Current practice in Australia and New Zealand for defunctioning ileostomy after rectal cancer surgery with anastomosis: Analysis of the Bi-National Colorectal Cancer Audit (BCCA)

AIM: This study aimed to investigate the use of defunctioning stomas after rectal cancer surgery in Australia and New Zealand (ANZ), as current practice is unknown. METHODS: From the Bi-National Colorectal Cancer Audit (BCCA) database, rectal cancer patients who underwent a resection between 2007 and 2019 with the formation of an anastomosis were extracted and analysed. Primary outcome was the rate of defunctioning stoma formation. Secondary outcomes were: anastomotic leakage (AL) rates and other postoperative complications, length of hospital stay (LOS), readmissions and 30-day mortality rates between stoma and no stoma groups. Propensity score-matching was performed to correct for differences in baseline characteristics between stoma and no-stoma groups. RESULTS: In total, 2,581 (89%) received a defunctioning stoma and 319 (11%) did not. There were more male patients in the stoma group (65.5 vs. 57.7% for the no-stoma group; p=0.006). The median age was 64 years in both groups. The stoma group underwent more ultra-low anterior resections (79.9 vs. 30.1%; p<0.0001), included more AJCC stage III patients (53.7 vs. 29.2%; p<0.0001) and received more neoadjuvant therapy (66.9 vs. 16.3%; p<0.0001). The AL rate was similar in both groups (5.1 vs. 6.0%; p=0.52). LOS was longer in the stoma group (8 vs. 6 days; p<0.0001) with higher 30-day readmission rates (14.9 vs. 8.3%; p=0.003). After propensity score-matching (n=208 in both groups), AL rates remained similar (2.9% for stoma vs. 5.8% for no stoma group; p=0.15), but stoma patients required less reoperations (0% vs. 8%; p=0.016). The stoma group had higher postoperative ileus rates and an increased LOS. CONCLUSION: In ANZ, most patients who underwent rectal cancer resections with the formation of an anastomosis received a defunctioning stoma. A defunctioning stoma does not prevent anastomotic leakage from occurring but is mostly associated with a lower reoperation rate. Patients with a defunctioning stoma experienced a higher postoperative ileus rate and had an increased length of hospital stay.Vera E. M. Grupa, Hidde M. Kroon, Izel Ozmen, Sergei Bedrikovetski, Nagendra N. Dudi-Venkata, Ronald A. Hunter, Tarik Sammou

A prospective study of diagnostic accuracy of multidisciplinary team and radiology reporting of preoperative colorectal cancer local staging

Published on: 17 June 2022Introduction: The aim of this study was to correlate and assess diagnostic accuracy of preoperative staging at multidisciplinary team meeting (MDT) against the original radiology reports and pathological staging in colorectal cancer patients. Methods: A prospective observational study was conducted at two institutions. Patients with histologically proven colorectal cancer and available preoperative imaging were included. Preoperative tumor and nodal staging (cT and cN) as determined by the MDT and the radiology report (computed tomography [CT] and/or magnetic resonance imaging [MRI]) were recorded. Kappa statistics were used to assess agreement between MDT and the radiology report for cN staging in colon cancer, cT and cN in rectal cancer, and tumor regression grade (TRG) in patients with rectal cancer who received neoadjuvant therapy. Pathological report after surgery served as the reference standard for local staging, and AUROC curves were constructed to compare diagnostic accuracy of theMDT and radiology report. Results:Atotal of 481 patients were included. Agreement betweenMDT and radiology report for cN stage was good in colon cancer (k = .756, Confidence Interval (CI) 95% .686–.826). Agreement for cT and cN and in rectal cancer was very good (kw = .825, CI 95% .758–.892) and good (kw = .792, CI 95% .709–.875), respectively. In the rectal cancer group that received neoadjuvant therapy, agreement on TRG was very good (kw = .919, CI 95% .846–.993). AUROC curves using pathological staging indicated no difference in diagnostic accuracy betweenMDT and radiology reports for either colon or rectal cancer. Conclusion: Preoperative colorectal cancer local staging was consistent between specialist MDT review and original radiology reports, with no significant differences in diagnostic accuracy identified.Sergei Bedrikovetski, Nagendra N. Dudi-Venkata, Hidde M. Kroon, Luke H. Traeger, Warren Seow, Ryash Vather, Michael Wilks, JamesW.Moore, Tarik Sammou

Local recurrences in western low rectal cancer patients treated with or without lateral lymph node dissection after neoadjuvant (chemo) radiotherapy: An international multi-centre comparative study

Background: In the West, low rectal cancer patients with abnormal lateral lymph nodes (LLNs) are commonly treated with neoadjuvant (chemo)radiotherapy (nCRT) followed by total mesorectal excision (TME). Additionally, some perform a lateral lymph node dissection (LLND). To date, no comparative data (nCRT vs. nCRT + LLND) are available in Western patients. Methods: An international multi-centre cohort study was conducted at six centres from the Netherlands, US and Australia. Patients with low rectal cancers from the Netherlands and Australia with abnormal LLNs (≥5 mm short-axis in the obturator, internal iliac, external iliac and/or common iliac basin) who underwent nCRT and TME (LLND-group) were compared to similarly staged patients from the US who underwent a LLND in addition to nCRT and TME (LLND + group). Results: LLND + patients (n = 44) were younger with higher ASA-classifications and ypN-stages compared to LLND-patients (n = 115). LLND + patients had larger median LLNs short-axes and received more adjuvant chemotherapy (100 vs. 30%; p < 0.0001). Between groups, the local recurrence rate (LRR) was 3% for LLND + vs. 11% for LLND- (p = 0.13). Disease-free survival (DFS, p = 0.94) and overall survival (OS, p = 0.42) were similar. On multivariable analysis, LLND was an independent significant factor for local recurrences (p = 0.01). Sub-analysis of patients who underwent long-course nCRT and had adjuvant chemotherapy (LLND-n = 30, LLND + n = 44) demonstrated a lower LRR for LLND + patients (3% vs. 16% for LLND-; p = 0.04). DFS (p = 0.10) and OS (p = 0.11) were similar between groups. Conclusion: A LLND in addition to nCRT may improve loco-regional control in Western patients with low rectal cancer and abnormal LLNs. Larger studies in Western patients are required to evaluate its contribution

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

Introduction Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction. Method An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co‐developed and may be combined to form a common output with disease‐specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal‐group stakeholder discussions; online‐facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized. Dissemination and implementation The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi‐faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set

Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.Laura Bravo ... COVIDSurg Collaborative : (Royal Adelaide Hospital, N. N. Dudi-Venkata, H. M. Kroon, T. Sammour) ... et al.

Core outcome set for clinical studies of postoperative ileus after intestinal surgery

Postoperative ileus is a common and distressing complication after intestinal surgery. . It presents clinically as impairment of intestinal motility, characterized by abdominal pain, vomiting, and delayed recovery of defaecatory function. For patients, this increases the risk of serious complications, such as pneumonia, venous thromboembolic events, and malnutrition . For healthcare systems, it leads to a substantial economic burden associated with increased medical, nursing, dietitian, and laboratory costs . Accordingly, postoperative ileus is now recognized as a research priority by expert and public stakeholder groups . Numerous clinical interventions have been evaluated in efforts to prevent postoperative ileus, but few have led to meaningful patient benefit . A key challenge for researchers is the absence of a standardized and agreed framework to describe the effectiveness of new interventions in clinical studies . Common outcomes include the time taken until first passage of flatus/stool, time until tolerance of oral diet, and the return of bowel sounds. It remains unclear, however, whether these are sufficiently relevant to patients and healthcare professionals when evaluating new treatments and implementing them in clinical practice . A solution to this problem is the development of an agreed core outcome set developed through patient–clinician consensus. Core outcome sets provide a minimum set of outcomes that should be reported in all studies of a defined clinical condition and are supported by the Core Outcome Measures in Effective Trials (COMET) Initiative . The present report describes the international development and final content of an agreed core outcome set for postoperative ileus relevant to patients undergoing intestinal surgery.S.J. Chapman ... H. Kroon ... T. Sammour ... J. Han ... Tripartite Gastrointestinal Recovery Post-operative IIeus Group ... et al

Towards a zero percent anastomotic leak rate using a defined risk reduction strategy

Background Anastomotic leak (AL) remains one of the most serious complications after colorectal surgery. This study reports prospective data on a defined risk reduction strategy used by one surgeon over a 3-year period. Methods Using a single surgeon case series with a predefined risk reduction strategy for all anastomoses, a prospectively maintained database on demographic, perioperative, and postoperative outcomes of patients undergoing colorectal resections with formation of anastomosis between January 2017 and July 2020 was evaluated. Data were analysed using descriptive statistics. Results There were 145 anastomoses formed in 134 patients. The median age of patients was 67 years (32–87), and the mean body mass index (BMI) was 27.7 kg/m2. Seventy-three (50.3%) procedures were performed open and 72 (49.7%) were minimally invasive. Major complications (Clavien–Dindo grade ≥3) occurred in 13 (9.0%) cases. Two patients had an AL (1.3%) that could be treated with antibiotics (grade A). No patient experienced grade B or C leaks (requiring intervention). Median length of hospital stay was 8 days, and 2 patients died within 30-days postoperatively (1.4%). Conclusions A predefined risk reduction strategy may help improve patient selection and reduce anastomotic leak rates. A prospective comparative study is warranted.Sergei Bedrikovetski, Nagendra N. Dudi-Venkata, Hidde M. Kroon, Ryash Vather, Tarik Sammou

A global survey of surgeons' preferences and practice with regard to laxative use after elective colorectal surgery

Purpose: The role of laxatives after elective colorectal surgery is unclear, resulting in heterogenous guidelines and variability in clinical practice. This study aimed to gauge surgeons’ preferences and practice with regard to laxative use following elective colorectal surgery. Methods: A short one-minute anonymous web-based questionnaire designed in English and Chinese (Mandarin) using the Research Electronic Data Capture application (REDCap) was distributed to member surgeons of every identifiable international colorectal specialist society via email communication, physical newsletters and social media channels. Frequency of laxative use after elective colorectal surgery, type of laxative used, and, if not used, the reasons for not using laxatives were collected. Results: A total of 852 surgeons, representing 28 surgical societies completed the survey: 80% were colorectal surgeons and 20% were general surgeons with colorectal interest. Twenty-seven percent of the respondents routinely prescribed laxatives after colorectal surgery. There was wide variation in the type of laxatives used, with magnesium-based laxatives (42%), macrogol (Movicol, 36%) and lactulose (Duphalac, 22%) being the most common. Geographical location was correlated with choice of laxative. Those not routinely using laxatives stated the reasons as being no evidence for benefit (48%), potential of adverse events (24%), more than one reason (21%) and other (7%). The majority (93%) non-users would consider using laxatives if better evidence was available. Conclusion: Most surgeons do not routinely prescribe laxatives after elective colorectal surgery due to lack of evidence. Amongst those surgeons who do use them, there is wide variability in the type of laxatives used.Nagendra N. Dudi-Venkata, Hidde M. Kroon, Sergei Bedrikovetski, James W. Moore, Michelle L. Thomas and Tarik Sammou

Impact of timing of reversal of loop ileostomy on patient outcomes: a retrospective cohort study

Published online: 9 September 2021Background: Diverting loop ileostomies (DLIs) are ideally reversed 6–12 weeks after the index operation. However, reversal surgery is frequently delayed in a real-world setting, with potential implications on patient’s quality of life and postoperative complications. The aim of this study was to investigate the impact of timing of the reversal on patient outcomes at a tertiary referral hospital. Methods: Consecutive patients who underwent elective reversal of loop ileostomy (RLI) between January 2007 and January 2019 were included. The primary outcomes were incidence of postoperative ileus (POI) and 30-day postoperative complications. Results: Of 251 eligible patients, 158 (63%) were men, the median age was 64 years (range 23–88 years), and the most common index operation was an ultra-low anterior resection in 106 (42%). The median time to reversal for the entire cohort was 7.4 months (range 1–28). RLI was performed within 6 months after the index surgery in 89 patients (35%, early group), 6–12 months in 120 (48%, middle group) and after more than 12 months in 42 (17%, late group) patients. A significantly lower incidence of postoperative ileus (13.5% vs. 25.8% vs. 38.1%, p = 0.006), and 30-day postoperative complications (29.2% vs 41.7% vs. 57.1%, p = 0.011) were seen in the early group compared to the middle and late groups, respectively. There was no difference in the return to theater, length of hospital stay, and readmission rate between groups. Conclusion: Delayed RLI is associated with increased risk of postoperative complications.T.-W. Khoo, N. N. Dudi, Venkata, Y. Z. Beh, S. Bedrikovetski, H. M. Kroon, M. L. Thomas, T. Sammou