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Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.

PURPOSE OF REVIEW Patients presenting for surgery are increasingly older and frail. Prehabilitation offers the best hope of preemptive functional optimisation to improve postoperative outcomes. Systematic reviews and meta-analyses show signals of improved function and reduced complications and length of stay, but are hampered by small trials with heterogeneous nature of interventions. RECENT FINDINGS The value proposition for prehabilitation is strengthened by applying the following considerations to the evidence. Multimodal prehabilitation programmes incorporating elements of exercise, nutrition, and psychological preparation have a sound physiological basis and will help standardise care delivery and evidence gathering. Targeting prehabilitation resources at high-risk patients may yield higher returns. Effective prehabilitation programmes must be individualised and pragmatic to address known barriers to adherence. The evidence for functional improvement is clear and this aligns with the values of older patients. A comprehensive analysis of value incorporates functional, quality of life, and cost outcomes in addition to conventional morbidity and mortality measures. SUMMARY Multimodal prehabilitation delivered by a multidisciplinary team improves functional outcomes following surgery. Function is an integral part of multidimensional value assessment including clinical and experiential measures. Future value enhancements include addressing frailty and overcoming barriers through targeted programme design.

Introduction Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution. Methods This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity. Results 51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported. Conclusion Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

Major abdominal surgery in the elderly is challenging and complex. Frailty as a clinical entity in the elderly is increasingly recognized as a useful assessment tool to identify at-risk patients. We aim to review recent literature on frailty in surgical preoperative evaluation and postoperative recovery and determine its applications in emergency surgery. Frailty has been established as an independent predictor of morbidity and mortality in elderly surgical patients. Individualized treatment goals and tailor-made interventions to optimize clinical conditions in frail patients before and after surgery improve outcomes. Sarcopenia is increasingly recognized as a predictor of poor surgical outcome in elderly; its use in emergency surgery is promising. More research into this area is needed. Frailty is a useful tool to identify at-risk patients for optimization and targeted intervention before major surgery. To meet the complex needs of these patients, an integrated transdisciplinary approach is recommended.

Aim Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence‐based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL. Methods A prospective single‐center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions. Results There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30‐day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien–Dindo IV complications (11.2% versus 3.1%, p, This article highlights the difficulties in standardizing care for patients undergoing emergency laparotomy. Through implementation of a transdisciplinary care pathway, we highlight the improvement in outcomes seen as well as areas that are lacking.

INTRODUCTION Sporadic colorectal cancers with BRAF mutations constitute two distinct subgroups of colorectal cancers. Recent studies have linked the presence of the BRAF mutation to a familial inheritance pattern. This was a proof-of-concept study that aimed to examine: (a) the extent of field change in sporadic colorectal cancers with BRAF mutation; and (b) the extent of resection margins required and the pattern of DNA mismatch repair protein loss in these tumours. METHODS Eight microsatellite instability-high tumours with positive BRAF mutation from an existing histopathological database were selected for BRAF mutation and mismatch repair protein analysis. RESULTS All the resection margins were negative for BRAF mutation. Three tumours had loss of MLH1 and PMS2 expressions, and five tumours had no protein loss. Six peritumoral tissues were negative and one was positive for BRAF mutation. CONCLUSION The results suggest that any early field change effect is restricted to the immediate vicinity of the tumour and is not a pan-colonic phenomenon. Current guidelines on resection margins are adequate for BRAF mutation-positive colorectal cancers. Any suggestion of a hereditary link to these tumours is likely not related to germline BRAF gene mutations. The pattern of protein loss reinforces previous findings for the two subgroups of BRAF mutation-positive colorectal cancers.

The successful implementation of a falls prevention exercise program for older adults hinges on self-maintenance after active intervention. However, little is known about the pattern of adherence from the intervention to the maintenance phase of such programs, and the factors influencing adherence. We investigate transitions in exercise adherence trajectories from the active intervention to the maintenance phase of a falls prevention exercise program in Singapore, and whether exercise self-efficacy is associated with adherence in the maintenance phase. We analyze data of 143 older adults who participated in a 12-week, group-based falls prevention exercise program, followed by a 6-month maintenance phase, in 2018-2019. Sequential process latent class growth modeling identifies the distinct exercise adherence trajectories in the active intervention and the maintenance phase separately and their transition patterns. Multivariable regression examines whether baseline and change in self-efficacy during the active intervention predict adherence during the maintenance phase. The analysis reveals three exercise adherence trajectories— adherent (40% of participants), intermittent (38%), and disengaged (22%)—in the active intervention phase, and two trajectories—adherent (33%) and disengaged (67%)—in the maintenance phase. Those adherent in the maintenance phase comprise participants who were adherent (42%) or intermittent (58%) in the active intervention phase. Baseline and increase in exercise self-efficacy during the active intervention are positively associated with adherence in the maintenance phase. The findings capture the heterogeneity in exercise adherence patterns within and across the active intervention and maintenance phases of falls prevention exercise program, and the importance of exercise self-efficacy in continued adherence to exercise.

The aging population is an increasing healthcare concern in developing countries. In Singapore, 25% of the local population are expected to be older than 65 years old by 2030. Colorectal cancer (CRC) is ranked third most diagnosed cancers worldwide with up to 1.8 million new cases diagnosed in 2018. 60% of newly diagnosed CRC are among patients who are 70 years or older and hence majority of these patients will invariably face challenges with frailty and multiple comorbidities that require appropriate assessment and stratification. The standard of care in patients with stage I or II CRC is surgery with curative intent. For patients with stage III CRC, upfront surgical resection of tumor along with adjuvant chemotherapy is the internationally recommended treatment approach. As for those patients with metastatic disease, they are usually managed within a multidisciplinary team and considered for surgical resection if deemed feasible. Elderly patients are mostly burdened with frailty, functional dependency and existing co-morbidities, all of which are predictors of early postoperative mortality and morbidity in patients with CRC. This article thus aims to review existing evidence to discuss the intricate decision-making process for the surgical management of elderly patient with CRC.

Aim The Emergency Surgery and Trauma (ESAT) team is a dedicated consultant‐led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on‐call model. Methods A retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May–October 2014 (6 months pre‐ESAT) versus January–June 2017 (post‐ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated. Results There were 192 patients in the pre‐ESAT period and 179 patients in the post‐ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 ± 46.9 min versus 127 ± 102 in the pre‐ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 ± 55.2 min compared to 157.3 ± 209.1 (P, The Emergency Surgery and Trauma service is associated with better efficiency outcomes, such as reduced waiting time to surgery, with good clinical outcomes for patients with acute appendicitis.

Objective: Enhanced recovery after surgery (ERAS) provides a multimodal approach to postsurgical recovery, seeking to reduce a patient’s stress response and promoting recovery. This study aimed to determine the suitability of ERAS protocols for elderly patients above 75 years of age. Methods: This is a retrospective analysis of all patients who had undergone major colorectal resections under ERAS protocols in Khoo Teck Puat Hospital, Singapore and the Faculty of Medicine Siriraj Hospital, Thailand between 2013 and 2014. Data collected included patient characteristics and outcomes, including length of hospitalization, and time to first flatus and mobilization. Results: Of the 196 patients studied, 38 were above 75 years of age. Elderly patients were more likely to have more comorbidities, a higher ASA score and a higher POSSUM predicted mortality. They also had an increased risk of developing Clavien 2 complications (OR 2.41, 95% CI 1.10-5.29). Compared to their younger counterparts, elderly patients did not have a delay in first flatus or mobilization. However, they tended to stay longer (7.89 vs. 5.16 days, p

Inappropriate stoma site, improper management of stoma, and stoma complications lead to diminished quality of life of ostomates. Healthcare professionals involved in stoma creation and/or care should have the fundamental and updated knowledge of the management of stomas and their complications. This review article consists of the following major sections: principles of perioperative patient management, early complications, and late complications. In the “principles of perioperative patient management” section, the current concepts and trends in preoperative education, stoma site marking, postoperative education, and patient educational resources are discussed. In the “early complications” section, we have focused on the etiology and current management of ischemia/necrosis, fluid and electrolyte imbalances, mucocutaneous separation, and retraction. In the “late complications” section, we have focused on the etiology and current management of parastomal hernia, stoma prolapse, parastomal varices, and pyoderma gangrenosum. Pre- and postoperative patient education facilitates the patient's independence in stoma care and resumption of normal activities. Healthcare providers should have basic skills and updated knowledge on the management of stomas and complications of stomas, to act as the first crisis manager for ostomates.

An ileostomy is usually created to avert systemic sepsis in a patient with a tenuous anastomosis. However, what is often not reported are the numerous issues facing these patients subsequently, ranging from readmissions, non-reversal of the stoma, and complications from the closure. This study was performed to identify these issues among patients following creation of an ileostomy. We conducted a retrospective analysis of consecutive patients who had an ileostomy created from January 2011 to December 2016 at two institutions. Statistical analysis was performed to identify risk factors associated with readmissions and ileostomy non-reversal. In total, 193 patients had an ileostomy created during the study period. Twenty-six (13.5%) patients developed stoma-related complications requiring readmission. The most common cause of readmission (9.3%) was due to dehydration and acute kidney injury secondary to high stoma output. One hundred thirty (67.4%) patients had their ileostomy reversed. On multivariate analysis, only stomas created during an ultra-low anterior resection were associated with reversal (OR 2.88 [95% CI, 1.24–6.68]; p = 0.014). Among the patients who underwent ileostomy reversal, seven (3.6%) patients developed complications from their ileostomy reversal. Four patients (2.1%) suffered from an anastomotic leak which required repeat surgical intervention with one mortality from the ensuing sepsis. Almost half of the patients who had an Ileostomy had an undesirable outcome, including readmissions, non-reversal, and post-operative complications following closure. Patients need to be properly counselled about the risks involved prior to the index operation.

Early laparoscopic cholecystectomy (ELC) has shown to reduce length of stay and improve patients’ satisfaction as compared to delayed laparoscopic cholecystectomy (DLC). However, logistics and manpower limitations often preclude ELC. A retrospective study was conducted in a single institute to compare outcomes of AC before (August 2013–2014) and after (August 2017–2018) establishment of emergency surgery and trauma (ESAT). There were 82 patients in pre-ESAT period and 172 patients in ESAT period. Mean age was 52.3 ± 11.6 and 55.7 ± 13.8 years, respectively, p = 0.369. There were more patients with moderate–severe grading of cholecystitis based on Tokyo Guidelines (TG 18) in ESAT 143/172 (83.1%) as compared to pre-ESAT 65/82 (79.3%), p = 0.042. Index cholecystectomy was performed in 145/172 (84.3%) of patients in the ESAT vs 34/82 (41.5%) of patients in the pre-ESAT period (p = 0.001). Time interval between booking to surgery was 180 ± 56 min in ESAT vs 197 ± 98 min in pre-ESAT, p = 0.014. Operative duration was shorter in ESAT 121 ± 38.5 min vs 139 ± 53.4, in pre-ESAT period, p = 0.030. Conversion rates were lower in ESAT (4/172, 2.3%) vs (9/72, 11%) in pre-ESAT, p = 0.003. Length of stay was shorter in ESAT (DLC 1.89 ± 1.6 and ELC ± 2.9 days) as compared to pre-ESAT (DLC 4.55 ± 2.2 and ELC 5.03 ± 2.6 days), p = 0.001. 30-day readmissions were lower in ESAT (3/172, 1.7%) vs pre-ESAT (8/72, 9.8%). The ESAT model provided more early laparoscopic cholecystectomies with improved efficiency and clinical outcomes.

Laparoscopic ventral hernia repair (LVHR) has been increasing in popularity over the years. Seroma formation is a common complication of LVHR. The aim of this study is to review the current evidence on seroma prevention strategies following LVHR. A systematic search of PubMed, Embase (1946—13 February 2019) and Medline (1946—13 February 2019) databases was conducted using terms which include “seroma”, “hernia, ventral” and “laparoscopy”. All studies are comparative retrospective or prospective human adult studies in peer-reviewed journals describing at least one intra-operative intervention designed to decrease the rate of seroma formation in laparoscopic ventral hernia repair. The database searches identified 3762 citations, and 21 studies were included for final analysis. Five studies compared the different methods of mesh fixation, nine studies compared primary defect closure (PFC) and bridged repair, two studies compared the effect of different types of meshes, two studies looked into the use of electrical cauterization, one study compared single- site laparoscopy with conventional laparoscopy, one study looked into the use of fibrin sealant and one study compared transabdominal preperitoneal placement of mesh with conventional repair. PFC appears to be the most promising with large studies showing a low rate of seroma formation with additional benefits of decreasing wound infection and recurrence rate. Cauterisation of hernia sac and injection of fibrin sealant also show promising results but are mainly derived from small studies. Other strategies did not demonstrate benefit. Currently, primary fascial closure appears to be the most promising strategy available to decrease seroma formation after LVHR based on the results of large studies. Other promising strategies that decrease dead space such as cauterisation of the sac and fibrin sealant injection will require further multicentre trials to confirm benefit before an increase in operative time and cost can be justified for their routine use.

This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3 months of surgery and surgical complications based on Clavien-Dindo classification were analysed. The mean age was 67 years (67 ± 11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6 ± 2.5%) and 7.0% (7.0 ± 1.1%, p = 0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2 ± 3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2 ± 1.5%, p = 0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23–162, p = 0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22–94.1, p = 0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04–5.91, p = 0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450–4.98, p = 0.511). Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.

Summary Background Institutionalized patients pose various surgical difficulties as many have conditions requiring psychiatric medications with the propensity for anticholinergic side effects. This study was initiated to determine the impact of institutionalization and anticholinergic medication on postoperative outcomes. Methods A total of 430 colorectal resection cases from 2006 to 2012 were studied. Among them, 19 were institutionalized patients and 17 were on long-term anticholinergic medications. Surgical outcomes were quantified by Clavien scoring, need for reoperations and postoperative deaths. Results Patients who were institutionalized or on anticholinergic medication were more likely to have increased postoperative morbidity requiring invasive interventions or worse (Clavien score ≥ 3; odds ratios 5.02 and 3.63, 95% confidence intervals 1.93–13.06 and 1.29–10.21 respectively). However, only institutionalization was found to be an independent risk factor. Conclusion This study identified institutionalized patients as a higher risk group associated with postoperative complications compared to patients from the community. Thus, they merit a more thorough preoperative optimization closer postoperative monitoring regime.

BACKGROUND Early laparoscopic cholecystectomy (ELC) within 72 h of symptom onset is preferred for management of acute cholecystitis (AC). Beyond 72 h, acute-on-chronic fibrosis sets in rendering surgery challenging. This study aims to compare the outcomes of ELC for AC within and beyond 72 h of symptom onset by a dedicated acute surgical unit. METHODS This is a single-centre retrospective study of 217 patients with AC who underwent ELC by an acute surgical unit from January 2017 to August 2018. Outcomes collected include post-operative morbidity, length of hospitalization and operation duration. A subgroup analysis for the same outcomes was performed for elderly patients. RESULTS Of the 217 patients, 88 were operated within 72 h of symptom onset while 129 were operated beyond 72 h. Twenty-six patients received ELC after 7 days. There was no occurrence of bile duct injury. There was no statistical difference in conversion rates, wound infections and post-operative collections. Patients receiving ELC beyond 72 h had longer duration of operation (125.4 versus 116 min, P = 0.035) and length of hospitalization (4.59 versus 3.09 days, P = 0.001) without increase in morbidity. Patients older than 75 years had a higher incidence of post-operative collection (P

The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability. Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated. There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01). The ESAT WC service has sustained improved outcomes in our institution.

Background Open haemorrhoidectomy has been associated with considerable postoperative pain and discomfort. Perianal intradermal injection of methylene blue has been shown to ablate perianal nerve endings and may bring about temporary pain relief after haemorrhoidectomy. We hypothesized that the administration of intradermal methylene blue would reduce postoperative pain during the initial period after surgery. Method A randomized, prospective, single-blind placebo-controlled trial was conducted. Patients were randomized to intradermal injection at haemorrhoidectomy of either 4 ml 1% methylene blue and 16 ml 0.5% marcaine or of 16 ml 0.5% marcaine and 4 ml saline prior to surgical dissection. Patients were asked to fill in a pain diary with a visual analogue scale. The primary outcome measure was pain score and analgesic use. Secondary outcomes were complications. Results There were 37 patients in the methylene blue arm and 30 patients in the placebo arm. There were no statistically significant differences in the sex, type of haemorrhoid, number of haemorrhoids excised, duration of surgery or hospital stay. The mean pain scores were significantly lower and the use of paracetamol was also significantly less in the methylene blue group during the first three postoperative days. The risk ratio of acute urinary retention occurring when methylene blue was not used was 2.320 (95% CI 1.754–3.067). Other complication rates were not significantly different. Conclusion Perianal intradermal injection of methylene blue was useful in reducing the initial postoperative pain of open haemorrhoidectomy.

The last 15 years have seen changing patterns of injury in emergency surgery and trauma patients. The ability to diagnose, treat and manage these patients nonoperatively has led to a decline in interest in trauma surgery as a career. In addition, healthcare systems face multiple challenges, including limited resources, an ageing population and increasing subspecialisation of medical care, while maintaining government-directed standards and managing public expectations. In the West, these challenges have led to the emergence of a new subspecialty, 'acute care surgery', with some models of care providing dedicated acute surgical units or separating acute and elective streams with the existing manpower resources. The outcomes for emergency surgery patients and efficiency gains are promising. In Singapore, Khoo Teck Puat Hospital has implemented its first dedicated acute surgical unit. This article outlines the evolution of acute care surgery and its relevance to Asia.

Introduction The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery. Methods Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality. Results There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6–2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3–125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se. Conclusions Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

Background: A diverting ileostomy is often created following a low colorectal anastomosis to reduce the clinical consequences of an anastomotic leak. Whilst many patients are advised that these ileostomies are temporary, not all stomas will eventually be closed. This study aimed to look at the reversal rates of diverting ileostomy following anterior resections, and the reasons for delayed or non-reversal.Methods: A retrospective review of all patients who underwent an anterior resection with a diverting ileostomy from March 2011 to March 2013 was performed.Results: A total of 115 patients had a diverting ileostomy following anterior resection within the study period. Seventy-six (66.1%) patients had a reversal before March 2016. The median time to reversal was 8 months (range, 1-26 months) with only 13% reversed within 12 weeks. Two patients (2.6%) had anastomotic leaks post ileostomy reversal requiring surgery and 1 patient (1.3%) had significant hematochezia requiring hospitalization. In the 39 (33.9%) patients who did not have their ileostomies reversed, deterioration in the fitness of the patient for surgery was the most commonly cited reason (n=12, 30.8%). This was followed by disease progression (n=9, 23.1%) and patient’s choice (n=8, 20.5%).Conclusions: One in 3 diverting ileostomies performed following anterior resection is not reversed. The interval time to its closure is longer than typically expected. Patients should be made aware of the significant possibility of non-reversal.

Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program. A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously. Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery. Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.

This study aims to search for independent predictors of lateral node metastasis in low rectal cancers. We analyzed 1,046 patients who underwent curative resection for lower rectal cancer in our prospectively collected database. All lymph nodes were dissected from the fresh specimen, and their locations were documented prospectively according to the classification by the Japanese Society of Cancer of the Colon and Rectum. More than 35% of the patients had demonstrated upward nodal metastasis in the direction of the inferior mesenteric vessels, while 11% demonstrated lateral node metastasis, which was present in 17.3% of patients with T3 and T4 lesions. Multivariate analysis revealed five factors to be statistically significant independent predictors of lateral node metastasis: female sex, tumors that were not well differentiated, pathological T3 and above, positive microscopic lymphatic invasion, and positive mesorectal nodes. Using the variables sex, differentiation, T stage, and mesorectal nodes as risk factors, because these could be elucidated preoperatively, the presence of lateral node metastasis was then analyzed according to the number of positive risk factors. When there were fewer than three positive factors, the risk of lateral nodal spread was low (4.5%). When three or more risk factors were positive, the odds of lateral node metastasis were more than 7.5 times higher (p

Introduction The pattern of distribution of lymph node metastasis in resected specimens of colon cancer has been rarely reported in the English literature. The aim of this study was to determine the location of the first metastatic lymph node, giving insight into the drainage pattern of colon cancer lymphatics. Method All lymph nodes in the mesentery of the resected specimen were carefully harvested and their precise locations documented. Patients with a single metastatic node in the resected specimen were included in the study. Results Ninety-three patients with only one metastatic lymph node found on histology were studied. The mean number of lymph nodes per specimen was 22.3 (range: 8–72). The patients’ first metastatic node was not directly below the tumour in 48% of cases. The first metastatic node was found in the region either along the feeding vessels (skipping the pericolic nodes) or in the pericolic area outside 5 cm on either side of the tumour edge in 18% of cases. No factors were found to be predictive for lymph node metastasis occurring elsewhere other than in the pericolic region just below the tumour. Conclusion Although there has been recent resurgence of interest in using sentinel node biopsy to limit surgical dissection to facilitate minimally access and natural orifice surgery, the present study is a warning that this may compromise oncological clearance. Radical surgery should remain standard practice for colorectal cancer.

Sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) reduced postoperative intraabdominal adhesion. In this study, we examined whether Seprafilm reduces operative difficulties in ileostomy closure. During the creation of the ileostomy, Seprafilm was cut in half and used to wrap both the ileum and mesentery. Patients who underwent ileostomy closure before February 2008 (without Seprafilm, Group T, n = 18) and after March (with Seprafilm, Group S, n = 18) were enrolled in this study. All operations were performed by surgical residents. Operative time and perioperative complications were analyzed. The mean operative time of Group S (106.88 min) was significantly less than that of Group T (120.6 min). The amount of intraoperative bleeding in Groups S and T was not significantly different and there were no major complications. Seprafilm applied to the two limbs of the ileostomy and mesentery facilitate ileostomy closure done by non-expert surgeons.

Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer.A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates.The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classificationor =3 and comorbidity index 3 of 5or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity.Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Context Hemorrhoidal disease is the most common anorectal disorder that requires surgical intervention. Hemorrhoids require treatment when they result in symptoms such as bleeding or prolapse. Surgical intervention is indicated for significant prolapse, and a number of accepted and viable methods are available for treating prolapsing hemorrhoids that do not reduce spontaneously (Grade III and IV). Excision hemorrhoidectomy remains the gold standard treatment for Grade III and IV hemorrhoids despite great interest in alternative procedures such as stapled hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation with mucopexy. A large body of evidence demonstrates that excision hemorrhoidectomy is an effective, safe, and affordable procedure. Nevertheless, the main drawback of excision hemorrhoidectomy remains its notorious association with significant postoperative pain. Evidence Acquisition A comprehensive literature search was conducted through MEDLINE and the Cochrane database of systematic reviews. Only prospective case-controlled studies, review articles, and meta-analyses were considered. Results Many strategies have been put forward in the literature to address the issue of pain after excision hemorrhoidectomy. These strategies can be broadly categorized into surgical techniques (e.g., LigaSure hemorrhoidectomy) and pharmacological adjuncts (e.g., intradermal methylene blue and chemical sphincterotomy with glyceryl trinitrate ointment). In recent years, meta-analyses and randomized controlled trials have been performed to evaluate their effects. Conclusions This article evaluates the evidence behind these strategies and outlines the new methods available to improve the outcomes of an old technique.

Aim The frail elderly surgical patient is at increased risk of morbidity after major surgery. A transdisciplinary Geriatric Surgery Service (GSS) has been shown to produce consistently positive results in our institution. A trans-institutional transdisciplinary Start to Finish (STF) programme was initiated incorporating seamless prehabilitation and rehabilitation to enhance the outcome further. Method Patients who underwent major colorectal resection in Khoo Teck Puat Hospital and were managed under the GSS from January 2007 to December 2014 were included in this prospective study. The STF programme was initiated from January 2012. The surgical outcome of patients managed under the GSS before the initiation of STF was compared with that after its implementation. Results There were 57 patients after the initiation of the STF programme compared with 60 patients managed before STF. There were 26.4% and 25% of frail patients in the STF group compared with the non-STF group (P = 0.874). The mean length of hospital stay was significantly shorter in the STF group (8.4 days vs 11.0 days, P = 0.029). Functional recovery in patients available for follow-up at 6 weeks showed 100% (46/46) recovery in the elective STF group who received prehabilitation and 95.7% (45/47) in the elective non-STF group who did not (P = 0.157). There were no significant differences in a Clavien–Dindo complication score of Grade 3 or more and 30-day mortality between the two groups. Conclusion Through a trans-institutional transdisciplinary approach, we managed to achieve a significantly shorter hospital stay in frail patients having colorectal surgery. All elective patients who received prehabilitation achieved full functional recovery.