Category Archives: Colorectal Surgery

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer

Posted on by
Reply

One discussion this week involved the PCI cutoff for CRS/HIPEC for colorectal cancers.

References: Faron M, et al. Linear relationship of Peritoneal Cancer Index and survival in patients with peritoneal metastases from colorectal cancer. Annals of Surgical Oncology. 2016 Jan;23(1):114-119. doi:10.1245/s10434-015-4627-8.

Klaver CEL, et al. Recommendations and consensus on the treatment of peritoneal metastases of colorectal origin: a systematic review of national and international guidelines. Colorectal Disease. 2017 Mar;19(3):224-236. doi:10.1111/codi.13593

Summary: A diagnosis of peritoneal metastases (PM) is generally poor, approximately 5 months if untreated; however, CRS/HIPEC has been shown to increase median survival up to 22 months (Klaver et al, 2017).

Faron et al (2016) explored the relationship between the peritoneal cancer index (PCI) and overall survival in the setting of complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). In reviewing the literature, they found that CCRS/HIPEC is indicated for a PCI <12 and not appropriate for a PCI >17. There is an area of indecision in PCIs 12-17.

To bridge this PCI indecision gap, Faron et al (2016) recommend considering the following parameters (p.118):

  1. Presence of other site of metastases besides peritoneum
  2. General performance status and patient age, linked to morbidity and mortality
  3. Response to neoadjuvant chemotherapy, because progression of disease while receiving systemic chemotherapy reflects aggressive tumor behavior

In a systematic review of 21 guidelines, Klaver et al (2017) found a 71% consensus that CRS/HIPEC is the recommended treatment for PM. There is a need not only for additional evidence, but also an international platform for more trials on CRS/HIPEC and the overall treatment of PM (Klaver et al, 2017).

To drain or not to drain…the GRECCAR 5 randomized trial

Posted on by
Reply

One discussion this week focused on pelvic drains.

Reference: Denost Q, et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for Cancer: The GRECCAR 5 randomized trial. Annals of Surgery. 2017 Mar;265(3):474-480. doi:10.1097/SLA.0000000000001991.

Summary: The GRECCAR 5 randomized trial sought to explore the benefit of a drain for postoperative pelvic sepsis, overall morbidity and mortality, rate of re-operation, length of stay, and rate of stoma closure at 6 months (p.474). It involved 469 patients (236 with drains, 233 without) between 2011 and 2014.

Ultimately, the trial did not find any benefit of the pelvic drain after low anterior resection for rectal cancer. Thus, the authors “recommend not using pelvic drain after rectal excision for cancer, except in case of operative bleeding or beyond TME surgery” (p.480).

The drain did not contribute to an efficient diagnosis of sepsis, for the time to diagnosis of pelvic sepsis was an average of 7.8 days, yet the drain was removed at 5.5 days postop (see figure below; p.1478).

pelvic sepsis

There was no significant difference between the two groups for any of the noted measurements. Pelvic sepsis occurred in 16.1% of those with the drain and 18.0% of those without drain. Re-operation for pelvic sepsis was done in 10.2% of those with drain and 12.0% of those without drain.

Additional reading: Placer C. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: an unclosed debate [Letter to the Editor]. Annals of Surgery. 2018. doi:10.1097/SLA.0000000000003005. [Epub ahead of print]

Improving communication during patient handoffs between the OR and ICU

Posted on by
Reply

One discussion this week focused on improving handoffs in the ICU.

Reference: Mukhopadhyay D, et al. Implementation of a standardized handoff protocol for post-opearative admissions to the surgical intensive care unit. American Journal of Surgery. 2018 Jan;215(1):28-36. doi:10.1016/j.amjsurg.2017.08.005.

Summary:  Mukhopadhyay et al’s (2018) recent prospective intervention study explored the effectiveness of a standard protocol for patient transfer from the OR to the SICU. Prior to implementing a new protocol a team of individuals observed 31 patient handoffs. Next, the protocol was implemented over a 6 month period in which all caregivers involved in handoffs attended mandatory educational sessions. Finally, 31 handoffs were observed by the same team of individuals who had observed the previous handoffs.

Services included in the study: thoracic, neurosurgery, trauma, acute care, vascular, surgical oncology, urology, ENT, orthopedics, plastics, and neurointerventional radiology.

Handoff elements observed for completion: presence of all team-members at handoff; identification of patient and caregivers; detailed surgeon report; detailed anesthesia report; and duration/occurrence of key activities (time to ventilator, monitor set-up, total handoff duration).

Results: Pre- and post-implementation performance was measured on all handoff elements listed above. These were elements identified as crucial to the safe and successful patient transfer.

Notably, surgeons were the only group that believed communication was effective in the existing process. Anesthesia and ICU Nursing were dissatisfied. All three groups agreed that a more structured protocol was necessary for safe patient care (p.29).

The figure below show the changes in degree of detail in surgical reports (p.35). The article provides additional charts and data on other pre- and post- findings.

handoff report

Additional reading: Karamchandani K, et al. A multidisciplinary handoff process to standardize the transfer of care between the intensive care unit and the operating room. Quality Management in Health Care. 2018 Oct/Dec;27(4):215-222. doi:10.1097/QMH.0000000000000187.

The value of diverting loop ileostomy to prevent low pelvic anastomotic leak

Posted on by
Reply

One discussion this week focused on the impact of diverting ileostomy on low rectal anastamoses.

Reference: Matthiessen P, Hallbook O, Rutegard J, Simert G, et al. Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer: A Randomized Multicenter Trial. Annals of Surgery. 2007 Aug;246(2):2017-214. doi:10.1097/SLA.0b013e3180603024

Summary: Anastomotic leakage is a feared complication of rectal resections, reportedly occuring in 1-24% and increasing postoperative morbidity from 1-8% to 6-22% (Matthiessen et al, 2007). In a randomized multicenter trial of 234 patients (no easy feat for surgical technique studies), Matthiessen et al (2007) found “patients without diverting stoma leaked in 28.0%, compared to 10.3% of those with diverting stomas (OR = 3.4; 95% CI, 1.6-6.9; P < 0.001), a result not previously demonstrated in any randomized trial” (p.207).

surgmm_leakage

Among patients randomized for diverting ostomy, surgeons demonstrated a preference for loop ileostomy vs transverse colostomy (112/116) and in all 25 urgent diverting stomas. In 97% of the patients (227/234), surgeons chose to use pelvic drainage. All anastomotoses were made with a stapling device, none were handsewn.

The authors conclude that their trial accurately demonstrates a decreased rate of symptomatic ansatomotic leakage in diverted patients in low anterior resection. This is the first randomized trial to illustrate this result and, therefore, they recommend the use of a diverting stoma in low anterior resection of the rectum.

(Matthiessen et al, 2007, p.210)

Additional reading: Hanna MH, Vinci A, Pigazzi A. Diverting Ileostomy in Colorectal Surgery: When is it Necessary? Langenbeck’s Archives of Surgery. 2015 Feb;400(2):145-152. doi:10.1007/s00423-015-1275-1.