarker for increased risk of disease. However, molecular evidence of F. nucleatum did not predict progression of colonic lesions, which may lessen the utility of this bacterium as a biomarker for increased risk of disease.

Acute Diverticulitis in Young Patients: A Review of the Changing Epidemiology and Etiology

Acute diverticulitis is one of the leading gastrointestinal causes for hospitalization. The incidence of acute diverticulitis has been increasing in recent years, especially in patients under 50 years old. Historically, acute diverticulitis in younger patients was felt to represent a separate entity, being more virulent and associated with a higher rate of recurrence. Accordingly, young patients were often managed differently to older counterparts. Our understanding of the natural history of this condition has evolved, and current clinical practice guidelines suggest age should not alter management. The purpose of this review is to evaluate the changing epidemiology of acute diverticulitis, consider potential explanations for the observed increased incidence in younger patients, as well as review the natural history of acute diverticulitis in the younger population.

The Epidemiology and Etiology of Right-Sided Colonic Diverticulosis: A Review

Diverticulosis of the colon is a common condition in Western countries and most patients will remain asymptomatic, but some will present with symptoms of acute diverticulitis or bleeding. Our understanding of diverticulosis is evolving but is mostly derived from diverticulosis affecting the left-sided colon. In contrast, right-sided colonic diverticulosis (RCD) is more commonly seen in Asian countries but is much less common overall. Based on the marked differences in epidemiology, it is commonly thought that these are 2 distinct disease processes. A review of the literature describing the epidemiology and etiology of RCD was performed, with a comparison to the current understanding of left-sided diverticulosis. RCD is becoming increasingly common. The epidemiology of RCD shows it to be a mostly acquired condition, and not congenital as previously thought. Many factors in the etiology of RCD are similar to that seen in left-sided diverticulosis, with a few variations. It is therefore likely that most cases of RCD represent the same disease process that is seen in the left colon.

The prevalence of right-sided colonic diverticulosis in a New Zealand population

BACKGROUND

Once considered to be a congenital condition, the epidemiology of right-sided colonic diverticulosis (RCD) is evolving. Acute diverticulitis (AD) is a complication of RCD which is frequently misdiagnosed as appendicitis, resulting in unnecessary surgery, as there is strong evidence supporting medical management for right-sided AD. In general, the incidence of AD correlates with the prevalence of RCD, which shows marked geographic variation. Few data reporting RCD prevalence come from Western countries, so the aim of this study is to define the prevalence of RCD in a New Zealand population.

METHODS

Independent review of the imaging from 1000 consecutive patients undergoing a computed tomography Kidney/Ureter/Bladder scan for suspected urolithiasis at Christchurch Hospital between January and November 2017 was undertaken, to determine the presence or absence, and distribution of colonic diverticulosis. Patients were excluded if they had a history of colonic resection, known IBD, or were less than 18-years old.

RESULTS

Thirty-one patients were excluded, leaving 969 eligible patients. Overall, 95 patients (9.8%) had RCD identified. The prevalence of RCD increased significantly with advancing age, being present in 2.3% of those aged 18-29, increasing to 20.3% in those greater than 70-years old (p < 0.001).

CONCLUSION

The prevalence of RCD in a New Zealand population is relatively high and increases significantly with age. This adds support to the role of cross-sectional imaging in the evaluation of suspected appendicitis, to exclude right-sided AD. The association with advancing age supports RCD being an acquired condition rather than a congenital condition as was previously thought.

Quality of life preferences in colorectal cancer patients aged 80 and over

BACKGROUND

Management of patients with colorectal cancer (CRC) is about not only survival, but also quality of life (QoL). What patients want is important but is not well researched or understood for elderly patients where it is very relevant. This study aimed to measure and compare what patients with CRC aged 80 and over and surgeons consider important in terms of survivorship after surgery for CRC.

METHODS

Patients aged 80 and over who were having surgery for CRC were recruited and interviewed using closed and open questions about their expectations of surgery and various QoL dimensions. These were assessed preoperatively and 3 months post-operatively. Surgeons ranked the same QoL dimensions of patients by questionnaire.

RESULTS

Nineteen patients (median age 87.5, range 80-95, eight males and 11 females) were recruited. Patients rated items relating to health, mobility and independence (n = 23) as top three items most often followed by people outside self (n = 13). Surgeons underestimated importance in 17 domains with the biggest discrepancy being in 'avoiding a stoma' (4.11 versus 2.3, P < 0.01).

CONCLUSION

With patients over 80 years having surgery for CRC, there is a lack of concordance between what surgeons think is important and what patients think is important. Despite this, CRC patients aged 80 and older are almost always satisfied with the outcome of surgery. Surgeons should ensure that they understand patients' expectations and that they are aligned with likely outcomes of surgery.

Surgical outcomes following colorectal cancer resections in patients aged 80 years and over: results from the Australia and New Zealand Binational Colorectal Cancer Audit

AIM

The primary aim was to compare the 30-day morbidity and mortality in patients aged ≥80 years undergoing surgery for colorectal cancer with those aged <80 years. The secondary aim was to identify independent outcome predictors.

METHOD

This was a retrospective study of patients undergoing surgery for colorectal cancer between January 2007 and February 2018. Patients were divided into those <80 years and those ≥80 years at the time of surgery. Data had been collected prospectively by the Australasian Binational Colorectal Cancer Audit and included patient demographics, site and stage of tumour, comorbidity, operative details, American Society of Anesthesiologists score (ASA), pathological staging, 30-day mortality and morbidity (medical and surgical). Univariate and multivariate analyses were used to identify predictors of 30-day morbidity and mortality.

RESULTS

During the study period, 4600 out of 20 463 (22.5%) patients were ≥80 years. They had a greater 30-day mortality after both colonic (97/2975 [3.3%] vs. 66/7010 [0.9%], P < 0.001) and rectal resections (50/1625 [3.1%] vs. 36/9006 [0.4%], P < 0.001) compared with younger patients. They also had an increased length of stay (colon cancer, 9 vs. 7 days; rectal cancer, 10 vs. 8 days; P < 0.001) and medical complications (colon cancer, 23.5% vs. 12.7%; rectal cancer, 25.2% vs. 11.2%; P < 0.001). Surgical complications were equivalent. Age ≥80 years was not an independent predictor of 30-day morbidity or mortality. Patients ≥80 years who were ASA 2/3 and had rectal cancer seemed to fare worse in terms of 30-day mortality (ASA 2, 22%, 95% CI 9%-36%, P < 0.001; ASA 3, 11%, 95% CI 4%-19%, P< 0.001).

CONCLUSIONS

Postoperative morbidity and mortality are significantly greater in patients ≥80 years undergoing colorectal cancer surgery. Any recommendation for surgery in this age group should take into account patient comorbidity and not be based on age alone.

Predicting pathological response to chemoradiotherapy for rectal cancer: a systematic review

Introduction: Pathological complete response (pCR) rates of approximately 20% following neoadjuvant long-course chemoradiotherapy for rectal cancer have given rise to non-operative or watch-and-wait (W&W) management. To improve outcomes there has been significant research into predictors of response. The goal is to optimize selection for W&W, avoid chemoradiotherapy in those who won't benefit and improve treatment to maximize the clinical complete response (cCR) rate and the number of patients who can be considered for W&W.Areas covered: A systematic review of articles published 2008-2018 and indexed in PubMed, Embase or Medline was performed to identify predictors of pathological response (including pCR and recognized tumor regression grades) to fluoropyrimidine-based chemoradiotherapy in patients who underwent total mesorectal excision for rectal cancer. Evidence for clinical, biomarker and radiological predictors is discussed as well as potential future directions.Expert opinion: Our current ability to predict the response to chemoradiotherapy for rectal cancer is very limited. cCR of 40% has been achieved with total neoadjuvant therapy. If neoadjuvant treatment for rectal cancer continues to improve it is possible that the treatment for rectal cancer may eventually parallel that of anal squamous cell carcinoma, with surgery reserved for the minority of patients who don't respond to chemoradiotherapy.

Clinical predictors of response to chemoradiotherapy for rectal cancer as an aid to organ preservation

AIM

Clinical predictors of pathological response to chemoradiotherapy for rectal cancer can influence patient management including selection for organ preservation. This study aimed to identify clinical predictors at a tertiary referral hospital.

METHODS

A retrospective review of clinical records was undertaken after identifying all patients with stage 1-3 rectal cancer treated with long course chemoradiotherapy and total mesorectal excision from 2013 to 2018. Clinicopathological factors were recorded and multivariate analysis performed to identify predictors of pathological complete response (pCR) and good response (AJCC TRG 0-1).

RESULTS

A total of 470 patients with rectal cancer were identified of which 164 met the inclusion criteria for the study. The pCR rate was 14.6% and good response (TRG 0-1) rate 43.7%. On univariate analysis, lower T stage, older age, node negative status, anterior tumour position and shorter tumour length on magnetic resonance imaging (MRI) were associated with good response (TRG 0-1). On univariate analysis cN stage, carcinoembryonic antigen <5 and shorter tumour length on MRI were associated with pCR. On binary logistic regression shorter length on MRI and lower clinical nodal stage were predictive of pCR and lower body mass index, anterior tumour position and higher haemoglobin were predictive of good response (TRG 0-1).

CONCLUSION

Anterior tumour position is newly identified as an independent predictor of good response (TRG 0-1) to nCRT for rectal cancer and this should be explored in future studies. Higher haemoglobin and lower body mass index were also independent predictors of good response (TRG 0-1) and optimisation of these factors should be considered when using neoadjuvant chemoradiotherapy for rectal cancer.

APC Mutations Are Not Confined to Hotspot Regions in Early-Onset Colorectal Cancer

Simple Summary

Mutation of the APC gene is a common early event in colorectal cancer, however lower rates have been reported in younger cohorts of colorectal cancer patients. In sporadic cancer, mutations are typically clustered around a mutation cluster region, a narrowly defined hotspot within the APC gene. In this study we used a sequencing strategy aimed at identifying mutations more widely throughout the APC gene in patients aged 50 years or under. We found high rates of APC mutation in our young cohort that were similar to rates seen in older patients but the mutations we found were spread throughout the gene in a pattern more similar to that seen in inherited rather than sporadic mutations. Our study has implications both for the sequencing of the APC gene in early-onset colorectal cancer and for the etiology of this disease.

Abstract

While overall colorectal cancer (CRC) cases have been declining worldwide there has been an increase in the incidence of the disease among patients under 50 years of age. Mutation of the APC gene is a common early event in CRC but is reported at lower rates in early-onset colorectal cancer (EOCRC) than in older patients. Here we investigate the APC mutation status of a cohort of EOCRC patients in New Zealand using a novel sequencing approach targeting regions of the gene encompassing the vast majority of known APC mutations. Using this strategy we find a higher rate (72%) of APC mutation than previously reported in EOCRC with mutations being spread throughout the gene rather than clustered in hotspots as seen with sporadic mutations in older patients. The rate of mutations falling within hotspots was similar to those previously seen in EOCRC and as such our study has implications for sequencing strategies for EOCRC patients. Overall there were low rates of both loss of heterozygosity and microsatellite instability whereas a relatively high rate (40%) of APC promoter methylation was found, possibly reflecting increasing exposure of young people to pro-oncogenic lifestyle factors.

O2 No Longer the Go2: A Systematic Review and Meta-Analysis Comparing the Effects of Giving Perioperative Oxygen Therapy of 30% FiO2 to 80% FiO2 on Surgical Site Infection and Mortality

OBJECTIVE

To determine the effects of perioperative high (80%) versus low (30%) fraction of inspired oxygen (FiO₂) on surgical site infection (SSI) and mortality in adult surgical patients.

BACKGROUND

The routine use of high fraction perioperative oxygen in patients is "standard of care" and recommended by the World Health Organisation; however, whether there is truly any benefit to this therapy has been challenged by some authors. Questions have also been raised about the possibility of harm from oxygen therapy.

METHOD

Randomised control trials comparing high-to-low FiO₂ were located by searching MEDLINE, Embase, CENTRAL and Web of Science. The primary outcomes were SSI up to 15 days and up to any time point postoperatively and mortality up to 30 days. The data were analysed using random effects meta-analysis.

RESULTS

Twelve studies involving 10,212 participants were included. At 15 days postoperatively, and at the longest point of post-operative follow-up, there was no statistically significant reduction in the risk of SSI when comparing patients who received a perioperative FiO₂ of 30% to those with an FiO₂ of 80% (RR 1.41, 95% CI 1.00-2.01, p 0.05 and RR 1.23, 95% CI 1.00-1.51, p 0.05). There was no statistically significant difference in mortality between the 30% FiO₂ and the 80% FiO₂ groups (RR 1.12, 95% CI 0.56-2.22, p 0.76).

CONCLUSION

This meta-analysis showed no statistically significant difference in post-operative SSI or mortality when comparing patients receiving an FiO₂ of 80% to those receiving an FiO₂ of 30%.

Pre-operative frailty is predictive of adverse post-operative outcomes in colorectal cancer patients

BACKGROUND

An increasing number of elderly patients are presenting for elective surgery. Pre-operative risk assessment in this population is inexact due to the complex interplay between age, comorbidity and functional status. Frailty assessment may provide a surrogate measure of a patient's physiological reserve and aid operative decision-making. The aim of this study is to determine the association between pre-operative frailty, as assessed using the Edmonton Frail Scale, and post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery.

METHODS

A prospective analysis of 86 patients over the age of 65 undergoing elective colorectal cancer surgery at a tertiary centre between October 2017 and October 2018 was performed. Frailty assessment was conducted pre-operatively using the Edmonton Frail Scale. Primary outcomes included length of stay and post-operative complication rates. Multivariable logistic regression analyses were used to determine the influence of frailty on post-operative outcomes including mortality, prolonged hospital admission, complication rates and quality of life.

RESULTS

Of 86 patients, 12 (14.0%) were identified as frail. Frailty was associated with a significantly increased median length of stay (20 days versus 6 days, incidence rate ratio 2.83, P < 0.01) and a significantly increased risk of major post-operative complications (50.0% versus 6.7%, odds ratio 13.8, P < 0.01). Frailty was not associated with a significant reduction in quality of life scores at 30 and 90 days post-operatively.

CONCLUSION

Frailty is associated with adverse post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery. Frailty assessment is an important component of pre-operative risk assessment and may identify targets for pre-operative optimisation.

The association between low pre-operative step count and adverse post-operative outcomes in older patients undergoing colorectal cancer surgery

Background

Multiple tools exist estimating perioperative risk. With an ageing surgical demographic, frailty is becoming an increasingly important concept in perioperative medicine due to its association with adverse post-operative outcomes. Reduced physical activity is a hallmark of frailty, and we postulate that a low pre-operative step count may be an objective measure of frailty. This study aimed to determine the association between low pre-operative step count and post-operative outcomes in patients undergoing elective colorectal cancer surgery.

Methods

A prospective analysis of 85 older patients undergoing major elective colorectal surgery was performed at a tertiary centre between October 2017 and October 2018. Patients aged 65 years and over who met inclusion criteria were provided with an activity tracker to wear for 14 days prior to planned surgery. Their median daily step count was measured and a cut-off of < 2500 steps/day was used to define a reduced step count. Primary outcomes included length of stay and 30-day post-operative complication rate. Multivariable logistic regression analyses were used to analyze the influence of low pre-operative step count and other preoperative variables, on post-operative outcomes including mortality, prolonged hospital admission, and complication rates.

Results

Of 85 patients, 17 (20%) were identified as having a low pre-operative step count. A low pre-operative step count was associated with a significantly increased length of stay (14 vs. 6 days, IRR 2.09, 95% CI 1.55–2.83, p ≤ 0.01) and rate of major post-operative complications (29.4% vs. 8.8%, OR 3.34, 95% CI 1.03–14.3, p = 0.04). It was also associated with significantly increased rates of discharge to care facilities (p < 0.01) and requiring support on discharge (p = 0.03).

Conclusion

Low pre-operative step count (< 2500 steps/day) is predictive of an increased risk of post-operative morbidity in patients undergoing elective colorectal surgery. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of using a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an important avenue for future study.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12618000045213).

MinION Sequencing of colorectal cancer tumour microbiomes-A comparison with amplicon-based and RNA-Sequencing

BACKGROUND

Recent evidence suggests a role for the gut microbiome in the development and progression of many diseases and many studies have been carried out to analyse the microbiome using a variety of methods. In this study, we compare MinION sequencing with meta-transcriptomics and amplicon-based sequencing for microbiome analysis of colorectal tumour tissue samples.

METHODS

DNA and RNA were extracted from 11 colorectal tumour samples. 16S rRNA amplicon sequencing and MinION sequencing was carried out using genomic DNA, and RNA-Sequencing for meta-transcriptomic analysis. Non-human MinION and RNA-Sequencing reads, and 16S rRNA amplicon sequencing reads were taxonomically classified using a database built from available RefSeq bacterial and archaeal genomes and a k-mer based algorithm in Kraken2. Concordance between the three platforms at different taxonomic levels was tested on a per-sample basis using Spearman's rank correlation.

RESULTS

The average number of reads per sample using RNA-Sequencing was greater than 129 times that generated using MinION sequencing. However, the average read length of MinION sequences was more than 13 times that of RNA or 16S rRNA amplicon sequencing. Taxonomic assignment using 16S sequencing was less reliable beyond the genus level, and both RNA-Sequencing and MinION sequencing could detect greater numbers of phyla and genera in the same samples, compared to 16S sequencing. Bacterial species associated with colorectal cancer, Fusobacterium nucleatum, Parvimonas micra, Bacteroides fragilis and Porphyromonas gingivalis, were detectable using MinION, RNA-Sequencing and 16S rRNA amplicon sequencing data.

CONCLUSIONS

Long-read sequences generated using MinION sequencing can compensate for low numbers of reads for bacterial classification. MinION sequencing can discriminate between bacterial strains and plasmids and shows potential as a cost-effective tool for rapid microbiome sequencing in a clinical setting.

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

AIM

Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery.

METHOD

A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres.

RESULTS

In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001).

CONCLUSION

Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.

Influence of obesity on the risk of recurrent acute diverticulitis

BACKGROUND

Acute diverticulitis (AD) is a common surgical problem with increasing incidence. Obesity has become epidemic in western countries. Obesity has been shown to increase the risk of developing AD; however, little is known about its influence on the risk of recurrence. The decision to perform elective surgical resection to reduce the risk of recurrent AD is made on an individual basis considering perceived risk of recurrence weighed against patient comorbidity. The aim of this study is to assess whether obesity affects the likelihood of developing recurrent AD.

METHODS

A retrospective audit was conducted of all admissions with AD to a tertiary centre between 1998 and 2010. Medical records were reviewed and patients with an index presentation with AD included in the analysis. Imaging was used to calculate body mass index (BMI) for assessment of obesity. Follow-up was for a minimum of 3 years from admission.

RESULTS

A total of 1299 patients were admitted with an index presentation of AD in the study period. 18.3% overall had recurrent AD, all of whom had confirmation on imaging. Computed tomography was used to calculate BMI in 849 patients, of whom 470 (55.4%) were considered obese (BMI >30). The likelihood of recurrent AD was not significantly different in obese patients compared to their non-obese counterparts (P = 0.2473).

CONCLUSION

While obesity increases the risk of developing AD overall, it does not appear to increase the likelihood of developing recurrent AD. This has implications for risk stratification when considering surgical resection to prevent recurrent AD.

CDH1 gene mutation in early-onset, colorectal signet-ring cell carcinoma

AIM

Colorectal signet-ring cell carcinomas (SRCC) are highly malignant tumours with poor prognosis that disproportionately affect younger patients. There is growing evidence of a unique set of molecular features that separate SRCC from conventional colorectal adenocarcinoma. Identification of these distinct features may have diagnostic and prognostic significance for patients and families. CDH1, which encodes E-cadherin, a cell adhesion protein, is commonly mutated in gastric SRCC and our study aimed to identify whether CDH1 mutation was also a common phenomenon in colorectal SRCC.

METHODS

DNA was extracted from formalin-fixed paraffin embedded tumour tissue, the CDH1 gene was analysed by next generation sequencing and the pathogenicity of mutations assessed in silico. Sections cut from the same blocks were immunostained to identify the presence of the E-cadherin protein.

RESULTS

We found 8 CDH1 mutations that meet our inclusion criteria in seven of 11 samples. Of these, five (from four patients), were likely to be germline mutations. E-cadherin staining was absent or markedly reduced in all of the seven samples with CDH1 mutation.

CONCLUSION

Our finding of CDH1 mutations in a proportion of signet-ring cell carcinomas and associated reduction in E-cadherin in these tumours supports previous findings of a role for mutation of this gene in the development of this disease. In addition, the finding of likely germline mutations suggests that a subset of these tumours may be familial. Loss of E-cadherin staining in the absence of CDH1 mutations however also suggests a role for environmental factors in a subset of these tumours.

A Disclosure Form for Work Submitted to Medical Journals-A Proposal From the International Committee of Medical Journal Editors

Editorial message

SPAR - a randomised, placebo-controlled phase II trial of simvastatin in addition to standard chemotherapy and radiation in preoperative treatment for rectal cancer: an AGITG clinical trial

BACKGROUND

Retrospective studies show improved outcomes in colorectal cancer patients if taking statins, including overall survival, pathological response of rectal cancer to preoperative chemoradiotherapy (pCRT), and reduced acute and late toxicities of pelvic radiation. Major tumour regression following pCRT has strong prognostic significance and can be assessed in vivo using MRI-based tumour regression grading (mrTRG) or after surgery using pathological TRG (pathTRG).

METHODS

A double-blind phase 2 trial will randomise 222 patients planned to receive long-course fluoropyrimidine-based pCRT for rectal adenocarcinoma at 18+ sites in New Zealand and Australia. Patients will receive simvastatin 40 mg or placebo daily for 90 days starting 1 week prior to standard pCRT. Pelvic MRI 6 weeks after pCRT will assess mrTRG grading prior to surgery. The primary objective is rates of favourable (grades 1-2) mrTRG following pCRT with simvastatin compared to placebo, considering mrTRG in 4 ordered categories (1, 2, 3, 4-5). Secondary objectives include comparison of: rates of favourable pathTRG in resected tumours; incidence of toxicity; compliance with intended pCRT and trial medication; proportion of patients undergoing surgical resection; cancer outcomes and pathological scores for radiation colitis. Tertiary objectives include: association between mrTRG and pathTRG grouping; inter-observer agreement on mrTRG scoring and pathTRG scoring; studies of T-cell infiltrates in diagnostic biopsies and irradiated resected normal and malignant tissue; and the effect of simvastatin on markers of systemic inflammation (modified Glasgow prognostic score and the neutrophil-lymphocyte ratio). Trial recruitment commenced April 2018.

DISCUSSION

When completed this study will be able to observe meaningful differences in measurable tumour outcome parameters and/or toxicity from simvastatin. A positive result will require a larger RCT to confirm and validate the merit of statins in the preoperative management of rectal cancer. Such a finding could also lead to studies of statins in conjunction with chemoradiation in a range of other malignancies, as well as further exploration of possible mechanisms of action and interaction of statins with both radiation and chemotherapy. The translational substudies undertaken with this trial will provisionally explore some of these possible mechanisms, and the tissue and data can be made available for further investigations.

TRIAL REGISTRATION

ANZ Clinical Trials Register ACTRN12617001087347. (www.anzctr.org.au, registered 26/7/2017) Protocol Version: 1.1 (June 2017).

Complications After Extended Radical Resections for Locally Advanced and Recurrent Pelvic Malignancies: A 25-Year Experience

BACKGROUND

The oncological role of pelvic exenteration for locally advanced and recurrent pelvic malignancies arising from the anorectum, gynaecological, or urological systems is now well-established. Despite this, the surgical community has been slow to accept pelvic exenteration, undoubtedly due to concerns about high morbidity and mortality rates. This study assessed the general major complications and predictors of morbidity following extended radical resections for locally advanced and recurrent pelvic malignancies.

METHODS

Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were major complications (Clavien-Dindo 3 or above) and predictors for morbidity.

RESULTS

A total of 646 consecutive patients required extended surgery for local advanced pelvic malignancies. The median age was 63 (range 19-89) years, and the majority were female (371; 57.4%). One or more major complications were observed in 106 patients (16.4%). The most common major complications were intra-abdominal collection (43.7%; n = 59/135) and wound infection (14.1%; n = 19/135). The overall inpatient mortality rate was 0.46% (n = 3/646). Independent predictors for major morbidity following surgery for locally advanced or recurrent pelvic malignancies were squamous cell carcinoma of anus, sacrectomy, and blood transfusion requirement.

CONCLUSIONS

This series adds increasing evidence that good outcomes can be achieved for extended radical resections in locally advanced and recurrent pelvic malignancies. A coordinated approach in specialist centres for beyond TME surgery demonstrates that this is a safe and feasible procedure, offering low major complication rates.

Detection of the Bacteroides fragilis toxin gene in sheep with and without small intestinal adenocarcinoma

Aims: To determine if presence of the Bacteroides fragilis toxin (bft) gene, a molecular marker of colonic carriage of entertoxigenic Bacteroides fragilis (ETBF) in humans, was associated with a finding of small intestinal adenocarcinomas (SIA) in sheep in New Zealand. Methods: Samples of jejunal tissue were collected from the site of tumours and from grossly normal adjacent tissue in 20 sheep, in different consignments, diagnosed with SIA based on gross examination of viscera following slaughter. Two jejunal samples were also collected from a control sheep in the same consignment that had no gross evidence of SIA. A PCR assay was used to detect the presence of the bft gene in the samples. Results: Of the sheep with SIA, the bft gene was amplified from one or both samples from 7/20 (35%) sheep, and in sheep that had no gross evidence of SIA the bft gene was amplified from at least one sample in 11/20 (55%) sheep (RR 0.61; 95% CI = 0.30-1.25; p = 0.34). Of 11 positive samples analysed, ETBF subtype bft-1 was detected in one, bft-2 was detected in 10, and none were bft-3. Conclusions and Clinical Relevance: There was a high prevalence of detection of the bft gene in both SIA-affected and non-affected sheep, but there was no apparent association between carriage of ETBF, evidenced by detection of the bft gene, and the presence of SIA. ETBF are increasingly implicated in the aetiology of human colorectal cancer, raising the possibility that sheep may provide a zoonotic reservoir of this potentially carcinogenic bacterium. Abbreviation: Bft: Bacteroides fragilis toxin; ETBF: Enterotoxigenic Bacteroides fragilis; SIA: Small intestinal adenocarcinoma.

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

BACKGROUND

Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers.

METHODS

Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure.

RESULTS

Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease.

CONCLUSION

This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

Prevalence of frailty in a tertiary hospital: A point prevalence observational study

INTRODUCTION

Frailty is an important concept in modern healthcare due to its association with adverse outcomes. Its prevalence varies in the literature and there is a paucity of literature looking at the prevalence of frailty in an inpatient setting. Its significance lies on its impact on resource utilisation and costs.

AIM

To determine the prevalence of frailty in the adult population in a tertiary New Zealand hospital.

METHODS

Eligible patients aged 18 years and over were invited to participate, and frailty assessment was performed using the Reported Edmonton Frail Scale. A score of 8 or more was considered frail. Factors associated with frailty were assessed.

RESULTS

Of 640 occupied inpatient beds, 420 patients were assessed. 220 patients were excluded, of which 89 were absent from their bed-space, 73 declined and 41 were critically unwell. The overall prevalence of frailty across assessed patients was 48.8%. The prevalence of frailty increased significantly with age; patients aged 85 and over were significantly more likely to be frail compared to those aged under 65 (OR 6.25, 95% CI 3.17-12.7). Maori patients were significantly more likely to be frail (OR 4.0, 95% CI 1.45-11.9). When compared to those patients admitted to a medical specialty, patients admitted to surgical specialty were less likely to be frail (OR 0.52 95% CI 0.31-0.86) and those admitted for rehabilitation were more likely to be frail (OR 1.86 95% CI 1.03-3.41). Frail patients were more likely to come from a rest home (OR 2.81, 95% CI 1.38-6.14) or hospital level care (OR 9.62, 95% CI 2.68-61.6).

CONCLUSION

Frailty is highly prevalent in the hospital setting with 48.8% of all inpatients classified as frail. This high number of frail patients has significant resource implications and an increased understanding of the burden of frailty in this population may aid targeting of interventions towards this vulnerable population.

Clinical implications of the genetics of sporadic colorectal cancer

Colorectal cancer (CRC) is common and at least 80% of cases are sporadic, without any significant family history. Prognostication and treatment have been relatively empirical for what has become increasingly identified as a genetically heterogeneous disease. There are three main genetic pathways in sporadic CRC: the chromosomal instability pathway, the microsatellite instability pathway and the CpG island methylator phenotype pathway. There is significant overlap between these complex molecular pathways and this limits the clinical application of CRC genetics. Recent Australian and New Zealand guidelines recommend routine testing of mismatch repair (MMR) status for new cases of CRC and selective KRAS and BRAF testing on the basis of diagnostic, prognostic and therapeutic implications. It is important that all clinicians treating CRC have an understanding of the importance of and basis for identifying key genetic features of CRC. It is likely that in the future better molecular characterization such as that allowed by the consensus molecular subtype classification will allow improved prognostication and targeted therapy in order to deliver more personalized treatment for CRC.

Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer

BACKGROUND

Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer.

METHODS

This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis.

RESULTS

A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively.

CONCLUSION

There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.

Frailty in surgical patients

OBJECTIVE

To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.

BACKGROUND

Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.

METHODS

Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.

RESULTS

Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.

CONCLUSION

Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.

Frailty in surgical patients

OBJECTIVE

To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.

BACKGROUND

Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.

METHODS

Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.

RESULTS

Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.

CONCLUSION

Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival

BACKGROUND

Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC.

METHODS

A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival.

RESULTS

Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01).

CONCLUSIONS

OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

Impact of restenting for recurrent colonic obstruction due to tumour ingrowth

Background

Endoscopic stenting is used to palliate malignant large bowel obstruction. A proportion of patients will develop recurrent obstruction due to tumour ingrowth and require reintervention. This study aimed to assess the outcome (clinical success and complication rates) of endoscopic reintervention compared with surgical intervention in patients with stent obstruction due to tumour ingrowth.

Methods

This was an observational study using data from a database of patients who underwent palliative colonic stenting between January 1998 and March 2017 at Christchurch Public Hospital.

Results

A total of 190 patients underwent colonic stent insertion, for palliation in 182 cases. Reintervention was performed in 55 (30·2 per cent). Thirty-one patients (17·0 per cent) developed obstruction within the stent at a median of 4·6 (i.q.r. 2·3-7·7) months after the procedure. Of these, 21 had endoscopic restenting and ten underwent surgery. Restenting had technical and clinical success rates of 100 per cent, and involved a significantly shorter length of stay compared with surgery (median 2 (i.q.r. 1-4) versus 11 (6-19) days respectively; P = 0·006). Seven of the 21 patients in the restented group underwent a third palliative intervention. The overall stoma rate in the restented group was significantly lower than that in the surgical group (4 of 21 versus 10 of 10; P < 0·001). There was no difference in complications or survival between the two groups.

Conclusion

Among palliative patients who develop malignant stent obstruction, endoscopic restenting had a high chance of technical success. It resulted in a shorter hospital stay and lower stoma rate than those seen after surgery.