BACKGROUND: The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes. METHODS: The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups. RESULTS: There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed. CONCLUSION: Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.

BACKGROUND: With the introduction of laparoscopic Tenckhoff catheter insertion in the early 1990s, catheter malposition resulting in malfunction remains a frequent complication, often requiring surgical or radiological intervention. In this pioneer study, we describe the technique of suturing the Tenckhoff catheter using an EndoClose (Medtronic, Macquarie Park, NSW, Australia) device to the anterior abdominal wall during laparoscopic insertion and compare its outcomes with those not sutured. METHODS: This is a retrospective study of all patients who underwent laparoscopic Tenckhoff catheter insertion at Western Health from January 2013 to June 2018. All procedures were undertaken or supervised by one surgeon. The primary outcome was catheter malposition requiring surgical revision. Secondary outcomes were time to malposition and complications. Peri- and post-operative factors were analysed to adjust for confounders using the Cochran-Mantel-Haenszel test. RESULTS: There were 82 patients in the sutured group and 63 patients in the non-sutured group. Catheter malposition occurred in 7.32% in the sutured group and 19.05% in the non-sutured group (P = 0.034; 95% confidence interval for the difference 0.007-0.237). There was an overall reduction in the odds of catheter malposition of 63% in favour of the sutured group. The median time-to-malposition was 128 and 182 days for the non-sutured and sutured group, respectively, but not statistically different. No differences were found for the number of post-operative complications. CONCLUSION: Suturing of Tenckhoff catheter with an EndoClose device to the anterior abdominal wall during laparoscopic insertion is a simple, safe and useful method of reducing catheter malposition.

BACKGROUND: Splenectomy is a surgical procedure indicated in a variety of medical conditions including trauma. Post-operatively, there is a lifelong risk of developing overwhelming sepsis from encapsulated bacteria, most commonly due to Streptococcus pneumoniae. Splenic autotransplantation has been proposed as a method to recover splenic function in patients requiring splenectomy with otherwise normal spleens. This study aims to systematically review the literature to determine the efficacy of spleen autotransplantation. METHODS: MEDLINE, PubMed and the Cochrane Library were searched for all studies assessing splenic autotransplantation (January 1947 to July 2018). Data were extracted on study characteristics, outcomes assessed, including spleen scintigraphy results, blood film counts and serum immunoglobulin (Ig) levels. RESULTS: Data were obtained from 18 primary studies. All studies demonstrated return of regenerated spleen tissue in the majority of their patients (95.3%) on spleen scintigraphy. In 12 studies, 90.2% of patients had blood films return to normal following transplantation. Ig levels were shown to return to normal in all 12 studies where it was assessed. In 11 studies, 3.7% of patients had post-operative complications. In five studies, 1.3% of patients had post-operative infections in the follow-up period. CONCLUSION: Splenic autotransplantation is a safe procedure with minimal complications that can return splenic filtration function and Ig levels to normal ranges. It has not been confirmed whether autotransplantation provides meaningful protection against overwhelming post-splenectomy infections.

AIM: Routine elective colectomy after acute diverticulitis is not recommended, yet significant numbers are still being performed. Amidst global concern over the rising costs of surgery and the value of healthcare, acute diverticulitis is a disease that is amenable to optimization of strategies for operative intervention. We aim to compare rates of elective colectomy after acute diverticulitis in the USA, England and Australia. METHOD: Index unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2012 for hospitals in the USA, England and Australia. Recurrent unplanned admissions for acute diverticulitis and any subsequent elective admissions for colectomy were found between 2008 and 2014 to allow a minimum 2-year follow-up period. The primary outcome measured was elective colectomy rate. Secondary outcomes included rates of emergency operative intervention and recurrence. Multivariable analysis was performed to control for patient and disease factors. RESULTS: There were 7842 index unplanned admissions for acute diverticulitis over 4 years in selected hospitals from the USA, England and Australia. The elective colectomy rates were 13%, 5.4% and 3.4% for the USA, England and Australia, respectively. The propensity for elective colectomy was higher in the USA (OR 4.2, P < 0.001) and England (OR 1.8, P < 0.001) than in Australia. The recurrence rate in all patients with acute diverticulitis was 10% across the countries. CONCLUSION: There is a higher propensity for elective colectomy after acute diverticulitis in the USA than in England and Australia. This highlights the possibilities for a less aggressive surgical approach to reduce resource utilization, but prospective analysis of information on quality of life is required to support this.

BACKGROUND: The use of colonoscopy has been increasing in Australia. This case series describes management and outcomes of colonoscopic perforation managed by a single tertiary referral unit. METHODS: An analysis of 13 years (2003-2015) of prospectively collected data on patients who had a colonoscopic perforation and were managed by the colorectal unit at a single tertiary referral centre was performed. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications. RESULTS: Sixty-two patients had perforations (median age of 69 years). Thirty-eight (61.2%) patients had their colonoscopy performed in another institution. The incidence rate decreased to 0.37 perforations per 1000 colonoscopies within Western Health. Overall, diagnostic colonoscopies accounted for 56% of perforations and perforations were likely to occur in the left colon (P = 0.006). Fifty-one (82%) patients underwent surgery during their admission, with 24% of these being laparoscopic procedures. An earlier diagnosis was associated with significantly less intra-abdominal contamination. Gross peritoneal contamination was more likely to be associated with the decision to form a stoma (37%, n = 19, P = 0.04). Thirty-day mortality was 1.6% (n = 1). CONCLUSIONS: Colonoscopic perforations occur in experienced hands and may have serious implications. We demonstrated a difference in patterns of injury between therapeutic and diagnostic colonoscopies. Those who have an earlier diagnosis are less likely to have severe intra-abdominal contamination requiring a stoma formation.

AIM: There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. METHOD: Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side-to-side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. RESULTS: One thousand three hundred and forty-seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54-1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52-1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46-4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04-2.64, P = 0.04). CONCLUSION: This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high-risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration.

BACKGROUND: Maintaining high standards in colon cancer surgery requires the measurement of quality indicators and the re-allocation of resources to address deficiencies. We used state-wide administrative data to determine the inpatient mortality for patients undergoing elective colon cancer surgery and to compare individual hospital rates. METHODS: The Dr Foster Quality Investigator Tool was used to explore the Victorian Admitted Episodes Dataset for elective admissions for colon cancer surgery between 2012 and 2016. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured. Risk-adjusted rates were used to compare public and private hospitals. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. RESULTS: There were 6120 colectomies performed for colon cancer in Victoria over 3 years. The crude inpatient mortality rate was 1.3%. It was significantly higher in public than private hospitals, even after risk adjustment. Variation in crude mortality was demonstrated among 14 selected hospitals. The lowest volume hospitals had significantly higher inpatient mortality rates. Right hemicolectomy was the commonest procedure performed. CONCLUSION: Using an efficient method of complete state-wide data capture, we have demonstrated that the inpatient mortality rate after elective colon cancer surgery in Victoria is low. However, complexity remains around the interpretation of inter-hospital variation, defining outliers, and comparing outcomes between public and private hospitals. Resolving these complexities and defining additional quality indicators remain a priority in the use of administrative data to audit the quality of colon cancer care.

Background: Our study aimed to identify the search engines and terms commonly used by inflammatory bowel disease (IBD) patients and aimed to assess the quality and readability of these resources.Methods: Patients attending IBD clinic were surveyed, regarding search engines, terms and number of websites viewed. Websites according to these predetermined criteria were identified. Website content was described and quality was assessed using DISCERN. Readability was graded using the Flesch Reading Ease Score (FRES).Results: From 33 survey responses, Google was universally utilised. Forty-two websites met the inclusion criteria (19 for Crohn’s disease (CD), 23 for ulcerative colitis (UC). Only one website originated from Australia. Websites were infrequently updated (CD 21%, UC 17%) within the previous 12 months. Overall readability was poor with a mean FRES of 35.8 (11.8, range 15.7-57.7) for CD and 35.7 (11.3, range 19.4-54.3) for UC websites. Quality was moderate to poor with only five (12%) websites being rated as high quality (2 CD, 3 UC).Conclusions: There is very little Australian based web information available on IBD surgery and overall, it is of a low readability and poor content quality. There is need for the development of patient targeted health literature to help these patients.

BACKGROUND: Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS: From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS: There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION: This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

AIM: Colorectal cancer surveillance is an essential part of care and should include clinical review and follow-up investigations. There is limited information regarding postoperative surveillance and survivorship care in the Australian context. This study investigated patterns of colorectal cancer surveillance at a large tertiary institution. METHODS: A retrospective review of hospital records was conducted for all patients treated with curative surgery between January 2012 and June 2017. Provision of clinical surveillance, colonoscopy, computed tomography (CT), and carcinoembryonic antigen (CEA) within 24 months postoperatively were recorded. Kaplan-Meier estimates were used to evaluate time-to-surveillance review and associated investigations. RESULTS: A total of 675 patients were included in the study. Median time to first postoperative clinical review was 20 days (95% confidence interval (CI), 18-21) with only 31% of patients having their first postoperative clinic review within 2 weeks. Median time to first CEA was 100 days (95% CI, 92-109), with 47% of patients having their CEA checked within the first 3 months, increasing to 68% at 6 months. Median time to first follow-up CT scan was 262 days (95% CI, 242-278) and for colonoscopy, 560 days (95% CI, 477-625). Poor uptake of surveillance testing was more prevalent in patients from older age groups, those with multiple comorbidities, and higher stage cancers. CONCLUSION: Colorectal cancer surveillance is multi-disciplinary and involves several parallel processes, many of which lead to inconsistent follow-up. Further prospective work is required to identify the reasons for variation in care and which aspects are most important to cancer patients.

Studies in multiple solid tumor types have demonstrated the prognostic significance of ctDNA analysis after curative intent surgery. A combined analysis of data across completed studies could further our understanding of circulating tumor DNA (ctDNA) as a prognostic marker and inform future trial design. We combined individual patient data from three independent cohort studies of nonmetastatic colorectal cancer (CRC). Plasma samples were collected 4 to 10 weeks after surgery. Mutations in ctDNA were assayed using a massively parallel sequencing technique called SafeSeqS. We analyzed 485 CRC patients (230 Stage II colon, 96 Stage III colon, and 159 locally advanced rectum). ctDNA was detected after surgery in 59 (12%) patients overall (11.0%, 12.5% and 13.8% for samples taken at 4-6, 6-8 and 8-10 weeks; P = .740). ctDNA detection was associated with poorer 5-year recurrence-free (38.6% vs 85.5%; P < .001) and overall survival (64.6% vs 89.4%; P < .001). The predictive accuracy of postsurgery ctDNA for recurrence was higher than that of individual clinicopathologic risk features. Recurrence risk increased exponentially with increasing ctDNA mutant allele frequency (MAF) (hazard ratio, 1.2, 2.5 and 5.8 for MAF of 0.1%, 0.5% and 1%). Postsurgery ctDNA was detected in 3 of 20 (15%) patients with locoregional and 27 of 60 (45%) with distant recurrence (P = .018). This analysis demonstrates a consistent long-term impact of ctDNA as a prognostic marker across nonmetastatic CRC, where ctDNA outperforms other clinicopathologic risk factors and MAF further stratifies recurrence risk. ctDNA is a better predictor of distant vs locoregional recurrence.