Background and Objective: One of the uses of indocyanine green (ICG) in the surgical field is the evaluation of the anastomotic margins in colorectal surgery. This is of particular importance because fluorescence imaging may aid in detecting vascular compromise, allowing the surgeon to change the resection margin thereby decreasing the chance of an anastomotic leak. To date, there has been no study with its use locally. This study aimed to determine whether the use of ICG can safely identify if the margins of resection are well-vascularized in patients undergoing left-sided colon or rectal surgery, which in turn may reduce anastomotic leak rates. Methods: Through a retrospective study design, the investigators gathered data of patients who underwent left-sided colon or rectal surgery. The groups were divided into those with and without the use of ICG and a comparative data on the anastomotic leak rates were analyzed. Results: Eighty-six (86) patients with similar patient characteristics, tumor staging, and surgical approach were compared. Both the leak rates identified during the initial hospital stay and at 30 days post-operatively were lower in those where ICG was used (p=0.035, p=0.047, respectively) than those where ICG was not used. Conclusion ICG fluorescence imaging may reduce the anastomotic leak rates in patients undergoing colorectal surgery.
indocyanine green ; colon ; rectum ; colorectal surgery ; anastomosis, surgical ; anastomotic leak

Purpose: This study aims to evaluate surgical outcomes (i.e. length of stay [LOS], 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the Enhanced Recovery After Surgery (ERAS) pathway, and determine its association with the rate of compliance to the different ERAS components. Methods: This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then retrospectively compared to outcomes prior to the implementation of ERAS. Results: A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92.0% (SR, 91.8%; CR, 93.1%; RR, 90.7%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.1±6.7 days vs. 10.0±5.4 days, P=0.002) and RR (19.9±11.4 days vs. 16.9±10.5 days, P=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar. Conclusion Increased compliance to ERAS protocol is associated with a decrease in morbidity across all surgery types. The implementation of an ERAS protocol significantly decreased mean hospital LOS, without any increase in major surgical complications. Having your own hospital ERAS pathway improves documentation and accuracy of reporting surgical complications.

INTRODUCTION: The use of neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) has shown promising results in the management of locally advanced rectal carcinoma, and is associated with improvement in local control, disease free survival (DFS) and overall survival (OS). However, these clinical endpoints cannot be properly assessed due to poor follow up among many patients. Other endpoints such as negative circumferential resection margins (CRM), pathologic complete response (pCR) and sphincter-preserving surgery (SPS) may serve as indirect means of assessing successful treatment. This study reports the experience of the Philippine General Hospital (PGH) Colorectal Polyp and Cancer (CRPoCan) Study Group in using neoadjuvant CRT and TME in the management of locally advanced rectal carcinoma, towards quality care.
METHODS: The Integrated Surgical Information System (ISIS) database of the Department of Surgery, PGH was queried for rectal cancer patients with pretreatment clinical stage II and III disease that underwent neo-adjuvant CRT followed by TME between January 2008 and December 2009. The final surgical pathology reports of the subjects were reviewed for treatment response. Response was categorized as: (1) positive or negative CRM; and (2) with or without pCR. The study assessed whether SPS was done.
RESULTS: Of 140 potential neoadjuvant CRT patients followed by TME, 82 patients completed the treatment. Thirty two of the patients who completed treatment (39%) were eligible since the other 50 patients (61%) had no post-operative histopathology results. Among those eligible, 10 patients (31%) had pCR. Only 1 patient had a positive CRM. Of the 14 patients whose tumor distance was ?5cm from the anal verge, only 1 patient underwent SPS. The small sample size was mainly attributed to low resources or treatment. Non-availability of post-operative histopathology results was due to poor record keeping.
CONCLUSION: The PGH CRPoCan Study Group's use of neoadjuvant CRT followed by TME for locally advanced rectal carcinoma has resulted in acceptable numbers of pCR and clear CRM but has not translated into an increased number of SPS. Despite the limitations of the study, the institutionalization of the multidisciplinary team in the PGH CRPoCan Study Group and the implementation of the ISIS database program are considered the first steps towards quality health care.

Human ; Male ; Female ; Neoadjuvant Chemoradiotherapy ; Total Mesorectal Excision ; Polyp ; Surgical Pathology ; Rectal Cancer

INTRODUCTION: Fournier's gangrene is the development of a progressive necrotizing infection in the genital and perianal region with findings of gangrenous and necrotic tissueinvolving the skin and subcutaneous tissue down to the fascia. This study aims to review cases of Fournier's gangrene in the Hospital from 2004 up to 2010 and to provide a profile of patients afflicted with the disease and describe its surgical management in this institution.?

METHODOLOGY: A retrospective chart and database review wasperformed involving patients with a diagnosis of Fournier's gangrene treated at the Hospital from 2004-2010. The following variables were analyzed: 1) total number of cases; 2) gender; 3) age range, distribution and mean age; 4) source of infection, whether the initial lesion started from the urogenital or perianal area; 5) associated co-morbid conditions; 6) the extent of infection, whether it's confined to the urogenital or perineal area or has involved adjacent areas; 7) the time between initial symptoms to the first hospital consult; 8) number of debridement done at the operating room for each patient; 9) the presence of other surgeries aside from debridement; 10) outcome (recovered or expired).?

RESULTS: The incidence of Fournier's gangrene is 8.7 patients per year in our institution. There were 36 patients included in this study. There is a male preponderance, affecting 4 males for every 1 female. The mean age is 49.5 years with a range of 18-73. Sixty four percent had infection starting from the perianal area while the rest had an initial lesion from the urogenital area. Seventy two percent had lesions confined to the perianal/urogenital areas while the rest had extended infections. Diabetes mellitus was the most common comorbid condition, involving 47 percent of the cases. Majority of the patients (70%) underwent just a single debridement. Ourinstitution mortality rate is 11 percent.No statistical significance was established between number of debridement and time of consult with mortality.?

CONCLUSION: The optimal management of Fournier's gangrene include all the ff: 1) appropriate anti-microbial therapy; 2)intensive pre and post-operative resuscitation; 3) aggressive and timely surgical intervention.While this disease may be rare, it always presents a challenge to the surgeon and the intensives, requiring a more thorough understanding of its presentation and treatment outcomes.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Gangrene ; Subcutaneous Tissue ; Debridement ; Fournier Gangrene ; Comorbidity ; Surgeons ; Fascia ; Genitalia ; Diabetes Mellitus

OBJECTIVES: The study aimed to describe the use of an improvised vacuum-assisted closure (VAC) system in the management of enterocutaneous fistulas in patients admitted at the Philippine General Hospital (PGH) from January to December 2009. Demographic data as well as outcomes of patients were described.

METHODS: The study is a case series involving patients with enterocutaneous fistulas admitted at the PGH from January to December 2009 on whom an improvised VAC system was employed. Pertinent data were gathered, and frequencies and percentages were also computed.

RESULTS: The modified VAC system was employed in 19 patients. The most common etiology reported was iatrogenic (74%). Nine patients (47%) had spontaneous resolution during admission. The mean time to spontaneous closure with VAC usage was 17 days (range: 5 to 56). Three patients were discharged after a mean of 21 days (range: 8 to 44) on VAC, with efficient effluent collection using a stoma appliance. Of the three, 2 to patients had spontaneous fistula closure on follow up. Five patients declined further treatment. There was one mortality reported.

CONCLUSION: The use of an improvised VAC system may contribute to and hasten successful non-surgical treatment of patients with enterocutaneous fistulas.

Human ; Negative-pressure Wound Therapy ; Hospitals, General ; Iatrogenic Disease ; Philippines ; Intestinal Fistula ; Patient Discharge

Stercoral perforation commonly occurs in the colon, and is mainly due to a hard fecaloma obstructing the sigmoid and eventually perforating the wall due to increased intraluminal pressure causing ischemic necrosis and erosion. In the Philippines, we see cases of colon perforation from ingestion of fruit seeds, usually the santol, Sadoricum koetjape, which is abundant in the country. We report a rare case of a 46-year-old female who presented with an indirect inguinal hernia on the left, which on exploration was found to ahve incarceration of the terminal ileum and perforation from santol seeds. She subsequently underwent limited right hemicolectomy and primary hernia repair. From the literature avaliable, there has never been report of terminal ileal perforation from fruit seeds in Asian or Western countries.

Human ; Female ; Middle Aged ; Colon, Sigmoid ; Hernia, Inguinal ; Herniorrhaphy ; Fruit ; Philippines ; Intestinal Perforation ; Colonic Diseases ; Ileum ; Colectomy

For so many years, abdominoperineal excision has been the mainstay of surgical treatment for rectal cancer 7 cm and below the anal verge. With continued research and introduction of new technology, the management of rectal malignancies has involved making it possible to save the sphincter complex mechanism despite the distance from the verge. Concurrent with these developments is the introduction of a multidisciplinary team approach which the UP-Philippine General Hospital Colorectal Division has adopted in managing colorectal cancer cases. With the adoption of these advancements in the management of patients with rectal cancer, it is surmised that the institution's APR rates have decreased.

OBJECTIVES: The study aimed to document and compare the abdominoperineal resection (APR) rates at the Philippine General Hospital (PGH), before and after the introduction of a multidisciplinary team for colorectal cancer, over the course of 5 years (2005-2009).

METHODS: The study included all adult patients undergoing resection for low to mid rectal cancer, described as a tumor with distal extent of 11 cm or below from the anal verge (FAV), from January 1, 2005 to December 31, 2009. Data pertinent to the management were gathered. Frequencies and rates before and after the introduction of a multidisciplinary team approach were computed and compared.

RESULTS: There were a total of 230 rectal resection for cancer over a five-year period. The patients' mean age was 53 years (range: 26 to 83). There were 122 males and 108 females. Almost half of the patients (48.7%) presented with a clinical stage of Stage IIIB. Forty-three percent of patients underwent either pre-operative radiotherapy or combined chemoradiotherapy. Cumulatively, the APR rate was 30.90 percent (sphincter-saving rate 69.10%) The APR rate for 2009 was 12.82 percent (sphincter-saving rate 87.18) corresponding to a 39.18 percent decrease in APR rate from the highest APR rate recorded in 2006 (52%).

CONCLUSION: A multidisciplinary team (MDT) approach resulted in lower APR rates among patients with rectal cancer at the UP-PGH.

Human ; Aged 80 And Over ; Aged ; Middle Aged ; Colorectal Neoplasms ; Hospitals, General ; Philippines ; Rectal Neoplasms ; Rectum ; Chemoradiotherapy ; Digestive System Surgical Procedures ; Patient Care Team

A rare case of a young pregnant patient on her 32nd week of pregnancy, diagnosed with colorectal cancer, presenting with rectal bleeding, is reported. The various issues concerning the management of this malignancy in a pregnant patient is described and the value of a multidisciplinary approach to achieve favorable results for both the mother and child is emphasized. Key words: colorectal cancer, complications in pregnancy, rectal bleeding

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