Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer

IntroductionPrevious treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre.Material and methodsData regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer.ResultsPatients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60–1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34–4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36–1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32–5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival.ConclusionRectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location

Short learning curve in transition from laparoscopic to robotic-assisted rectal cancer surgery : a prospective study from a Finnish Tertiary Referral Centre

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien–Dindo III–IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.Peer reviewe

Computer-generated structured electronic medical records are preferable to conventional medical records for patients with acute abdominal pain : a prospective, double-blinded study

Objectives: Structured medical records improve readability and ensure the inclusion of information necessary for correct diagnosis and treatment. This is the first study to assess the quality of computer-generated structured medical records by comparing them to conventional medical records on patients with acute abdominal pain. Materials and methods: A prospective double-blinded study was conducted in a tertiary referral center emergency department between January 2018 and June 2018. Patients were examined by emergency department physicians and by experience and inexperienced researcher. The researchers used a new electronical medical records system, which gathered data during the examination and the system generate structured medical records containing natural language. Conventional medical records dictated by physician and computer-generated medical records were compared by a group of independent clinicians. Results: Ninety-nine patients were included. The overall quality of the computer-generated medical records was better than the quality of conventional human-generated medical records – the structure was similar or better in 99% of cases and the readability was similar or better in 86% of cases, p < 0.001. The quality of medical history, current illness, and findings of physical examinations were likewise better with the computer-generated recording. The results were similar when patients were examined by experienced or inexperienced researcher using the computer-generated recording. Discussion: The quality of computer-generated structured medical records was superior to that of conventional medical records. The quality remained similar regardless of the researcher’s level of experience. The system allows automatic risk scoring and easy access for quality control of patient care. We therefore consider that it would be useful in wider practice.publishedVersionPeer reviewe

Akuutin appendisiitin leikkaushoito. Haavan paraneminen, vakavat komplikaatiot ja kuolleisuus

Akuutin umpilisäkkeen tulehduksen diagnostiikka on osa jokaisen päivystävän lääkärin arkipäivää. Diagnostiikka on selkeissä tapauksissa suoraviivaista ja leikkauspäätös voidaan tehdä ilman monimutkaisia tutkimuksia. Aina näin ei ole ja terveiden umpilisäkkeiden poistojen (negatiivinen appendikektomia) määrä onkin säilynyt korkeana huolimatta diagnostiikan kehittymisestä. Kuolleisuuden ja komplikaatioiden määrän on todettu olevan yhteydessä negatiivisiin appendikektomioihin. Suomessa kuolleisuutta appendikektomioihin on selvitetty vain 60-luvulla ja mainintana appendisiitin insidenssiin keskittyvässä tutkimuksessa. Appendikektomioihin liittyviä vakavia komplikaatioita ei ole Suomessa aiemmin tutkittu ja maailmallakin vain muutamissa tutkimuksissa. Umpilisäkkeen poistoleikkaus eli appendikektomia on yleisin vatsakirurginen päivystysleikkaus meillä ja maailmalla. Avoleikkauksen tekniikka on kehitetty jo yli sata vuotta sitten. Pääsääntöisesti toimenpide on säilynyt alkuperäisen tekniikan mukaisena. Vaikka tähystysleikkaukset ovat lisääntyneet viime vuosikymmenenä, perinteinen avoleikkaus on silti monissa päivystyspisteissä yleinen toimenpide. Maailmanlaajuisesti avoleikkaus on edelleen yleisempi kuin tähystysleikkaus, jonka vaatimukset osaamisen, välineiden ja resurssien suhteen ovat korkeammat. Appendikektomiahaavat on perinteisesti suljettu muutamalla poistettavalla ompeleella lisääntyneen haavainfektioriskin pelossa. Tällaisen haavansulun kosmeettinen tulos on vaatimaton ja muutaman ompeleen poiston vuoksi potilaan hoitoon joudutaan käyttämään terveydenhoidon resursseja. Sulavien ihonsisäisten eli intradermaalisten ompeleiden käyttö on leikkaushaavojen sulussa yleistynyt ja niiden kosmeettinen tulos on osoitettu hyväksi. Lasten appendiketomioissa sulavan ihonsisäisen ompeleen käyttö on vakioitunut menetelmä. Väitöskirjatyö koostuu neljästä itsenäisestä osasta. Kahden ensimmäisen osatyön tavoitteena oli selvittää sulavan ihonsisäisen ompeleen käytön soveltuvuus aikuispotilaiden appendikektomiahaavoissa haavan paranemisen ja kosmeettisen tuloksen kannalta. Kahdessa seuraavassa työssä tavoitteenamme oli selvittää appendikektomiaan liittyviä vakavia komplikaatioita ja kuolleisuutta Suomessa. Väitöskirjan ensimmäisessä osatyössä (I) selvitimme sulavan ihonsisäisen ompeleen käytön turvallisuutta aikuispotilailla. Tutkimusasetelmassamme 200 umpilisäkkeen poistoon suunniteltua potilasta satunnaistettiin haavan sulun osalta kahteen ryhmään: perinteiseen poistettavien ompeleiden ja sulavan ihonsisäisen haavansulun ryhmään. Tuloksena oli, että sulavan ompeleen käyttöön ei liittynyt merkittävästi enempää haavainfektioita kuin perinteiseenkään haavan sulkuun. Lievempien haavakomplikaatioiden suhteen (haavan raottuminen ja pitkittynyt eritys) sulava ommel osoittautui merkittävästi paremmaksi kuin perinteinen haavan sulkumenetelmä. Toisessa osatyössä (II) selvitimme ensimmäiseen tutkimukseen osallistuneiden potilaiden leikkaushaavojen kosmeettista tulosta. Saimme sekä subjektiivisilla että objektiivisilla mittareilla tilastollisesti merkitsevän tuloksen: kosmeettinen tulos on parempi käyttäen sulavaa ihonsisäistä ommelta haavan sulkuun. Kolmannessa osatyössä (III) tavoitteena oli selvittää umpilisäkkeen poistoleikkaukseen liittyviä vakavia komplikaatioita Potilasvakuutuskeskukseen tehtyjen vahinkoilmoitusten avulla. Totesimme appendikektomioihin liittyvien potilasvahinkojen määrän olevan vähäinen . Tähystysleikkauksiin liittyvät komplikaatiot olivat vakavampia kuin avoleikkauksiin liittyvät, lisäksi tähystysleikkauksiin liittyen oli tehty suhteellisesti enemmän potilasvahinkoilmoituksia. Tutkimusjakson aikana ero kuitenkin tasoittui tähystysleikkauksien määrän lisääntyessä. Leikkauskomplikaatiot olivat yhteydessä komplisoituneisiin tulehduksiin, negatiivisiin appendikektomioihin, ikääntymiseen ja lisääntyneisiin perussairauksiin. Tutkimuksemme perusteella totesimme, että paremmalla diagnostiikalla osa komplikaatioista saattaa olla vältettävissä. Uuden tekniikan aloittamiseen liittyen tutkimusjakson aikana on ollut suhteellisesti enemmän potilasvahinkoja tähystysleikkauksiin liittyen. Neljännessä osatyössä (IV) selvitimme THL:n ja Tilastokeskuksen rekisterien avulla umpilisäkkeen poistoon liittyvää kuolleisuutta Suomessa. Appendikektomioihin liittyvä kuolleisuus Suomessa on 2.1/1000 leikkausta. Totesimme kuolleisuuden laskeneen alle puoleen lähtötasostaan tutkimusjakson aikana. Samana ajanjaksona tähystysleikkausten määrä lisääntyi ja negatiivisten appendikektomioiden määrä väheni merkittävästi. Kuolleisuus oli yhteydessä ikääntymiseen, negatiiviseen appendikektomiaan, komplisoituneeseen tulehdukseen, mies sukupuoleen ja avoleikkaukseen. Moni muuttuja analyysi tuki näitä löydöksiä. Johtopäätöksenä totesimme parantuneen diagnostiikan todennäköisesti vähentäneen kuolleisuutta appendikektomioihin liittyen. Umpilisäkkeen poistoleikkauksen perinteenä on ollut haavakomplikaatioiden pelossa sulkea haavat vanhanaikaisella menetelmällä. Tutkimuksessamme pystyimme osoittamaan uuden ihonsisäisen sulavan ompeleen olevan turvallinen ja parempaan kosmeettiseen tulokseen johtava menetelmä. Niinikään traditiona on ollut hyväksyä kohtalaisen suuri negatiivisten appendikektomioiden määrä. Komplikaatio- ja kuolleisuustutkimuksiemme perusteella totesimme, että pyrkimys hyvään diagnostiikkaan voi vähentää sekä vakavia komplikaatioita, että kuolleisuutta. Täsmällinen diagnostiikka on erityisen tärkeää ikääntyvien ja perussairaiden potilaiden kohdalla. Operatiivisen hoidon komplikaatiot ja kuolleisuus ovat tärkeä vertailukohta, kun lähdetään kehittämään akuutin appendisiitin konservatiivista hoitoa. Tuloksemme kannustavat laparoskooppisen tekniikan käyttöön sekä tarkempaan diagnostiikkaan appendisiitin operatiivisessa hoidossa.The diagnostics of appendicitis is a surgeon’s, everyday work at emergency units. In many cases diagnosis of appendicitis is straightforward and the decision of surgery is simple. However, the diagnosis can be challenging, and despite of advanced diagnostic imaging, the rate of removal of healthy appendices in suspicion of appendicitis (negative appendectomies) remains high. Earlier studies have shown a connection between negative appendectomies and increased complications and mortality. Appendectomy-related mortality in Finland is not well defined. Severe complications related to appendectomy have not been studied in Finland previously and worldwide only few studies are published. Appendectomy is the most frequently performed emergency operation in the field of alimentary tract surgery worldwide. Open technique for appendectomy has been developed over a hundred years ago. The technique has more or less remained the same over the years. In last two decades laparoscopic appendectomy has increased in popularity and is presently the method of choice in many centers. Worldwide, open appendectomy is still a valid technique, as laparoscopy requires higher skills, complex instrumentation and more resources. Open appendectomy wounds have traditionally been closed with few interrupted, non-absorbable sutures in the fear of wound infection, which is the most common complication after appendectomy. This wound closure method results in suboptimal cosmetic outcome with the inconvenience of stich removal to the patient and a burden to the health care system. Absorbable intradermal suturing has become a common wound closure method. In children, intradermal absorbable suturing is already accepted as a routine method for appendectomy wound closure. This thesis consists of four independent articles. The aim of the first two parts was to investigate the feasibility of intradermal absorbable suturing in appendectomy wound closure in adults. In the first study (I) we randomized 200 appendectomy patients into two groups of wound closure groups: traditional non-absorbable interrupted sutures and absorbable intradermal continuous suturing. The result was, that the methods were equal in regards of the frequency of wound infection; however mild wound complications (dehiscence) were significantly more frequent in non-absorbable suture group. In the second study (II) we examined the cosmetic outcome of the two wound closure methods. The patients included in the first study, were evaluated by both subjective and objective scar assessments, which showed statistically significant benefit of absorbable intradermal wound closure in terms of cosmetic outcome. In the third study (III) the aim was to define severe complications related to appendectomies based on the Patients Insurance Centre’s register data. We found that patients’ complains related to appendectomy are rare (0.2%). The complaints were more frequently related to laparoscopic operations, than to open surgery. This difference equalized towards the end of the study period, as the percentage of laparoscopic operations increased. Severe complications were more often related to laparoscopic surgery, complicated infection, negative appendectomy and aging. We concluded that with better diagnostics some of the severe complications may be avoided. The increased complication rate related to laparoscopic appendectomies during the study period was in correlation to adopting a new technique. In the fourth (IV) study we investigated the mortality related to appendectomies in Finland, based on the register data of the National Institute of Health and Welfare and Statistics Finland. Over the study period of two decades, the appendectomy-related mortality in Finland was 2.1/1000 operations. The mortality decreased to less than half over the study period. At the same time the rate of negative appendectomies decreased and the percentage of laparoscopic surgery increased. Mortality was related to male gender, aging, complicated infection, negative appendectomy and open appendectomy. We concluded that better diagnostics may have decreased the appendectomy-related mortality in Finland. Appendectomy wounds have been traditionally closed with an old-fashioned way in the fear of wound infection. In this thesis we were able to prove, that a more modern wound closure method with absorbable intradermal suturing is safe in terms of wound infection, and it yields a better cosmetic outcome in appendectomy wounds. Another tradition has been to accept a relatively high rate of negative appendectomies. In our studies on complications and mortality, we were able to conclude; that an attempt to better diagnostics may decrease both severe complications and mortality. The importance of knowing the present figures is that they act as a valid reference value when examining the benefits of conservative treatment of acute appendicitis. Our results encourage the use of laparoscopic procedures and proper diagnostic work up in the operative treatment of appendicitis

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi-centre, prospective audit.

This is the peer reviewed version of the following article: , (2018), Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi‐centre, prospective audit. Colorectal Dis, 20: 15-32. doi:10.1111/codi.14362, which has been published in final form at https://doi.org/10.1111/codi.14362. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived VersionsINTRODUCTION: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). METHODS: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. RESULTS: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30-0.92, P = 0.02) but MBP was not (OR 0.92, 0.63-1.36, P = 0.69) compared to NBP. CONCLUSION: This non-randomised study adds 'real-world', contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice