Background
Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local ...recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates.
Methods
Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan–Meier estimates were used to compare local recurrence.
Results
In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty‐six patients (35·7 per cent) had a stoma at latest follow‐up; 39 (24·8 per cent) were permanent.
Conclusion
Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.
Antecedentes
La resección total del mesorrecto transanal (transanal total mesorectal excision, TaTME) para el cáncer de recto se ha propuesto como una alternativa al abordaje abdominal tradicional. Sin embargo, la recidiva local (local recurrence, LR) después de este procedimiento es motivo de preocupación. El objetivo de este estudio fue evaluar la LR en pacientes operados mediante TaTME. Los objetivos secundarios incluyeron la mortalidad postoperatoria, las fugas anastomóticas y el porcentaje de estomas.
Métodos
Se registraron los datos de todos los pacientes operados mediante TaTME y se compararon con las cohortes nacionales del Registro Noruego de Cáncer Colorrectal (Norwegian Colorectal Cancer Registry, NCCR) y del Registro Noruego de Cirugía Gastrointestinal (Norwegian Registry for Gastrointestinal Surgery, NoRGast) utilizando estimaciones de Kaplan‐Meier y la prueba de log‐rank para comparar curvas de LR.
Resultados
En Noruega, 157 pacientes se sometieron a TaTME por cáncer de recto entre octubre de 2014 y octubre de 2018. Tres de siete hospitales abandonaron el TaTME después de un total de cinco procedimientos. La LR observada fue 12/157 (7,6%), siendo ocho de ellas multifocales o extensas. La tasa estimada de LR a 2,4 años fue de 11,6 % (i.c. del 95% 6,6 a 19,9) versus 2,4 % (1,4 a 4,3) en el NCCR (log rank P < 0,001). El cociente de riesgos instantáneos (hazard ratio, HR) ajustado fue 6,7 (i.c. del 95% 2,9 a 15,3). Las fugas anastomóticas que precisaron una reintervención después de TaTME ocurrieron en un 8,4% versus 4,5% en el registro NoRGast (P = 0,047). Cincuenta y seis pacientes (35,7%) tenían un estoma en el último seguimiento; 39 (24,8%) eran permanentes.
Conclusión
Las tasas de fuga anastomótica tras una TaTME fueron más altas que los datos nacionales con tasas de LR y patrones de crecimiento desfavorables.
The local recurrence rate after transanal total mesorectal excision was high. The adjusted estimated hazard ratio compared with the national cohort after 2·4 years was 6·71. The anastomotic leak rate and the rate of permanent stomas were unfavourable.
Worrying results
"Research has repeatedly shown that educational opportunities are distributed unevenly in all countries. Therefore, the question is not whether family background and educational outcomes are related ...but to what degree they are related. This latter question then invites a comparative perspective. That is, does social inequality in education differ across time and countries? If yes, which institutional characteristics can explain differences in educational inequality? Educational inequality is conceptualized as the association between individuals' and their parents' highest educational level attained. Intergenerational educational mobility processes are analysed for 20 industrialized nations by means of log-linear and log-multiplicative models. The results show that the degree of educational mobility has remained stable across the second half of the 20th century in virtually all countries. However, nations differ widely in the extent to which parents' education influences their children's educational attainment. The degree of educational inequality is associated with the institutional structure of national education systems. Rigid systems with dead-end educational pathways appear to be a hindrance to the equalization of educational opportunities, especially if the sorting of students occurs early in the educational career. This association is not mediated by other institutional characteristics included in this analysis that do not exert notable influences on educational mobility." Die Untersuchung enthält quantitative Daten. Forschungsmethode: empirisch-quantitativ; empirisch; Sekundäranalyse; Querschnitt; Längsschnitt. Die Untersuchung bezieht sich auf den Zeitraum 1994 bis 1998. (author's abstract, IAB-Doku).
Abstract Introduction Stoma formation delays discharge after colorectal surgery. Stoma education is widely recommended, but little data are available regarding whether educational interventions are ...effective. The aim of this prospective study was to investigate whether an enhanced recovery after surgery (ERAS) programme with dedicated ERAS and stoma nurse specialists focusing on counselling and stoma education can reduce the length of hospital stay, re-admission, and stoma-related complications and improve health-related quality of life (HRQoL) compared to current stoma education in a traditional standard care pathway. Methods In a single-center study 122 adult patients eligible for laparoscopic or open colorectal resection who received a planned stoma were treated in either the ERAS program with extended stoma education (n = 61) or standard care with current stoma education (n = 61). The primary endpoint was total postoperative hospital stay. Secondary endpoints were postoperative hospital stay, major or minor morbidity, early stoma-related complications, health-related quality of life, re-admission rate, and mortality. HRQoL was measured by the generic 15D instrument. Results Total hospital stay was significantly shorter in the ERAS group with education than the standard care group (median range, 6 days 2–21 days vs. 9 days 5–45 days; p < 0.001). Regarding overall major and minor morbidity, re-admission rate, HRQoL, stoma-related complications and 30-day mortality, the two treatment groups exhibited similar outcomes. Conclusion Patients receiving a planned stoma can be included in an ERAS program. Pre-operative and postoperative stoma education in an enhanced recovery programme is associated with a significantly shorter hospital stay without any difference in re-admission rate or early stoma-related complications.
Background and Aims:
The International Study Group of Rectal Cancer has proposed that a pelvic abscess in the proximity of the anastomosis is considered an anastomotic leak, whether or not its point ...of origin is detectable. This study describes how the inclusion of pelvic abscesses alters the leakage rate.
Material and Methods:
Risk factors and postoperative complications in patients with visible anastomotic leakage (“direct leakage”), pelvic abscesses alone in the vicinity of a visibly intact anastomosis (“abscess leakage”), and no leakage were retrospectively evaluated.
Results:
In total, 341 patients operated with anterior resections and who received an anastomosis within 15 cm as measured from the anal verge were included. A total of 37 patients (10.9%) had direct leakage, 13 (3.8%) had abscess leakage, and 291 (85.3%) had no leakage. The overall anastomotic leakage rate was 14.7% (50 patients). In accordance with the grading system outlined by International Study Group of Rectal Cancer, 7 patients (2.1%) experienced Grade A leakage, 19 (5.6%) Grade B, and 24 (7.0%) Grade C. Direct leak patients had more often a reoperation due to anastomotic complications (odds ratio = 19.7, p = 0.001), a permanent stoma (odds ratio = 28.5, p = 0.001), and a longer hospital stay than abscess leak patients (29.0 vs 15.5 days, p = 0.030).
Conclusion:
Abscess leakage accounted for over one-fourth of the overall leakage rate, raising the leakage rate. Direct leak patients were at a higher risk of requiring a reoperation, permanent stoma, and longer hospital stay than abscess leak patients. Abscess leak patients were at a greater risk for a urinary tract infection, wound infection, and postoperative intestinal obstruction than non-leak patients.
Solid-state 13C and 19F NMR spectroscopy offers a non-destructive, highly selective protocol for the identification of forensically relevant synthetic cannabinoids on herbal substrates. Using this ...technique, well resolved 13C spectra were obtained that readily enabled structural identification; in some instances complemented by 19F spectral data. The approach described has potential for related applications such as the direct detection of pesticides on plants.
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•Elucidation of synthetic cannabinoids on the surface of herbal substrates.•No sample pre-treatment required.•Compounds of interest on plant based material generate excellent peak shape.•High level of ordering of the compounds on the surface as the organic solvent evaporates.
Aim
The aim of this randomized clinical trial was to compare patients treated using a multimodal approach enhanced recovery after surgery (ERAS), with a special focus on counselling, to patients ...treated in a standard conventional care pathway, who underwent elective colorectal resection.
Method
In a single‐centre trial, adult patients eligible for open or laparoscopic colorectal resection were randomized to an ERAS programme or standard care. The primary end‐point was postoperative total hospital stay. Identical discharge criteria were defined for both treatment groups. Secondary end‐points included postoperative complications, postoperative C‐reactive protein levels, postoperative hospital stay, readmission rate and mortality. All parameters were recorded before operation, on the day of surgery and daily thereafter until discharge.
Results
Total hospital stay was significantly shorter among patients randomized to ERAS than among the standard group median 5 days (range 2–50 days) vs median 8 days (range 2–48 days); P = 0.001. The two treatment groups exhibited similar outcomes regarding overall major and minor morbidity, reoperation rate, readmission rate and 30‐day mortality. There were also no differences in tolerance of enteral nutrition or in the inflammatory response, as reflected by postoperative C‐reactive protein levels.
Conclusion
ERAS care was associated with a significantly shorter length of hospital stay. Without any difference in surgical or general complications, tolerance of enteral nutrition or postoperative C‐reactive protein levels, peri‐operative information and guidance for ensuring that patients comply with the ERAS approach appear to be important factors to reduce the length of hospital stay.
Background:
Rectal cancer surgery is standardized, resulting in improved survival. Colon cancer has fallen behind and therefore more radical surgical techniques have been introduced. One technique is ...complete mesocolic excision. The aim of this article was to study the complications after the introduction of standardized complete mesocolic excision in a single center.
Methods:
Complete mesocolic excision was introduced in 2007, and data were collected from 286 patients prior to surgery (2007–2010). The surgeon decided on open or laparoscopic surgery. Follow-up information was recorded until 31 December 2015. Complications were classified according to a modified Clavien–Dindo classification.
Results:
Complications occurred in 47%, severe complications (grade III and IV) in 15%. In-hospital mortality was 3.5%. A total of 142 patients (49.7%) were operated by open surgery. Logistic regression revealed anemia (p = 0.001), open surgery (p < 0.001), and long operating time (p < 0.001) as significant factors for complications in general. Multinomial logistic regression revealed that severe complications occurred more often in males (odds ratio: 2.56; 95% confidence interval: 0.98–6.68), patients with anemia (odds ratio: 3.49; 95% confidence interval: 1.27–9.60), elevated body mass index (odds ratio: 1.14; 95% confidence interval: 1.02–1.28), and in open surgery (odds ratio: 9.95; 95% confidence interval: 2.58–38.35). Age was not associated with severe complications. Survival was not significantly influenced by complications. Overall survival (5 years) was 90% among patients with complications and 92% among those without complications.
Conclusion:
Severe complications following the introduction of complete mesocolic excision are patient dependent and related to open surgery. Patients selected for laparoscopy had less number of complications; therefore, introducing complete mesocolic excision by laparoscopy is justified. Identification of these factors can improve selection of appropriate surgical approach and postoperative patient safety.
Very few randomized studies on laparoscopic (L) versus open (O) living-donor nephrectomy (LDN) have been presented. The largest randomized series reported so far included 80 donors. In 2000, an ...Australian safety group concluded that the evidence base for L-LDN is inadequate to make recommendations regarding safety and efficacy.
With this background, at our single national center, 122 donors were randomized to left-sided L-LDN (n=63) or O-LDN (n=59), from February 2001 to May 2004. This article summarizes our experiences, in particular regarding complications and safety.
There were significant differences in favor of O-LDN regarding operative time, warm ischemia time, and vessel lengths, whereas the analgesic requirements and pain data were significantly in favor of the laparoscopic procedure. In the L-LDN group, there were five major postoperative complications resulting in reoperations (8%), including two intestinal perforations. No major complications occurred in the O-LDN group.
These results from our randomized study do suggest that conventional O-LDN is a very secure procedure, superior to L-LDN regarding donor safety. There has been an unacceptably high rate of reoperations in our L-LDN series but without mortality or significant sequelae. A careful look at some other L-LDN series also suggests increased morbidity/mortality. Our data do, however, support the view that a perfect, uncomplicated L-LDN appears to be the superior procedure, and the laparoscopic procedure is still evolving. Donor safety may be improved by avoiding obese donors, stapling of the renal artery (not clipping), and perhaps by hand assistance. Furthermore, we will consider the retroperitoneal approach.
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