Early Outcomes for Rectal Cancer Surgery in the Republic of Ireland Following a National Centralization Program

Background

Following a national audit of rectal cancer management in 2007, a national centralization program in the Republic of Ireland was initiated. In 2010, a prospective evaluation of rectal cancer treatment and early outcomes was conducted.

Methods

A total of 29 colorectal surgeons in 14 centers prospectively collated data on all patients with rectal cancer who underwent curative surgery in 2010.

Results

Data were available on 447 patients who underwent proctectomy with curative intent for rectal cancer in 2010; 23.7 % of patients underwent abdominoperineal excision. The median number of lymph nodes identified was 12. The 30-day mortality rate was 1.1 %. Compared with 2007, there was a reduction in positive circumferential margin rate (15.8 vs 4.5 %, P < 0.001), clinical anastomotic leak rate (10.8 vs 4.3 %, P = 0.002), and postoperative radiotherapy use (17.8 vs 4.0 %, P < 0.001). Also, 53.9 % received preoperative radiotherapy in 2010. Four centers gave statistically more patients (high-administration), and four centers gave fewer patients (low-administration) preoperative radiotherapy for T2/T3 tumors (P < 0.05). On multivariate analysis, being treated in a “high-administration center” increased the likelihood (likelihood ratio [LR], 2.9; 95 % CI 1.7–4.8; P < 0.001) while attending a “low-administration center” (LR, 0.3; 95 % CI 0.2–0.5; P < 0.001) reduced the likelihood of receiving preoperative radiotherapy for a T2/T3 rectal cancer.

Conclusions

Patients undergoing rectal cancer surgery in hospitals following a national centralization initiative received high-quality surgery. Significant heterogeneity exists in radiotherapy administration, and evidence-based guidelines should be developed and implemented.     

OPTIMISING THE MEDICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA

SUMMARY The ageing population is presenting an increasing demand on future healthcare services. In males, prostatic disease is one of the commonest disorders contributing to this. Alternatives to surgical intervention have to be considered as the preferred option for individuals and whether this be a therapeutic or a financial option to be taken. Two major medical alternatives are alpha-blockers and 5-alpha reductase inhibitors. The results of such treatment can be very beneficial in selected groups of patients. Side-effects with improved drugs electivity are reducing. Overall, while surgery still holds the gold standard, medical therapy has a significant role in the treatment of benign prostatic hypertrophy. Cost analysis may be a factor in deciding which treatment to have.     

Traumatic Arteriovenous Fistula

Traumatic arteriovenous fistula in the head and neck may present a difficult problem in management. We present a surgical case of traumatic arteriovenous fistula between the right subclavian artery and internal jugular vein with false aneurysm formation. Traumatic injury of the subclavian artery causing arteriovenous fistula with false aneurysm is a serious surgical emergency with appreciable morbidity and mortality that requires early recognition and prompt surgical intervention.     

Skin closure and the incidence of groin wound infection: A prospective study

Groin wound infection is a dreaded complication of vascular surgery and may jeopardize an underlying graft. A variety of skin closures have been used and the object of this study was to prospectively determine the relationship between skin closure and wound infection. One hundred fourteen consecutive patients (70 men and 44 women) undergoing bypass surgery with a groin incision (n = 173) were randomly assigned to skin closure with subcuticular Maxon, interrupted nylon, continuous nylon, or clips following a standard two-layer closure of subcutaneous tissue. Fourteen (12%) patients had diabetes and 50 (44%) had digital ulceration and gangrene. Aortofemoral bypass was performed in 25% of the patients and infrainguinal bypass in the remaining 75%. Perioperative wound cultures were obtained before closure. Wounds were inspected and cultures repeated on postoperative days 3, 5, 7, 10, and 14. Infection was defined as a positive culture. Groin wound infection occurred in 3% of the population and graft infection in 0.6%. The type of suture did not influence the incidence of infection. This study failed to demonstrate a significant difference in the incidence of wound infection with the use of different suture materials. We conclude that suture material should be selected on the basis of surgeon preference and costs.     

INFLUENCE OF TEACHING ON THE TRIAGE OF MULTIPLE INJURY PATIENTS

SUMMARY Attempts to improve the standard of early trauma management through the training and instruction of medical personnel have had variable results. Knowledge of trauma care is inadequate among all grades of medical and paramedical staff, and not much improvement has been made by the availability of instruction courses in trauma management. Staff most likely to attend such courses are seemingly already more proficient than staff who choose not to. To achieve maximum benefit from future courses, therefore, we believe attendance should be compulsory for all personnel involved in acute trauma care.