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0000-0002-5602-6045
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Publisher: Wiley
Date: 23-10-2023
DOI: 10.1111/ANS.18750
Publisher: Wiley
Date: 12-02-2014
DOI: 10.1111/CODI.12487
Abstract: The decision to create a stoma after anterior resection has significant consequences. Decisions under uncertainty are made with a variety of cognitive tools, or heuristics. Past experience has been shown to be a powerful heuristic in other domains. Our aim was to identify whether the misfortune of recent anastomotic leakage or surgeon propensity to take everyday risks would affect their decision to defunction a range of anastomoses. Questionnaires were sent to members of the Colorectal Surgical Society of Australia and New Zealand. Participants were asked for demographic information, questions regarding risk-taking propensity, when their last anastomotic leakage occurred and whether they would defunction a range of hypothetical rectal anastomoses grouped according to height, American Society of Anesthesiologists grade and use of preoperative radiotherapy. Scores were derived for hypothetical patient likelihood of having a stoma created and in idual surgeon propensity for stoma formation. Hazard regression analysis was used to assess demographic predictors of stoma formation. In total, 110 (75.3%) of 146 surveyed surgeons replied 72 (65.5%) reported anastomotic leakage within the last 12 months. Surgeons' propensity for risk-taking was comparable (24.6 vs 27.53, 95% confidence interval, Mann-Whitney-U) to previously studied participants in economic models. Surgeon age (< 50 years) and lower propensity for risk-taking were demonstrated to be independent predictors of stoma formation on regression analysis. Although the decision to create a stoma after anterior resection may be made in the belief that its foundation derives from rational thought, it appears that other unrecognized operator factors such as age and risk-taking exert an effect.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2001
DOI: 10.1007/BF02234591
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-1995
DOI: 10.1007/BF02052448
Publisher: Wiley
Date: 26-07-2023
DOI: 10.1111/ANS.18635
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2017
DOI: 10.1038/AJG.2016.545
Publisher: Springer Science and Business Media LLC
Date: 06-2003
DOI: 10.1007/S00192-002-1025-0
Abstract: It has been suggested that, apart from obstetric trauma, chronic straining at stool may also result in pudendal nerve damage, contributing to the etiology of genuine stress incontinence (GSI). The benign joint hypermobility syndrome (BJHS) has been associated with rectal as well as uterovaginal prolapse, suggesting that connective tissue abnormalities may also be implicated. This study was undertaken in order to further investigate whether - and if so, why - an association may exist between symptoms of obstructive defecation, lifetime constipation, chronic heavy lifting and lower urinary tract (LUT) dysfunction. Cases were female patients referred for urodynamic assessment with symptoms of LUT dysfunction. Controls were age-, sex- and postcode-matched community controls. Both cases and controls were assessed using a detailed questionnaire that also asked about symptoms of BJHS. Cases were also ided into their urodynamic classification of LUT dysfunction. All symptoms of obstructive defecation (52.3% vs 33.6%, P=0.00003), as well as chronic straining at stool (38.6% vs 23.4%, P=0.0005), were significantly more common in women with LUT dysfunction than in community controls. BJHS, chronic heavy lifting and a history of uterovaginal prolapse were significantly associated with patients with LUT and obstructive defecation compared to those with LUT dysfunction alone. Overall, symptoms of obstructed defecation were not more prevalent in any one urodynamic diagnostic group than in others. However, childhood constipation and current constipation were significantly more prevalent in women with voiding dysfunction than in those with other urodynamic diagnoses (16.7% vs 5.5%, P = 0.0030 and 13.0% vs 5.7%, P = 0.017). We concluded that women with LUT dysfunction are more likely to have symptoms of obstructive defecation than are community controls. Connective tissue disorders such as BJHS may be an important factor in this association.
Publisher: Springer Science and Business Media LLC
Date: 05-02-2015
DOI: 10.1245/S10434-015-4391-9
Abstract: The aim of this systematic review and meta-analysis was to compare the role of FDG-positron emission tomography (PET) or PET/computed tomography (CT) with conventional imaging in the detection of primary and nodal disease in anal cancer, and to assess the impact of PET or PET/CT on the management of anal cancer. A systematic review of the literature was performed. Eligible studies included those comparing PET or PET/CT with conventional imaging in the staging of histologically confirmed anal squamous cell carcinoma (SCC), or studies that performed PET or PET/CT imaging to assess response following treatment. Twelve studies met the inclusion criteria. For the detection of primary disease, CT and PET had a sensitivity of 60 % (95 % confidence interval [CI] 45.5-75.2) and 99 % (95 % CI 96-100), respectively. Compared with conventional imaging, PET upstaged 15 % (95 % CI 10-21) and downstaged 15 % (95 % CI 10-20) of nodal disease. This led to a change in nodal staging in 28 % of patients (95 % CI 18-38). When only studies performing contemporary PET/CT were considered, the rate of nodal upstaging was 21 % (95 % CI 13-30) and the TNM stage was altered in 41 % of patients. Following chemoradiotherapy, 78 % (95 % CI 65-88) of patients had a complete response on PET. Compared with conventional imaging, PET or PET/CT alters the nodal status in a sufficient number of cases to justify its routine use in the staging of patients with anal SCC.
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1016/J.JCLINEPI.2009.04.005
Abstract: To compare the results of meta-analysis of nonrandomized comparative studies (NRCSs) of a surgical procedure with that of randomized controlled trials (RCTs), and to assess the effect of design and conduct issues in NRCSs on measured outcomes. Two meta-analyses of RCTs and NRCSs (2,512 and 6,438 procedures, respectively) of laparoscopic resection for colorectal cancer were performed according to accepted protocols, and 13 outcomes common between them were compared. Odds ratios (ORs) and 95% confidence intervals (CI) for dichotomous outcomes were assessed for the degree of overlap. Continuous outcomes were compared using cumulative weighted ratios (CWRs) and percentages for which a mean and standard deviation (SD) were calculated. The effects of design and conduct issues in the meta-analysis of NRCSs on measured morbidity rates were assessed using subgroup analysis. The ORs of the three dichotomous outcomes overlapped widely. For the 10 continuous variables, the mean difference (SD) in the results of the two meta-analyses was only 5.6% (4.9%). Fulfillment of certain quality and conduct issues in the NRCSs determined the statistical homogeneity of the results of meta-analysis and their comparability with the "gold standard." Meta-analysis of well-designed NRCSs of surgical procedures is probably as accurate as that of RCTs.
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.BJPS.2006.01.050
Abstract: The use of the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap in pelvic reconstruction is well documented. It can be used to fill large defects after pelvic exenteration, reconstruct the vagina and provide skin coverage in perineal reconstruction. This study examines an alternate prepelvic pathway for the flap to enhance its versatility and reliability. A female patient with recurrent squamous cell carcinoma in the pelvis, who underwent radical pelvic exenteration and a successful VRAM flap reconstruction with a prepelvic tunnel. The patient experienced a small area of epithelial tip necrosis over the sacral promontory from shear forces. This healed with dressings within two weeks. There were no major flap complications and the patient had good flap integrity at one-year follow-up. The prepelvic pathway for the VRAM flap is advantageous to the conventional transpelvic course in perineal reconstruction. The more direct, shorter path to the defect allows for a more reliable skin paddle design without the need for de-epithelialisation. A greater area of skin paddle is available and creates a more versatile flap with no tension on the pedicle. This is especially in cases where a skin paddle is needed for vaginal reconstruction or when pelvic organs such as bladder and uterus are left in situ. These advantages may result in less flap complications.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2009
Publisher: Springer Science and Business Media LLC
Date: 03-01-2014
DOI: 10.1007/S00268-013-2441-7
Abstract: Previous studies have quantitatively assessed Enhanced Recovery After Surgery (ERAS) guideline implementation and compliance, and identified the existence of compliance issues with the programs. This is the first study to qualitatively assess the reasons behind compliance issues in ERAS programs. The aim of this study was to elicit barriers to implementation and functioning of the ERAS program at Royal Prince Alfred Hospital. A series of interviews were carried out with key stakeholders in order to explore barriers preventing effective functioning of the program 1 year after implementation. Interview transcripts were analysed. Data analysis involved a grounded theory methodology. Analysis of the data identified four key themed areas of practice that presented barriers: patient-related factors, staff-related factors, practice-related issues, and resources. These overarching themes were generated from subcategories that were linked to generate theory. For the ERAS program to be implemented successfully with high levels of element compliance, the four key areas need to be addressed. As barriers to ongoing effective care become apparent, these should be managed in order to optimize the synergistic effects of this multimodal program of patient care.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2008
Publisher: Oxford University Press (OUP)
Date: 24-11-2009
DOI: 10.1002/BJS.6785
Abstract: A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented. A total of 592 eligible patients were entered and studied from 1998 to 2005. Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70·3(11·0) years). Forty-three laparoscopic operations (14·6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0·002), owing primarily to a lower rate in patients aged 70 years or more (P = 0·002). Fewer patients in the laparoscopic group experienced any complication (P = 0·035), especially patients aged 70 years or above (P = 0·019). Treatment choices for colonic cancer depend principally upon disease-free survival however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection. Registration number: NCT00202111 (www.clinicaltrials.gov).
Publisher: Elsevier BV
Date: 03-1992
DOI: 10.1016/0002-9610(92)90016-K
Abstract: Intraoperative ultrasonography is now established as the most accurate technique for detecting and localizing hepatic tumors, be they primary or metastatic. A major problem is the accurate placement of any lesions found by intraoperative ultrasound and, hence, the correlation of the lesions found by ultrasound to the current classification of hepatic segments and to lesions seen by other imaging techniques. This paper outlines an objective and reproducible method of mapping hepatic lesions into territories defined solely by the major hepatic veins and their tributaries. It is a simple technique that can be readily used by any surgeon, which accurately determines the presence, number, size, and site of hepatic metastases.
Publisher: Elsevier BV
Date: 08-2013
Publisher: Oxford University Press (OUP)
Date: 25-07-2008
DOI: 10.1002/BJS.6303
Abstract: Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear. A systematic review of all randomized controlled trials evaluating the effectiveness of biofeedback in adults with PFD was carried out. All online databases from 1950 to 2007 were searched. This was supplemented by hand searching references of retrieved articles. Seven trials fulfilled the inclusion criteria. Three compared biofeedback with non-biofeedback treatments and four compared different biofeedback modalities. Electromyography feedback was most widely utilized. The trials were heterogeneous with varied inclusion criteria, treatment protocols and definitions of success. Most had methodological limitations. Quality of life and psychological morbidity were assessed rarely. Meta-analysis of the studies involving any form of biofeedback compared with any other treatment suggested that biofeedback conferred a sixfold increase in the odds of treatment success (odds ratio 5·861 (95 per cent confidence interval 2·175 to 15·794) random-effects model). Although biofeedback is the recommended treatment for PFD, high-quality evidence of effectiveness is lacking. Meta-analysis of the available evidence suggests that biofeedback is the best option, but well designed trials that take into account quality of life and psychological morbidity are needed.
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.INJURY.2007.05.004
Abstract: Patient satisfaction is an intuitively important outcome measure and has been previously linked to general health status. Previous research on patient satisfaction after injury has concentrated on satisfaction with medical care. This study aims to explore possible predictors of patient satisfaction with outcome following major trauma. A cross-sectional survey involving consecutive adult patients involved in major accidental trauma from a major metropolitan trauma centre, over a 5-year period, was performed between 1 and 6 years post-injury. The outcome used was patient satisfaction with progress since the injury. Multiple logistic regression was used to develop a model of significant predictors of patient satisfaction. The survey was mailed to 728 eligible patients, 56 were excluded due to death or inability to complete the survey, 93 refused to participate and 90 were not contactable. One hundred and thirty-four patients did not respond and 355 completed surveys were returned. Patient dissatisfaction was found to be significantly associated with unemployment at the time of follow up (OR, 2.38 95% CI, 1.38-4.08 p=0.004), having one or more chronic illnesses at the time of injury (OR, 2.57 95% CI, 1.45-4.55 p=0.001), being involved in a motor vehicle accident (OR, 1.83 95% CI, 1.02-3.30 p=0.04) and having an unsettled compensation claim (OR, 5.19 95% CI, 2.80-9.65 p<0.0001). Patient satisfaction was not significantly associated with any measure of injury severity. Having an unsettled compensation claim after major trauma is the strongest predictor of patient dissatisfaction following major trauma, allowing for other factors.
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1016/J.JCLINEPI.2007.04.005
Abstract: To determine whether including the study questionnaire with a letter of invitation improves the response rate in a telephone-based survey. This randomized controlled trial was part of a larger study to assess patient preferences for novel and controversial treatments for inflammatory bowel disease at Royal Prince Alfred Hospital, a tertiary referral teaching hospital in Sydney, Australia. Of 270 eligible patients, 124 (46%) were randomized to receive the questionnaire plus invitation whereas 146 (54%) were in the control group receiving a letter of invitation only. The consent rate was 26% for those receiving the questionnaire and 36% for the control group. The odds ratio for consent to participate among those sent the questionnaire to those not sent the questionnaire was 0.63 (95% CI=0.37-1.07). This study found that the advance mailing of a questionnaire to potential participants in a telephone survey reduced the likelihood of their participation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2015
DOI: 10.1016/J.IJSU.2015.10.004
Abstract: Strong evidence supports the use of neoadjuvant radiotherapy in rectal cancer to improve local control. This randomised controlled trial aimed to determine the effect of clinical and non-clinical factors on decision making by colorectal surgeons in patients with rectal cancer. Two surveys comprising vignettes of alternating short (4) and long (12) cues identified previously as important in rectal cancer, were randomly assigned to all members of the CSSANZ. Respondents chose from three possible treatments: long course chemoradiotherapy (LC), short course radiotherapy (SC) or surgery alone to investigate the effects on surgeon decision and confidence in decisions. Choice data were analysed using multinomial logistic regression models. 106 of 165 (64%) surgeons responded. LC was the preferred treatment choice in 73% of vignettes. Surgeons were more likely to recommend LC over SC (OR 1.79) or surgery alone (OR 1.99) when presented with the shorter, four-cue scenarios. There was no significant difference in confidence in decisions made when surgeons were presented with long cue vignettes (P = 0.57). Significant effects on the choice between LC, SC and surgery alone were tumour stage (P < 0.001), nodal status (P < 0.001), tumour position in the rectum (P < 0.001) and the circumferential location of the tumour (P < 0.001). A T4 tumour was the factor most likely associated with a recommendation against surgery alone (OR 335.96) or SC (OR 61.73). This study shows that clinical factors exert the greatest influence on surgeon decision making, which follows a "fast and frugal" heuristic decision making model.
Publisher: Springer Science and Business Media LLC
Date: 21-03-2016
DOI: 10.1007/S10151-016-1456-0
Abstract: This article describes a novel technique for en bloc resection of locally recurrent rectal cancer that invades the high sacral bone (above S3). The involved segment of the sacrum is mobilised with osteotomes during an initial posterior approach before an anterior abdominal phase where the segment of sacral bone is delivered with the specimen. This allows en bloc resection of the involved sacrum while preserving uninvolved distal and contralateral sacral bone and nerve roots. The goal is to obtain a clear bony margin and offer a chance of cure while improving functional outcomes by maintaining pelvic stability and minimising neurological deficit.
Publisher: Elsevier BV
Date: 03-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-1995
DOI: 10.1007/BF02049147
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2010
Publisher: Wiley
Date: 15-11-2021
DOI: 10.1111/CODI.15402
Abstract: This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan–Meier plots. Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance ( P 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33% P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively ( P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts ( P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration ( P = 0.0546). This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
Publisher: BMJ
Date: 2006
DOI: 10.1111/J.1525-1438.2006.00424.X
Abstract: This study investigates the acceptability and feasibility of conducting randomized controlled trials (RCTs) in gynecological oncology by ascertaining the views of the Australian Society of Gynaecologic Oncologists (ASGO) about important clinical questions in this field, current treatment preferences, and willingness to participate in trials to address these questions. Members of ASGO received a mailed survey. Thirty-one gyneoncologists participated in this study (79% response fraction). There was considerable support for an RCT (81% 95% confidence interval [CI], 63-93%) to compare sentinel node biopsy with total groin dissection for women with vulval cancer. This clinical question was also rated as "extremely" or "very" important by 91% (95% CI, 74-98%) of respondents, who also indicated high levels of in idual equipoise. Another priority for research involved the use of second-line chemotherapy for women who have rising CA125 titers. This clinical question was rated as extremely or very important by 71% (95% CI, 52-86%), exhibited high levels of in idual equipoise, with 74% (95% CI, 55-88%) of respondents willing to participate in an RCT to address this issue. The conduct of surveys of representative groups of clinicians provides useful empirical data to focus clinical research efforts where they are most likely to be successful based on equipoise, feasibility, and clinical interest.
Publisher: Rockefeller University Press
Date: 03-07-2006
DOI: 10.1084/JEM.20060468
Abstract: Abnormalities in CD4+CD25+Foxp3+ regulatory T (T reg) cells have been implicated in susceptibility to allergic, autoimmune, and immunoinflammatory conditions. However, phenotypic and functional assessment of human T reg cells has been h ered by difficulty in distinguishing between CD25-expressing activated and regulatory T cells. Here, we show that expression of CD127, the α chain of the interleukin-7 receptor, allows an unambiguous flow cytometry–based distinction to be made between CD127lo T reg cells and CD127hi conventional T cells within the CD25+CD45RO+RA− effector/memory and CD45RA+RO− naive compartments in peripheral blood and lymph node. In healthy volunteers, peripheral blood CD25+CD127lo cells comprised 6.35 ± 0.26% of CD4+ T cells, of which 2.05 ± 0.14% expressed the naive subset marker CD45RA. Expression of FoxP3 protein and the CD127lo phenotype were highly correlated within the CD4+CD25+ population. Moreover, both effector/memory and naive CD25+CD127lo cells manifested suppressive activity in vitro, whereas CD25+CD127hi cells did not. Cell surface expression of CD127 therefore allows accurate estimation of T reg cell numbers and isolation of pure populations for in vitro studies and should contribute to our understanding of regulatory abnormalities in immunopathic diseases.
Publisher: Wiley
Date: 10-2008
Publisher: Hindawi Limited
Date: 09-02-2015
DOI: 10.1111/ECC.12288
Abstract: Clinicians are less likely to recommend adjuvant chemotherapy for older adults based on their age alone. This study aimed to develop a mortality risk model to assist treatment decision making by identifying patients who are unlikely to live to benefit from chemotherapy. All lymph node-positive colon cancer patients ≥65 years who received surgery in New South Wales, Australia in 2007/2008 were identified using a linked population-based dataset (n = 1550). A model predicting 1-year all-cause mortality was built using multilevel logistic regression. Risk scores derived from model factors were summed for each patient. One-year mortality was 11.5%. The risk model consisted of 14 factors, including comorbidities, hospital admission factors and other markers of frailty or health status. People with a total score of 0, 1 or 2 were considered at low risk (predicted 1-year mortality of 2.9%), those scoring 3 to 8 at medium risk (7.4% mortality) and those scoring 9 or above at high risk (24.7% mortality). The model had good discrimination (area under the receiver operating characteristic curve = 0.788, 95% confidence interval: 0.752-0.825) and calibration (P = 0.46). The risk model accurately predicts mortality for this cohort and could be useful in shifting the emphasis in chemotherapy decision making from chronological age to the identification of those of any age who will benefit.
Publisher: Oxford University Press (OUP)
Date: 18-04-2005
DOI: 10.1002/BJS.4917
Abstract: Establishing trust between a patient and his or her surgeon is of paramount importance. The aim of this study was to assess the relative importance of the ‘attributes of trust’ between surgeon and patient with colorectal cancer. A discrete-choice questionnaire was conducted with 60 men and 43 women who had completed primary treatment for colorectal cancer in two teaching hospitals in Sydney, Australia. Forty-seven of the 103 patients based their choice of surgical management on a single attribute and the remainder were willing to trade between different attributes. In order of importance, patients based their choice of surgical management on specialty training (β coefficient = 0·83), surgeon's communication (β = 0·82), type of hospital (β = 0·72) and who decides treatment (β = 0·01). Patients who were vigilant in their decision-making style and those who did not have tertiary education were more likely to change their preferences in the repeat interview. Clinicians may have a better chance of meeting a patient's expectations about the process of care if they assess the patient's desire for knowledge and give those who do not have tertiary education more time to assimilate information about their treatment.
Publisher: Elsevier BV
Date: 07-2023
Publisher: Wiley
Date: 05-2002
DOI: 10.1046/J.1463-1318.2002.00330.X
Abstract: BACKGROUND: Pre-operative combined modality therapy (CMT) is used in locally advanced rectal cancer. Its use affects the clinicopathological staging based on the resected specimen. Assessment of the tumour response in the resected specimen may provide prognostic information. This study was undertaken to determine the histological response to pre-operative chemoradiation and to assess the interobserver reliability of a newly developed tumour response grading system for rectal cancer. METHODS: Pre-operative biopsy specimens and the resected specimens of 21 patients with low rectal cancer were assessed. The patients underwent pre-operative CMT consisting of radiotherapy (45 Gy) with 5-FU either as a continuous infusion or as a bolus intravenous infusion with leucovorin. After four to six weeks tumour response was assessed by comparing pre-operative transrectal ultrasound (TRUS) findings (uT1-4, uN0-1) with postoperative histopathological assessment (pT1-4, pN0-1) using UICC TNM characteristics. Tumour response was defined as a decrease in T status. The histological response to CMT was based on the tumour regression grade (TRG) and ranged from fibrosis extending through the rectal wall with no residual cancer (TRG 1), to no evidence of tumour response (TRG 5). Inter-observer reliability was assessed using weighted and unweighted kappa statistics. RESULTS: Local downstaging was demonstrated in 11/21 (52%) of patients. Three of 21 patients had a TRG 1 response. Thirteen of 21 (62%) patients had TRG 1-3 responses to CMT. There was no significant correlation between local downstaging and TRG. The interobserver correlation coefficient for assessment of TRG was 0.88 (unweighted kappa). CONCLUSIONS: Local downstaging by pre-operative CMT can be demonstrated if pre-operative TRUS staging is compared to standard pathology staging in patients with rectal cancer. Local downstaging is not directly related to histologic response as assessed by TRG. Inter-observer reporting of tumour regression grade (TRG) is reliable.
Publisher: Wiley
Date: 2008
Publisher: Oxford University Press (OUP)
Date: 2002
DOI: 10.1046/J.0007-1323.2001.01957.X
Abstract: The objectives of this study were to compare both subjective clinical outcomes and the objective stress response of laparoscopic and open abdominal rectopexy in patients with full-thickness rectal prolapse. Abdominal rectopexy for patients with rectal prolapse is well suited for a laparoscopic approach as no resection or anastomosis is necessary. Forty patients with a full-thickness rectal prolapse were randomized before operation to a laparoscopic group and an open group. They agreed to conform to a clinical pathway (CP) of liquid diet (CP1) and full mobility (CP2) on day 1, solid diet (CP3) on day 2 and discharge (CP4) before day 5. Their compliance was monitored by an assessor blinded to the operative group, who also rated pain and mobility. Patient-controlled morphine use was documented. Neuroendocrine and immune stress response and respiratory function were measured. Some 75 per cent of all clinical pathway objectives of early recovery were achieved in the laparoscopic group compared with 37 per cent in the open group (P & 0·01). Significant differences in favour of laparoscopy were noted with regard to narcotic requirements, and pain and mobility scores. Differences in objective measures of stress response favouring laparoscopy were found for urinary catecholamines, interleukin 6, serum cortisol and C-reactive protein. No differences were noted in respiratory function but significant respiratory morbidity was greater in the open group (P & 0·05). None of the measured outcomes, subjective or objective, favoured the open group apart from operating time, which was significantly shorter (153 versus 102 min P & 0·01). This study has demonstrated significant subjective and objective differences in favour of a laparoscopic technique for abdominal rectopexy. The advantages were all short term but no evidence of any adverse effect on longer-term outcomes was observed.
Publisher: Wiley
Date: 03-1999
DOI: 10.1046/J.1440-1622.1999.01522.X
Abstract: The surgical literature perceives that the elderly cohort of Crohn's patients may have increased risk with surgery. A retrospective review and prospective database analysis of all patients with histologically proven Crohn' s disease who had a laparotomy at a single Sydney teaching hospital were performed. The last laparotomy of each patient was included in the analysis for morbidity and mortality to assess whether an older cohort was at an increased risk. A total of 156 patients had 298 laparotomies for histopathologically proven Crohn's disease. The frequency distribution of age at last laparotomy was bimodal, and the statistically determined cut-off age between younger and older cohorts was 55 years. Thirty-three patients were older than 55 years. There was no difference in duration of symptoms before first diagnosis (older, 17 months vs younger, 25 months), previous number of Crohn's operations (42.4 vs 39.8%), or duration of known Crohn's disease. Isolated large bowel disease was more common in the elderly cohort (42.4 vs 18.7%, chi2 = 8.09, P < 0.01). Small bowel and ileocaecal resections were more common in the younger cohort (72.4 vs 51.6%, chi2 = 5.19, P < 0.025). There was one death in each cohort (overall mortality 1.3%) and anastomotic leak rates (defined as the number of leaks per number of patients with anastomoses), were 4.3% (older) vs 5.3% (younger) despite frank sepsis present in 21.2% of all subjects at the time of surgery. The older group had more cardiac (18.2 vs 0.8%, P < 0.001) and respiratory complications (18.2 vs 2.4% P = 0.0003) and a longer mean but not median postoperative hospital admission. In conclusion, clinical features and presentation are similar in the older and younger Crohn's patients having a laparotomy. However, in the older patient there is a greater likelihood of large bowel disease, ileocaecal resection is done less commonly, there is a higher risk of minor cardiopulmonary postoperative complications, but with similar mortality and anastomotic leak rates to the younger patient.
Publisher: Wiley
Date: 08-2000
DOI: 10.1046/J.1440-1622.2000.01897.X
Abstract: The purpose of the present study was to evaluate the changing role of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period. From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospital: 79% of patients had locoregional disease alone and 21% had distant metastasis. Radiation therapy consisted of irradiation (definitive or palliative) alone to the primary tumour in 9.7% of cases preoperative radiation in 7.3% of cases: preoperative chemoradiation in 7.5% of patients: postoperative radiation in 15.3% of patients: postoperative chemoradiation in 12.31% of patients: treatment of pelvic recurrence in 23.5% of patients and treatment of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated (13.4%). There was an average annual 14% increase in referrals over the accrual period. Recurrent rectal cancer decreased from approximately 30% of referrals during 1982-91 to approximately 10% in 1995-7. The use of postoperative adjuvant radiation reached a peak of 50% in 1993. The use of preoperative radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatment. The median survival time from initial diagnosis was 35 months, with 2- and 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, respectively. The present study illustrates the changing role of radiation therapy in the management of rectal cancer. The increase in referrals over the observation period was due to increased multidisciplinary input into the initial management of these patients, based on reported clinical trials. The steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical results. The sequencing of adjuvant therapy is changing currently, with greater emphasis on preoperative adjuvant treatment. Currently most adjuvant therapy includes chemotherapy.
Publisher: Elsevier BV
Date: 03-2005
DOI: 10.1016/J.SOCSCIMED.2004.07.006
Abstract: In this era of shared doctor-patient decision-making, eliciting and incorporating patients' treatment choices is essential to ensure all patients receive the treatment that is right for them. Clinicians and researchers should fully understand the many factors that influence and guide patients in their preferences for treatment. One of these influences is an in idual's general risk propensity or willingness to take risks, yet there is little in the literature about methods for measuring risk propensity. A systematic review was undertaken to identify instruments that measure risk propensity and to appraise their validity and relevance for a clinical setting. Of 3546 articles, 139 were potentially relevant. From these, 14 instruments were identified. Eight measured risk propensity, whereas six measured personality traits associated with risk propensity. Most instruments demonstrated good internal reliability but their appropriateness for patients, particularly older adults, remains unclear. While no instrument was specific to or tested in a clinical setting, instruments that directly measured risk propensity were considered to be the most useful for clinical populations. The further adaptation and validation of these instruments among older adults are important avenues for future research.
Publisher: Elsevier BV
Date: 08-2000
Publisher: Wiley
Date: 09-10-2015
DOI: 10.1111/CODI.12944
Abstract: The surgical management of locally recurrent rectal cancer (LRRC) has become widely accepted to afford cure and improve quality of life in this subset of patients. Thus far, traditional surgical and oncological markers have been used to highlight the success of surgical intervention. The use of patient-reported outcomes, specifically health-related quality of life (HRQoL), is sparse in these patients. This may be in part due to the lack of well-designed, validated instruments. This study identifies HRQoL issues relevant to patients undergoing surgery for LRRC, with the aim of developing a conceptual framework of HRQoL specific to LRRC to enable measurement of patient-reported outcomes in this cohort of patients. Qualitative focus groups were undertaken at two institutions to identify relevant HRQoL themes. The principles of thematic content analysis were used to analysis data. NViVo10 was used to analyse data. Twenty-one patients participated in six consecutive focus groups. Two patterns of themes emerged related to HRQoL and healthcare service delivery and utilization. Identified themes related to HRQoL included symptoms, sexual function, psychological impact, role and social functioning and future perspective. Under healthcare service and delivery and utilization the subdomain of disease management, treatment expectations and healthcare professionals were identified. This is the first qualitative study undertaken exclusively in patients with LRRC to ascertain relevant HRQoL outcomes. The impact of LRRC on patients is wide-ranging and extends beyond traditional HRQoL outcomes. The study operationalizes the identified outcomes into a conceptual framework, which will provide the basis for the development of a LRRC-specific patient-reported outcome measure.
Publisher: Oxford University Press (OUP)
Date: 27-11-2013
DOI: 10.1002/BJS.9002
Abstract: This study aimed to explore and quantify the selection process to guide the decision on closure type (myocutaneous flap repair (MFR) or primary closure) for people undergoing pelvic exenteration. This was a retrospective analysis of a prospectively maintained database with review of hospital records for verification and capture of missing data. Associations between four risk factors (previous radiotherapy, previous abdominoperineal resection, need for total exenteration, need for sacrectomy) were assessed in idually and collectively as predictors of closure type and wound complications. A total of 203 pelvic exenteration procedures were reviewed (75 primary and 122 recurrent cancers). Thirty-nine patients (19·2 per cent) had MFR and 164 (80·8 per cent) primary closure. Patients who had MFR were significantly more likely to exhibit each risk factor, confirming the selective decision process. MFR had higher rates of complications across all four risk factors, in idually and combined. In the primary closure group, there was a significant correlation between the number of risk factors and the proportion of patients with a complication (r = 0·25, P = 0·008). In contrast, no such relationship was found for the MFR group (r = 0·01, P = 0·973). Among patients who had any complication, the primary closure group had significantly lower rates of any wound dehiscence (15 of 64 versus 17 of 28 P & 0·001) and total infection (16 of 64 versus 14 of 28 P = 0·019) compared with the MFR group. Rates of wound and septic complications after pelvic exenteration were low in patients with fewer than two risk factors who had a primary closure. MFR had significantly higher complication rates, and should be reserved for patients with two or more risk factors or extensive skin involvement.
Publisher: Oxford University Press (OUP)
Date: 08-10-2015
DOI: 10.1002/BJS.9915
Abstract: Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment. Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review. Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage. The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.
Publisher: Wiley
Date: 05-08-2006
Publisher: Elsevier BV
Date: 07-2023
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.EJSO.2011.12.002
Abstract: The aim of this study was to assess possible risk factors for urinary leakage of a newly formed urinary conduit after a partial or total pelvic exenteration. An analysis was conducted from prospectively collected data of patients who underwent a pelvic exenteration with conduit formation for advanced and recurrent pelvic cancer. Of 232 patients undergoing a pelvic exenteration, 74 (32%) had a conduit formed. Of these, 47 (64%) had an ileal conduit compared with 27 (36%) a colonic conduit. Twelve (16%) patients developed a leak, of which nine occurred within the first month. Factors associated with a conduit leak included involvement of R2 surgical margins (43%), the magnitude of the exenteration and a current cardiovascular medical history (27%). Leaks were not found to be associated with either radiotherapy or chemotherapy. The 30-day leak rate for ileal conduits was 17% (8/47) and 4% (1/27) for colonic conduits with enterocutaneous fistula only occurring in the ileal conduit group (2/47). Fistula, drained collections and sepsis occurred in 40% of ileal and 19% of colonic conduits (p < 0.01). Patients with a conduit leak had a longer length of stay (59 versus 23 days, p < 0.001). Urine leaks after conduit formation in association with exenterations are relatively common with a prolonged length of hospital stay. Positive surgical margins and exenterations involving all four quadrants of the pelvis were associated with higher leak rates. There was no evidence of a difference between ileal and colonic conduits and number of leaks. However colonic conduits had less total complications including sepsis, leak and pelvic collections with comparatively no complications of a small bowel fistula.
Publisher: BMJ
Date: 07-2000
DOI: 10.1136/GUT.47.1.43
Abstract: Colorectal cancer has been described in association with hyperplastic polyposis but the mechanism underlying this observation is unknown. The aim of this study was to characterise foci of dysplasia developing in the polyps of subjects with hyperplastic polyposis on the basis of DNA microsatellite status and expression of the DNA mismatch repair proteins hMLH1, hMSH2, and hMSH6. The material was derived from four patients with hyperplastic polyposis and between one and six synchronous colorectal cancers. Normal (four), hyperplastic (13), dysplastic (13), and malignant (11) s les were microdissected and a PCR based approach was used to identify mutations at 10 microsatellite loci, TGFbetaIIR, IGF2R, BAX, MSH3, and MSH6. Microsatellite instability-high (MSI-H) was diagnosed when 40% or more of the microsatellite loci showed mutational bandshifts. Serial sections were stained for hMLH1, hMSH2, and hMSH6. DNA microsatellite instability was found in 1/13 (8%) hyperplastic s les, in 7/13 (54%) dysplastic foci, and in 8/11 (73%) cancers. None of the MSI-low (MSI-L) s les (one hyperplastic, three dysplastic, two cancers) showed loss of hMLH1 expression. All four MSI-H dysplastic foci and six MSI-H cancers showed loss of hMLH1 expression. Loss of hMLH1 in MSI-H but not in MSI-L lesions showing dysplasia or cancer was significant (p<0.001, Fisher's exact test). Loss of hMSH6 occurred in one MSI-H cancer and one MSS focus of dysplasia which also showed loss of hMLH1 staining. Neoplastic changes in hyperplastic polyposis may occur within a hyperplastic polyp. Neoplasia may be driven by DNA instability that is present to a low (MSI-L) or high (MSI-H) degree. MSI-H but not MSI-L dysplastic foci are associated with loss of hMLH1 expression. At least two mutator pathways drive neoplasia in hyperplastic polyposis. The role of the hyperplastic polyp in the histogenesis of sporadic DNA microsatellite unstable colorectal cancer should be examined.
Publisher: Springer Science and Business Media LLC
Date: 04-04-2016
Publisher: Springer Science and Business Media LLC
Date: 11-1996
Abstract: Perianal disease occurs in up to 90% of patients with Crohn's disease [1-4]. Many of these patients have only mild symptoms or are asymptomatic and thus require no intervention. Clinical features are variable and include hypertrophic skin tags, ulceration, perianal abscess and fistulae, anal canal ulcers, fissures, induration and stenosis. Perianal abscess and fistula often occur simultaneously and are usually symptomatic. Symptoms range from pain, discharge, bleeding, to gross faecal incontinence with restriction of lifestyle and sexual activity. There is little uniformity amongst clinicians in the investigation and management of perianal Crohn's disease [5]. This is due, in part, to the variability in both frequency and severity of attacks and to spontaneous remissions and exacerbations of perianal disease. Secondly, assessment of severity of illness and the response to treatment is difficult to objectively quantitative. Improvement in quality of life is the aim of therapy not cure of perianal disease. Investigative modalities for perianal Crohn's are changing due to the limitations of conventional fistulography, CT scanning and clinical evaluation. MRI scanning has been introduced more recently, however, requires an endorectal coil to obtain good anatomical visualisation and has limited availability [6-12]. Endorectal ultrasonography has been shown to detect more abscesses and fistula in Crohn's patients than clinical examination, proctosigmoidoscopy and CT scanning, better delineation of fistulous tracts than fistulography and has the ability to change the clinical management of referring physicians [13-16]. Most fistulae are not explored surgically and therefore the documentation of fistulae in symptomatic Crohn's disease has been limited and are usually classified only as high or low [4]. Park's has pointed out this terminology for cryptoglandular disease is "... an ambiguous one" and hence developed a more precise nomenclature [17]. The objective of this study was to document prospectively by transanorectal ultrasonography fistulae and abscesses in symptomatic perianal Crohn's disease and to classify them according to Park's nomenclature and determine the incidence of these at the time of referral for a new exacerbation of the disease. Anal wall thickness was measured prospectively by ultrasonography as it has been shown to be increased in patients with perianal Crohn's disease and may reflect disease activity [13, 18].
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1016/J.CGH.2007.09.003
Abstract: Computerized tomography colonography (CTC) is a highly accurate test for the detection of colorectal polyps and cancers and has been proposed as a potential alternative to colonoscopy. Bowel cancer screening using fecal occult blood testing (FOBT) and follow-up diagnostic colonoscopy is an effective intervention that currently is being implemented in screening programs internationally. Because of high false-positive rates for FOBT, concerns have been raised about patient uptake and access to colonoscopy services. This study assessed the value of CTC as an alternative to colonoscopy in FOBT-positive in iduals. A systematic review of studies comparing the accuracy of CTC and colonoscopy for the detection of lesions 10 mm or greater and cancers in nonscreening populations was conducted. A modeled economic analysis was undertaken to assess cost per life-year saved. Five eligible studies were identified. Pooled sensitivity and specificity for the detection of lesions 10 mm or greater were 63% (95% confidence interval [CI], 55%-71%) and 95% (95% CI, 94%-97%) for CTC, and 95% (95% CI, 90%-98%) and 99.8% (95% CI, 99.5%-100%) for colonoscopy, respectively (3 studies). Pooled sensitivity and specificity for the detection of cancer were 89% (95% CI, 70%-98%) and 97% (95% CI, 95%-98%) for CTC, and 96% (95% CI, 80%-100%) and 99.7% (95% CI, 99%-100%) for colonoscopy, respectively (3 studies). The base case economic analysis showed that CTC is less effective and more costly than colonoscopy. At a low prevalence of polyps, sensitivity analysis found CTC was less effective and less costly than colonoscopy if CTC was more sensitive than colonoscopy, CTC was more effective, at higher cost. Overall, CTC appears less accurate, less effective, and potentially more costly than colonoscopy in in iduals with a positive FOBT.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2002
DOI: 10.1007/S10350-004-6350-6
Abstract: The aim of this study was to assess the long-term clinical and quality of life outcomes for patients after referral to a four-month treatment program for fecal incontinence based on pelvic floor exercises and biofeedback. Secondary objectives were to document patients' subsequent treatment activities and their perception of the biofeedback training to establish the long-term outcomes and initial predictors for the subset of patients who did not complete the treatment, or who failed to improve during the program and to correlate changes in clinical outcome measures and quality of life over time. Patients were contacted by telephone to determine their perception of progress subsequent to the treatment program, any subsequent treatment or activities relating to their fecal incontinence, and which aspect of the treatment program they believed was most helpful. St. Mark's and Pescatori fecal incontinence scores were also recorded, along with patients' self-assessments of their incontinence severity and quality of life. Eighty-three (69 percent) patients were contacted for interviews at a median of 42 (range, 26-56) months after program completion. At the time of follow-up, patients who completed the program continued to enjoy strongly significant improvements in all outcome measures, with 75 percent perceiving a symptomatic improvement and 83 percent reporting improved quality of life. For many patients, improvement continued subsequent to program completion. Patients whose incontinence scores became worse during treatment still reported improvement in their quality of life and perceived incontinence severity during the same time period many experienced some degree of "catch-up" in their continence scores during the follow-up period. Fourteen patients (17 percent) went on to have surgery for fecal incontinence of these, 6 (7 percent) had a stoma. Twenty (24 percent) regularly took antidiarrheal medication. Thirty program completers (41 percent) were continuing pelvic floor exercises. This study confirms the long-term improvement in fecal incontinence achieved through treatment with biofeedback and pelvic floor exercises. In this study, patients also continued to improve after treatment completion, possibly because of the strong emphasis placed on patients during treatment to continue the pelvic floor exercises on their own. The poor correlation between quality of life and quantitative scores of fecal incontinence suggests that there are important aspects of continence that are not being appropriately recognized.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2013
Publisher: Springer Science and Business Media LLC
Date: 25-03-2009
DOI: 10.1007/S00520-009-0615-5
Abstract: The identification and management of unmet supportive care needs is an essential component of health care for people with cancer. Information about the prevalence of unmet need can inform service planning/redesign. A systematic review of electronic databases was conducted to determine the prevalence of unmet supportive care needs at difference time points of the cancer experience. Of 94 articles or reports identified, 57 quantified the prevalence of unmet need. Prevalence of unmet need, their trends and predictors were highly variable in all domains at all time points. The most frequently reported unmet needs were those in the activities of daily living domain (1-73%), followed by psychological (12-85%), information (6-93%), psychosocial (1-89%) and physical (7-89%). Needs within the spiritual (14-51%), communication (2-57%) and sexuality (33-63%) domains were least frequently investigated. Unmet needs appear to be highest and most varied during treatment, however a greater number of in iduals were likely to express unmet need post-treatment compared to any other time. Tumour-specific unmet needs were difficult to distinguish. Variations in the classification of unmet need, differences in reporting methods and the erse s les from which patients were drawn inhibit comparisons of studies. The ersity of methods used in studies hinders analysis of patterns and predictors of unmet need among people with cancer and precludes generalisation. Well-designed, context-specific, prospective studies, using validated instruments and standard methods of analysis and reporting, are needed to benefit future interventional research to identify how best to address the unmet supportive care needs of people with cancer.
Publisher: Wiley
Date: 03-2006
DOI: 10.1002/HED.20315
Abstract: This study investigated the in idual and collective ("community") equipoise of surgeons and oncologists and their willingness to take part in each of six hypothetical randomized controlled trials in head and neck oncology. A survey was mailed to Australasian head and neck specialists. Among 109 respondents (74% response), the scenario with the highest level of in idual equipoise pertained to the use of adjuvant interferon for patients with high-risk malignant melanoma, with 45% indicating complete uncertainty between treatment approaches. Significant differences in levels of community equipoise were demonstrated between surgeons and oncologists for three of the scenarios. Willingness to participate in randomized controlled trials ranged from 39% to 72%. Increasing strength of treatment preference was associated with unwillingness to participate in randomized controlled trials for two of six scenarios. High levels of equipoise and willingness to participate in clinical research augur well for future randomized controlled trials in head and neck oncology.
Publisher: Wiley
Date: 16-12-2014
DOI: 10.1111/CODI.12399
Abstract: Care coordination is an important aspect of the quality of cancer care but is difficult to evaluate due to the lack of valid and reliable measures. This study was conducted to identify a set of objective measures of colorectal cancer care coordination that could be included in a medical record audit tool. A two-stage Delphi study was conducted to gain consensus among a national panel of experts about the validity of 41 potential indicators of colorectal cancer care coordination that had been identified during a literature review. The expert panel comprised 20 members from the National Health and Medical Research Colorectal Cancer Guidelines Working Party plus representatives from cancer nursing/coordination, general practice and cancer consumers. Consensus was reached on the validity of 15 of 41 potential indicators, including those that focused on practical aspects of communication (legibility, clarity, content and timeliness of hospital discharge letters, documentation of outcomes of multidisciplinary team meetings) and appropriateness (documentation of preoperative consultation with a stoma therapist, discussions and referrals for adjuvant therapy for appropriate patients, and treatment by an experienced colorectal surgeon). There was lack of consensus on the validity of indicators relating to access to and efficiency of services. The study has identified a core set of measures considered to be valid indicators of colorectal cancer care coordination. A medical record audit based on these measures could be used to monitor adequacy of cancer care coordination and will complement subjective measures based on self-reported experiences of patients and carers.
Publisher: Springer Science and Business Media LLC
Date: 30-08-2012
DOI: 10.1007/S00520-012-1575-8
Abstract: Family caregivers of patients with poor prognosis upper gastrointestinal (GI) cancers are at high risk of experiencing psychological distress and carer burden. The early postoperative period is a time of high patient care needs and transition of care, with carers new to the caring role. This study aimed to explore the experiences of family caregivers of people diagnosed with upper GI cancer after surgical intervention to (1) identify their unmet supportive care needs and (2) investigate how family caregivers perceive their role during this time. Family caregivers of newly diagnosed postsurgical upper GI cancer patients were recruited. Semi-structured telephone interviews were conducted at 3 weeks and 3 months post-surgery. Analysis involved a constant comparative approach. S ling was discontinued when information redundancy was achieved. Fifteen family caregivers participated in the first interview and eight agreed to a second interview. Family caregivers reported significant information and support needs. Family caregiver distress was exacerbated by a lack of patient care knowledge. Access to support was limited by caregivers' lack of understanding of the health system. Family caregivers view their role as part of their family responsibility. This study provides new insight into the supportive care needs of family caregivers of upper GI cancer patients and the impact of unmet need on the emotional well-being of family caregivers. These results will inform future supportive care service development and intervention research aimed at reducing unmet supportive care needs and psychological distress of family caregivers of patients with poor prognosis upper GI cancer.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2008
DOI: 10.1007/S10350-008-9365-6
Abstract: Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there is little long-term follow-up and functional outcome data available. Patients who had abdominal surgery for prolapse during a ten-year period were identified and interviewed to ascertain details of prolapse recurrence, constipation, incontinence, cosmesis, and satisfaction. Additional details on recurrences that required surgery and mortality were obtained from chart review and the State Death Registry. Of 321 prolapse operations, laparoscopic rectopexy was performed in 126 patients, open rectopexy in 46, and resection rectopexy in 21 patients. At a median follow-up of five years after laparoscopic rectopexy, there were five (4 percent) confirmed full-thickness recurrences that required surgery. Actuarial recurrence rates of laparoscopic rectopexy were 6.9 percent at five years (95 percent confidence interval, 0.1-13.8 percent) and 10.8 percent at ten years (95 percent confidence interval, 0.9-20.1 percent). Seven patients underwent rubber band ligation for mucosal prolapse and seven required other surgical procedures. There was one recurrence after open rectopexy (2.4 percent) and one after resection rectopexy (4.7 percent), and there was no significant difference between groups. Overall constipation scores were not increased after laparoscopic rectopexy, with no significant difference to open rectopexy or resection rectopexy. This study has demonstrated that laparoscopic rectopexy has reliable long-term results for treating rectal prolapse, including low recurrence rates and no overall change in functional outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2005
DOI: 10.1007/S10350-005-0198-2
Abstract: Biofeedback is an effective treatment for patients with fecal incontinence, yet little is known about how it works or the minimum regime necessary to provide clinical benefit. This study compares the effectiveness of a novel protocol of telephone-assisted biofeedback treatment for patients living in rural and remote areas with the standard face-to-face protocol for patients with fecal incontinence. A new treatment program comprising an initial face-to-face assessment and treatment with transanal manometry and ultrasound biofeedback, followed by three treatments conducted via telephone and a final face-to-face assessment, was developed. Standard treatment involved five face-to-face treatment sessions with manometry and ultrasound. Patients from rural areas were offered the telephone-assisted treatment protocol. Data gathered prospectively included incontinence scores, a quality of life index, anal manometry, and external sphincter isometric and isotonic fatigue times. A total of 239 consecutive patients treated between July 2001 and July 2004 were enrolled. There were no significant differences in demographic details, past history, or pretreatment measures of the two groups. Forty-six of 55 patients (84 percent) treated with the telephone protocol and 129 of 184 (70 percent) treated by the standard technique completed treatment. There were substantial, significant improvements after treatment, including 54 percent mean improvement in patient's own rating of their incontinence in both groups a mean decrease of 3.1 and 3.2 on the St. Mark's incontinence score (from 7.9 to 4.7 and 7.4 to 4.2 of 13) and relative improvements of 128 and 130 percent in the quality of life index (from 0.29 to 0.65 and 0.3 to 0.69 of 1) for the telephone-assisted and standard groups respectively. Importantly, there were no significant differences between the telephone-assisted or standard groups in any outcome. Of patients who completed treatment, 78 percent were better or much better. A less intensive regime of biofeedback seems to be equally effective as the standard intensive protocol. This finding adds weight to the evolving concept that the physical aspects of biofeedback treatment, such as manometry or ultrasound, may not be necessary in the treatment of most patients with fecal incontinence. This needs to be further tested in a randomized, controlled trial.
Publisher: Wiley
Date: 22-09-2022
DOI: 10.1111/ANS.17212
Abstract: To determine the effectiveness of an in idualised, daily targeted step count intervention and usual care compared with usual care alone on improving surgical and patient reported outcomes. The Fit‐4‐Home trial was a pragmatic, randomised controlled trial conducted from April 2019 to February 2021. Patients undergoing elective surgery for liver, stomach or pancreatic cancer in two Australian hospitals were recruited. Participants were randomly allocated to receive an in idualised, targeted step count intervention and usual care (intervention) or usual care alone (control). A wearable activity tracker was provided to the intervention group to monitor their daily step count target. Primary outcome was the length of stay in the gastrointestinal ward. Secondary outcomes included postoperative complication rates, discharge destination, quality of life, physical activity, pain, fatigue, distress and hospital re‐admission within 30 days. Outcome measures were compared between groups using non‐parametric statistics. Of the 96 patients recruited, 47 were randomised to the intervention group and 49 were randomised to the control group. The median (interquartile) length of stay in the ward was 7 days (5.0–13.0) in the intervention group and 7 days (5.0– 12.0) in the control group ( p = 0.330). Fatigue scores were worse in the intervention group when compared to control ( p = 0.018). No other differences between groups were observed. An in idualised, daily targeted step count intervention and usual care did not confer additional benefits in reducing the length of stay in the ward compared to usual care alone for patients undergoing gastrointestinal cancer surgery. Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000194167).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2002
DOI: 10.1007/S10350-004-6444-1
Abstract: Development of quality-of-life measures has been the focus of research in colorectal disorders in recent years. The assessment of quality of life for fecal incontinence should be more important than quantitative measurement of soiling. This study assesses specific patient quality-of-life objectives, categorizes objectives, and correlates these objectives with continence scores. One hundred eighteen patients entered into a randomized, controlled trial of biofeedback were assessed using the Direct Questioning of Objectives quality-of-life measure. All objectives were documented, categorized, and correlated with continence scores and analog scales. In patients with neuropathic fecal incontinence, the most frequent quality-of-life group concerned the ability to get out of home, to socialize outside of home, to go shopping, and not to have to worry about the location of the nearest toilet while out of home (34 percent 123/364). At least one of these four objectives was stated by 72 percent of patients (85/118). Only 31 percent of patients (37/118) nominated an objective related to the physical act of soiling. The ability to travel (29 percent), exercise including walking (25 percent), perform home duties (19 percent), family and relationships (22 percent), and job (13 percent) were less frequently cited by patients. Continence scores focus heavily on the physical aspects of incontinence such as soiling and hygiene, aspects which seem to be less important to the patients themselves. It is important, therefore, that assessments of fecal incontinence should include reference to quality of life, and in particular to its impact on activities relating to "getting out of the house."
Publisher: Wiley
Date: 21-04-2022
DOI: 10.1111/ANS.17698
Abstract: Early‐onset colorectal cancer (EOCRC) ( years) incidence has increased in Australia and worldwide. However, the diagnosis of EOCRC is often delayed. Recent research has discovered some differences from later‐onset colorectal cancer (LOCRC) ( years). An awareness of the unique features of EOCRC is crucial to reduce time from symptom onset to diagnosis. A literature search was conducted on electronic databases (MEDLINE, EMBASE and Cochrane Library) using the search terms “early onset colorectal cancer” or “young onset colorectal cancer.” The American Cancer Society has reduced the colorectal cancer screening initiation age to 45 for average‐risk adults whilst screening programmes in the United Kingdom and Australia remain unchanged with initiation at 60 and 50, respectively. Exposures resulting in dysbiosis (obesity, westernised diet, alcohol, antibiotic and sugar‐sweetened beverage consumption) have been linked with increased EOCRC risk. EOCRC is often left‐sided presenting with rectal bleeding, altered bowel habit and constitutional symptoms. EOCRC is more commonly sporadic than hereditary, harbouring different genetic mutations than LOCRC. Comparative survival outcomes of EOCRC and LOCRC are conflicting with studies suggesting either better or poorer survival. Young patients better tolerate treatment‐related toxicities, which may account for their improved survival despite comparatively advanced stages and poorer histopathological features at diagnosis. Current EOCRC literature is limited by American‐focused datasets and heterogenous EOCRC definitions and study designs (the greatest strength of evidence exists for EOCRC risk factor studies comprised of large retrospective cohorts). There is minimal research into the quality of life and surgical outcomes of EOCRC patients, and this area warrants further investigation.
Publisher: Wiley
Date: 06-03-2022
DOI: 10.1111/ANS.17577
Abstract: There is clinical uncertainty regarding an association between preoperative functional capacity of cancer patients, and postoperative outcomes. The aim of this systematic review and meta‐analysis is to investigate whether poor performance on preoperative six‐minute walk test (6MWT) or five‐times sit to stand test (5STS) is associated with worse postoperative complication rates and prolonged length of hospital stay (LOS) in cancer patients. An electronic search was performed from earliest available record to 26th February 2021 in MEDLINE, Embase and AMED. Studies investigating the association between preoperative physical function (measured using either 6MWT or 5STS) and postoperative outcomes (complications and LOS) in patients with gastrointestinal, abdominal and pelvic cancers were included. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Where possible, summary odds ratios (OR) or mean differences (MD), and 95% confidence intervals (CI) were calculated using random‐effect models. Five studies (379 patients) were included, of which none utilized the 5STS. Overall, studies were rated as having low to moderate risk of bias. Higher preoperative performance on the 6MWT (≥400 m) was associated with low grade postoperative complications (OR = 0.38 95% CI = 0.15–0.95) but was not associated with a shorter LOS (MD = 3.29 95%CI = −1.07–7.66). The available evidence suggests that in cancer patients, a higher preoperative functional capacity may be associated with reduced postoperative complications. Conversely, there is no significant association between preoperative function and LOS. Further high‐quality studies are needed in this area, including studies involving 5STS.
Publisher: Elsevier BV
Date: 05-1996
Publisher: Elsevier BV
Date: 06-2008
DOI: 10.1016/J.JCLINEPI.2007.07.012
Abstract: Our study aimed to examine the effect of an instant lottery ticket incentive on the response rate to a mailed questionnaire in a population of trauma patients. A randomized controlled trial at a major trauma center with 728 patients randomized into 2 groups prior to mailing of a questionnaire. One group of patients (Group A) had a sentence inserted into the cover letter stating that they would receive a $4 instant lottery ticket upon receipt of a completed questionnaire Group B did not have an incentive. The response rate for both groups was measured after the initial mailing and at the end of the study. The results were analyzed using the X2 test to compare 2 proportions and a P value of .05 was considered significant. The early response rate in Group A was lower than in Group B, and the response rates for both groups were similar at final follow-up. The differences at both time periods were not statistically significant. The use of an instant lottery ticket incentive did not improve the response rate to a mailed questionnaire.
Publisher: Elsevier BV
Date: 1994
DOI: 10.1016/S0002-9610(05)80154-0
Abstract: Intraoperative hepatic ultrasonography (IOUS) has been used to accurately identify and localize hepatic tumors as an adjunct to hepatic resection and for the detection of occult liver metastases during primary resection of other gastrointestinal carcinomas. The face validity of IOUS to identify more lesions than conventional diagnostic modalities and the content validity of IOUS to change the planned surgical management has been assessed in a blinded, prospective manner. Sixty-two patients were studied at two institutions by one surgeon. IOUS was compared with computed tomography (CT) angioportography in 30 patients undergoing planned hepatic resection (19 metastatic, 11 primary) and with conventional hepatic ultrasonography (+/- venous enhanced CT scan) in 32 patients undergoing primary excision of gastrointestinal carcinomas. Twenty of the 30 hepatic resections (67%) were changed or guided by IOUS as determined by the operating surgeon at the completion of the laparotomy. IOUS detected 26 more metastases (44%) in 10 of 19 patients (1 to 5 per patient). Two patients had preoperatively suspected metastases refuted by IOUS-guided biopsy. Eight of the 11 patients (73%) undergoing resection of primary carcinoma of the liver had the planned procedure changed or guided by IOUS. This included four hepatocellular carcinomas with more extensive involvement at the confluence of the hepatic veins and the inferior vena cava, necessitating resection with the aid of total vascular isolation. In 32 patients undergoing primary resection of gastrointestinal carcinomas, 5 patients (16%) had the stage of disease altered by IOUS when compared with conventional ultrasound (+/- venous enhanced CT scan). The validity of IOUS is good. IOUS guided the intraoperative surgical management of two thirds of the patients undergoing hepatic resection when compared with CT angioportography. Intraoperative hepatic ultrasonography using a reproducible systematic approach can change the clinical management of patients undergoing hepatic resection for malignancy.
Publisher: Wiley
Date: 06-2017
DOI: 10.1111/ANS.13949
Publisher: American Society of Hematology
Date: 04-2006
DOI: 10.1182/BLOOD-2005-06-2403
Abstract: Regulatory T cells (TREGs) constitutively expressing CD4, CD25, and the transcription factor Foxp3 can prevent a wide range of experimental and spontaneous autoimmune diseases in mice. In humans, CD4+CD25bright T cells, predominantly within the CD45RO+ activated/memory subset in adults and the CD45RA+ naive T-cell subset in infants, are considered to be the equivalent subset. Using novel combinations of monoclonal antibodies (mAbs), we examined expression of CD25 in human infant thymus, cord blood, adult peripheral blood, lymph node, and spleen. In addition to the CD4+CD25bright T cells, subfractionation on the basis of CD45 splice variants indicated that all s les contained a second distinct population of cells expressing a slightly lower level of CD25. In adult peripheral blood, this population expressed a naive CD45RA+ phenotype. The corresponding population in lymph node, spleen, and cord blood showed some evidence of activation, and expressed markers characteristic of TREGs, such as cytotoxic T lymphocyte-associated antigen 4 (CTLA-4). Sorted CD4+CD25+CD45RA+ T cells from both cord and adult blood expressed very high levels of mRNA for Foxp3 and manifested equivalent suppressive activity in vitro, indicating that they are bone fide members of the regulatory T-cell lineage. Targeting naive TREGs in adults may offer new means of preventing and treating autoimmune disease.
Publisher: The Company of Biologists
Date: 10-2015
DOI: 10.1242/JEB.120717
Abstract: Tropical coral reef organisms are predicted to be especially sensitive to ocean warming because many already live close to their upper thermal limit, and the expected rise in ocean CO2 is proposed to further reduce thermal tolerance. Little, however, is known about the thermal sensitivity of a erse and abundant group of reef animals, the gastropods. The humpbacked conch (Gibberulus gibberulus gibbosus), inhabiting subtidal zones of the Great Barrier Reef, was chosen as a model because vigorous jumping, causing increased oxygen uptake (ṀO2), can be induced by exposure to odour from a predatory cone snail (Conus marmoreus). We investigated the effect of present-day ambient (417–454 µatm) and projected-future (955–987 µatm) PCO2 on resting (ṀO2,rest) and maximum (ṀO2,max) ṀO2, as well as ṀO2 during hypoxia and critical oxygen tension (PO2,crit), in snails kept at present-day ambient (28°C) or projected-future temperature (33°C). ṀO2,rest and ṀO2,max were measured both at the acclimation temperature and during an acute 5°C increase. Jumping caused a 4- to 6-fold increase in ṀO2, and ṀO2,max increased with temperature so that absolute aerobic scope was maintained even at 38°C, although factorial scope was reduced. The humpbacked conch has a high hypoxia tolerance with a PO2,crit of 2.5 kPa at 28°C and 3.5 kPa at 33°C. There was no effect of elevated CO2 on respiratory performance at any temperature. Long-term temperature records and our field measurements suggest that habitat temperature rarely exceeds 32.6°C during the summer, indicating that these snails have aerobic capacity in excess of current and future needs.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2016
DOI: 10.1097/DCR.0000000000000679
Abstract: Locally advanced pelvic malignancy can be associated with disabling symptoms and reduced quality of life. If resectable with clear margins, a pelvic exenteration can offer long-term survival and improved quality of life. Its role in the palliation of symptoms has been described however, the clinical outcomes and surgical indication are poorly defined. This study describes the clinical and quality-of-life outcomes after palliative pelvic exenteration for advanced pelvic malignancy. Clinical data and patient-reported outcomes were collected for patients undergoing pelvic exenteration for symptom palliation. This study was conducted at a tertiary referral center for pelvic exenteration. All of the patients undergoing palliative pelvic exenteration for advanced primary rectal or recurrent cancer were included in our analysis. Patient-reported quality of life and physical and mental health status were measured. Quality-of-life trajectories were modeled over the 12 months from the date of surgery using linear mixed models. A total of 39 patients underwent pelvic exenteration for symptom palliation. Although there were no in-hospital deaths, 34% experienced significant morbidity. Patient-reported quality of life reduced postoperatively and gradually declined thereafter. Overall median survival was 24 months, with a 1-year mortality rate of 31%. There was a significant survival difference for the 39 patients undergoing pelvic exenteration compared with those patients who only had a debulking/bypass procedure or were closed without definitive treatment (overall median survival = 24 versus 9 months p = .02). Disease and patient heterogeneity limit the interpretation of these results. Palliative pelvic exenteration is a technically demanding operation that can be performed safely in a dedicated exenteration center. However, no durable palliation of symptoms with associated improved or sustained quality of life was observed, and the role of palliation therefore remains highly controversial in this complex group of patients.
Publisher: Wiley
Date: 12-10-2009
DOI: 10.1111/J.1463-1318.2008.01723.X
Abstract: Chemoradiotherapy is the mainstay of treatment for the majority of patients with anal cancer, with abdominoperineal resection reserved for salvage. The purpose of this study was to evaluate our results after radiotherapy with or without chemotherapy, and/or surgery in terms of overall survival and colostomy free survival in patients with anal cancer. A review of patients diagnosed with anal cancer between 1991 and 2004 was performed. The principle end-points of the study were overall and colostomy-free survival. One hundred and twenty patients were identified. The T stage distribution was T1 32, T2 44, T3 19, T4 17 and TX 8. Eighteen patients had clinically involved regional nodes. Eighty patients received radiotherapy as a component of their treatment. Twenty-four of the 80 patients had a colostomy. The most common late toxicity was faecal incontinence. The overall survival and colostomy-free survival rates for all 120 patients were 58% and 79% at 5 years, respectively. For the 80 patients who received radiotherapy, the corresponding figures were 66% and 82% at 5 years, respectively. Chemoradiation is effective organ preserving treatment for anal cancer. Grade 1 and 2 faecal incontinence is a relatively common late toxicity experienced by patients.
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.SURG.2015.01.022
Abstract: Colorectal stents have been available as a management option in obstruction for 23 years, yet there is little randomized evidence of their effectiveness. This study investigated current surgeon-related barriers to conducting a randomized, controlled trial (RCT) of colorectal stent insertion for obstruction in patients with colorectal cancer. A binational survey of current members of the Colorectal Surgical Society of Australia and New Zealand was conducted by a mailed questionnaire assessing perceived barriers to adoption of colonic stents and willingness to participate in future multicentre randomized controlled trials, and surgeons' treatment preferences in 16 hypothetical clinical scenarios. Of 148 eligible surgeons, 96 (65%) responded. Colonic stenting was available to 98% of respondents. In the clinical setting of colorectal obstruction, only 29% (95% CI, 20-39%) of surgeons expressed a willingness to participate in a RCT involving colonic stents in the curative setting. More than 70% of surgeons preferred the use of stents in unfit patients for palliation, and preferred surgery in fit patients with curable disease. In the curative setting, most respondents considered colonic stents not cost effective (90% 95% CI, 82-94%) and believed that their patients would not prefer stents over surgery (80% 95% CI, 71-87%). This study highlights the limitation to conducting a future randomized controlled trial to assess the efficacy of colonic stenting, especially in the curative setting, based on surgeon preference, despite the lack of level I evidence.
Publisher: Springer Science and Business Media LLC
Date: 13-06-2002
DOI: 10.1007/S00384-002-0408-5
Abstract: There appears little doubt that microvascular ischaemia is involved in Crohn's disease. Studies have consistently demonstrated that the number of blood vessels and the total volume of blood feeding segments of bowel with Crohn's disease are reduced. However, the aetiology of the microvascular ischaemia is yet to be determined. Potential aetiological factors that appear to be disease specific include increased mesenteric platelet aggregation and increased platelet surface expression of P-selectin and GP53. However, there are several other factors known to be raised in active and quiescent disease for which disease specificity is not yet known, including increased submucosal endothelial endothelin-1 receptor expression, increased m RNA expression for several interleukins and cytokines including TNFalpha, increased PAF and thrombomodulin and finally altered cellular adhesion molecule expression. Proving cause and effect will always be a difficult task given the self-perpetuating nature of the inflammatory and coagulation cascades and our inability at present to identify persons who subsequently develop Crohn's disease at a point prior to mucosal inflammation. Results to date however, are supportive of each of these factors, alone or in combination playing an integral part in the development of microvascular ischaemia, a pathological process which appears to precede the classic changes which characterize Crohn's disease.
Publisher: Elsevier BV
Date: 04-2009
DOI: 10.1016/J.INJURY.2008.08.039
Abstract: Patient satisfaction has only recently gained attention as an outcome measure in orthopaedics, where it has been reported for joint replacement surgery. Little has been published regarding predictors of patient satisfaction in orthopaedic trauma. This study aims to explore the predictors of patient satisfaction, and of surgeon satisfaction, after orthopaedic trauma. Adult patients admitted to hospital with fractures after motor vehicle trauma were surveyed on admission, and at six months. Demographic, injury, socio-economic and compensation-related factors were measured. The two outcomes were satisfaction with progress of the injury, and satisfaction with recovery. The treating surgeons were also surveyed at six months to determine surgeon satisfaction with progress, and recovery (using the same questions), and the presence or absence of fracture union and any complications. Multivariate analysis was used to determine significant predictors of satisfaction for both groups, and satisfaction rates were compared between surgeons and patients. Of 306 patients recruited, 232 (75.8%) returned completed questionnaires, but only 141 (46.1%) surgeons responded. Patients rated their satisfaction with progress and recovery as 74.6% and 44.4%, respectively, whereas surgeon-rated satisfaction with progress and recovery was significantly higher, at 88.0% and 66.7%, respectively (p<0.0001). Significant predictors of patient dissatisfaction were: blaming others for the injury, being female, and using a lawyer. Patient-rated satisfaction was not significantly associated with objective injury or treatment factors. The only significant predictor of surgeon dissatisfaction was fracture non-union. Orthopaedic surgeons overestimated the progress of the injury and the level of recovery compared to patients' own ratings. Surgeons' ratings were influenced by objective, treatment-related factors, whereas patients' ratings were not. Measures of outcome commonly used by orthopaedic surgeons, such as fracture union, do not predict patient satisfaction.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2001
DOI: 10.1007/BF02234696
Publisher: Wiley
Date: 21-11-2013
DOI: 10.1111/CODI.12391
Abstract: This study aimed to evaluate the long-term outcome of the anal fistula plug in the treatment of anal fistula of cryptoglandular origin. A review of all patients who had at least one anal fistula plug inserted from March 2007 to August 2008 was performed. Only anal fistulae of cryptoglandular origin were included. Success was defined as the closure of the external opening with no further purulent discharge or collection. Thirty anal fistula plugs were inserted in 26 patients [median age 40 (26-70) years]. Twenty-six of the fistulae were transsphincteric and three were suprasphincteric. One patient had a high intersphincteric fistula, which was the only fistula that did not have a seton inserted. The median duration between seton insertion and the plug procedure was 12 (4-28) weeks. The median length of the fistula tract was 3 (1-7.5) cm. After a median follow-up of 59 (13-97) weeks, 26 (86.7%) fistulae recurred. Of the 26 failures, the median time to failure was 8 (2-54) weeks. Subsequent surgical interventions were performed in 20 of the failures. The role of the fistula plug in the management of anal fistula of cryptoglandular origin remains debatable and warrants further evaluation.
Publisher: Wiley
Date: 04-08-2021
DOI: 10.1111/CODI.15834
Abstract: Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this study was to determine the short‐term functional outcomes following pelvic exenteration surgery using objective measures of physical function. Patients undergoing pelvic exenteration surgery between January 2017 and May 2020 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary measures were the 6‐min walk test (6MWT) and the five times sit to stand (5STS) test. Data were collected at baseline (preoperatively), 10 days postoperatively and at discharge from hospital, and were analysed according to tumour type, extent of exenteration, sacrectomy, length of hospital stay, major nerve resection and postoperative complications. The cohort of patients that participated in functional assessments consisted of 135 patients, with a median age of 61 years. Pelvic exenteration patients had a reduced 6MWT distance preoperatively compared to the general population ( P 0.001). Following surgery, we observed a further decrease in 6MWT distance ( P 0.001) and an increase in time to complete 5STS ( P 0.001) at postoperative day 10 compared to baseline, with a slight improvement at discharge. There were no differences in 6MWT and 5STS outcomes between patients based on comparisons of surgical and oncological factors. Pelvic exenteration patients are functionally impaired in the preoperative period compared to the general population. Surgery causes a further reduction in physical function in the short term however, functional outcomes are not impacted by tumour type, extent of exenteration, sacrectomy or nerve resection.
Publisher: Wiley
Date: 06-01-2022
DOI: 10.1111/ANS.17461
Abstract: Anastomotic leak (AL) is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary erting ileostomy (TDI) does not prevent an AL and presents inherent complications of its own. Numerous drain fluid biomarkers (BM) have been studied in colorectal surgery and extravasated intraluminal substances (EILS) such as amylase have shown promise. The aim of this study was to assess drain fluid amylase (DFA) as a BM of AL after minimally invasive rectal resection without a TDI. A single centre prospective cohort study performed from 2018 to 2021. The primary outcome was DFA measured daily whilst the drain was in situ . Rectal tube amylase was also measured for the first two post‐operative days to quantitate the intra‐luminal levels of the enzyme. DFA was compared between patients who experienced AL and those who did not. Of the 62 patients studied, six (9.7%) experienced AL. There was a statistically significant difference in DFA between patients who experienced AL (Median:1373.5 U/L IQR: 306–7953) and patients who did not experience an AL (Median: 27.0 U/L IQR: 16–38) p 0.0001. The measurement of drain fluid amylase is a highly sensitive BM of early clinical anastomotic leak in patients undergoing a rectal resection with an extraperitoneal anastomosis and when a TDI is not incorporated. This simple, inexpensive and non‐invasive test should be considered in all patients as an adjunct to the clinical diagnosis and differentiation of AL from other postoperative complications.
Publisher: Wiley
Date: 18-05-2009
DOI: 10.1111/J.1463-1318.2009.01898.X
Abstract: The aim of the study was to investigate the frequency and detail of family history recorded for patients diagnosed with potentially high-risk colorectal cancer, and to determine the proportion of these patients referred to a high-risk assessment clinic. Medical records of patients diagnosed with colorectal cancer under the age of 50 admitted to a major Sydney teaching hospital were reviewed. The proportion of records containing information about family history was calculated. Associations between recording of family history and demographic and clinical characteristics of patients were investigated. Logistic regression modelling was performed to identify significant, independent predictors of study outcomes. Of 113 patients with colorectal cancer diagnosed under the age of 50 years, 61 (54%, 95% CI: 44-63%) had an entry in their hospital medical record about family history. Family history was significantly less likely to be recorded for females, for those admitted via the Emergency Department, and for those with shorter lengths of stay. A significant family history was found in 51% of the 61 patients who had a family history recorded. Records of patients attending specialist colorectal surgeons were significantly more likely to contain information about family history than those who attended other specialists (P = 0.04). Only 14 patients (12%, 95% CI: 7-20%) were formally referred for further genetic assessment. These results suggest that family history is still being neglected in routine clinical practice, and high-risk assessment services are underutilized, implying the need for further dissemination of guidelines with regard to the recognition and management of hereditary colorectal cancer.
Publisher: Wiley
Date: 21-08-2008
Publisher: Wiley
Date: 03-1999
DOI: 10.1046/J.1440-1622.1999.01523.X
Abstract: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.EJCA.2015.10.060
Abstract: To assess health-related quality of life (HRQOL) in patients participating in a randomised trial of neoadjuvant short course radiation (SC) or long course chemoradiation (LC) for operable rectal cancer. Eligible patients with T3N0-2M0 rectal cancer completed the European Organisation for Research and Treatment of Cancer quality of life questionnaire (QLQ-C30) and the colorectal cancer specific module (QLQ C38) at randomisation and 1, 2, 3, 6, 9 and 12 months later. Of 326 patients randomised, 297 (SC 143, LC 154) were eligible for completion of HRQOL questionnaires. Baseline scores were comparable across the SC and LC groups. Patients reported low scores on sexual functioning and sexual enjoyment. Defaecation problems were the worst of the symptoms at baseline. Surgery had the most profoundly negative effect on HRQOL, seen in both the SC and LC treatment groups to the same extent. The most severely affected domains were physical function and role function and the most severely affected symptoms were fatigue, pain, appetite, weight loss and male sexual problems. Most domains and symptoms returned to baseline levels by 12 months apart from body image, sexual enjoyment and male sexual problems. Future perspective was better than prior to treatment. There is no overall difference in HRQOL between SC and LC neoadjuvant treatment strategies, in the first 12 months, after surgery. In the immediate postoperative period HRQOL was adversely affected in both groups but for the most part was temporary. Some residual sexual functioning concerns persisted at 12 months.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-1994
DOI: 10.1007/BF02050988
Publisher: American Society of Clinical Oncology (ASCO)
Date: 10-2013
Abstract: To investigate the effectiveness of a centralized, nurse-delivered telephone-based service to improve care coordination and patient-reported outcomes after surgery for colorectal cancer. Patients with a newly diagnosed colorectal cancer were randomly assigned to the CONNECT intervention or usual care. Intervention-group patients received standardized calls from the centrally based nurse 3 and 10 days and 1, 3, and 6 months after discharge from hospital. Unmet supportive care needs, experience of care coordination, unplanned readmissions, emergency department presentations, distress, and quality of life (QOL) were assessed by questionnaire at 1, 3, and 6 months. Of 775 patients treated at 23 public and private hospitals in Australia, 387 were randomly assigned to the intervention group and 369 to the control group. There were no significant differences between groups in unmet supportive care needs, but these were consistently low in both groups at both follow-up time points. There were no differences between the groups in emergency department presentations (10.8% v 13.8% P = .2) or unplanned hospital readmissions (8.6% v 10.5% P = .4) at 1 month. By 6 months, 25.6% of intervention-group patients had reported an unplanned readmission compared with 27.9% of controls (P = .5). There were no significant differences in experience of care coordination, distress, or QOL between groups at any follow-up time point. This trial failed to demonstrate substantial benefit of a centralized system to provide standardized, telephone follow-up for postoperative patients with colorectal cancer. Future interventions could investigate a more tailored approach.
Publisher: Wiley
Date: 11-04-2020
DOI: 10.1111/CODI.15036
Publisher: Oxford University Press (OUP)
Date: 25-11-2023
DOI: 10.1093/BJS/ZNAC414
Abstract: The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510–678 min) and significant blood loss (median 2–5 l). R0 resection can be achieved in 58–82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30–40 per cent) and perioperative mortality is acceptable (0–4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.JGO.2014.02.007
Abstract: To investigate the effect of patient age on receipt of stage-appropriate adjuvant therapy for colorectal cancer in New South Wales, Australia. A linked population-based dataset was used to examine the records of 580 people with lymph node-positive colon cancer and 498 people with high-risk rectal cancer who underwent surgery following diagnosis in 2007/2008. Multilevel logistic regression models were used to determine whether age remained an independent predictor of adjuvant therapy utilisation after accounting for significant patient, surgeon and hospital characteristics. Overall, 65-73% of eligible patients received chemotherapy and 42-53% received radiotherapy. Increasing age was strongly associated with decreasing likelihood of receiving chemotherapy for lymph node-positive colon cancer (p<0.001) and radiotherapy for high-risk rectal cancer (p=0.003), even after adjusting for confounders such as Charlson comorbidity score and ASA health status. People aged over 70years for chemotherapy and over 75years for radiotherapy were significantly less likely to receive treatment than those aged less than 65. Emergency resection, intensive care admission, and not having a current partner also independently predicted chemotherapy nonreceipt. Other predictors of radiotherapy nonreceipt included being female, not being discussed at multidisciplinary meeting, and lower T stage. Adjuvant therapy rates varied widely between hospitals where surgery was performed. There are continuing age disparities in adjuvant therapy utilisation in NSW that are not explained by patients' comorbidities or health status. Further exploration of these complex treatment decisions is needed. Variation by hospital and patient characteristics indicates opportunities to improve patient care and outcomes.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.JIM.2014.11.001
Abstract: Extensive surface profiles of colorectal cancer (CRC) cells and tumor infiltrating lymphocytes (TIL) have been obtained from 45 surgical resection s les. Live cells were captured on an antibody microarray and stained with fluorescently-labeled antibodies. Minimal panels of 11 CRC antigens (CD13, CD24, CD26, CD49d, CD138, CD166, CA-125, CA19-9, EGFR, Galectin-4 and HLA-DR) and 11 T-cell antigens (CD10, CD11b, CD11c, CD25, CD31, CD95, CD151, CD181, Galectin-4, CA19-9, TSP-1) provide signatures for relapse and survival. Hierarchical clustering of profiles from CRC cells and TIL identified groups of patients for survival, systemic relapse and death. The groups from CRC and TIL profiles for systemic relapse showed 79.2% concordance, enabling prediction of relapse after surgery. The results demonstrate communication between CRC cells and TIL.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2003
DOI: 10.1007/S10350-004-6524-2
Abstract: Adjuvant therapy, either preoperatively or postoperatively, and modifications of surgery have been used to try to improve outcome of surgery for rectal cancer in regard to both local recurrence and survival. Assessment of prognosis in patients after resection is currently primarily based on clinicopathologic factors. These predict the subsequent behavior of the tumor only imperfectly. The aim of this study was to evaluate three potential molecular genetic markers of prognosis (p53, deleted in colorectal cancer gene, and thymidylate synthase) in Dukes Stage B and C low rectal tumors treated with adjuvant therapy and to determine whether they correlate with survival, local recurrence, or the pathologic response to adjuvant therapy (assessed by extent of tumor regression and tumor down-staging). Sixty locally advanced low rectal tumors resected after preoperative chemoradiotherapy or radiotherapy alone were studied by immunohistochemical staining for p53, deleted in colorectal cancer gene, and thymidylate synthase. In addition, p53 gene mutations were sought by polymerase chain reaction-single-strand conformation polymorphism analysis. These results were correlated with survival, local recurrence, and pathologic response to adjuvant therapy. Lack of thymidylate synthase staining by immunohistochemistry was associated with tumor down-staging after preoperative chemoradiotherapy but not after radiotherapy or for these two combined groups. There was no correlation between p53, deleted in colorectal cancer gene, or thymidylate synthase immunohistochemical staining or between p53 polymerase chain reaction-single-strand conformation polymorphism and local recurrence or survival in locally advanced low rectal cancers treated with preoperative adjuvant therapies. Prediction of prognosis in patients with locally advanced low rectal cancers treated with preoperative adjuvant therapies continues to be problematic. Thymidylate synthase immunohistochemistry appears to be the most promising factor of those assessed in predicting tumor down-staging after preoperative chemoradiotherapy for locally advanced low rectal cancers.
Publisher: Elsevier BV
Date: 11-2006
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-1996
DOI: 10.1007/BF02049468
Publisher: Springer Science and Business Media LLC
Date: 07-02-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2007
DOI: 10.1007/S10350-007-0259-9
Abstract: This study used a novel questionnaire to assess quality of life and psychologic adjustment among young adults aged 18 to 35 years with a diagnosis of, or at risk of, developing familial adenomatous polyposis. Eighty-eight participants (25 males) were recruited through four Australian Hereditary Bowel Cancer Registries. The average age of participants was 28 years, and the average age of these participants at the time of their last genetic consultation was 23 years. Seventy-one participants (81 percent) had clinical familial adenomatous polyposis, of whom 57 had undergone an ileorectal anastomosis or formation of an ileal pouch with anal anastomosis to prevent colorectal cancer. The ileal-pouch-with-anal-anastomosis group had significantly more adverse outcomes for physical functioning, body image, sexual impact, and negative affect compared with the no-surgery group -- and significantly more negative outcomes for physical functioning and negative affect compared with the ileorectal-anastomosis group. Among the total s le, a small proportion (11.4 percent) had avoidance scores indicative of a significant stress response, and being single was associated with higher levels of avoidance responses about familial adenomatous polyposis (z = -3.19 P = 0.001). Familial adenomatous polyposis may have a negative impact across a broad range of life domains. Being single is an important risk factor for adverse psychologic outcomes. Delaying surgery, especially ileal pouch with anal anastomosis may minimize the negative impact on physical and psychologic functioning. Referral for psychologic intervention may be required for a small proportion of those affected by familial adenomatous polyposis, and ongoing access to genetic services may help to identify and address the needs of this group.
Publisher: Wiley
Date: 07-2017
DOI: 10.1111/CODI.13665
Abstract: Obstructed defaecation (OD) has a high prevalence and high disease impact however, patients often experience suboptimal management. This problem reflects the complex pathophysiology of OD as well as health service delivery factors. This study aimed to identify the factors that act as a barrier to effective management of OD as perceived by specialist colorectal surgeons treating this disorder. A postal questionnaire was administered to a bi-national s ling of colorectal specialists in Australia and New Zealand who were registered with their specialty society. Questions addressed variables relevant in OD management, including clinical access, decision-making, patient factors and surgeon experience and perceptions, and used Likert scales. Statistical analyses compared surgeon practice variables. The response rate was 68.5% (n = 113). Most surgeons managed OD (94%), and preferred to treat OD patients themselves (87%) however, 33% of these respondents were dissatisfied with their management, 46% felt they lacked management expertise and 33% stated they had inadequate expertise in OD investigations. Clinical investigation services were more limited in private than public practice, and many surgeons lacked access to biofeedback (31%). Other barriers included heterogeneity in decision-making by surgeon age and practice location (P < 0.05), dual pathologies (e.g. irritable bowel syndrome) and psychological factors, and limited uptake of multidisciplinary services and standardized (Rome) diagnostic criteria. Barriers to OD management include surgeon-specific factors, patient-specific factors and healthcare access factors. Increased utilization of pelvic floor and multidisciplinary services, increased training and standardization of OD investigations and improved access to specialist investigations and allied-health management services could improve outcomes for OD.
Publisher: Wiley
Date: 24-01-2022
DOI: 10.1111/ANS.17475
Abstract: Anastomotic leak (AL) is the anathema of colorectal surgery, with well‐documented adverse impacts on patient morbidity and mortality. The long‐term consequences of AL on bowel function and quality of life (QoL) is less well‐defined after minimally invasive surgery. By omitting a temporary erting ileostomy (TDI), it is postulated that the minimally invasive approach will lead to early diagnosis and expedient management of AL. This retrospective and cross‐sectional study included patients who underwent minimally invasive restorative rectal surgery with a low pelvic colorectal anastomosis and without a TDI at two tertiary hospitals in Brisbane, Australia between 2004 and 2018. Surgical management of AL is described and long‐term functional outcomes were evaluated through validated questionnaires. Two hundred and twenty‐four patients met inclusion criteria. AL was associated with lesion proximity to the anal verge ( P = 0.011), total mesorectal excision (TME) ( P .001) and advanced malignant disease ( P = 0.019). Twenty‐four patients experienced an AL (11%) diagnosed at a median of 5.5 days post‐operative. Survey responders ( n = 99, 62%) included 10 (10%) AL and 89 (90%) non‐AL patients, with a median follow‐up of 4 and 6.4 years. SF‐36 and FISI scores were comparable between groups, however AL patients had worse LARS scores ( P = 0.028). Patients undergoing TME, irrespective of AL, had poorer low anterior resection syndrome (LARS) ( P .001) and FISI scores ( P = 0.001). AL in patients undergoing minimally invasive low pelvic colorectal anastomosis without a TDI does not impact long term QoL. The occurrence of LARS is dependent on the extent of resection, rather than the occurrence of AL.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: Springer Science and Business Media LLC
Date: 09-05-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2008
Publisher: Wiley
Date: 11-09-2014
DOI: 10.1111/ANS.12839
Abstract: This study aimed to (i) investigate the factors that influence donor and recipient decision making in adult-to-adult living donor liver transplantation (AALDLT) (ii) quantify the level of risk that would be acceptable to potential donors and (iii) determine from whom an in idual would be willing to receive a donation. A self-administered questionnaire using hypothetical scenarios centred on AALDLT was created and administered to participants recruited from the waiting room of an orthopaedic outpatient clinic at a teaching hospital in Sydney (n = 105). The questionnaire asked participants to consider scenarios in which they either (i) were a potential donor for a family member or close friend or (ii) themselves required a liver transplant. Ninety-five (90%) participants expressed an in-principal willingness to consider living organ donation. The factors most important in deciding to be living liver donors were the probability of a good outcome for the recipient, the likelihood of the potential recipient's survival until a deceased donor liver became available and the risk of donor death. Donor death was also rated as the least acceptable donor outcome. Participants expressed a willingness to receive a donation from all proposed donor groups equally. The acceptability of hypothetical living organ donation was very high in the population group studied. Participants were also willing to accept significantly higher risks of complications from organ donation than they would actually be exposed to. Clinicians should feel encouraged to discuss the risks and benefits of living donation frankly with patients and their families.
Publisher: Oxford University Press (OUP)
Date: 06-01-2023
Abstract: Overall survival rates for locally recurrent rectal cancer (LRRC) continue to improve but the evidence concerning health-related quality of life (HrQoL) remains limited. The aim of this study was to describe the short-term HrQoL differences between patients undergoing surgical and palliative treatments for LRRC. An international, cross-sectional, observational study was undertaken at five centres across the UK and Australia. HrQoL in LRRC patients was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR29 and functional assessment of cancer therapy – colorectal (FACT-C) questionnaires and subgroups (curative versus palliative) were compared. Secondary analyses included the comparison of HrQoL according to the margin status, location of disease and type of treatment. Scores were interpreted using minimal clinically important differences (MCID) and Cohen effect size (ES). Out of 350 eligible patients, a total of 95 patients participated, 74.0 (78.0 per cent) treated with curative intent and 21.0 (22.0 per cent) with palliative intent. Median time between LRRC diagnosis and HrQoL assessments was 4 months. Higher overall FACT-C scores denoting better HrQoL were observed in patients undergoing curative treatment, demonstrating a MCID with a mean difference of 18.5 (P & 0.001) and an ES of 0.6. Patients undergoing surgery had higher scores denoting a higher burden of symptoms for the EORTC CR29 domains of urinary frequency (P & 0.001, ES 0.3) and frequency of defaecation (P & 0.001, ES 0.4). Higher overall FACT-C scores were observed in patients who underwent an R0 resection versus an R1 resection (P = 0.051, ES 0.6). EORTC CR29 scores identified worse body image in patients with posterior/central disease (P = 0.021). Patients undergoing palliative chemoradiation reported worse HrQoL scores with a higher symptom burden on the frequency of defaecation scale compared with palliative chemotherapy (P = 0.041). Several differences in short-term HrQoL outcomes between patients undergoing curative and palliative treatment for LRRC were documented. Patients undergoing curative surgery reported better overall HrQoL and a higher burden of pelvic symptoms.
Publisher: Wiley
Date: 18-02-2005
DOI: 10.1111/J.1463-1318.2004.00745.X
Abstract: Suprasphincteric fistulae remain the most difficult to cure. The purpose of this study was to evaluate the healing rate of suprasphincteric anal fistula treated by ano-cutaneous advancement flap repair, and the impact of this procedure on continence and quality of life. Sixteen patients with complex, recurrent or chronic suprasphincteric fistulae associated with significant tissue damage (necrotizing fasciitis, keyhole deformity and anal stenosis) or who had failed previous surgical procedures were treated by ano-cutaneous flap closure. They were assessed pre and postoperatively by the treating surgeon for wound healing and fistula recurrence and later followed up by phone interview using the St Mark's Hospital incontinence score and the Perianal Disease Activity Index (PDAI) as indicators of treatment outcome. Fifteen patients had successful healing of their fistula with the cutaneous flap, with recurrence in only one. The most common short-term complications were minor graft site wound separation, which healed in all cases without intervention, and wound pain, which settled over time and was not associated with recurrence. Continence improved for almost 70% of the patients, with a significant reduction in St Mark's incontinence scores (t = 2.62, 15 d.f., P = 0.02). PDAI also decreased significantly (t = 7.55, 15 d.f., P < 0.001), demonstrating improvement in quality of life for most patients. Ano-cutaneous flap can achieve healing of complex and recurrent suprasphincteric anal fistula in patients who had previously failed at other forms of treatment thus improving their quality of life and continence.
Publisher: Wiley
Date: 07-08-2021
DOI: 10.1111/CODI.15844
Abstract: Anastomotic leak (AL) is the most important complication of intestinal surgery with an anastomosis. Whilst a number of studies have defined risk factors for AL, frustratingly, low‐risk patients still develop AL. Studies have looked at drain fluid analysis for detection of AL, but these findings have failed to translate into routine clinical practice. This umbrella systematic review aims to provide an overview of the promising candidate biomarkers (BMs) that show potential to translate into clinical practice. A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane, KSR Evidence and the Epistemonikos databases on the 14 April 2021. Only systematic reviews of cohort or controlled studies measuring drain fluid biomarkers in humans were included. The methodological quality of the reviews was assessed using the AMSTAR 2 instrument. Clinical trial registries were searched for trials actively investigating drain fluid BMs. Candidate BMs were classified, and threshold values investigated. Nine systematic reviews, published between 2007 and 2020, met the inclusion criteria, and contained a total of 36 cohort studies. A total of 38 different BMs were studied. The most promising category of drain fluid BM was the extravasated intra‐luminal substances (EILS) and five registered trials of these BMs were found. Two of nine reviews were of moderate quality. The majority of BMs show inconsistent threshold values and are in the experimental stage. A number are not readily available for adoption into routine clinical practice. Most do not state a cut‐off value to be considered as diagnostic.
Publisher: Wiley
Date: 17-08-2020
DOI: 10.1111/CODI.15280
Abstract: Acute urinary retention (AUR) is a well‐known complication after rectal surgery. It can be associated with additional morbidity. Causes of postoperative AUR are often multifactorial – involving patient‐, pathology‐ and treatment‐related factors. A proportion of men undergoing total mesorectal excision (TME) have preexisting urinary dysfunction and this may predispose to AUR. The aim of this study was to prospectively assess the influence of preoperative urinary function on postoperative AUR in men undergoing TME. A prospective multicentre cohort study was conducted. All adult men undergoing rectal resection between June 2016 and January 2018 were recruited. Combined pelvic resections, inability to void per urethra and emergency surgery were excluded. Preoperative urinary function was assessed with uroflowmetry, prostate ultrasound and the International Prostate Symptom Score (IPSS). The incidence of postoperative AUR, urinary tract infection (UTI) and length of hospital stay (LOS) were measured. Seventy‐seven patients (mean age 61 years) were recruited. The overall incidence of AUR was 21%. Preoperative urinary function, IPSS and past urological history were not predictive for postoperative AUR. AUR was not associated with UTI and did not affect LOS. Patients with UTI had a higher intravesical protrusion of the prostate. Preoperative urinary dysfunction in men is not predictive of postoperative AUR after TME. It should not preclude early trial of void after TME. AUR did not predispose to UTI, nor did it prolong LOS.
Publisher: Wiley
Date: 16-08-2010
DOI: 10.1111/J.1445-2197.2010.05433.X
Abstract: This paper describes the distinctions between major surgical and pharmaceutical trials and questions the application of a common ethical paradigm to guide their conduct and reporting. Surgical trials differ from other trials in cumulative therapeutic effects, operator dependence, the clinical setting, interdependence of short- and long-term outcomes, and equipoise. A principal tenant of randomized controlled trial management is the maintenance of interim data confidentiality. Its application to complete surgical short-term data is examined across a variety of common clinical trial circumstances that influence data integrity and the reliability of conclusions regarding the benefit-to-risk profile of experimental interventions. Complete perioperative results describe important treatment ends that cannot influence primary outcomes. These short-term results may inform patient consent, teaching and provide valuable procedural insights to surgeons outside trial precincts. Structured experimentation standards are necessary. But, the common paradigm applied across all clinical trials and the prohibition on short term data reporting may not serve the achievement of safe and effective advancements in surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2008
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2021
DOI: 10.2106/JBJS.RVW.20.00088
Abstract: This articlewas updated on October 25, 2021, because of a previous error.On page 8, in Figure 3, the figure keys that had been inverted now correctly define the orange and blue data points as the Gunning Fog Index and the Flesch-Kincaid Readability Score, respectively. An erratum has been published: JBJS Reviews. 2021 Oct (10):e20.00088ER. Knee arthroplasty is a high-risk, resource-intensive procedure that should be reserved for patients in whom the benefit will outweigh the risks. The provision of high-quality, publicly available decision aids can help patients to balance the benefits against the harms of treatments and to assist informed decision-making. The aim of this study was to identify and evaluate the content and readability of freely available knee arthroplasty decision aids. A systematic search using an environmental scan methodology of publicly available online materials was performed in December 2018. Included materials were assessed for quality using the International Patient Decision Aid Standards instrument (IPDASi), understandability and actionability from a patient’s perspective using the Patient Education Materials Assessment Tool (PEMAT), and readability grade level using the Flesch-Kincaid Grade Level and the Gunning Fog Index. Of 761 online materials screened, 26 decision aids were identified. Only 18 (69%) may be considered to meet criteria to be defined as a decision aid and 4 (15%) met criteria suggesting that the material did not introduce potential harmful bias according to the IPDASi. The mean score (and standard deviation) for all decision aids was 74% ± 12% for understandability and 44% ± 19% for actionability using the PEMAT. Readability indices indicated a mean minimum reading level of Grade 10 (10.8 ± 2.5). No decision aid included a wait-and-see option. Few high-quality decision aids exist for patients considering knee arthroplasty and none include a wait-and-see option. Many do not provide actionable options and are pitched at above-average reading levels. Developers need to address these issues to encourage high-quality decision-making, especially for those with low health literacy.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/DCR.0000000000000656
Abstract: Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist. This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration. A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period. This study was conducted at a tertiary level exenteration unit. Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality. Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6–15) hours, and median blood loss was 2971 (range, 300–8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years ( r = 1.4–12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common. This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous s le. Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.
Publisher: MDPI AG
Date: 24-04-2023
Abstract: Background: To determine the feasibility, reliability, and safety of the remote five times sit to stand test (5STS) test in patients with gastrointestinal cancer. Methods: Consecutive adult patients undergoing surgical treatment for lower gastrointestinal cancer at a major referral hospital in Sydney between July and November 2022 were included. Participants completed the 5STS test both face-to-face and remotely, with the order randomised. Outcomes included measures of feasibility, reliability, and safety. Results: Of fifty-five patients identified, seventeen (30.9%) were not interested, one (1.8%) had no internet coverage, and thirty-seven (67.3%) consented and completed both 5STS tests. The mean (SD) time taken to complete the face-to-face and remote 5STS tests was 9.1 (2.4) and 9.5 (2.3) seconds, respectively. Remote collection by telehealth was feasible, with only two participants (5.4%) having connectivity issues at the start of the remote assessment, but not interfering with the tests. The remote 5STS test showed excellent reliability (ICC = 0.957), with limits of agreement within acceptable ranges and no significant systematic errors observed. No adverse events were observed within either test environment. Conclusions: Remote 5STS for the assessment of functional lower extremity strength in gastrointestinal cancer patients is feasible, reliable, and safe, and can be used in clinical and research settings.
Publisher: Wiley
Date: 26-03-2001
DOI: 10.1046/J.1440-1622.2001.02059.X
Abstract: An Australia-wide postal survey was undertaken to determine surgeons' attitudes towards guidelines and their preferred strategies for dissemination and implementation of guidelines for the management of colorectal cancer, developed by the Australian Cancer Network (ACN) and the Clinical Oncological Society of Australia (COSA). This survey was conducted as a baseline before the release of the definitive guidelines. All members of the Royal Australasian College of Surgeons (RACS) with a self-nominated special interest in colorectal surgery and members of the Colorectal Surgical Society of Australia (CSSA) were surveyed. A total of 195 of the 219 surgeons eligible for the study returned questionnaires (89% response rate). Most (86%) were aware that these guidelines were being developed. More than one-half had read at least one draft version. Almost half (44.6% 95%CI: 37.6-51.9%) agreed that guidelines represented 'cookbook medicine' and one-third (33.3% 95%CI: 26.9-40.5%) agreed that guidelines might increase the number of malpractice suits. Local adaptation of guidelines and 'academic detailing' were most favourably ranked to assure implementation. Further, 54.9% (95%CI: 47.6-61.9%) of respondents believed that a successful legal defence of a surgeon whose practice had been within the guidelines would encourage uptake. Surgeons operating outside teaching hospitals were more likely to endorse this view than others. These results demonstrate that an important target group for colorectal cancer guidelines, namely surgeons, appears receptive to clinical practice guidelines. These results could also permit interventions that target attitudinal barriers to implementing guidelines and subgroups of surgeons who have particular concerns. Expensive strategies for implementation ought to be subject to rigorous evaluation for their impact in modifying clinical practice.
Publisher: Wiley
Date: 09-1991
DOI: 10.1111/J.1445-2197.1991.TB00318.X
Abstract: A consecutive series of 107 patients with early breast cancer treated by tumourectomy, axillary dissection and postoperative radiotherapy was retrospectively reviewed. The average age at presentation was 48, range 30-79. Only 23.4% of women were post-menopausal. Average follow-up time was 48 months, range 19-94 months. Eight-three per cent had palpable lesions, the remaining 16.8% had needle localization. Ninety-four patients (88.7%) had lesions less than 2 cm in diameter clinically. One patient had a lesion greater than 3 cm in diameter clinically. Seventy-two per cent had invasive duct carcinoma. Twenty (18.9%) had invasive disease at the margins and fifteen were re-excised. Of the 20 patients who had invasive disease at the margins, three developed local recurrence. True loco-regional recurrence rate (i.e., loco-regional recurrence rate without distant metastasis) was 2.8%. All had level I and II axillary dissections and 26.4% were up-staged from clinical stage 1 to pathological stage II. Five patients died, three with recurrences and two with unrelated disease. Tumourectomy, axillary dissection and postoperative radiotherapy is an acceptable regimen for early carcinoma of the breast.
Publisher: Springer Science and Business Media LLC
Date: 15-01-2015
Publisher: SAGE Publications
Date: 07-2013
DOI: 10.2190/HS.43.3.L
Abstract: Need is a pivotal concept within health systems internationally given its driving force in health care policy, development, and delivery at population and in idual levels. Needs assessments are critical activities undertaken to ensure that health services continue to be needed and to identify new target populations that demonstrate unmet need. The concept of need is underpinned by varied theoretical definitions originating from various disciplines. However, when needs are assessed, or health interventions developed based on need, little, if any, detail of the theoretical or conceptual basis of what is being measured is ever articulated. This is potentially problematic and may lead to measurement being invalid and planned health services being ineffective in meeting needs. Seldom are theoretical definitions of need ever compared and contrasted. This critical review is intended to fill this gap in the literature. Interpretations of the concept of need drawing from areas such as psychology, social policy, and health are introduced. The concept and relevance of unmet need for health services are discussed. It is intended that these definitions can be used to operationalize the term “need” in practice, theoretically drive needs assessment, and help guide health care decisions that are based upon need.
Publisher: Wiley
Date: 09-05-2014
DOI: 10.1111/AJCO.12082
Abstract: Telephone-delivered supportive care interventions hold potential as a sustainable, low-resource option to improve patients' outcomes. Such interventions may be delivered centrally or locally. There is limited information about clinicians' preferences for these alternative models of service delivery. This study investigated the views of cancer clinicians who had experience of a centralized model. Interviews were conducted with 16 surgeons and nurses across New South Wales, Australia, who had participated in a trial of a centralized telephone-based supportive care intervention. Content analysis was conducted. Data were analyzed inductively and responses organized into categories and then higher order themes. All clinicians valued the role of telephone follow ups as they would allow patients to ask questions and receive reassurance. Clinicians believed these services could reduce hospital presentations and provide equity and standardized care, particularly to those outside metropolitan centers. Although clinicians accepted a centralized model of delivery would be cheaper, most (n = 15) indicated a preference for local delivery. This preference was based on the perception that local nurses would have superior knowledge of the local context. Despite the improved feasibility of a telephone-only service, clinicians felt some face-to-face contact with patients was essential. Key at-risk groups to target were identified. Clinicians acknowledged there could be overlap with cancer nurses locally requiring local decisions about implementation. There was clear endorsement of additional telephone support with a preference for a local model of service delivery. The limited acceptability of centralized telephone-based supportive care interventions may restrict their uptake.
Publisher: Wiley
Date: 2022
DOI: 10.1111/ANS.17364
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2004
DOI: 10.1007/S10350-004-0723-8
Abstract: Clinicopathologic staging of colorectal cancer remains the best predictor of survival. Prognostication for an in idual with colorectal cancer remains elusive. This study was designed to investigate the incidence of free surface colorectal cancer cells detected by cytology during elective open curative resection, to correlate their presence with particular clinicopathologic variables and determine whether their presence was predictive of cancer-specific survival. Over a six-year period in one institution, all elective colon and intraperitoneal rectal cancer specimens were assessed during primary resection for the presence of free colorectal cancer cells by means of a simple and tested specimen imprint cytology methodology. Clinicopathologic variables were assessed prospectively and blinded to cytology results. All patients were followed up routinely until death and if the patient was not seen within the last six months, information was obtained from the New South Wales Registry of Births, Deaths and Marriages in Australia. Overall, 26 of 281 (9.25 percent) colorectal cancers had positive cytology for cancer cells on the peritoneal surface of the bowel. Poorly differentiated tumors were significantly associated with positive cytology. Tumor penetration, presence of vascular or neural invasion, mucinous characteristics, lymph node status, and operative procedure performed were not statistically significant predictors of positive cytology. Overall, 43 of the 281 patients (15.3 percent) died during the mean follow-up period of 49.2 months from cancer-related deaths. Of these patients, 8 had positive cytology and 35 had negative cytology results. Cancer-specific survival assessed with the log-rank test was significantly associated with positive cytology in univariate (P = 0.008) and multivariate analysis (P < 0.001). In this study, the presence of free surface colorectal cancer cells has been shown to be predictive of survival and is independent of direct peritoneal invasion and lymph node status. Thus, further assessment of this simple prognostic variable is warranted and selection of patients with positive cytology for possible adjuvant therapies may be beneficial.
Publisher: Wiley
Date: 16-08-2006
DOI: 10.1111/J.1445-2197.2006.03878.X
Abstract: There is currently a need to assess the reasons for non-entry of eligible patients into surgical randomized controlled trials to determine measures to improve the low recruitment rates in such trials. Reasons for non-entry of all eligible patients not recruited into the Australasian Laparoscopic Colon Cancer Study were prospectively recorded using a survey completed by the participating surgeons for a period of 6 months. In the 6-month period of the study, 51 (45%) out of 113 eligible patients examined by the 18 actively participating surgeons were recruited into the trial. Eighty-nine reasons were recorded for the non-entry of the 62 eligible patients. The most commonly recorded reason was preference for one form of surgery (42%) or the surgeon (31%) by the patient (45 patients (73%) in total). This was followed by lack of time (10 patients (16%)), hospital accreditation (7 patients (11%)) or staffing/equipment (6 patients (10%)). Concern about the doctor-patient relationship or causing the patient anxiety was recorded for three (5%) and two (3%) patients, respectively. Recruitment was positively associated with the availability of a data manager (chi2 = 19.91 P < 0.001, odds ratio (95% confidence interval) = 9.50 (3.53-25.53)) and negatively associated with an increased caseload (more than five eligible patients seen by the surgeon in the study period) (continuity adjusted chi2 = 16.052 P < 0.001, odds ratio (95% confidence interval) = 0.11(0.04-0.30)). Having a preference for one form of surgery by the patient or the surgeon was the most common reason for non-entry of eligible patients in the Australasian Laparoscopic Colon Cancer Study. Concern about the doctor-patient relationship played a minimal role in determining the outcome of recruitment. Patient and surgeon preferences, caseload and the distribution of supportive staff such as data managers according to patient population density should be considered in the planning of future trials.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2006
DOI: 10.1007/S10350-005-0264-9
Abstract: Surgical treatment of females with rectal endometriosis is challenging. The aim of this study was to review the results of laparoscopic intervention in the management of females with this complex disorder. All cases of complex tertiary referral pelvic endometriosis requiring laparoscopic surgical intervention of the rectum were identified and reviewed from a prospective database. Between April 1996 and August 2004, 95 patients with pelvic endometriosis involving the rectum had laparoscopic surgical procedures performed by one gynecologist and one colorectal surgeon. Eighty percent of rectal procedures were completed laparoscopically. Forty-three (45 percent) were treated with diathermy excision, 18 (19 percent) had shave partial-thickness disc excision, 20 (21 percent) had full-thickness disc excision (including 14 endoanally using a circular stapler), while 14 (15 percent) were managed with laparoscopic-assisted segmental low anterior resection. A history of rectal pain during defecation present only during menstruation (adjusted odds ratio=8.6, 95 percent confidence interval (CI)=1.8-41.2) and previous laparoscopy (adjusted odds ratio=3.2, 95 percent CI=1.2-8.3) independently predicted a need for more extensive surgery than diathermy excision. There were no rectal anastomotic leaks, with 8 percent overall morbidity. The only significant predictor of ongoing postoperative symptoms was a history of dyspareunia (P=0.03). Patients with complex endometriosis of the rectum can be safely managed laparoscopically using a multidisciplinary approach. This case series suggests that a history of rectal pain during defecation that occurs only during menstruation is predictive of females with more extensive rectal disease.
Publisher: Elsevier BV
Date: 07-2009
DOI: 10.1016/J.PEC.2008.12.013
Abstract: To ascertain the feasibility of implementing three decision support tools (DSTs) for people with rectal cancer within the surgical consultation. Twenty colorectal surgeons participated in a focus group or in idual interviews. Colorectal surgeons were also asked to complete a self-administered questionnaire. All surgeons responded encouragingly to the concept of DSTs. However, for every positive statement an accompanying caveat was made and these were either a criticism of each tool or a barrier to their implementation. Surgeons stated DSTs should be used by patients and surgeons together (80%). The majority (70-75%) thought each tool was 'useful' or 'extremely useful'. However, there were strong views that in their current form the DSTs would not feasible to be used within the surgical consultation. Time restraints, personal and clinical characteristics of the patient, the content of each tool, the potential negative impact on the doctor-patient relationship were noted as real barriers to their implementation. Surgeons have identified a number of barriers that may limit implementation of DSTs into routine clinical practice. Feasibility and implementation studies have the potential to provide important information to help guide development, evaluation and implementation of DSTs.
Publisher: Elsevier BV
Date: 2011
Publisher: Elsevier BV
Date: 04-2006
DOI: 10.1016/J.SURG.2005.08.014
Abstract: The low recruitment rates into surgical randomized controlled trials (RCTs) threaten the validity of their findings. We reviewed the reasons for nonentry of eligible patients into surgical RCTs that would form the basis for future prospective research. A systematic review of the English language literature for studies reporting reasons for nonentry of eligible patients into surgical RCTs and of recommendations made to improve the low recruitment rates. We reviewed 401 articles, including 94 articles presenting the results of 62 studies: 23 reports of recruitment into real surgical RCTs, 11 surveys of patients regarding hypothetical surgical RCTs, 10 surveys of clinicians and 18 literature reviews. The most frequently reported patient-related reasons for nonentry into surgical RCTs were preference for one form of treatment, dislike of the idea of randomization, and the potential for increased demands. Distrust of clinicians caused by a struggle to understand, explicit refusal of a no-treatment (placebo) arm, and the mere inability to make a decision were frequently reported in studies of real RCTs and patient surveys, but were not emphasized in surveys of clinicians and review articles. Difficulties with informed consent, the complexity of study protocols, and the clinicians' loss of motivation attributable to lack of recognition were the most commonly reported clinician-related reasons. There seems to be a discrepancy between real reasons for nonentry of eligible patients into surgical RCTS and those perceived by the clinicians, which require further prospective research. A summary and discussion of main recommendations sighted in the literature is presented.
Publisher: Wiley
Date: 04-05-2022
DOI: 10.1111/CODI.16149
Abstract: The decision‐making process to defunction a pelvic colorectal anastomosis involves complex heuristics and is framed by surgeon personality factors. Risk taking propensity may be an important factor in these decisions and patient preferences have not been evaluated alongside surgeons and nurses. A prospective cross‐sectional study involving a one‐off interview and questionnaire assessing how risk taking propensity affects nurse, surgeon and patient preferences for a temporary defunctioning ileostomy (TDI) was performed. The risk taking index (RTI) was employed to evaluate risk taking propensity and the validated prospective measures of preference instruments to evaluate preferences for stoma avoidance in several scenarios by asking the in idual to consider trading or gambling years of remaining life expectancy. One hundred and fifty participants met the inclusion criteria, which included 30 (20.0%) surgical nurses, 20 (13.3%) colorectal surgeons and 100 (66.7%) patients. Surgeons had a significantly higher RTI (mean ± SD: 26.8 ± 6.7) than patients (mean ± SD: 20.0 ± 9.8) and nurses (mean ± SD: 23.0 ± 6.6) p = 0.002. Surgeons would consider that it would be in a patient's best interest to have a TDI at an AL rate of 15% or greater, whereas nurses and patients would do so at 28% and 25%, respectively ( p = 0.007). Surgeons were shown to have a higher risk taking propensity than patients and nurses but a significantly lower threshold of AL where they would consider a TDI is in the best interest of the patient.
Publisher: Oxford University Press (OUP)
Date: 12-2015
DOI: 10.1002/BJS.9683
Abstract: The purpose of this study was to analyse retrospectively the pooled results after pelvic exenteration for locally advanced T4 rectal cancer. Historically, patients with T4 rectal cancers requiring pelvic exenteration have been offered only palliative surgery or no operation. The basic treatment principle was preoperative (chemo)radiotherapy, radical surgery and, in some patients, adjuvant chemotherapy. Risk factors for local recurrence, distant metastases and overall survival were studied in univariable and multivariable analyses. Ninety-five patients with T4 rectal cancer who underwent pelvic exenteration in two tertiary referral centres up to 2013 were studied. Clear margins (R0) were achieved in 87 per cent of patients. Adjuvant chemotherapy was administered in 33 per cent, independent of the resection margin, lymph node status and postoperative T category. The 5-year local recurrence rate was 17 per cent, with a distant metastasis rate of 16 per cent and overall survival rate of 62 per cent. In multivariable analysis the only factor associated with death was omission of adjuvant chemotherapy (P = 0·016). The effect of adjuvant chemotherapy was more pronounced in the elderly: patients aged over 70 years who had chemotherapy had a 5-year overall survival rate of 80 per cent, compared with 39 per cent of elderly patients who did not receive chemotherapy (P = 0·019). Pelvic exenteration led to an R0 resection rate of 87 per cent for T4 rectal cancer, giving good local control and overall survival comparable to population-based colorectal cancer survival rates. Adjuvant chemotherapy may improve overall survival further, even in the elderly.
Publisher: Oxford University Press (OUP)
Date: 05-06-2021
DOI: 10.1093/BJS/ZNAB105
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: American Society of Clinical Oncology (ASCO)
Date: 02-2005
Publisher: American Medical Association (AMA)
Date: 06-10-2015
Abstract: Laparoscopic procedures are generally thought to have better outcomes than open procedures. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection. To determine whether laparoscopic resection is noninferior to open rectal cancer resection for adequacy of cancer clearance. Randomized, noninferiority, phase 3 trial (Australasian Laparoscopic Cancer of the Rectum ALaCaRT) conducted between March 2010 and November 2014. Twenty-six accredited surgeons from 24 sites in Australia and New Zealand randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. Open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238). The primary end point was a composite of oncological factors indicating an adequate surgical resection, with a noninferiority boundary of Δ = -8%. Successful resection was defined as meeting all the following criteria: (1) complete total mesorectal excision, (2) a clear circumferential margin (≥1 mm), and (3) a clear distal resection margin (≥1 mm). Pathologists used standardized reporting and were blinded to the method of surgery. A successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and 208 patients (89%) in the open surgery group (risk difference of -7.0% [95% CI, -12.4% to ∞] P = .38 for noninferiority). The circumferential resection margin was clear in 222 patients (93%) in the laparoscopic surgery group and in 228 patients (97%) in the open surgery group (risk difference of -3.7% [95% CI, -7.6% to 0.1%] P = .06), the distal margin was clear in 236 patients (99%) in the laparoscopic surgery group and in 234 patients (99%) in the open surgery group (risk difference of -0.4% [95% CI, -1.8% to 1.0%] P = .67), and total mesorectal excision was complete in 206 patients (87%) in the laparoscopic surgery group and 216 patients (92%) in the open surgery group (risk difference of -5.4% [95% CI, -10.9% to 0.2%] P = .06). The conversion rate from laparoscopic to open surgery was 9%. Among patients with T1-T3 rectal tumors, noninferiority of laparoscopic surgery compared with open surgery for successful resection was not established. Although the overall quality of surgery was high, these findings do not provide sufficient evidence for the routine use of laparoscopic surgery. Longer follow-up of recurrence and survival is currently being acquired. anzctr.org Identifier: ACTRN12609000663257.
Publisher: Wiley
Date: 25-12-2022
DOI: 10.1111/ANS.18220
Abstract: Pelvic exenteration surgery is complex, necessitating co‐ordinated multidisciplinary input and improved referral pathways. A state‐wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. All patients referred for discussion between August 2021 and July 2022 to the SA State‐wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty‐eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non‐malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non‐surgical treatment, palliation, or re‐discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). The establishment of a dedicated state‐wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
Publisher: MyJove Corporation
Date: 25-09-2011
DOI: 10.3791/3322
Publisher: Wiley
Date: 12-02-2014
DOI: 10.1111/CODI.12473
Abstract: Enterocutaneous fistula (ECF) presents a complex management problem with significant mortality and morbidity. The aim of this study was to assess the outcome of patients undergoing surgical cure for ECF and to predict factors that might relate to increased postoperative morbidity. Medical records of all patients who underwent definitive surgery for cure of an ECF within our colorectal surgery unit between 2000 and 2010 were reviewed. Forty-one patients (18 male) were identified, in whom 44 definitive procedures were performed. The median age was 54 (17-81) years. The median postoperative length of stay in hospital was 14 (2-213) days. Half (50%) of the ECFs occurred as a postoperative complication followed by spontaneous fistulation in Crohn's disease (36%). The interval to definitive surgery was influenced by the aetiology of the fistula. The median time to surgery after formation of postoperative fistula was 240 days (7.9 months). There was no 30-day postoperative mortality. There were two (4.5%) recurrences at 3 months. Thirty-eight (86%) patients suffered postoperative morbidity as defined by the Clavien-Dindo classification. High-grade morbidity occurred in 32% of patients. On univariate analysis, factors identified as being significantly associated with high-grade morbidity included a fistula output of > 500 ml/day (P = 0.004) in patients with postoperative ECF, malnutrition at presentation (P = 0.04) and a serum albumin value of < 30 g/l (P = 0.02) in patients with spontaneous ECF due to Crohn's disease. The majority of persistent complex ECFs can be cured surgically with low mortality and recurrence in a multidisciplinary setting. Postoperative morbidity, however, remains a significant burden.
Publisher: Wiley
Date: 21-06-2021
DOI: 10.1111/ANS.17016
Abstract: Despite relatively few COVID‐19 cases within New South Wales, the uncertainty surrounding the pandemic has prevented a return to business as usual for the delivery of surgical services. This study aims to describe the evolving impact of COVID‐19 on surgical activity and patient outcomes at a major public tertiary referral hospital. A retrospective cohort study involving adult surgical patients treated at a large public tertiary referral hospital in Sydney, Australia. Surgical activity, surgical outcomes and patient demographics were compared across two time periods, including the ‘first wave’ (February–May 2020 vs. February–May 2019) and the ‘perseverance phase’ (June–September 2020 vs. June–September 2019). Variables across both groups were compared using an independent t test or chi‐squared test. A −32% reduction in surgical separations was observed in the ‘first wave’, including −20% emergency and −37% elective. In the ‘perseverance phase’, there was a −19% reduction in surgical activity, including 0% emergency and −27% elective. The average length of stay, intensive care admissions, postoperative complications and in‐hospital costs significantly increased in the ‘first wave’. The proportion of public patients increased marginally (3%) in the ‘first wave’. The impact of COVID‐19 was most severely experienced in the initial months of the pandemic and observed in the number of patients treated. Although there was an initial effect on surgical outcomes, overall, the standard of care remained safe. The delivery of elective surgery remains a challenge and reflects the ongoing system‐wide changes that are required to manage the COVID‐19 pandemic.
Publisher: Wiley
Date: 14-07-2023
DOI: 10.1111/ANS.18588
Abstract: Ileal pouch‐anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. A retrospective data linkage study of the NSW population over a 19‐year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3–10.8%) and 10.6% (95% CI 8.0–13.1%) at 5‐ and 10‐years, respectively. Increasing age and non‐elective admission were associated with higher failure rates. One‐third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three‐quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2008
Publisher: Oxford University Press (OUP)
Date: 29-04-2008
DOI: 10.1002/BJS.6287
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-1993
DOI: 10.1007/BF02051183
Abstract: The evidence that BCG (bacille Calmette-Guerin) vaccine may increase the ability of the immune system to fight off pathogens other than tuberculosis has been studied in the past. This nonspecific immunity gained our interest, especially after initial reports of less cases in countries with universal BCG vaccination. In hopes of possible protective immunity, all staff of the Emirates International Hospital (United Arab Emirates) were offered a booster BCG vaccine in early March 2020. All the hospital staff were then tested for Covid-19 infection by the end of June 2020. We ided the subjects into two groups: booster vaccinated versus unvaccinated. The rate of Covid-19 infection was compared between the groups. Criteria included all staff who were offered the vaccine. Seventy-one subjects received the booster vaccination. This group had zero cases of positive COVID 19 infection. Two hundred nine subjects did not receive the vaccination, with 18 positive PCR confirmed COVID 19 cases. The infection rate in the unvaccinated group was 8.6% versus zero in the booster vaccinated group (Fisher's exact test
Publisher: Wiley
Date: 12-08-2017
DOI: 10.1111/ANS.12814
Abstract: To evaluate the results obtained from cases of perianal Paget's disease (PPD) and to provide a current perspective in the diagnostic evaluation and surgical management of this condition. A retrospective review of a single quaternary referral centre's experience with PPD from January 1994 to December 2013 was performed. Medical records were reviewed to collect data on demographics, preoperative investigations, complications, pathology and recurrence. A review of existing literature was also performed. Five patients (four females, one male) with histologically confirmed PPD were identified. The median age of presentation was 72 (range 61 to 78). Three patients were recurrences following previous excisions and first presentations in two patients. Only one patient had an underlying diagnosis of cancer. The median time to diagnosis was 24 months. Four patients underwent wide local excision with skin graft and/or local flap reconstruction and one patient required an abdominoperineal excision for recurrence. Four patients had involved lateral margins despite wide local excision but follow-up to date has only revealed one local recurrence. A review of available literature suggests that synchronous cancers can occur in up to 33% of patients and that a further 10% may be associated with metachronous cancers. Surveillance recommendations seem anecdotal and do not appear to be supported by available literature. PPD is a management challenge. Association with synchronous and metachronous carcinomas may not be as strong as initially thought. Surgery is the mainstay treatment with the need to balance between minimizing disease recurrence and functional sequelae from excessive tissue loss.
Publisher: Springer Science and Business Media LLC
Date: 15-07-2011
Publisher: Wiley
Date: 07-09-2017
DOI: 10.1002/CNCR.30326
Abstract: Improving care coordination is a key priority for health services. The aims of this study were to identify patient‐ and health service–related predictors of poorly coordinated care and to explore patient preferences to assist care coordination. Patients with incident colorectal cancer, identified from a state‐wide cancer registry, completed a self‐report questionnaire 6 to 8 months after their diagnosis. Care coordination was assessed with the Cancer Care Coordination Questionnaire for Patients. Multiple linear regression models were used to predict factors associated with a poor experience with cancer care coordination. Among 560 patients (56% response rate), care coordination experiences were normally distributed (mean score, 76.1 standard deviation, 10.9). Patients who had 3 or more comorbid conditions (β, –4.56 standard error [SE], 1.46 P = .006), little or no understanding of the health system (β, –4.34 SE, 0.94 P .001), and no regular general practitioner (GP β, –4.09 SE, 2.07 P = .049) experienced poorer care coordination. At the health service level, patients who did not receive a written pretreatment plan (β, –4.15 SE, 0.95 P .001) or did not see a cancer care coordinator (β, –3.29 SE, 1.03 P = .001) had lower scores. The most preferred resources included information packs (92%), written care plans (88%), and improved access to their own personal medical records (electronic, 86 paper, 84%), with most patients preferring a shared GP and surgeon care model. There was wide variation in experiences across the state. The factors associated with lower scores provide a focus for targeted strategies for improving patients' experience with colorectal cancer care coordination. Cancer 2017 :319–326. © 2016 American Cancer Society .
Publisher: Springer Science and Business Media LLC
Date: 28-12-2014
Publisher: Wiley
Date: 21-11-2023
DOI: 10.1111/CODI.16391
Abstract: Lynch syndrome is an inherited cancer syndrome associated with an increased lifetime risk of colorectal cancer (CRC) and characterized by germline mutations to one of four DNA mismatch repair (MMR) genes. Immunohistochemical (IHC) testing is used to screen for Lynch syndrome however, despite routine completion following resection of primary CRC, it is only variably completed following resection of recurrent disease. This may be significant, as MMR protein expression can change from primary to recurrent CRC. The primary aim of this study is to investigate how MMR profiles change from primary to recurrent CRC the secondary aim is to assess rates of MMR testing of primary and recurrent disease. We conducted a retrospective analysis of patients undergoing surgery for recurrent CRC from 2018–19 at a high‐volume institution. MMR profiles were obtained following both primary and recurrent resection of CRC, and MMR protein expression was evaluated from both time points. A total of 107 patients met the inclusion criteria and IHC results were obtained for both primary and recurrent resections in 85 cases. MMR profiles changed in nine patients (10.6%), with a loss of staining from primary to recurrent disease in six (7.1%) and a gain of staining in three (3.5%). IHC testing was completed following 88.7% of primary and 39.3% of recurrent resections. MMR profiles can change from primary to recurrent CRC and repeat MMR testing for recurrent CRC is completed in only a minority of cases.
Publisher: Elsevier BV
Date: 08-2021
DOI: 10.1016/J.EJSO.2021.03.258
Abstract: Reporting of pelvic exenteration specimens for locally recurrent rectal cancer (LRRC) can be challenging for structured pathological analysis and currently, there is a lack of specific guidelines. The aim of this study was to assess the quality of pathology reporting in a cohort of patients who underwent pelvic exenteration for LRRC in a high-volume tertiary unit. In a retrospective analysis of histopathology reports of consecutive patients who underwent pelvic exenteration for LRRC from 1996 to 2018, the quality of pathology reporting was assessed using the Structure Reporting Protocol for Colorectal Cancer. The primary endpoint was the completeness of pathology reporting, secondary endpoints were the association between the reporting style (narrative versus synoptic), reporting period (the first half versus the second half), as well as the activity of the pathologists with the completeness of pathology reporting. 221 patients who underwent pelvic exenteration for LRRC were included into the study. There was a high variability in completeness of pathology reporting within the cohort, ranging from 9.5% to 100%. Notably, microscopic clearance was reported in only 92.4% of the reports. Overall, a significantly higher rate of completeness was observed in synoptic reports when compared to narrative reports and in more recent compared to earlier reports. There was no significant association between the activity of pathologists and the completeness of reporting. This study shows a significant variability in the quality of reporting in pelvic exenteration for LRRC. The use of synoptic reporting clearly resulted in more complete reports.
Publisher: Wiley
Date: 28-06-2008
DOI: 10.1111/J.1445-2197.2008.04578.X
Abstract: Post-traumatic stress disorder (PTSD) is a common sequel to physical trauma, but there is disagreement regarding the predictors of this condition. This study aims to examine the role of physical, psychosocial and compensation-related factors in the development of PTSD following major trauma. Participants were consecutive adult patients presenting to one major trauma centre with major trauma (Injury Severity Score 16 or higher). Baseline characteristics and clinical data were obtained from the hospital trauma database. The presence of PTSD (as measured by the PTSD Checklist, civilian version) and additional data were obtained from a questionnaire mailed to patients between 1 and 6 years after the injury. Multiple linear regression was used to identify significant independent associations with PTSD. Among 355 patients (61.0% response fraction), 129 (36.3%, 95% confidence interval 43.2-53.2%) were classed as having PTSD. Symptoms of PTSD were not significantly related to measures of injury severity, the time since the injury, education level, household income or employment status at the time of injury. PTSD was significantly associated with younger age (P < 0.0001), the presence of chronic illnesses (P < 0.0001), unemployment at the time of follow up (P < 0.0001), use of a lawyer (P < 0.0001), blaming others for the injury (P = 0.003) and having an unsettled compensation claim (P = 0.007). Post-traumatic stress disorder after major trauma was not related to measures of injury severity, but was related to other factors, such as blaming others for the accident and the processes involved in claiming compensation.
Publisher: Wiley
Date: 03-2021
DOI: 10.1111/ANS.16294
Publisher: Mary Ann Liebert Inc
Date: 04-2004
DOI: 10.1089/109264204322973808
Abstract: Laparoscopic ileocolic (LI) resection for Crohn's disease has several potential advantages over the traditional open technique. The objective of this study was to compare early surgical outcomes in patients having laparoscopic versus open ileocolic resections for Crohn's disease. Data collected prospectively from 21 patients having LI resection for Crohn's disease between 1995 and 2001 were compared to data from 19 patients having open ileocolic resection for Crohn's disease between 1990 and 1995. Patients in both groups had similar ages, sex distribution, and rates of previous abdominal surgery. Mean operating time was not significantly different between the groups. There was a nonsignificant trend to less postoperative analgesic requirement in the laparoscopic group. Resumption of liquid (P <.001) and solid (P =.01) diet, return of bowel function [flatus (P =.008), feces (P =.008)] and time to discharge (P =.001) all occurred significantly more quickly in the laparoscopic group. There was no difference in the rates of morbidity between the two groups. LI resection for Crohn's disease appears to be safe and has comparable if not superior results to open surgery in the short term.
Publisher: Wiley
Date: 07-2003
DOI: 10.1046/J.1445-1433.2003.02611.X
Abstract: Clinical epidemiology, which is concerned with the application of epidemiological principles to patient care, provides the scientific basis for evidence-based medicine. The present paper reviews the epidemiological concepts of selection bias, measurement bias and confounding in surgical research and discusses ways in which these sources of bias can be minimized in surgical studies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1993
DOI: 10.1007/BF02050300
Publisher: Wiley
Date: 08-2008
DOI: 10.1111/J.1445-2197.2008.04616.X
Abstract: The best operation for high anal fistulas is difficult to nominate because they have varying cure and incontinence rates. The objective of this study was to quantify the relative importance of the outcomes of cure, continence and other quality-of-life (QOL) factors. A questionnaire was sent in October 2006 to patients with anal fistulas and to colorectal surgeons. Participants were asked to nominate up to five QOL domains. They were also asked to choose between two treatment options (with different cure and continence rates). Seventy-five of 134 (56%) surgeons and 28 of 199 (14%) patients replied. Comparing draining and cutting setons, surgeons (57 of 71, six neutral) favoured the former and patients (15 of 27, four neutral) preferred the latter. Comparing mucosal advancement flap with cutting seton, both surgeons (71 of 75, four neutral) and patients (13 of 26, two neutral) preferred the former. There was greater uncertainty among surgeons when comparing draining seton (23) and mucosal advancement flap (33), with 18 neutral. Patients preferred the mucosal advancement flap (19) to draining seton (three) and four were neutral. In direct questioning of objectives, surgeons nominated continence, leakage, pain, cure and sepsis as the five most important QOL factors. Patients nominated independent activity, pain, continence, psychological health and leakage as their five factors. Functional impairment and QOL do not necessarily correlate. The development of a validated specific QOL scale for patients with anal fistulas would be important to compare the results of different treatment options. This scale should include social and psychological factors in addition to the physical outcomes.
Publisher: BMJ
Date: 07-2004
DOI: 10.1136/EBM.9.4.112
Publisher: Wiley
Date: 03-03-2023
DOI: 10.1111/ANS.18356
Abstract: To determine surgical, survival and quality of life outcomes across different tumour streams and lessons learned over 28 years. Consecutive patients undergoing pelvic exenteration at a single, high volume, referral hospital, between 1994 and 2022 were included. Patients were grouped according to their tumour type at presentation as follows, advanced primary rectal cancer, other advanced primary malignancy, locally recurrent rectal cancer, other locally recurrent malignancy and non‐malignant indications. The main outcomes included, resection margins, postoperative morbidity, long‐term overall survival, and quality of life outcomes. Non‐parametric statistics and survival analyses were performed to compare outcomes between groups. Of the 1023 pelvic exenterations performed, 981 (95.9%) unique patients were included. Most patients underwent pelvic exenteration due to locally recurrent rectal cancer ( N = 321, 32.7%) or advanced primary rectal cancer ( N = 286, 29.2%). The rates of clear surgical margins (89.2% P 0.001) and 30‐days mortality were higher in the advanced primary rectal cancer group (3.2% P = 0.025). The 5‐year overall survival rates were 66.3% in advanced primary rectal cancer and 44.6% in locally recurrent rectal cancer. Quality of life outcomes differed across groups at baseline, but generally had good trajectories thereafter. International benchmarking revelled excellent comparative outcomes. The results of this study demonstrate excellent outcomes overall, but significant differences in surgical, survival and quality of life outcomes across patients undergoing pelvic exenteration due to different tumour streams. The data reported in this manuscript can be utilized by other centres as benchmarking as well as proving both subjective and objective outcome details to support informed decision‐making for patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2013
Publisher: American Thoracic Society
Date: 04-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2003
Publisher: Wiley
Date: 28-12-2023
DOI: 10.1111/CODI.16442
Abstract: This study aimed to investigate the implementation and pain‐related outcomes of a peri‐operative pain‐management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital. This is a single‐site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain‐management algorithm regarding the use of opioid‐sparing multimodal analgesia was developed between the departments of anaesthesia, pain management and intensive care. The primary outcomes were: compliance with a pain‐treatment algorithm compared with a similar retrospective surgical patient cohort in 2013–2014 and requirements for regular doses of opioid analgesia at discharge, measured in oral morphine equivalent daily dose (oMEDD). Following the introduction of a pain‐management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017–2018 cohort compared with 13/73 (17.8%) of the 2013–2014 cohort ( p 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge, from 150 mg (interquartile range [IQR]: 75.0–235.0 mg) in the 2013–2014 cohort to 10 mg (IQR: 0.00–45.0 mg) in the 2017–2018 cohort ( p 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score) or oMEDD in the first 7 days following surgery. Since implementation of a novel peri‐operative pain‐treatment algorithm, the use of opioid‐sparing regional techniques and preperitoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.
Publisher: Wiley
Date: 07-2022
DOI: 10.1111/CODI.16203
Abstract: As the “empty pelvis syndrome” continues to pose challenges in patients undergoing radical pelvic exenteration, there remains an ongoing need to consider solutions to mitigate or avoid its associated morbidity. As such, this study aims to review the long‐term outcomes of a proposed strategy of pelvic reconstruction with BioA mesh. We conducted a retrospective observational cohort study, reviewing cases of pelvic exenteration and/or pelvic bone resection involving BioA mesh pelvic reconstruction between 2017 and 2021 at our quaternary institution, identified from a prospectively collected database. The primary outcome was pelvic complications including perineal fistula, wound breakdown and pelvic collections. Over a 4‐year period, there were a total of 36 patients who had pelvic exenteration and/or pelvic bone resection with BioA mesh pelvic reconstruction. The overall pelvic complication rate was 36% ( n = 13), including 11 symptomatic pelvic collections, two enteroperineal fistulas, and no cases of perineal hernia. Reoperation was required in two patients. There was no perioperative mortality. Given that pelvic complications post BioA mesh reconstruction are of an acceptable rate and can be considered minor, using this technique is a safe and practical strategy in patients undergoing major pelvic surgery with or without pelvic bone resection.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2003
DOI: 10.1007/S10350-004-6643-9
Abstract: A prospective, three-armed, randomized, controlled trial was performed to assess whether pelvic floor exercises with biofeedback using anal manometry or transanal ultrasound are superior to pelvic floor exercises with feedback from digital examination alone in terms of continence, quality of life, physiologic sphincter strength, and compliance. Its secondary objectives were to assess whether there are any differences in these outcomes between biofeedback with transanal ultrasound vs. anal manometry and to correlate the physiologic measures with clinical outcome. One hundred twenty patients with mild to moderate fecal incontinence were randomized into one of three treatment groups: biofeedback with anal manometry, biofeedback with transanal ultrasound, or pelvic floor exercises with feedback from digital examination alone. Commencing one week after an initial 45-minute assessment session, patients attended monthly treatments for a total of five sessions. Each session lasted 30 minutes and involved sphincter exercises with biofeedback that involved instrumentation or digital examination alone, and patients were encouraged to perform identical exercises twice per day between outpatient visits. One hundred two patients (85 percent) completed the four-month treatment program. Across all treatment allocations, patients experienced modest but highly significant improvements in all nine outcome measures during treatment, with 70 percent of all patients perceiving improvement in symptom severity and 69 percent of patients reporting improved quality of life. With the possible exception of isotonic fatigue time, there were no significant differences between the three treatment groups in compliance, physiologic sphincter strength, and clinical or quality-of-life measures. Correlations between physiologic measures and clinical outcomes were much stronger with ultrasound-based measures than with manometry. Although patients in this study who completed pelvic floor exercises with feedback from digital examination achieved no additional benefit from biofeedback and measurement with transanal ultrasound or manometry, it may be that the guidance received through digital examination alone offered patients in the pelvic floor exercise group an effective biofeedback mechanism. Contrary to our hypothesis, the use of transanal ultrasound offered no benefit over manometry, but the use of ultrasound for isotonic fatigue time and isometric fatigue contractions provided potentially important physiologic measures that require further study. This study has confirmed, through a large s le of patients, that pelvic floor retraining programs are an effective treatment for improving physiologic, clinical, and quality-of-life parameters in the short term.
Publisher: Oxford University Press (OUP)
Date: 19-07-2021
DOI: 10.1093/BJS/ZNAB127
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2014
Publisher: Elsevier BV
Date: 08-2017
DOI: 10.1016/J.UROLOGY.2017.03.015
Abstract: Robotic surgery represents a new horizon in minimally invasive urologic surgery. This systematic review of the literature and meta-analysis examines the effectiveness of robotic surgery compared with laparoscopic or open surgery for major uro-oncological procedures. Twenty-five articles reported findings from 8 trials of prostatectomy (4 trials) and cystectomy (4 trials) including 1033 participants. Robotic surgery is comparable with laparoscopic or open surgery for oncological outcomes and overall complications, and provides somewhat better functional outcome when compared with laparoscopic and open surgery.
Publisher: Oxford University Press (OUP)
Date: 26-05-2004
DOI: 10.1002/BJS.4640
Abstract: The safety and efficacy of laparoscopic resection (LR) for colorectal cancer remains to be established. A meta-analysis of randomized clinical trials comparing the short-term outcomes of laparoscopic with those of open resection for colorectal cancer was undertaken. A literature search was performed for relevant articles published by the end of 2002. Two reviewers independently appraised the trials using a predetermined protocol. Results were analysed using Comprehensive Meta-analysis®. The outcomes of 2512 procedures from 12 trials were analysed. LR took on average 32·9 per cent longer to perform than open resection but was associated with lower morbidity rates. Specifically, wound infection rates were significantly lower (odds ratio 0·47 (95 per cent confidence interval 0·28 to 0·80) P = 0·005). In patients undergoing LR, the average time to passage of first flatus was reduced by 33·5 per cent, that to tolerance of a solid diet by 23·9 per cent and that to 80 per cent recovery of peak expiratory flow by 44·3 per cent. Early narcotic analgesia requirements were also reduced by 36·9 per cent, pain at rest by 34·8 per cent and during coughing by 33·9 per cent, and hospital stay by 20·6 per cent. There were no significant differences in perioperative mortality or oncological clearance. LR for colorectal cancer is associated with lower morbidity, less pain, a faster recovery and a shorter hospital stay than open resection, without compromising oncological clearance.
Publisher: Wiley
Date: 02-02-2015
DOI: 10.1111/JEP.12327
Abstract: Previous studies investigating agreement between data sources for co-morbidity and adjuvant therapy information have suggested agreement varies depending on how the information is collected. The aim of this study was to compare agreement among three data sources: patient report, clinician report and medical record. Data were collected as part of a nurse-delivered telephone intervention (the CONNECT programme). Patient report was collected using a self-administered questionnaire. Clinician report was collected from the patient's treating surgeon. Medical record information was extracted by a member of the research team. The proportion of specific agreement [positive (PA) and negative agreement (NA)] and Kappa statistics were calculated. The study s le comprised 756 surgical patients with colorectal cancer. For the majority of co-morbidities the lowest level of agreement was found between the patient and clinician (PA 0.29-0.64, Kappa values ranged from 0.22 to 0.58). The highest agreement and Kappa values for co-morbidities were generally found between the patient report and medical record (PA 0.36-0.80 and NA 0.92-0.99 Kappa 0.34-0.77). There was good agreement between patient and clinician reports for receipt adjuvant therapy {Kappa 0.78 [confidence interval (CI) 0.72-0.84] and 0.84 [CI 0.80-0.88], respectively PA 0.87 and 0.92, respectively}. No consistent pattern in the predictors of non-agreement was found. Given there was higher agreement between patient report and medical record review, the use of patient self-report questionnaires to ascertain co-morbid conditions remains a valid method for health services research.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2003
DOI: 10.1007/S10350-004-6798-4
Abstract: Gallstone disease is reported to be higher in patients with Crohn's disease than in the general population. This study was designed to determine the prevalence of cholecystectomy in patients with Crohn's ileitis, attempt to identify any associated risk factors, and determine whether it is justified to perform prophylactic cholecystectomy during ileocolic resection. A total of 191 patients with Crohn's ileitis who were treated medically or who had an ileocolic resection were retrospective reviewed. A questionnaire survey was performed. Telephone interviews were conducted for the non respondents. Further review of medical records was performed to determine the details of admissions for any gallstone disease and/or subsequent cholecystectomy. A control group matched for age and gender was obtained. A total of 191 questionnaires were mailed, and the overall response rate was 70.2 percent (134/191) after telephone interview follow-up. There were 2 of 45 medical and 18 of 89 surgical patients with symptomatic cholelithiasis, i.e., 14.9 percent (20/134) of respondents. As a result, 2 patients (1.5 percent) required endoscopic sphincterotomy, 17 patients (12.7 percent) needed cholecystectomy, and 1 patient (0.7 percent) did not have any intervention. Only five patients had a cholecystectomy after their ileal resections. In the control group of 150 patients, 15 patients (14 females mean age, 51.9 years range, 34-78 years) had previous cholecystectomy. There was no significant difference with prevalence of cholecystectomy in Crohn's patients compared with controls (17/134 vs. 15/150 P = not significant). Furthermore, the number of ileal resections did not affect the cholecystectomy rate, but patients who had >30 cm of ileum resected were more likely to have cholecystectomy (P = 0.056). The prevalence of gallstone disease in Crohn's ileitis requiring cholecystectomy is similar to that of the general population with a female predominance. In addition, the number of patients requiring cholecystectomy after ileal resection was low. Thus, synchronous prophylactic cholecystectomy during ileocolic resection for Crohn's ileitis is not justified.
Publisher: Oxford University Press (OUP)
Date: 22-06-2004
DOI: 10.1002/BJS.4643
Abstract: The introduction of new laparoscopic techniques has important cost implications. The aim of this study was to compare the cost effectiveness of laparoscopic rectopexy with that of open abdominal rectopexy for full-thickness rectal prolapse. A cost effectiveness study was conducted alongside a randomized trial of laparoscopic versus open abdominal rectopexy. The efficacy trial demonstrated significant subjective and objective differences in favour of the laparoscopic technique. The mean operating time was 51 min longer for laparoscopic rectopexy than for the open procedure. Laparoscopic disposables incurred a mean cost of £291 per patient. The mean duration of hospital stay was significantly shorter for the laparoscopic group (P = 0·001). Laparoscopic rectopexy was associated with an overall mean cost saving of £357 (95 per cent confidence interval £164 to £592 P = 0·042) per patient. Laparoscopic rectopexy is associated with superior clinical outcomes and is cheaper than the open approach.
Publisher: Wiley
Date: 06-2006
DOI: 10.1111/J.1445-2197.2006.03747.X
Abstract: The selective publication of articles based on factors, such as positive outcome, statistical significance and study size is known as publication bias. If publication bias is present, any clinical decision based on a review of the published work will also be biased. Publication bias has been shown in various specialties, based on review of publication rates for abstracts presented at major scientific meetings. This study was conducted to investigate publication bias in orthopaedics. Abstracts presented at the 1998 Australian Orthopaedic Association Annual Scientific Meeting were reviewed independently by two reviewers. Details of s le size, study setting, country of origin, outcome and study type were recorded for each abstract. Publication within 5 years was ascertained by electronic searching of Medline and Embase databases and direct author contact. Logistic regression analysis was used to identify predictors of publication. The overall publication rate was 31%. Publication was more likely if the study was a laboratory study, rather than a clinical study (odds ratio (OR), 3.45 95% confidence interval (CI) 1.69-7.01, P < 0.001). S le size, country of origin, study type, statistical significance and positive outcome were not significantly associated with publication. According to this study, laboratory studies were significantly more likely to be published than clinical studies. In contrast to previous studies, publication bias due to the selective publication of papers with a positive outcome or those reporting statistical significance was not found.
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1016/J.BREAST.2014.01.014
Abstract: Management of the ICBN during axillary dissection is controversial and the ision of ICBN is often trivialised. The effect of iding the ICBN, and its association with sensory disturbance, is unclear. A systematic review and meta-analysis was performed to evaluate the effect of preserving the ICBN during axillary dissection. A systematic literature review and meta-analysis is performed according to the PRISMA and Cochrane Collaboration guidelines. Three RCTs and four non-RCTs were reviewed. A meta-analysis demonstrated that the incidence of sensory disturbance was significantly lower with preservation of ICBN compared to ision of the ICBN with Mantel-Haenzel combined odds ratio 0.31 (0.17-0.57, 95% CI). There was relatively low level of heterogeneity (I(2) = 19%, χ(2) = 2.48, df = 2). The sensory disturbance was more likely to be hyposensitivity when compared to hypersensitivity (p < 0.0001). No difference on number of lymph nodes dissected or operating time was noted. This meta-analysis demonstrates that ision of the ICBN is associated with higher risk of sensory disturbance, and that the nature of this sensory disturbance is more likely to be hyposensitivity, attributable to reduced nerve function.
Publisher: Informa UK Limited
Date: 08-2013
DOI: 10.2147/PPA.S50970
Publisher: Wiley
Date: 06-2003
DOI: 10.1046/J.1445-2197.2003.T01-1-02648.X
Abstract: The aim of the present paper is to provide an economic perspective on current and emerging issues relating to surgical decision-making. The central issue discussed in the paper is choice and how this relates to patient management. The paper explores three factors that may influence the nature of choice they are--evidence-based medicine, patient involvement in making choices and the role of cost-effectiveness analysis in surgery. Together, these factors are driving a shift from the traditional model of care based on medical beneficence to one based more on in idual patient autonomy. This shift has been described as a move towards 'evidence-based patient choice' (EBPC). The concept of EBPC is relatively new and ill defined. Yet it encapsulates what is happening now and what will occur more dramatically in the future that is, the nature of the relationship between surgeon and patient is changing. We hope that this paper will provoke discussion on the concept of EBPC and cost-effectiveness analysis in surgical decision-making.
Publisher: Wiley
Date: 18-10-2021
DOI: 10.1111/ANS.17275
Abstract: To describe our institutional experience in the management of locally advanced primary, and recurrent pelvic sarcoma through pelvic exenteration (PE). Patients undergoing PE for locally advanced primary or recurrent pelvic sarcoma between 2003 and 2017 were identified from a prospectively maintained database at a single quaternary referral hospital in Sydney, Australia were eligible for review. The primary outcomes measured were surgical resection margin and survival. Secondary outcome measures included 30‐day morbidity, in hospital length of stay (LOS) and return to theatre. There were 29 patients who underwent PE for pelvic sarcoma during the study period, with 55% ( n = 16) having advanced primary tumours and 45% ( n = 13) having recurrent disease. The R0 resection rate was 52% ( n = 15) and five‐year‐survival of 38% ( n = 11). The R0 resection was noted to be higher in patients having primary advanced tumours (56%) compared to those with recurrent disease (46%), however this failed to reach statistical significance in this cohort. There was no recorded 30‐day mortality. Grade 3 or higher Clavien‐Dindo complications were uncommon (14%), but more likely in patients undergoing surgery for recurrent disease (75%). In our cohort of patients with locally advanced and recurrent disease, more than 50% achieved an R0 resection. Recurrent disease makes R0 resection more difficult and can lead to higher morbidity, need for 30‐day re‐intervention and longer in hospital LOS. PE surgery remains the only curative option for locally advanced, and recurrent sarcoma in the pelvis, and can be performed with acceptable survival and morbidity outcomes.
Publisher: Elsevier BV
Date: 06-2014
DOI: 10.1016/J.EJSO.2013.09.024
Abstract: Urine leak following pelvic exenteration for locally advanced pelvic malignancy is a major complication leading to increased mortality, morbidity and length of stay. We reviewed our experience and developed a diagnostic and management algorithm for urine leaks in this patient population. Consecutive patients who underwent en bloc cystectomy and conduit formation as part of pelvic exenteration at a single quaternary referral centre from 1995 to 2012 were reviewed. Patients with urine leak were identified. Medical records were reviewed to extract data on diagnosis and management and a suggested clinical algorithm was developed. Of 325 exenterations, there were 102 conduits, of which 15 patients (15%) developed a conduit related urine leak. Most (14/15) patients were symptomatic. Diagnosis was made by drain creatinine studies (12/15) and/or imaging (15/15). Management comprised of conservative management, radiologic urinary ersion, early surgical revision and late surgical revision in 3, 11, 2 and 1 patients respectively. Important lessons from our 17 year experience include a high index of suspicion in a patient who is persistently septic despite appropriate treatment, the importance of regular drain creatinine studies, CT (computer tomography) with delayed images (CT intravenous pyelogram) when performing a CT for investigation of sepsis and early aggressive management with radiologic urinary ersion to facilitate early healing. Urine leak after pelvic exenteration is a complex problem. Conservative management usually fails and early diagnosis and intervention is the key. It is hoped that our algorithms will facilitate diagnosis and subsequent management of this group of patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2014
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2017
Publisher: Wiley
Date: 14-03-2014
DOI: 10.1111/CODI.12538
Abstract: When treating patients with refractory ulcerative colitis (UC), the choice between escalating medical management or surgery can be difficult. The aim of this study was to quantify the preferences of patients and clinicians for the treatment options in UC. Ulcerative colitis outpatients were interviewed to measure their preferences for five scenarios examining the management of acute and chronic UC, using a prospective measure of preference method that generates two utility scores: willingness and amount of expected life to trade or gamble. A self-administered questionnaire was mailed to Australian and New Zealand colorectal surgeons and gastroenterologists. Fifty-five patients (26 medical and 29 surgical), 91 surgeons and 78 gastroenterologists were surveyed. In the acute setting, 89% of patients, 69% of gastroenterologists and 55% of surgeons were willing to trade part of their life expectancy to avoid a permanent stoma, while for chronic disease 71% of patients were prepared to trade to avoid an operation with a permanent stoma compared with 55% for an operation with a pouch (P = 0.01). Both patients and gastroenterologists were more prepared to gamble or trade to avoid any surgery than were colorectal surgeons. All groups were aligned in their decision to undergo yearly colonoscopy surveillance rather than to undergo definitive surgery that would result in a stoma. Patient preferences for the treatment of UC were more aligned to those of gastroenterologists than those of colorectal surgeons. Despite postoperative studies revealing an equal quality of life for pouch and stoma patients, this study confirmed that a pouch is the preferred surgical option.
Publisher: Springer London
Date: 2015
Publisher: Wiley
Date: 18-01-2020
DOI: 10.1111/CODI.14950
Abstract: There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer. A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging. Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications. Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.
Publisher: Oxford University Press (OUP)
Date: 11-10-2023
DOI: 10.1093/BJS/ZNAD311
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.AVSG.2015.01.028
Abstract: This article describes a great saphenous vein spiral graft technique for reconstruction of iliac vessels after en bloc resection during pelvic exenteration. Use of different size syringes as a scaffold allows the surgeon to construct autologous vascular interposition conduits of variable diameter to match the luminal size of the vessel requiring reconstruction. Autologous vascular grafts are preferred in exenteration surgery in which the operative field is commonly contaminated by concomitant bowel resection, which carries an increased risk of graft infection.
Publisher: Wiley
Date: 12-2001
DOI: 10.1046/J.1445-1433.2001.02264.X
Abstract: One of the most obvious but controversial trends in contemporary surgical practice is that of subspecialization. There is a lack of definitive evidence that subspecialization improves cancer outcomes largely because previous research is compromised by confounding variables of referral practice, lack of standardized definitions of surgical skills and selection bias. Randomized controlled trials of generalized versus subspecialist surgical care are unlikely ever to be performed. The present study of surgeons' views about the role of subspecialization in the care of colorectal cancer patients demonstrates partisan reactions among surgeons themselves (89% response rate). Results of national audits will contribute to wider debate about surgical subspecialization in colorectal cancer.
Publisher: Springer London
Date: 14-12-2013
Publisher: Oxford University Press (OUP)
Date: 15-02-2017
DOI: 10.1002/BJS.10469
Abstract: Returning to the operating theatre for management of early postoperative complications after colorectal surgery is an important key performance indicator. Laparoscopic surgery has benefits that may be useful in surgical emergencies. This study explored the evidence for the advantages of laparoscopic reoperation. A systematic review was performed to identify publications reporting the outcomes of laparoscopy as a mode of reoperation for the management of early postoperative complications of colorectal surgery. The main outcomes examined were 30-day mortality, 30-day morbidity, length of hospital stay, second reoperation rate, ICU admission and stoma formation at reoperation. After screening 3657 citations, ten non-randomized cohort studies were identified (1137 reoperations). Laparoscopic reoperation was equivalent to or better than open reoperation, with lower rates of 30-day mortality (0–4·4 versus 0–13·6 per cent), 30-day morbidity (6–40 versus 30–80 per cent), length of stay (mean(s.d.) 15·8(2·8) versus 29·1(14·5) days), ICU admission and duration of stay in the ICU. Anastomotic leak was the most common indication, after which more patients received a defunctioning loop stoma instead of an end stoma at laparoscopic than open reoperation. Laparoscopic reoperation is feasible in selected patients, with the advantages of improved short-term outcomes.
Publisher: Elsevier BV
Date: 10-2010
Publisher: Springer Science and Business Media LLC
Date: 20-05-2010
Publisher: Wiley
Date: 12-2002
Publisher: Elsevier BV
Date: 04-2021
Publisher: Springer Science and Business Media LLC
Date: 20-01-2009
Abstract: Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article in order to assess the usefulness and validity of research findings. The most important components of a critical appraisal are an evaluation of the appropriateness of the study design for the research question and a careful assessment of the key methodological features of this design. Other factors that also should be considered include the suitability of the statistical methods used and their subsequent interpretation, potential conflicts of interest and the relevance of the research to one's own practice. This Review presents a 10-step guide to critical appraisal that aims to assist clinicians to identify the most relevant high-quality studies available to guide their clinical practice.
Publisher: Wiley
Date: 10-2008
DOI: 10.1111/J.1445-2197.2008.04678.X
Abstract: This article describes the initiation and implementation of the multicentre Australia and New Zealand prospective randomized controlled clinical study comparing laparoscopic and conventional open surgical treatments of right-sided and left-sided potentially curable colon cancer (Australasian Laparoscopic Colon Cancer Study). Six hundred and one adult patients were admitted with a clinical diagnosis of a single adenocarcinoma based on a physical examination and colonoscopy, barium enema or computed tomography scan and randomly allocated to either laparoscopic or open surgery. The primary aim of the study is to compare 5-year mortality and tumour recurrence rates between the two groups. Secondary aims include comparisons of safety (intraoperative and early postoperative complications, wound site recurrence, postoperative recovery and 30-day mortality), quality of life, in-hospital costs and short-term mortality and tumour recurrence. The data for 592 patients have been collected. There are currently 3141 person years of follow up. In all 370 patients have been assessed at 5 years. This study shows that large cooperative Australia-New Zealand surgical trials can and should be carried out to address significant clinical issues. When possible, coherence with similar, concurrent international trial protocols ensures broader analyses and applicability of results. It is important to recognize that special attention to sustained funding, surgeon credentialing, clinical protocol standardization, data management, publication policy and the protection of study credibility is required from the outset. The Australasian Laparoscopic Colon Cancer Study will achieve its aims with 5-year assessments of all entered patients in March 2010.
Publisher: Korean Society of Coloproctology
Date: 2014
Publisher: Wiley
Date: 16-10-2021
DOI: 10.1111/CODI.15378
Publisher: Wiley
Date: 10-2013
DOI: 10.1111/CODI.12306
Abstract: Minimal data are available on the role of pelvic exenteration in patients with recurrent squamous cell carcinoma (SCC) of the pelvic organs. This study aimed to highlight our experience of pelvic exenteration in patients with recurrent and re-recurrent SCC of the pelvic organs. A retrospective review of all patients who underwent pelvic exenteration for recurrent SCC of the pelvic organs arising from the embryological cloaca from 1994 to 2010 was performed. Twenty-four patients (median age 59, range, 27-79 years) underwent pelvic exenteration for recurrent SCC of the anus (18), cervix and upper vagina (2), lower vagina (1) and the vulva (3). Nine patients with anal SCC had undergone abdominoperineal excision prior to pelvic exenteration. Ten (41.7%) patients underwent a complete pelvic exenteration procedure, while sacrectomy was performed in 13 (54.2%) patients. There was no 30-day inpatient mortality. An R0 resection was achieved in 15 (62.5%) patients. Three (12.5%) had R1 resections while 6 (25%) had R2 resections. In the 15 patients with an R0 resection, 7 (46.7%) developed metastatic disease at a median of 18 (range 10-131) months. After a median follow-up of 26 (range 4-169) months, 1- and 2-year overall survival rates were 64% [95% confidence interval (CI), 44-84%] and 57% (95% CI 35-79%), respectively. Pelvic exenteration for recurrent SCC of the cloaca is safe and feasible even after previous salvage surgery. An R0 resection can be achieved in 62.5% of the patients with reasonable early survival though less than published recurrent rectal cancer studies.
Publisher: Wiley
Date: 07-1990
DOI: 10.1111/J.1445-2197.1990.TB07423.X
Abstract: Extrahepatic portal hypertension was induced in the rabbit by a one-stage complete ligation of the portal vein. End renal vein to side splenic vein shunts (renosplenic) were performed with haemorrhagic necrosis of the left kidney occurring after ligation of the left renal vein lateral to the adrenolumbar tributary. Thus the ureteric, lumbar, and pericapsular collaterals cannot adequately drain the left kidney. Ligation of the left renal vein on the medial side of the adrenolumbar tributary maintained a patent left renal vein in all cases with 60% of left kidney biopsies showing no histological evidence of changes to glomeruli or tubules, and the remainder showing early acute tubular necrosis.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2005
DOI: 10.1007/S10350-004-0830-6
Abstract: This study was designed to review the results of long-term indwelling seton or depezzar catheter in the management of perianal Crohn's disease. A retrospective case review from data extracted from a prospective endorectal ultrasound database was performed. All patients underwent an intraoperative endorectal ultrasound to identify the extent of the fistulas and to assess anal wall thickness. Fistulas were classified by Parks' criteria. All patients then underwent insertion of a seton or depezzar catheter under ultrasound guidance. All patients were followed clinically and with endorectal ultrasound by the senior author. Outcome measures included symptom control, number of procedures required, fecal continence, and reduction in anal wall thickness. Twenty-eight patients with 43 complex perianal Crohn's fistulas were identified. Median follow-up was 13 (range, 2-81) months. Twenty-one percent of patients developed recurrent or new perianal symptoms while the seton was in situ. Eleven percent of patients required further surgical intervention. The median anal wall thickness at the time of diagnosis was 18.5 mm reducing to a median of 14 mm after seton insertion and symptom control (P < 0.02). No patient reported a deterioration in fecal continence after seton insertion. In multivariate analysis, patient age (P < 0.005), reduction in anal wall thickness after seton insertion (P < 0.04), and length of follow-up (P < 0.03) were significant predictors of long-term symptom control. Long-term indwelling seton is an effective management modality for complex perianal Crohn's fistulas, which does not negatively impact fecal continence. Clinical symptoms and course are associated with anal wall thickness as measured by endorectal ultrasound.
Publisher: Elsevier BV
Date: 11-2022
DOI: 10.1016/J.EJSO.2022.01.019
Abstract: Advanced pelvic malignancy, regardless of the cancer of origin, is often multivisceral and complex. The management of advanced pelvic malignancy is resource-intensive and requires multidisciplinary input. The definition of resectability is evolving with improving multimodal therapy, preoperative staging and optimisation, perioperative care, and advanced surgical techniques. Pelvic exenteration is a highly morbid procedure and has been shown to improve survival and quality of life when performed with a curative intent. Unresectable distant solid organ or lymph node metastases and an inability to achieve a clear resection margin preclude curative pelvic exenteration. Patients with advanced pelvic malignancy who are deemed palliative are mostly managed by non-operative treatment such as chemo-, radio-, immuno-, hormonal therapy, pain management and palliative care, as well as allied health and psychosocial support team. These patients may present with severe and debilitating symptoms including intractable pain, ulcerating roliferating tumour, pelvic fistula/sepsis/bleeding, urinary and bowel obstruction/incontinence. Interventional radiological and surgical procedures such as percutaneous drainage, nephrostomy, intestinal and urinary ersion, intestinal bypass, and venting gastrostomy have an important role in symptom control and improving quality of life. Palliative pelvic exenteration should be carefully considered along with life expectancy, patient wishes and tumour characteristics. Comprehensive discussion with patient is crucial to achieve realistic expectations. These patients should not only be discussed in a multidisciplinary team meeting with palliative care input, but also be referred for a formal palliative care consultation. Tumour anatomical extent should be considered both for and against pelvic exenteration whether involving the posterior compartment i.e. sacrectomy lateral compartment incorporating neurovascular bundle and the anterior compartment requiring pubic bone excision as all can be associated with high morbidity rates. Patient recovery may be protracted too if surgery is complicated by perineal wound or flap breakdown in cases necessitating wide perineal skin and soft tissue excision. Furthermore, evidence from quality of life and cost-effectiveness studies do not provide robust data to support pelvic exenteration with palliative intent. Whilst a relatively 'straightforward' central soft tissue pelvic exenteration may offer reasonable symptomatic relief in a patient with an acceptable life expectancy, palliative pelvic exenteration overall should only be considered in highly selected patients.
Publisher: AMPCo
Date: 04-2014
DOI: 10.5694/MJA13.10710
Abstract: To identify predictors of variation in colorectal cancer care and outcomes in New South Wales. Multilevel logistic regression analysis using a linked population-based dataset based on the records of patients with cancer of the colon, rectosigmoid junction or rectum who were registered in 2007 and 2008 by the NSW Central Cancer Registry and treated in 105 hospitals in NSW. Six outcome measures (30-day mortality, 28-day emergency readmission, prolonged length of stay, 30-day wound infection, 90-day venous thromboembolism, 1-year mortality) and five care process measures (discussion at multidisciplinary team [MDT] meeting, documented cancer stage, recorded pathological stage, treatment within 31 days of decision to treat, treatment within 62 days of referral). We analysed data for 6890 people. There was wide variation between hospitals in care process measures, even after adjusting for patient and hospital factors. Older adults were less likely to be discussed at an MDT meeting and receive treatment within suggested time frames (all P < 0.001 for colon cancer). Increasing patient age, greater extent of disease, higher Charlson comorbidity score and resection after emergency admission consistently showed strong evidence of an association with poor outcomes. Much of the variation between hospitals in outcome measures was accounted for by patient characteristics. Patient characteristics should be included in risk-adjustment models for comparing outcomes between hospitals and for quantifying hospital variation. Further exploration of the reasons why certain hospitals and patients appear to be at risk of poorer care is needed.
Publisher: Elsevier BV
Date: 12-2023
Publisher: Wiley
Date: 08-01-2023
DOI: 10.1111/CODI.16462
Abstract: Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for ex le the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short‐term outcomes. Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS‐1. The search found 21 studies that reported pain following pelvic exenteration [ n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%–100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection. Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.
Publisher: Wiley
Date: 12-2008
Publisher: Wiley
Date: 07-02-2012
DOI: 10.1111/J.1463-1318.2011.02613.X
Abstract: Crohn's disease is a chronic inflammatory condition that has been associated with high rates of mental illness. Perianal lesions are prevalent however, their specific impact on depression has not been studied. The aim of our study was to investigate the prevalence and associations of self-reported depressive symptoms in the subset of Crohn's patients with perianal disease. Patients with perianal Crohn's disease from one institution were surveyed to elicit the frequency of self-reported depressive symptoms. Patients completed a questionnaire and consented to medical records audit. Of the 130 patients invited, 69 (53%) returned a survey. Depressive symptoms were self-reported at very high rates, with 73% reporting feeling depressed and 13% reporting feeling suicidal at some point. Associations were found between depressive symptoms and duration of disease, prior surgery, past or present stoma, and anal stenosis. Patients who self-reported depressive symptoms had lower overall utilities, and were willing to trade very significant proportions (upwards of 15%) of their life expectancy for disease cure. This study suggests that many patients with perianal Crohn's disease experience significant emotional distress that impairs their overall quality of life. Further controlled studies are required to assess the impact of perianal disease and to address the need to target interventions to meet the mental health needs of this population.
Publisher: Elsevier BV
Date: 06-2003
DOI: 10.1067/MSY.2003.119
Publisher: Wiley
Date: 06-1999
DOI: 10.1046/J.1440-1622.1999.01552.X
Abstract: Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series. Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation. After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis. Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.
Publisher: American Medical Association (AMA)
Date: 04-2008
DOI: 10.1001/ARCHSURG.143.4.389
Abstract: Patients and their clinicians hold varying preferences for surgical and adjuvant treatment therapies for rectal cancer. Preferences were determined using the Prospective Measure of Preference. Royal Prince Alfred and St Vincent's hospitals in Sydney, Australia. Patients with colorectal cancer were interviewed during their postoperative hospital stay, and physicians were asked to complete a mailed survey. The Prospective Measure of Preference method produces 2 outcome measures of preference: willingness to trade and prospective measure of preference time trade-off. Patients' strongest preference was to avoid a stoma: more than 60% would give up a mean of 34% of their life expectancy to avoid this surgical option. This was followed by treatment options involving chemoradiotherapy, where more than 50% would give up a mean of almost 25% of their life to avoid treatment. Surgeons held stronger preferences against all adjuvant options compared with oncologists (P </= .01). Patients had strong preferences against all treatment options, and these preferences frequently differed from those of physicians. These results highlight the importance of determining patients' own preferences in the clinical encounter. Furthermore, the ersity of preferences of clinical subspecialists emphasizes the need for multidisciplinary treatment planning to ensure a balanced approach to treatment decision making for patients with rectal cancer.
Publisher: Wiley
Date: 17-10-2023
DOI: 10.1111/ANS.18701
Publisher: Oxford University Press (OUP)
Date: 29-04-2022
DOI: 10.1093/BJS/ZNAC122
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2007
Publisher: Wiley
Date: 07-2003
DOI: 10.1046/J.1445-1433.2003.02662.X
Abstract: This second of two articles about clinical epidemiology reviews the generation and synthesis of evidence for the effectiveness of surgical procedures. While well-designed randomized controlled trials of surgical procedures are considered the 'gold standard' of evaluation design, they may achieve high internal validity at the expense of external validity (generalizability). Improving the -evidence-base in surgery likely will require a comprehensive approach to surgical outcomes assessment, involving both improvements in the quality and quantity of randomized controlled trials as well as recognition of the complementary role of alternate study designs.
Publisher: Wiley
Date: 19-07-2022
DOI: 10.1111/CODI.16238
Abstract: Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short‐term morbidity reported from this procedure is well established however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long‐term (more than 90‐day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43% P 0.01) with either major bony (70% vs. 50% P 0.01) and/or nerve (40% vs. 25% P = 0.03) resections at index exenteration. The patho‐anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero‐cutaneous fistula, entero‐perineal fistula, small bowel obstruction and local management of perineal wound complications. Six per cent of PE patients will require re‐intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive however, surgical management is feasible with acceptable short‐term outcomes with the optimum strategy to be selected on an in idual patient basis.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2007
DOI: 10.1007/S10350-006-0847-0
Abstract: Crohn's disease poses difficult choices in which the most appropriate treatment option is not always obvious. When this state of uncertainty exists, patients' preferences should have an increasingly important part of clinical decision making. The purpose of this study was to compare patients' preferences for surgical intervention in Crohn's disease with the preferences of surgeons and gastroenterologists. Outpatients with Crohn's disease were interviewed to quantify their preferences for six scenarios by using the prospective preference measure. An identical questionnaire was mailed to all Australian and New Zealand colorectal surgeons and a random s le of 300 Australian gastroenterologists. Forty-one of 123 patients with Crohn's disease (33 percent), 92 of 127 colorectal surgeons (72 percent), and 74 of 272 gastroenterologists (27 percent) participated. There were significant differences between patients and gastroenterologists for three of six scenarios and between surgeons and gastroenterologists in four of six scenarios. Seventy-six percent of gastroenterologists were willing to gamble to avoid an ileocolic resection compared with 37 percent of surgeons (chi-squared = 25.44 P < 0.0001) and 39 percent of patients (chi-squared = 15.44 P < 0.001). Patients and clinicians were able to trade and gamble life expectancy as a measure of preference for varying hypothetical surgical treatments, even though these treatment options impacted on quality of life rather than survival. Patients' preferences did not align with clinicians. For most scenarios, colorectal surgeons' preferences were significantly different to those of gastroenterologists.
Publisher: Wiley
Date: 08-2003
Publisher: Wiley
Date: 03-2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2014
Publisher: Hindawi Limited
Date: 02-2011
DOI: 10.1111/J.1365-2354.2010.01187.X
Abstract: Although it is widely recognised that better coordination of cancer care holds considerable potential to improve patients' experience of care and their outcomes, there is no agreed definition of the term 'care coordination' or consensus as to what it entails. An explorative descriptive qualitative study was undertaken to explore the views and experiences of key stakeholders to identify the key components of cancer care coordination. We conducted semi-structured in idual and focus groups interviews with patients (n= 20) who have been treated for any cancer and carers (n= 4) as well as clinicians (n= 29) involved in cancer care, using open-ended questions. Data were collected until saturation of concepts was reached. A phenomenological approach based on grounded theory was used to explore the participants' experiences and views. Seven key components were identified: organisation of patient care, access to and navigation through the healthcare system, the allocation of a 'key contact' person, effective communication and cooperation among the multidisciplinary team and other health service providers, delivery of services in a complementary and timely manner, sufficient and timely information to the patient and needs assessment. The components of cancer care coordination identified provide an empirical basis for the development of metrics and interventions to improve this aspect of cancer care.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
DOI: 10.1097/DCR.0000000000000839
Abstract: Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 th century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: MDPI AG
Date: 15-10-2022
Abstract: Pelvic exenteration surgery has become a widely accepted procedure for treatment of locally advanced (LARC) and locally recurrent rectal cancer (LRRC). However, there is still unwarranted variation in peri-operative management and subsequently oncological outcome after this procedure. In this article we will elaborate on the various reasons for the observed differences based on benchmarking results of our own data to the data from the PelvEx collaborative as well as findings from 2 other benchmarking studies. Our main observation was a significant difference in extent of resection between exenteration units, with our unit performing more complete soft tissue exenterations, sacrectomies and extended lateral compartment resections than most other units, resulting in a higher R0 rate and longer overall survival. Secondly, current literature shows there is a tendency to use more neoadjuvant treatment such as re-irradiation and total neoadjuvant treatment and perform less radical surgery. However, peri-operative chemotherapy or radiotherapy should not be a substitute for adequate radical surgery and an R0 resection remains the gold standard. Finally, we describe our experiences with standardizing our surgical approaches to the various compartments and the achieved oncological and functional outcomes.
Publisher: American Medical Association (AMA)
Date: 06-04-2005
Abstract: Compensation, whether through workers' compensation or through litigation, has been associated with poor outcome after surgery however, this association has not been examined by meta-analysis. To investigate the association between compensation status and outcome after surgery. We searched MEDLINE (1966-2003), EMBASE (1980-2003), CINAHL, the Cochrane Controlled Trials Register, and reference lists of retrieved articles and textbooks, and we contacted experts in the field. The review included any trial of surgical intervention in which compensation status was reported and results were compared according to that status. No restrictions were placed on study design, language, or publication date. Studies were selected by 2 unblinded independent reviewers. Two reviewers independently extracted data on study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Two hundred eleven studies satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (workers' compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and 1 described a benefit associated with compensation. A meta-analysis of 129 studies with available data (n = 20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval, 3.28-4.37 by random-effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all subgroups. Compensation status is associated with poor outcome after surgery. This effect is significant, clinically important, and consistent. Because data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Compensation status should be considered a potential confounder in all studies of surgical intervention. Determination of the mechanism for this association requires further study.
Publisher: Oxford University Press (OUP)
Date: 20-02-2021
DOI: 10.1093/BJS/ZNAB047
Publisher: Oxford University Press (OUP)
Date: 19-08-2021
DOI: 10.1093/BJS/ZNAB286
Publisher: Wiley
Date: 05-10-2023
DOI: 10.1111/ANS.18713
Publisher: Wiley
Date: 26-12-2020
DOI: 10.1111/CODI.15435
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2013
Publisher: Wiley
Date: 16-09-2014
DOI: 10.1111/CODI.12721
Publisher: Oxford University Press (OUP)
Date: 11-2002
DOI: 10.1046/J.1365-2168.2002.02222.X
Abstract: Hepatic metastasis from colorectal cancer is a common problem. Hepatic resection offers the only chance of cure. Prognosis of patients following hepatic resection is currently based on clinicopathological factors (of both the primary cancer and the hepatic metastasis), which do not accurately predict the subsequent behaviour of the tumour. The aim of this study was to evaluate three molecular genetic markers – p53, DCC (deleted in colonic cancer) and thymidylate synthase – in both the primary colorectal tumour and the resected hepatic metastases, and to determine their correlation, if any, with survival in patients with resected hepatic metastases from colorectal cancer. Sixty-three patients with hepatic metastases and 40 corresponding colorectal primary tumours were studied using immunohistochemical staining for p53, DCC and thymidylate synthase, as well as p53 gene mutations using polymerase chain reaction–single-stranded conformational polymorphism (PCR-SSCP) analysis. The results were correlated with survival. There was no correlation between p53, DCC or thymidylate synthase immunohistochemical staining, or between p53 PCR-SSCP analysis, and survival for either hepatic metastases or the colorectal primary tumour. Prediction of prognosis in patients having resection of hepatic metastases from colorectal cancer continues to be problematic. Other genetic markers or combination of markers need to be evaluated.
Publisher: BMJ
Date: 10-2008
DOI: 10.1136/EBM.13.5.144
Publisher: Wiley
Date: 24-01-2003
DOI: 10.1046/J.1440-1746.2003.02953.X
Abstract: It has been suggested that smoking protects against the development of ulcerative colitis (UC). Evidence is mainly driven from the way data from a multitude of case-control studies have been interpreted. An age- and sex-matched case-control study was conducted to further assess the association between history of smoking, past surgery, childhood, and other potential causative factors with the development of UC using the answers to a detailed questionnaire. The data were analyzed using univariate analysis and logistic regression. The results are presented as odds ratios (OR) and 95% confidence intervals. One hundred and two cases and an equal number of matched controls were included in the study. Using a three-level comparison, at the age of diagnosis, the risks of developing UC were 0.41 (0.19-0.87), 3.45 (1.62-7.35) and 0.78 (0.44-1.37) for smokers, ex-smokers and non-smokers, respectively. When compared to in iduals who have never smoked, ex-smokers were at a higher risk of developing the disease (OR = 3.00 (1.38-6.51)). The specific history of quitting smoking prior to the age of onset of symptoms was associated with an increased risk for developing the disease (OR = 3.45 (1.62-7.35)). Active smoking was associated with a low risk for the development of UC, but the lack of history of smoking was not associated with an increase in the risk. History of quitting smoking prior to the onset of symptoms, in contrast, was associated with a significant increase in the risk of developing the disease. These findings make the theory of a simple protective effect of smoking on the development of UC difficult to justify. It may be plausible to suggest that the withdrawal of the immunosuppressive effect of smoking triggers the disease onset in a genetically susceptible in idual or simply unmasks its symptoms.
Publisher: Wiley
Date: 03-2006
Abstract: A technique of fluorescence multiplexing is described for analysis of the plasma membrane proteome of colorectal cancer cells from surgically resected specimens, enabling detection and immunophenotyping when the cancer cells are in the minority. A single-cell suspension was prepared from a colorectal tumour, and the mixed population of cells was captured on a CD antibody microarray. The cancer cells were detected using a fluorescently tagged antibody for carcinoembryonic antigen (CEA-Alexa647) or epithelial cell adhesion marker (EpCAM-Alexa488). Using this multiplexing procedure, dot patterns from colorectal cancers were distinct from those of adjacent normal tissue. Subtraction of the expression levels for each antigen from normal tissue from those for the cancer shows differential expression in the cancer of CD66c, CD15s, CD55, CD45, CD71, CD45RO, CD11b and CEA, in descending order. Cells captured on the same microarray were also labelled with fluorescent CD3-phycoerythrin antibody revealing the presence of tumour-infiltrating lymphocytes. The immunophenotypes of T lymphocytes from the tumour s les showed differential expression of HLA-DR, TCR alpha/beta, CD49d, CD52, CD49e, CD5, CD95, CD28, CD38 and CD71, in descending order. Fluorescence multiplexing of mixed cell populations captured on a single antibody microarray enables expression profiling of multiple sub-populations of cells within a tumour s le.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2017
DOI: 10.1097/DCR.0000000000000825
Abstract: Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2014
DOI: 10.1016/J.IJSU.2014.03.016
Abstract: To understand how surgeons arrive at a decision in the complex and controversial field of radiotherapy in rectal cancer by identifying which variables are important in this decision and to assess the influence of age, training, area of practice and access to radiotherapy on decisions in this field. A self-administered survey was distributed to 150 members of the CSSANZ. They were asked to rank the importance of 33 variables considered when making decisions to use radiotherapy in the treatment of rectal cancer. The responses were assessed for association of surgeon age, area of practise or access to radiotherapy with decisions in this field. A hierarchy of variables was produced which showed tumour characteristics had the highest average importance, higher than that attained by patient characteristics and side effects. There were subtle but statistically significant differences in the ranking of importance when surgeons were grouped by age, site of subspeciality training, site of practise and availability of radiotherapy service. This study identifies a hierarchy of variables used in decision making concerning radiotherapy in rectal cancer treatment, which may be used in heuristic decision making. Decisions on using radiotherapy are influenced by age, site of practise, site of training, and the presence of radiotherapy on site.
Publisher: Wiley
Date: 13-10-2008
DOI: 10.1111/J.1471-0528.2008.01892.X
Abstract: To quantify the risk of morbidity from vaginal delivery (VD) that pregnant women would be prepared to accept before requesting an elective caesarean section and to compare these views with those of clinicians. Cross-sectional survey. Major teaching hospital (nulliparas and midwives) and national s les of medical specialists. Nulliparas (n = 122), midwives (n = 84), obstetricians (n = 166), urogynaecologists (n = 12) and colorectal surgeons (n = 79). Face-to-face interviews (nulliparas) and mailed questionnaire (clinicians). Maximum level of risk participants would be prepared to accept before opting for an elective caesarean section for each of 17 potential complications of VD. Utility scores for each complication were calculated with higher scores (closer to 1) indicating a greater acceptance of risk. Pregnant women were willing to accept higher risks than clinicians for all 17 potential complications. They were least accepting of the risks of severe anal incontinence (mean utility score 0.32), emergency caesarean section (0.51), moderate anal incontinence (0.56), severe urinary incontinence (0.56), fourth-degree tears (0.59) and third-degree tears (0.72). The views of midwives were closest to those of pregnant women. Urogynaecologists and colorectal surgeons were the most risk averse, with 42 and 41%, respectively, stating that they would request an elective caesarean for themselves or their partners. Pregnant women were willing to accept significantly higher risks of potential complications of VD than clinicians involved in their care. Pregnant women's views were more closely aligned to midwives than to medical specialists.
Publisher: Elsevier BV
Date: 07-2007
DOI: 10.1016/J.SURG.2007.01.013
Abstract: The assessment of patients' and clinicians' willingness to participate in clinical trials is advisable as part of a feasibility exercise prior to the commencement of randomized controlled trials (RCTs) to ensure adequate support in terms of likely accrual to achieve the required s le size in a timely fashion. Furthermore, understanding why patients are unwilling to enter RCTs is imperative before the current trend of low participation can be reversed. Patients, colorectal surgeons, and medical and radiation oncologists, were presented with 5 different, detailed treatments for locally advanced rectal cancer. They were asked whether they would be willing to enter an RCT comparing each treatment choice. Patients who would not participate were asked to indicate their reason for refusal. Patients' willingness to participate in each trial was consistently low (19% to 32%). Similar low levels of participation were indicated by each clinical subspecialty (15% to 38%). Of the scenarios, patients and clinicians were most willing to enter a trial investigating surgery plus preoperative radiotherapy. A dislike of randomization, a desire to be involved in decision-making, and quality of life considerations were the most commonly stated reasons for refusal. This study highlights the difficulties in performing RCTs in surgery and oncology. However, results suggest that improvements in communication regarding randomization and clinical trial processes and the actual, rather than perceived, side effects of treatments are strategies that may enhance patient participation.
Publisher: Wiley
Date: 03-2003
DOI: 10.1046/J.1445-2197.2003.02650.X
Abstract: The aim of the present study was to rate the importance of attributes of screening for bowel cancer. Randomly selected households in central Sydney were contacted to identify men and women aged 50-70 years who were then asked to complete a self-administered questionnaire about bowel cancer screening and related issues. Seven hundred and ninety-one residents (362 men and 429 women) returned questionnaires. Respondents were asked to rate the extent to which each of 34 attributes would encourage them to participate in bowel cancer screening. The three most highly rated attributes were: if the test was recommended by their general practitioner (GP 94% either 'strongly agreed' or 'agreed') if the test identified early cancers (92%) and if the test would avert a premature death due to bowel cancer (90%). Having a friend or relative with bowel cancer (61%), advertising (41%) or famous people promoting the program (62%) were less influential. Respondents who were unemployed or on a pension were less likely to participate in screening than those who were employed if there was an 'out of pocket' charge of 15.00 Australian dollars (chi 2 = 7.56, 2df, P = 0.006). Respondents with higher levels of education were significantly more concerned than respondents with lower levels of education about test accuracy (chi 2 = 15.76, 2df, P < 0.001), its availability from their local chemist (chi 2 = 16.96, 2df, P < 0.001), being able to return the test kit by post (chi 2 = 21.9, 2df, P < 0.001) or deposit it with their local chemist (chi 2 = 10.0, 2df, P < 0.01). They were also less likely to be influenced by a famous person promoting bowel cancer screening (chi 2 = 18.87, 2df, P < 0.001). Our results endorse the role of the GP in bowel cancer screening. However, the study also has demonstrated that test accuracy, the convenience of the screening service and notification of test results are valued differently by subgroups in the community, according to their level of education.
Publisher: Oxford University Press (OUP)
Date: 09-10-2013
DOI: 10.1002/BJS.9293
Abstract: Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators. Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots. A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15·9 (95 per cent confidence interval (c.i.) 14·2 to 17·6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38·2 (34·6 to 41·8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = −0·55, P = 0·019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2·14, 95 per cent c.i. 1·11 to 4·15). APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.
Publisher: Springer Science and Business Media LLC
Date: 02-11-2016
DOI: 10.1245/S10434-016-5640-2
Abstract: The aim of this video is to highlight key safety and critical techniques employed during laparoscopic pelvic side-wall lymph node resection for rectal cancer. In addition, a review of the key pelvic side-wall anatomical structures will be included. We report a case of a 50-year-old Chinese female who presented with per-rectal bleeding, with colonoscopy revealing a 1.5 cm moderately differentiated rectal adenocarcinoma 4 cm above the anorectal junction. Initial staging scans did not reveal any pelvic lymphadenopathy or distant metastasis and the patient underwent laparoscopic ultra-low anterior resection with concurrent total hysterectomy, bilateral salpingo-oophorectomy and natural orifice specimen extraction (NOTES) with defunctioning ileostomy. Final histology confirmed the diagnosis of moderately differentiated adenocarcinoma classified as pT1N0, resection R0. Subsequent follow-up detected a serial increase in carcinoembryonic antigen levels, and further investigations detected a 1.6 cm fluorodeoxyglucose (FDG)-avid right external iliac lymph node. Adhesiolysis was performed, and key structures in the right pelvic side-wall, such as the ureter, umbilical and gonadal vessels, external iliac vein, obturator artery, nerve and lymph nodes, and internal and external iliac artery, were identified. The right external iliac lymph node was dissected and extracted for histological examination. Laparoscopic pelvic side-wall lymph node dissection for rectal cancer is a good technique to employ when investigating and obtaining FDG-avid lymph nodes. Key structures will need to be identified during dissection to prevent any injuries.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-1998
DOI: 10.1007/BF02238247
Abstract: A 74-year-old man was admitted to our hospital to undergo radiofrequency catheter ablation (RFCA) of persistent atrial fibrillation (AF). We found that he had a history of heparin-induced thrombocytopenia (HIT). Thus, a direct thrombin inhibitor, Argatroban Hydrate (Argatroban
Publisher: American Society of Clinical Oncology (ASCO)
Date: 10-05-2013
Publisher: Oxford University Press (OUP)
Date: 10-01-2003
DOI: 10.1002/BJS.4042
Abstract: Accurate preoperative staging of anorectal neoplasia is required to identify patients for whom local excision or adjuvant therapy may be appropriate. The objectives of this study were to review the accuracy of endoluminal transrectal ultrasonography (TRUS) in the staging of rectal cancers and to determine the learning curve before optimal staging accuracy can be achieved. The results of all TRUS examinations for the assessment of anorectal neoplasia performed by two colorectal surgeons at two teaching hospitals of the University of Sydney from 1991 to 2001 were collected prospectively. Of the 433 patients examined by TRUS, 356 were included, of whom 263 (73·9 per cent) had nodal status assessed histologically. Of the 77 patients excluded, 50 had undergone radiotherapy before operation. TRUS achieved excellent accuracy when compared with histopathology reports using κ statistics for standard Union Internacional Contra la Cancrum (UICC) staging (κ = 0·89), tumour wall penetration (κ = 0·70), lymph node detection (κ = 0·66) and a proposed new staging system (κ = 0·94). In addition, the increase in TRUS accuracy with operator experience demonstrates the need to perform 50 or more procedures before optimal accuracy is achieved. TRUS provides an appropriate investigation with which to select patients with T1 tumours for local excision, and patients with T3 or T4 tumours for preoperative radiotherapy. The relative inaccuracy of staging T2 tumours by TRUS has led to a proposed alternative ultrasonographic staging system.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2014
Publisher: Wiley
Date: 17-07-2014
DOI: 10.1111/CODI.12614
Abstract: Limited data are available on the relationship between the histological features of the resected specimens in patients with ulcerative colitis (UC) or indeterminate colitis (IC) and the outcome of restorative proctocolectomy. The aim of our study was to determine if the histological features of the resected specimen in patients with UC and IC can predict ileal-pouch-related outcome. A review of all patients who had a restorative proctocolectomy created following completion proctectomy or proctocolectomy for UC and IC was performed. Between 1992 and 2011, 142 patients (132 with UC and 10 with IC) were reviewed. After a median follow-up of 36 (3-149) months, 51 (35.9%) developed a pouch-related complication. Forty-two (29.7%) developed pouchitis while three (2.1%) developed a pouch-cutaneous fistula. Four (2.8%) had pouch failure, while stricture of the anastomosis was seen in three (2.1%) patients. The presence of extension of the inflammation into the muscularis propria of the resected specimen was associated with an increased risk of pouch-related complications (P = 0.01). The presence of submucosal oedema was also a significant risk factor (P = 0.03). The extension of inflammation into the muscularis propria appears to predict pouch-related complications following restorative proctocolectomy for UC or IC.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2011
Publisher: Wiley
Date: 08-2004
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2007
DOI: 10.1007/S10350-006-0846-1
Abstract: Biofeedback is well established as a treatment for fecal incontinence but little is known about factors that may be associated with its effectiveness. This study assessed short-term outcomes, predictors of patients who completed treatment, and predictors of treatment success. This study was a retrospective review of consecutive patients treated with biofeedback at a tertiary referral colorectal clinic during ten years. Clinical, physiologic, and quality of life measures were collected prospectively at the time of treatment. Regression analysis was performed. Of 513 patients, 385 (75 percent) completed the treatment program. Each outcome was improved for more than 70 percent of patients. Incontinence scores decreased by 32 percent (from 7.5 to 5.2 of 13), patient assessment of continence increased by 40 percent (from 5.3 to 3.2 of 10), quality of life improved by 89 percent (from 0.34 to 0.67 of 1.0), and maximum anal sphincter pressure increased by a mean 12 mmHg (14 percent from 90 to 102 mmHg). Patients who did not complete treatment were younger, were more likely to be male, and had less severe incontinence. Treatment success was predicted by completion of all treatment sessions (odds ratio, 10.34 95 percent confidence interval, 4.46-24.19), female gender (odds ratio, 4.11 95 percent confidence interval, 1.04-7.5), older age (odds ratio, 1.02 per year 95 percent confidence interval, 1-1.04), and more severe incontinence before treatment (odds ratio, 1.19 per unit increase in St. Mark's score 95 percent confidence interval, 1.05-1.34). More than 70 percent of patients in this large series demonstrated improved short-term outcomes. Treatment success was more likely in those who completed six training sessions, were female, older, or had more severe incontinence. Patients were less likely to complete treatment if they were male, younger, or had milder incontinence.
Publisher: Wiley
Date: 12-12-2006
DOI: 10.1111/J.1463-1318.2006.01151.X
Abstract: The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia. The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results. Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005). A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.
Publisher: Springer Science and Business Media LLC
Date: 17-06-2011
DOI: 10.1007/S00520-011-1214-9
Abstract: Cancer is primarily a disease of ageing, yet the unmet supportive care needs of older cancer patients are not well understood. This study aims to explore how unmet needs differ by age over the 3 months following colorectal cancer surgery. Control groups from pilot phases of an ongoing randomised trial completed the Supportive Care Needs Survey-Short Form 34 (SCNS-SF34) at 1 and 3 months following hospital discharge (n = 57). Multiple regression was used to investigate whether age was an independent predictor of unmet needs in each of the five SCNS-SF34 domains. The proportion of patients with unmet needs and the pattern of item responses were compared between patients aged <65 and ≥ 65 years at both time points. Older age independently predicted significantly lower levels of unmet need than younger age in nearly all SCNS-SF34 domains. However, more than half of all older patients had unmet needs at both time points (56% and 65%), and age differences in unmet needs were less apparent by 3 months. Older patients were less likely than younger patients to report 'satisfied' needs, as older patients were significantly more likely to report items were 'not applicable' at both 1 month (mean difference 29%, p < 0.001) and 3 months (mean difference 23%, p = 0.01). While older patients reported lower levels of unmet need than younger patients, the high prevalence of unmet needs and age differences in item response patterns indicate that further research is needed to determine whether older patients' needs are being accurately captured.
Publisher: Elsevier BV
Date: 05-2008
DOI: 10.1016/J.SURG.2008.01.009
Abstract: One of the major barriers to randomized trials in the field of surgery is the presence of strong preferences for one of the treatment options. Patients and surgeons who favor strongly a particular treatment approach are usually reluctant to participate in trials where operative intervention is determined on the basis of randomization. This then affects both the feasibility of the trial in terms of achieving the required s le size as well as the generalizability of the study's findings. Therefore, measurement of patient and surgeon preference is a crucial component of the feasibility assessment for surgery trials. In this article, we introduce the Prospective Measure of Preference, which is a novel method to measure preferences that has been designed to accommodate the complexity of surgical decision-making. We also present a simple method to measure in idual and community equipoise among expert clinicians to assess the feasibility of future randomized trials in surgery.
Publisher: Wiley
Date: 29-04-2004
Publisher: Springer Science and Business Media LLC
Date: 04-1998
Abstract: In iduals with chronic ulcerative colitis are at increased risk of developing colorectal carcinoma, particularly if there is long-standing disease or extensive colitis. It is generally accepted that the risk of colorectal cancer does not begin until 8 to 10 years after the time of diagnosis of ulcerative colitis. Thereafter it increases by approximately 0.5% to 1.0% per year. In patients with Crohn's disease, the risk of malignancy is smaller and less well defined. The most significant predictor of the risk of malignancy in patients with inflammatory bowel disease is the presence of dysplasia in colonic biopsies. There is considerable controversy in the literature regarding the efficacy of colonoscopic surveillance programs and the role of prophylactic surgery to prevent colorectal cancer. Surveillance certainly fails to detect carcinoma in some patients who are having regular colonoscopy. Concerns have also been raised as to the cost-benefit of colonoscopic surveillance in patients with colitis. Randomized controlled trials of surveillance programs are highly unlikely in view of the low prevalence of IBD in the population, the long period of observation required, and the probability of contamination of surveillance programs by colonoscopy for assessment of disease activity. Despite the lack of clear guidelines, surveillance colonoscopy and biopsy continues to be widely practiced. Research is proceeding to identify genetic and biochemical markers that may prove clinically useful for predicting cancer risk. At present, however, surveillance programs are likely to continue according to institutional practice. It is important for those participating in such programs to be aware of the limitations of colonoscopy and biopsy as a means of reducing the risk of cancer in inflammatory bowel disease.
Publisher: Wiley
Date: 18-11-2017
DOI: 10.1002/JSO.24511
Abstract: Total cystectomy and subsequent reconstruction of the urinary tract may be required for primary malignancy of the bladder, or in the context of multi-visceral resection for more advanced pelvic tumors. Complications following urinary ersion are a major source of morbidity, particularly in pelvic exenteration (PE) patients. All patients who underwent radical cystectomy alone or during PE at a single tertiary referral centre between 2008 and 2014 were reviewed. Postoperative urological complications were collected and compared between groups. Two hundred and thirty-one patients underwent en bloc cystectomy (98 cystectomy alone, 133 as part of a PE). Postoperative urological complications occurred in 33% of the cystectomy alone group and 59% of the PE group (P < 0.001). PE for recurrence had higher complications than PE for primary malignancy (67% vs. 48%, P = 0.035). Urological leaks occurred in 3%, 6%, and 14% of patient who had cystectomy alone, PE for primary malignancy and PE for recurrence. Major blood loss and previous pelvic radiotherapy independently predicted conduit-associated complications in PE patients (P = 0.002 and 0.035). Urological complications of cystectomy, particularly urine leaks and sepsis, are more common in patients undergoing PE compared to those with cystectomy alone. Prior pelvic radiotherapy, the extent of surgical resection and major blood loss may contribute to urological morbidity. J. Surg. Oncol. 2017 :307-311. © 2016 Wiley Periodicals, Inc.
Publisher: Wiley
Date: 05-01-2020
DOI: 10.1111/CODI.14925
Abstract: The aim was to compare postoperative quality of life (QOL) between patients undergoing pelvic exenteration (PE) and pelvic exenteration with sacrectomy (PES), and to investigate the influence of high (L5-S2) vs low (≤ S3) sacrectomy on QOL and functional outcomes. Patients undergoing en bloc sacrectomy as part of a PE and PE alone from 2008 to 2015 were identified from a prospectively maintained database. QOL and functional outcomes were assessed using the 36-Item Short Form Survey, the European Organization for Research and Treatment of Cancer Colorectal Cancer questionnaire and Quality of Life questionnaire, the Revised Musculoskeletal Tumour Scale, the Lower Extremity Functional Scale, the Sexual Health Inventory for Men and the Female Sexual Function Index. Of the 344 patients identified, data were available for 116 patients who underwent PE alone and 140 patients who underwent PES. PES patients had significantly poorer physical component scores (P < 0.001) but not mental component scores (P = 0.17). Of the 140 PES patients, 55 were eligible and were invited to participate in a second functional survey, with 30 patients returning the study questionnaire. High sacrectomy patients, compared with low sacrectomy, had significantly worse lower limb motor function (P = 0.03) and poorer physical (P = 0.001) and mental health component scores (P = 0.02). No differences were found in sexual, bladder and bowel function between high and low sacrectomy patients. Patients undergoing PES had worse physical component scores compared with PE alone, whereas high sacrectomy patients had significantly worse lower limb motor function and physical and mental component scores but comparable bowel, bladder and sexual functional outcomes compared with low sacrectomy patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-1993
DOI: 10.1007/BF02053518
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-1998
DOI: 10.1007/BF02237489
Abstract: [This corrects the article on p. 575 in vol. 82.].
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2009
Publisher: Springer Science and Business Media LLC
Date: 11-2008
DOI: 10.1007/S00068-007-7047-Z
Abstract: Neck pain after physical trauma is common but previous research regarding the role of psychological and physical predictors for neck pain is inconsistent. A retrospective survey of consecutive patients presenting to a metropolitan trauma centre with major accidental trauma was performed between 1 and 6 years post injury. Possible predictor variables (demographic, injury severity, and psychosocial factors) were determined from the hospital trauma registry and the questionnaire. The main outcome was a combined score of neck pain severity and functional limitation. Multivariate logistic regression was performed to develop a predictive model for neck pain. A multivariate analysis of 355 patients showed that neck pain was not significantly associated with measures of injury severity. Neck pain was significantly more likely to be severe in patients with a cervical spine fracture, with pre-existing chronic illnesses, those with post-traumatic stress disorder (PTSD) at the time of follow up, those who had retained the services of a lawyer regarding the injury, and those with lower education levels. Psychosocial factors are important predictors of neck pain after major physical trauma. These findings do not support models for post-traumatic neck pain that are restricted to physical factors.
Publisher: Springer Science and Business Media LLC
Date: 22-07-2010
DOI: 10.1007/S00520-009-0689-0
Abstract: This study aims to describe a pilot study of the feasibility, acceptability and likely impact of a nurse-delivered, telephone intervention to reduce unmet need and improve quality of life for surgical patients with colorectal cancer. The CONNECT intervention comprises five standardised calls over 6 months commencing on day 3 post-discharge. A prospective non-randomised control trial with patients who had surgery for colorectal cancer at Royal Prince Alfred Hospital, Sydney between July and December 2006 was conducted. Patients completed a telephone interview with an independent researcher at 1, 3 and 6 months to assess study outcomes, including unmet need (Supportive Care Needs Survey), psychological distress and quality of life (FACT-C). Patients' views of the intervention were ascertained. Forty-one patients participated, 20 in the intervention period. Intervention calls were successfully completed with 85% or more of patients at each of the five time points. Mean call duration ranged from 14-19 min with the highest number of needs (27 for 20 patients) identified on day 3. Patients indicated that the timing of the calls was appropriate and the majority (85%) felt the number of calls was sufficient. There were promising trends in outcomes. For both patient groups, there were clinically meaningful improvements in FACT-C scores over time, with a larger improvement in the intervention group (20.4 points) than the control group (11.7). The CONNECT intervention was found to be feasible and acceptable to patients. A larger randomised trial is underway to establish its effectiveness to improve patient outcomes.
Publisher: Wiley
Date: 25-11-2001
DOI: 10.1046/J.1463-1318.2001.00263.X
Abstract: Overlapping anterior sphincter repair is the accepted treatment for faecal incontinence resulting from sphincter disruption, however, wound breakdown has been reported to occur in up to 30% of patients. The aim of this study was to assess whether the type of wound closure affected the incidence of wound breakdown, and in particular whether island flap perineoplasty decreased this incidence. An historical control study was performed evaluating wound outcomes in patients undergoing different methods of wound closure after sphincter repair. Data were obtained from a prospectively collected database. 85 patients who underwent overlapping sphincter repair were studied. Five patients had their wounds left open to heal by granulation. Of the remaining 80 patients, wound dehiscence occurred in 33 patients (41%). When wound breakdown did occur, the mean time to healing was 9.1 weeks. Wound dehiscence was found to occur significantly less frequently in patients having an island flap perineoplasty than in those having other forms of wound closure (15 vs 54% P=0.0015). The presence of a complex injury such as cloacal defect or recto-vaginal fistula was also found to increase the incidence of wound breakdown, however, performing additional operations at the time of sphincter repair such as levator-plasty, gynaecological procedures or defunctioning colostomy did not affect the incidence of wound disruption. Wound disruption following overlapping anterior sphincter repair occurs in a significant proportion of patients and results in prolonged healing. Island flap perineoplasty significantly decreases the incidence of wound disruption in comparison to other forms of wound closure.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2009
Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.PEC.2013.07.003
Abstract: Telephone-based supportive care presents a potentially highly accessible means of addressing unmet supportive care needs for people with cancer. Identification of behaviours that facilitate communication is essential for development of training for telephone-based supportive care. The aim of this study was to describe communication behaviours within supportive care telephone calls in two contexts (1) a telephone outreach intervention and (2) cancer helpline calls, to identify potential areas for further training. 50 recorded calls were analysed using two standardised coding systems: the RIAS and Verona-CoDES-C. Mean call length was 21 min (304 utterances) for nurse-outreach calls and 23 min (355 utterances) for helpline calls. Closed questioning, verbal attentiveness and giving information/counselling were the most common communication behaviours identified. Emotional cues were most commonly responded to through non-explicit back-channelling, exploration of content or provision of reassurance or advice. This study confirmed the need to address the manner in which questions are framed to maximise patient disclosure. Responding to patent emotional cues was highlighted as an area for future training focus. Communication skills training that addresses each of these tasks is likely to improve the effectiveness of telephone-based delivery of supportive care.
Publisher: Wiley
Date: 08-09-2006
Publisher: Wiley
Date: 03-2002
DOI: 10.1046/J.1463-1318.2002.00320.X
Abstract: OBJECTIVE: The aim of this study is to assess the long-term outcomes of a biofeedback treatment programme for obstructive defaecation up to five years after completion of treatment, reporting from the patients' perspective the subsequent progression of defaecation difficulties and the perceived usefulness of the biofeedback training and its components. METHODS: A biofeedback program for obstructive defaecation at a major hospital in Sydney provided 37 patients with reading material, taught defaecation techniques, and prescribed simulated defaecation and anal relaxation exercises to practice between their monthly biofeedback sessions. Twenty-nine of these patients were contacted by telephone an average of 23 months after last attending and asked to rate the present severity of their condition, changes since last attending biofeedback, and which aspects of the program they found most helpful. RESULTS: Of patients who completed the program, 70% achieved at least a 15% improvement in perceived symptom severity. Those who completed the program and achieved benefit were more likely to name the exercises as the most helpful program component. At the time of follow-up, however, there was no difference in perceived symptom severity between program completers and noncompleters. Program completers, and those followed up more than two years after last attending biofeedback, were more likely to report a worsening in symptom severity subsequent to their final treatment session. CONCLUSIONS: This study confirms the favourable short-term outcomes achieved by some patients completing biofeedback treatment for obstructive defaecation. The findings suggest that biofeedback equipment may be economically used in an educative and corrective role, and that other factors such as education, exercises and counselling alone play an important role. Finally, the benefits of biofeedback may not be maintained through long-term follow-up, raising questions as to the natural history of the disorder and the long-term effectiveness of biofeedback treatment.
Publisher: Wiley
Date: 18-12-2017
DOI: 10.1111/ANS.13872
Abstract: To perform more radical surgery for complex pelvic malignancies and recurrent colorectal cancer, the surgeon must increasingly operate outside the conventional anatomical planes. Published in 1963 the 'Triangle of Marcille' (lumbosacral triangle) remained primarily of intellectual interest being found lateral to the traditional operating field. However, with the advancement of complex colorectal and gynaecological surgery it now provides a schema to assist surgeons in becoming acquainted with a complex and poorly understood anatomical region. Additionally, it prepares the surgeon for the extent of lateral dissection required to achieve the 'holy grail' for oncological surgery in pelvic malignancy, the complete resection (R0). To prosect a preserved cadaver in order to demonstrate, in vivo, the contents and borders of the Triangle of Marcille for the purposes of teaching surgeons and future surgeons. The Triangle of Marcille is both described and demonstrated in vivo, illustrated with diagrams and photographs. The importance of this region to the surgical management of complex colorectal and gynaecological surgery is discussed. The Triangle of Marcille is a vital anatomical region for advanced pelvic surgery, particularly in the current era of pelvic exenteration, and especially for those that include the lateral pelvic compartment.
Publisher: Elsevier BV
Date: 04-2010
DOI: 10.1016/J.JIM.2010.01.015
Abstract: A procedure is described for the disaggregation of colorectal cancers (CRC) and normal intestinal mucosal tissues to produce suspensions of viable single cells, which are then captured on customized antibody microarrays recognising 122 different surface antigens (DotScan CRC microarray). Cell binding patterns recorded by optical scanning of microarrays provide a surface profile of antigens on the cells. Sub-populations of cells bound on the microarray can be profiled by fluorescence multiplexing using monoclonal antibodies tagged with Quantum Dots or other fluorescent dyes. Surface profiles are presented for 6 CRC cell lines (T84, LIM1215, SW480, HT29, CaCo and SW620) and surgical s les from 40 CRC patients. Statistical analysis revealed significant differences between profiles for CRC s les and mucosal controls. Hierarchical clustering of CRC data identified several disease clusters that showed some correlation with clinico-pathological stage as determined by conventional histopathological analysis. Fluorescence multiplexing using Phycoerythrin- or Alexa Fluor 647-conjugated antibodies was more effective than multiplexing with antibodies labelled with Quantum Dots. This relatively simple method yields a large amount of information for each patient s le and, with further application, should provide disease signatures and enable the identification of patients with good or poor prognosis.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2009
Publisher: Oxford University Press (OUP)
Date: 25-08-2016
DOI: 10.1002/BJS.10259
Abstract: The rising cost of healthcare is well documented. The purpose of this study was to determine the cost-effectiveness of pelvic exenteration (PE). Consecutive patients referred for consideration of PE between 2008 and 2011 were recruited into a prospective non-randomized study that compared quality of life (QoL) between patients who did or did not undergo PE. Information on QoL and cost (in Australian dollars, AUD) was collected at baseline, during admission and up to 24 months after discharge. QoL data were converted into a utility-based measure. Quality-adjusted life-years (QALYs) were calculated. Bottom-up costing was performed. The incremental cost-effectiveness ratio (ICER) was calculated per life-year saved and per QALY. There were 174 patients with sufficient data for analysis. Of these, 139 underwent PE. R0 was achieved in 78·4 per cent of patients. The survival rate at 24 months after PE was 74·8 per cent compared with 43 per cent in those without exenteration (P = 0·001). Treatment costs were significantly higher for patients who had PE compared with those who did not (mean AUD 137 407 versus 79 174 P & 0·001). The ICER was AUD 124 147 (95 per cent c.i. 71 585 to 261 876) per life-year saved and AUD 227 330 (109 974 to 1 100 449) per QALY. Curative PE (R0) was found to be more cost-effective than non-curative PE (R1/R2), with an ICER of AUD 101 518 (60 105 to 200 428) versus 390 712 (74 368 to 82 256 739) per life-year saved. Treatment of advanced pelvic cancers is expensive regardless of the treatment intent. For a cost difference of only AUD 58 000 (€38 264), PE offers a chance of cure, and improves survival and QoL.
Publisher: Springer Science and Business Media LLC
Date: 26-06-2016
DOI: 10.1007/S00520-015-2817-3
Abstract: This study investigated the effectiveness of a structured telephone intervention for caregivers of people diagnosed with poor prognosis gastrointestinal cancer to improve psychosocial outcomes for both caregivers and patients. Caregivers of patients starting treatment for upper gastrointestinal or Dukes D colorectal cancer were randomly assigned (1:1) to the Family Connect telephone intervention or usual care. Caregivers in the intervention group received four standardized telephone calls in the 10 weeks following patient hospital discharge. Caregivers' quality of life (QOL), caregiver burden, unmet supportive care needs and distress were assessed at 3 and 6 months. Patients' QOL, unmet supportive care needs, distress and health service utilization were also assessed at these time points. Caregivers (128) were randomized to intervention or usual care groups. At 3 months, caregiver QOL scores and other caregiver-reported outcomes were similar in both groups. Intervention group participants experienced a greater sense of social support (p = .049) and reduced worry about finances (p = .014). Patients whose caregiver was randomized to the intervention also had fewer emergency department presentations and unplanned hospital readmissions at 3 months post-discharge (total 17 vs. 5, p = .01). This standardized intervention did not demonstrate any significant improvements in caregiver well-being but did result in a decrease in patient emergency department presentations and unplanned hospital readmissions in the immediate post-discharge period. The trend towards improvements in a number of caregiver outcomes and the improvement in health service utilization support further development of telephone-based caregiver-focused supportive care interventions.
Publisher: BMJ
Date: 10-2006
DOI: 10.1136/EBM.11.5.153
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2008
DOI: 10.1007/S10350-007-9152-9
Abstract: Surgery for recurrent rectal cancer is the only therapy with curative potential. This study was designed to assess factors that affect survival after surgery for locally recurrent rectal cancer. Prospective databases of patients undergoing surgical resection for recurrent rectal cancer at three tertiary centers between 1990 and 2006 were combined and analyzed. Cox regression and Kaplan-Meier survival analysis were used to assess factors associated with survival. A total of 160 patients (96 males) underwent surgery (median age, 63 (range, 27-93) years). Ninety-five patients (59 percent) received neoadjuvant radiotherapy. Sixty-three patients (39 percent) underwent radical resection and 90 (56 percent) underwent extended radical resection. Seven patients (5 percent) were irresectable. There was one death and 27 percent had major postoperative complications, independent of extent of resection. Negative resection margins were obtained in 98 patients (R0 61 percent). Median cancer-specific and overall survival was 48 months (41.5 percent 5-year survival) and 43 months (36.6 percent 5-year survival), respectively. Margin involvement was a significant predictor of cancer-specific (P<0.001) and overall survival (P<0.02). Resection for recurrent rectal cancer results in good survival with acceptable morbidity, unaffected by the extent of resection. Extended radical resection to obtain clear resection margins is the appropriate management of locally recurrent rectal cancer.
Publisher: MDPI AG
Date: 18-10-2023
Publisher: Oxford University Press (OUP)
Date: 13-01-2014
DOI: 10.1002/BJS.9392
Abstract: Pelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient-reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration. Consecutive patients referred for consideration of pelvic exenteration completed clinical and patient-reported outcome assessments at baseline, hospital discharge (exenteration patients only), and 1, 3, 6, 9 and 12 months. Outcomes included cancer-specific quality of life (Functional Assessment of Cancer Therapy – Colorectal FACT-C), physical and mental health status (Short Form 36 version 2), psychological distress (Distress Thermometer), and pain (study-specific composite) scores. Linear mixed modelling compared trajectories between exenteration and no-exenteration groups. Among 182 patients, 148 (81.3 per cent) proceeded to exenteration. There were no baseline differences between the two groups. Among patients who had exenteration, the mean FACT-C score at baseline of 93.0 had reduced by 14·4 points at hospital discharge, but increased to 86·7 at 1 month after surgery and continued to improve, returning to baseline by 9 months. For patients in the no-exenteration group, FACT-C scores decreased between baseline and 1 month, increased slowly to 6 months and then began to decline at 9 months. There were few statistically or clinically significant differences in any patient-reported outcomes between the groups. Quality of life and related patient-reported outcomes improve rapidly after pelvic exenteration surgery. For 9 months after surgery, these outcomes are comparable with those of similar do patients who do not have surgery thereafter, there is a decline in patients who do not have exenteration. Pelvic exenteration can be performed with acceptable quality of life and patient-reported outcomes.
Publisher: Wiley
Date: 18-10-2023
DOI: 10.1111/ANS.18741
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-1997
DOI: 10.1007/BF02050811
Abstract: The last several years have seen unprecedented advances in deciphering the genetic etiology of autism spectrum disorders (ASDs). Heritability studies have repeatedly affirmed a contribution of genetic factors to the overall disease risk. Technical breakthroughs have enabled the search for these genetic factors via genome-wide surveys of a spectrum of potential sequence variations, from common single-nucleotide polymorphisms to essentially private chromosomal abnormalities. Studies of copy-number variation have identified significant roles for both recurrent and nonrecurrent large dosage imbalances, although they have rarely revealed the in idual genes responsible. More recently, discoveries of rare point mutations and characterization of balanced chromosomal abnormalities have pinpointed in idual ASD genes of relatively strong effect, including both loci with strong a priori biological relevance and those that would have otherwise been unsuspected as high-priority biological targets. Evidence has also emerged for association with many common variants, each adding a small in idual contribution to ASD risk. These findings collectively provide compelling empirical data that the genetic basis of ASD is highly heterogeneous, with hundreds of genes capable of conferring varying degrees of risk, depending on their nature and the predisposing genetic alteration. Moreover, many genes that have been implicated in ASD also appear to be risk factors for related neurodevelopmental disorders, as well as for a spectrum of psychiatric phenotypes. While some ASD genes have evident functional significance, like synaptic proteins such as the SHANKs, neuroligins, and neurexins, as well as fragile x mental retardation-associated proteins, ASD genes have also been discovered that do not present a clear mechanism of specific neurodevelopmental dysfunction, such as regulators of chromatin modification and global gene expression. In its sum, the progress from genetic studies to date has been remarkable and increasingly rapid, but the interactive impact of strong-effect genetic lesions coupled with weak-effect common polymorphisms has not yet led to a unified understanding of ASD pathogenesis or explained its highly variable clinical expression. With an increasingly firm genetic foundation, the coming years will hopefully see equally rapid advances in elucidating the functional consequences of ASD genes and their interactions with environmental/experiential factors, supporting the development of rational interventions.
Publisher: Wiley
Date: 04-08-2001
DOI: 10.1046/J.1440-1622.2001.02164.X
Abstract: Traumatic cloacal defect is an injury sustained during childbirth in which the anovaginal septum is completely disrupted and the anus and vagina open as a common channel. Such injuries result in complete faecal incontinence and are difficult to repair both in terms of improving function and obtaining skin closure. Four cases of traumatic cloacal defect with a delayed presentation are illustrated here. All were treated with an overlapping anterior sphincter repair in combination with island flap perineoplasty to achieve skin closure. Anorectal function before and after surgery and the success of achieving primary wound healing were evaluated. In all four cases profound incontinence was found preoperatively all patients returned to normal or near normal continence following overlapping anterior sphincter repair. Island flap perineoplasty was successful in achieving primary healing in all cases and no flaps were lost to necrosis. Island flap perineoplasty is an effective method of achieving skin closure after anterior sphincter repair of traumatic cloacal defects.
Publisher: Wiley
Date: 05-2006
DOI: 10.1111/J.1365-2929.2006.02443.X
Abstract: Interactive forms of continuing medical education (CME) are more likely to improve clinical practice than traditional, passive approaches. This study investigated CME participation and preferences among surgeons. Questionnaire survey of surgeons in New South Wales, Australia. On average, respondents (n = 418, 77% response rate) committed 364 hours (interquartile range 228-512 hours) to CME per year. Surgeons working at tertiary referral teaching hospitals were twice as likely as those working in other types of hospital to report spending more than 12 hours per month on CME (OR 2.1, 95% CI: 1.4-3.1). Overall, reading accounted for 17% of CME time and attending conferences a further 12%. Clinical audit accounted for significantly less CME time (3.5%) (both P < 0.001). Conferences were considered the single most useful form of CME by 28% (95% CI: 24-33%). Over half (55%, 95% CI: 50-59%) ranked reading as 1 of the 3 most useful types of CME, whereas significantly fewer so ranked clinical audit (6%, 95% CI: 4-9%) (chi2 = 230.8, 1 d.f., P < 0.001). Australian surgeons commit a considerable amount of time to CME, but much of this time is spent in passive educational activities. Development of acceptable and effective CME programmes will benefit both surgeons and their patients.
Publisher: Wiley
Date: 28-08-2014
Abstract: Cyclic disulfide-rich peptides have exceptional stability and are promising frameworks for drug design. We were interested in obtaining X-ray structures of these peptides to assist in drug design applications, but disulfide-rich peptides can be notoriously difficult to crystallize. To overcome this limitation, we chemically synthesized the L- and D-forms of three prototypic cyclic disulfide-rich peptides: SFTI-1 (14-mer with one disulfide bond), cVc1.1 (22-mer with two disulfide bonds), and kB1 (29-mer with three disulfide bonds) for racemic crystallization studies. Facile crystal formation occurred from a racemic mixture of each peptide, giving structures solved at resolutions from 1.25 Å to 1.9 Å. Additionally, we obtained the quasi-racemic structures of two mutants of kB1, [G6A]kB1, and [V25A]kB1, which were solved at a resolution of 1.25 Å and 2.3 Å, respectively. The racemic crystallography approach appears to have broad utility in the structural biology of cyclic peptides.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2006
DOI: 10.1007/S10350-006-0614-2
Abstract: It has been suggested that nonrandomized studies of interventions can neither discriminate between the effect of an intervention and that of bias nor accurately estimate the magnitude of measured effects. This study was designed to compare the results of an historic control study of a surgical procedure with those of a subsequent randomized control trial conducted under similar circumstances. The results of an historic control study and a randomized, controlled trial of the safety and efficacy of laparoscopic rectopexy for rectal prolapse that were conducted 17 months apart by the same group of surgeons at the same institution were compared in terms of direction and magnitude of measured effects. The historic control study was reliable in determining the direction of measured effects in six of six (100 percent) outcomes common between the two studies, and there was agreement on the statistical significance (or lack of it) in five (83 percent) however, the magnitude of measured effects for all but one outcome assessed was 33 to 107 percent larger than in the randomized, controlled trial. There was no agreement in the medical literature on the effect of the historic control design on the direction and magnitude of measured effects. The results of a surgical historic control trial compared favorably with those of a randomized, controlled trial conducted under similar circumstances in determining the direction of measured effects but tended to yield larger estimates of effect magnitudes. The medical literature is ided on the effect of the historic control study design on study outcomes and more research is required to further define its role in evidence-based surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2009
Publisher: Wiley
Date: 28-06-2007
DOI: 10.1111/J.1445-2197.2007.04141.X
Abstract: Laparoscopic resection remains to be established as the procedure of first choice for operable colorectal cancer. The aim of the study was to conduct a systematic review of non-randomized comparative studies of laparoscopic resection for colorectal cancer. Published work in English was searched for relevant articles published by the end of 2003. The MOOSE statement was used to conduct the meta-analysis. Study quality was assessed by two investigators using the MINORS tool and the analysis was conducted using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA). One thousand two hundred and twenty abstracts were reviewed and 398 articles examined in detail. Out of 108 articles reporting the results of relevant studies, 75 were reports of 64 non-randomized comparative studies. Fifteen studies were excluded. Analysis of the outcomes of 6438 resections showed that the conversion rate was 13.3% with a statistically significant difference between studies with more than 50 versus those with 50 or less attempted resections (11.7 vs 16.5% P<0.001). Laparoscopic resection took 27.6% (41 min) longer to carry out than open resection. There was no significant difference between the two groups in early mortality rates (1.2 vs 1.1% P=0.787) or likelihood of re-operation (2.3 vs 1.5% P=0.319). Laparoscopic resection was associated with a lower morbidity rate (24.05 vs 30.80%, odds ratio (95% confidence interval)=0.77 (0.63-0.95) P=0.014, n=4111, random-effects model). Time until passage of first flatus, passage of a bowel motion, tolerating oral fluids and a solid diet was 1.2-1.6 days (26 to 37%) shorter, measurements of pain and narcotic analgesic requirements were 16-35% lower and hospital stay was 3.5 days (18.8%) shorter following laparoscopic resection compared with open resection. The two approaches were 99% similar in terms of adequacy of oncological clearance. Meta-analysis of non-randomized comparative studies favours laparoscopic over open resection for colorectal cancer. The results were remarkably similar to those of a contemporaneous meta-analysis of randomized controlled trials published by the end of 2002.
Publisher: Elsevier BV
Date: 09-1995
DOI: 10.1016/S0039-6060(05)80359-9
Abstract: The objective of this study was, first to determine what proportion of clinical treatment evaluation questions involving surgical operations could be answered by a randomized controlled trial (RCT). Second, for those questions not amenable to a RCT, to determine the problems that potentially preclude the initiation of RCT in an ideal clinical research setting. A s le of treatment evaluation questions involving a surgical procedure was obtained by a computerized search of the surgical literature. Problems precluding a RCT were defined. Their face validity and interobserver and intraobserver reliability were assessed. By use of these criteria, the s le questions were evaluated to determine whether a RCT could be performed and, if not, the predominant reasons precluding RCT of surgical procedures. Only 38.8% of treatment evaluation questions could have been answered by a RCT in an ideal clinical research setting. Patient preference was the most common precluding problem encountered (40% of all problems). The principal precluding problem was patient preference in 23.1%, an uncommon condition in 24.2%, and lack of community (clinical) equipoise in 10%. Methodologic issues (1.2%) and surgical preference (2.3%) were infrequent precluding problems. Questions evaluating therapy for malignant disease, comparing surgical with nonsurgical therapies, and where survival was the primary outcome were more likely to have problems precluding RCT. In the ideal situation RCT can be performed to evaluate only 40% of treatment questions involving surgical procedures. Patient preferences, uncommon conditions, and lack of surgical community equipoise appear to be the most common reasons precluding the of RCT of surgical operations.
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.EJSO.2016.02.016
Abstract: Radical surgery with pelvic exenteration offers the only potential for cure in patients with locally advanced primary rectal cancer. This study describes the clinical and patient-reported quality of life outcomes over 12 months for patients having pelvic exenteration for locally advanced primary rectal cancer at a specialised centre for pelvic exenteration. Clinical data of consecutive patients undergoing pelvic exenteration for locally advanced primary rectal cancer and patient-reported outcomes were collected at baseline, hospital discharge and at 1, 3, 6, 9 and 12 months. Patient-reported outcomes included cancer-specific quality of life (QoL) and physical and mental health status. Quality of life trajectories were modelled over the 12 months from the date of surgery using linear mixed models. 104 patients with locally advanced rectal cancer underwent pelvic exenteration at Royal Prince Alfred Hospital, Sydney, between December 1994 and October 2014. Complete soft tissue exenteration was performed in 38%. A clear margin was obtained in 86% with a 62% overall five-year survival. QoL outcome questionnaires were completed by 62% of patient cohort. The average FACT-C score returned to pre-surgery QoL by 2 months after surgery, and the average QoL continued to increase slowly over the 12 months. Our results support an aggressive approach to advanced primary rectal cancer and lend weight to the oncological role of pelvic exenteration for this group of patients. Quality of life improves rapidly after pelvic exenteration for locally advanced primary rectal cancer and continues to improve over the first year.
Publisher: Elsevier BV
Date: 11-2004
DOI: 10.1016/J.SURG.2004.04.012
Abstract: Equipoise is defined medically as a state of genuine uncertainty about the relative benefits of alternative treatment options. This study investigated in idual and collective equipoise among vascular surgeons for controversial clinical questions to assess the feasibility of conducting randomized controlled trials. Vascular surgeons throughout Australia and New Zealand received a survey by mail. Vascular surgeons (n=146, 77% response fraction) were able to quantify the strength of their treatment preferences and did so differentially between clinical scenarios using a simple scale. Almost one quarter (24% 95% CI, 18%-32%) were completely undecided about whether carotid endarterectomy or carotid stenting was preferable to treat carotid stenosis in high-risk patients, indicating in idual equipoise. In contrast, the vast majority of respondents (89% 95% CI, 82%-93%) favored carotid endarterectomy over carotid stenting for average-risk patients, suggesting lack of community equipoise for this patient group. Similarly, there was lack of community equipoise for treatments for abdominal aortic aneurysm in high-risk patients with 88% (95% CI, 81%-92%) favoring a minimally invasive approach. Older respondents were consistently less willing to take part in randomized trials, with strength of treatment preference also independently predicting willingness to participate in 4 of 6 trials. In idual and community equipoise can be measured in a representative s le of surgeons as part of the feasibility assessment for future randomized controlled trials.
Publisher: Wiley
Date: 24-05-2020
DOI: 10.1111/CODI.15106
Abstract: Reoperative pelvic surgery is rarely hostile and unsafe. Kraske’s procedure has historically been used to approach the mid‐rectum and to resect retrorectal tumors. However, it provides limited access to the pelvis and is best in the ‘virgin’ pelvis. We have encountered a select group of patients who required completion proctectomy or resection of a disconnected ileoanal J‐pouch where trans‐abdominal access to the pelvis was not possible and access to the pelvis could only be safely gained by a prone en bloc sacrectomy. We describe a prone approach that provides an alternative route of access to the hostile pelvis. After exposure of the sacrum and coccyx and transection of the sacrum, access to the mesorectal plane is achieved and a proctectomy (or resection of an ileoanal J‐pouch) can be completed. The procedure is similar to the Kraske approach but requires a higher and wider exposure similar to the extent of an abdominal resection however, the operation is performed in ‘reverse’. We found that this approach was feasible and safe in the previously operated, hostile pelvis. We employed it in one patient to excise a disconnected J‐pouch with chronic sepsis and in another patient for a completion proctectomy. Both patients had an uneventful recovery and clear margins were obtained with no complications. The en bloc prone sacrectomy approach is a useful alternative in a very select group of patients with difficult trans‐abdominal access to the pelvis. Experience in pelvic surgery and identification of clear anatomical landmarks is paramount to avoid catastrophic uncontrollable bleeding.
Publisher: American Society of Clinical Oncology (ASCO)
Date: 11-2012
Abstract: To compare the local recurrence (LR) rate between short-course (SC) and long-course (LC) neoadjuvant radiotherapy for rectal cancer. Eligible patients had ultrasound- or magnetic resonance imaging–staged T3N0-2M0 rectal adenocarcinoma within 12 cm from anal verge. SC consisted of pelvic radiotherapy 5 × 5 Gy in 1 week, early surgery, and six courses of adjuvant chemotherapy. LC was 50.4 Gy, 1.8 Gy/fraction, in 5.5 weeks, with continuous infusional fluorouracil 225 mg/m 2 per day, surgery in 4 to 6 weeks, and four courses of chemotherapy. Three hundred twenty-six patients were randomly assigned 163 patients to SC and 163 to LC. Median potential follow-up time was 5.9 years (range, 3.0 to 7.8 years). Three-year LR rates (cumulative incidence) were 7.5% for SC and 4.4% for LC (difference, 3.1% 95% CI, −2.1 to 8.3 P = .24). For distal tumors ( 5 cm), six of 48 SC patients and one of 31 LC patients experienced local recurrence (P = .21). Five-year distant recurrence rates were 27% for SC and 30% for LC (log-rank P = 0.92 hazard ratio [HR] for LC:SC, 1.04 95% CI, 0.69 to 1.56). Overall survival rates at 5 years were 74% for SC and 70% for LC (log-rank P = 0.62 HR, 1.12 95% CI, 0.76 to 1.67). Late toxicity rates were not substantially different (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer G3-4: SC, 5.8% LC, 8.2% P = .53). Three-year LR rates between SC and LC were not statistically significantly different the CI for the difference is consistent with either no clinically important difference or differences in favor of LC. LC may be more effective in reducing LR for distal tumors. No differences in rates of distant recurrence, relapse-free survival, overall survival, or late toxicity were detected.
Publisher: Oxford University Press (OUP)
Date: 06-04-2021
DOI: 10.1093/BJS/ZNAB070
Abstract: Tumour infiltration of the lateral pelvic compartment has previously been associated with the highest rate of involved resection margins and carries significant risk of morbidity. In this study, consecutive patients undergoing pelvic exenteration at a single centre between 1994 and 2019 who required en bloc resection of the common or external iliac artery or vein were included.The results demonstrate that complete resection of the iliac vascular system, including resection and reconstruction of the common and external iliac vessels, can be performed safely during pelvic exenteration with oncological outcomes comparable to more central tumours.
Publisher: Wiley
Date: 23-11-2016
DOI: 10.1111/ANS.13863
Abstract: To undertake a comprehensive needs assessment to determine the baseline of surgical research activity at a tertiary referral hospital in Sydney, Australia. The comprehensive needs assessment comprised three components: a retrospective audit of the hospital ethics committee records to identify surgical research activity a survey of all 17 surgical departments about the availability of 10 potential research resources and a survey of surgical staff to ascertain perceptions of research culture at the organizational, team and in idual levels. Of all research studies submitted to the hospital ethics committee in a 2-year period, only 9% were identified as surgical studies. Among the 17 surgical departments, there was wide variation in activity with only four defined as being 'research active'. On average, 52% of potential resources for surgical research were found to be in place within surgical departments. Only five departments were considered to be adequately research resourced (≥75% potential resources in place). Surgical research culture was rated 'moderate' at the organizational and team level, and 'low' at the in idual level. Medical staff rated research capacity significantly higher at the team and in idual levels compared to nursing staff. Collectively, the baseline results indicate there is considerable opportunity to enhance surgical research at the hospital level and to use this information to guide new and innovative approaches in the future.
Publisher: Wiley
Date: 20-09-2011
DOI: 10.1111/J.1463-1318.2010.02432.X
Abstract: Large bowel obstruction (LBO) is a surgical emergency that requires urgent operative intervention and often a stoma. The introduction of a self-expanding metallic stent provides an alternative for this group of patients. The aim of this study was to assess prospectively the results in the first 100 consecutive patients with LBO undergoing attempted self-expanding metallic stent insertion at the Royal Prince Alfred Hospital, Sydney, Australia. A prospective consecutive uncontrolled trial of 100 patients having an attempted self-expanding metallic stent insertion for LBO was performed after institutional ethical approval. The mean age was 63.9 years (range 16-95). Primary colorectal cancer was the most common cause of LBO (61%). A self-expanding metallic stent was inserted with a palliative intent in 89% of patients. An initial technical success rate of 87% was achieved. Overall 30-day mortality was 7% (95% CI, 3.4-13.7%), with only one stent-related death within 30 days of stent insertion. Morbidity occurred in 20% of patients. Surgery was avoided in 69 patients and permanent stoma was avoided in 72 patients. The median follow up was 34.5 months (range 1-64 months). In this uncontrolled study, self-expanding metallic stents had a low morbidity and a low procedure-related mortality. A randomized controlled trial has commenced in our institution, in which length of stay, quality of life, morbidity and mortality of patients with stents are compared with those of patients having open procedures during palliative care for LBO.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2015
Publisher: Wiley
Date: 07-1999
Publisher: Wiley
Date: 06-1999
Publisher: Elsevier BV
Date: 04-2012
Publisher: Wiley
Date: 08-11-2011
DOI: 10.1111/J.1463-1318.2010.02478.X
Abstract: There are limited data concerning the unmet needs experienced by patients with colorectal cancer. The aim of this study was to identify unmet supportive care needs of people with colorectal cancer following discharge from hospital. Health service utilization was used as a measure of expressed unmet need. A retrospective case note review was conducted of 521 patients surgically treated for colorectal cancer at Royal Prince Alfred Hospital, Sydney, between 1 January 2004 and 31 December 2007. Case notes maintained by a cancer nurse specialist were reviewed to identify postdischarge occasions-of-service where unmet need was expressed. Logistic regression was conducted to investigate predictors of unmet need. Of 521 patients, 219 (42%) patients had unmet supportive care needs, of which 50% of all needs was found in the physical domain. Twenty-six per cent of unmet needs was expressed within the first week following discharge from hospital after cancer surgery however, 21% persisted after 6 months. Multivariate analysis indentified that in this cohort, younger age predicted the expression of an unmet need (AOR, 0.97 95% CI, 0.96-0.99). People with rectal cancer remained significantly more likely to require more than one contact with the nurse to satisfy a need (AOR, 2.80 95% CI, 1.60-5.01) and to report a physical need (AOR, 3.56 95% CI, 2.03-6.27). This study has shown that auditing the interactions of a cancer nurse with patients can provide information about unmet supportive care needs, which can be used to develop relevant supportive care services or interventions for people with colorectal cancer.
Publisher: Elsevier BV
Date: 04-2006
DOI: 10.1080/00313020600580468
Abstract: Cellular senescence, the state of permanent growth arrest, is the inevitable fate of replicating normal somatic cells. Postulated to underlie this finite replicative span is the physiology of telomeres, which constitute the ends of chromosomes. The repetitive sequences of these DNA-protein complexes progressively shorten with each mitosis. When the critical length is bridged, telomeres trigger DNA repair and cell cycle checkpoint mechanisms that result in chromosomal fusions, cell cycle arrest, senescence and/or apoptosis. Should senescence be bypassed at such time, continued cell isions in the face of dysfunctional telomeres and activated DNA repair machinery can result in the genomic instability favourable for oncogenesis. The longevity and malignant progression of the thus transformed cell requires coincident telomerase expression or other means to negate the constitutional telomeric loss. Practically then, telomeres and telomerase may represent plausible prognostic and screening cancer markers. Furthermore, if the argument is extended, with assumptions that telomeric attrition is indeed the basis of cellular senescence and that accumulation of the latter equates to aging at the organismal level, then telomeres may well explain the increased incidence of cancer with human aging.
No related grants have been discovered for Michael Solomon.