Moxey PW, Hofman D, Hinchliffe RJ et al. Delay influences outcome after major lower limb amputation. Eur J Vasc and Endovasc Surg 2012; 44: 485-90.

In a nutshell
This is a retrospective study of all patients undergoing major lower limb amputation in England over a period of four years (April 2002-March 2006) except those undergoing major amputation for trauma or malignancy. The length of time between hospital admission and major amputation (length of wait/LOW) was calculated for all patients as well as the recovery time from date of surgery to discharge from hospital. The primary outcome measure was in-hospital mortality and post-procedure recovery time. Demographics, co-morbidities and attempts at revascularisation, whether surgical, endovascular or both were also documented.

Of the major amputations, 14,168 were identified during the study period. The ratio of above-knee to below-knee amputations was 1:1 (with a very small proportion of through-knee amputations). Only 9.1% of all patients had some attempt at revascularisation prior to the major amputation during the index admission. The in-hospital mortality rate was 17% and the one year mortality rate was 35.4%.

Male in-hospital mortality increased by 2% for every day of delay of amputation surgery (OR 1.02; p<0.0001). The median length of wait between admission and major amputation was 11 days. Recovery time also increased significantly with delays in amputation surgery in both males and females. Previous bypass or bypass and angioplasty significantly increased mortality rates whereas angioplasty had no effect on mortality.

Second opinion
The main finding of the study was that delaying major amputation leads to increased mortality. However, the findings mentioned may be explained by the fact that patients with more co-morbidities are likely to require a longer time of medical optimisation before they are deemed fit for surgery. The time when a decision was taken and the patient considered fit to proceed to surgery would have been useful in ruling out medical optimisation as the reason for the delay and therefore the higher risk of mortality in those patients who were delayed. Unless a prospective study is conducted this would be difficult to establish.

The study highlights the low proportion of patients undergoing revascularisation prior to major amputation during the index admission but no information is given about whether prior attempts had been made during previous admissions.

The study also highlights the high in-hospital mortality associated with major amputation surgery.

The verdict

• Delay in major amputation surgery is associated with significantly increased mortality.

Kevin Cassar

SR Preston, SR Markar, CR Baker, et al. Br J Surg 2013; 100:105-12.

In a nutshell
This article studied the impact of introducing a standardised oesophagectomy clinical pathway (SOCP) on postoperative outcomes. The clinical pathway was initially developed at the Virginia Mason Medical Centre (VMMC), Seattle, and was introduced to the Royal Surrey County Hospital, UK, in 2011, following a multidisciplinary unit visit to Seattle.

The study highlights the involvement of all healthcare professionals in the clinical pathway. It included daily goals for early mobilisation, fluid balance/nutrition, analgesia, and removal of drains/tubes, towards a target discharge of day seven. Patients underwent oesophagectomy by a hybrid or open approach. The pathway group (12) was compared with non-pathway patients in the unit (12), patients prior to the pathway being introduced (12), and patients at VMMC (74).

Significant improvements were seen following introduction of the pathway in terms of early extubation, mobilisation, complications, length of critical care stay, and median length of hospital stay (from 17 to 7 days). There were no deaths in any group.

Second opinion
This study uses the term ‘standardised care pathway’ rather than ‘enhanced recovery’ or ‘fast-track’ to highlight the infrastructure and multidisciplinary approach involved in developing such a pathway for oesophagectomy patients. The unit has successfully transferred a pathway which was originally developed in a different healthcare system. It focuses on a goal-directed approach for core areas of postoperative care; mobilisation, nutrition and fluid balance, and analgesia. By having clear documented goals and adopting a team approach to achieving these, a rapid improvement was demonstrated in short-term outcomes.

The study is limited by the small number of patients, and some differences between groups in terms of operating surgeon, and operative approach. Also, some aspects such as early extubation after surgery are already routine in many centres. Nevertheless, most surgeons would agree with the core points of the pathway and admire the attention to detail (such as new critical care beds and lighter drain bottles to aid mobilisation). Although discharge on day seven after oesophagectomy may not be adopted by all units there are certainly components of the pathway that should be.

The verdict

• Standardised care pathways can improve short-term outcomes following oesophagectomy
• A multidisciplinary approach is vital to successful implementation of such pathways.

Peter Lamb

Rodrigo Oliva Perez et al. Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: Another word of caution in dis colon rectum 2013; 56: 6-13.

In a nutshell
This single institution, prospective study assessed transanal endoscopic microsurgery (TEM) as the principal surgical treatment modality for the residual rectal cancer post-chemoradiation therapy. The proposed advantage of TEM was significantly decreased morbidity and mortality rates in comparison with standard radical surgery. The primary endpoint was local recurrence.

Tumour penetration of the rectal wall (pT0-2) was clinically, endoscopically and radiologically assessed post-treatment.

From January 2009 to October 2011, 190 patients received neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Sixty-three patients had a complete clinical response (excluded from study). Of the 127 with an incomplete response, only 27 patients were favourable for TEM resection (3 pT0, 6 pT1 and 18 pT2 disease). The patients received no systemic adjuvant therapy post TEM.

Local recurrence occurred in 4 patients (15%) after a median follow up period of 15 months. Five patients (19%) had a systemic recurrence (including 2 with local recurrence). No recurrences occurred in the pT0 group, 1:6 recurrence (17%) occurred in the pT1 and 3:18 (17%) in the pT2 group. Post-operative complications were minimal (post-operative haemorrhage necessitating transfusion and anorectal stenosis requiring dilatation under anaesthetic were the two most significant). Tumour size post-chemoradiotherapy (p 0.03) and lymphatic involvement (p 0.049) were the only predictive factors for local recurrence.

Second opinion
This paper highlights the limitations of new techniques and the need always to consider that such pathways of care result in at least the same measurable outcomes as historically proven approaches to complex surgical problems. The advantages of a minimally invasive approach must not sacrifice long-term outcome over short-term functional gains.

The assessment and treatment of rectal cancer is complex, and even in an era where laparoscopic surgery is utilised with increasing frequency, this is an area of controversy. With TEMS, a less invasive/ radical approach, we need to ensure comparable long-term survival and local recurrence rates to the gold standard of TME (c.f. Heald). Local recurrence rates of >15% compared with 5% with radical excision (TME), within short follow-up time following TEMS are not acceptable.

Both techniques of MRI and Intraluminal US may be required for staging rectal lesions to evaluate rectal wall involvement and adjacent regional lymph node morphology. Unfortunately, the categorisation of nodes as being ‘involved’ or ‘reactive’ is also difficult yet pivotal to treatment planning.

In this report, rectal cancer staging, critical for optimal pathway planning, shows poor correlation between radiological and pathological parameters (>25% pathological upgrading over radiological staging). Furthermore, recurrence rates in T1 lesions following TEMS may reflect less ‘radicality’ than TME as supported by the operative description of TEMS resection.

In the era of minimally invasive surgery one must respect basic surgical / oncological principles. Lympho-vascular invasion and encroachment on CRM are a concern (<1mm is an involved CRM). Historical studies of T2 transanal resections had unacceptable local recurrence rates as compared to radical surgery.

Continued development in minimally invasive surgery must be tempered by the danger of drawing too many conclusions from small case studies.

The verdict

• TEM for the treatment of residual rectal cancer post-chemoradiation therapy is associated with too high a local recurrence rate to be recommended
• Improvements in local radiological tumour staging and identification of patients with favourable pathology/ significant comorbidities may make this an appropriate treatment regime for specific patient subgroups.

John Robertson

David Anderson

Anjum A, von Allmen R, Greenhalgh R, Powell JT. Explaining the decrease in mortality from abdominal aortic aneurysm rupture. Br J Surg 2012; 99: 637-45.

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Bucher P, Pugin F, Buchs NC, Ostermann S, Morel P. Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. BJS 2011: 1695-702.

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