'rr.q. THE APPLICATION OF NEW TECHNOLOGY TO COLORECTAL SURGERY Thesis submitted in January 1999 for the degree of Doctor of Medicine in the University of Adelaide by Andrew James Luck, M.8., B.S. (Adel), F.R.A.C.S. The work described was performed within the Department of Surgery of the University of Adel aide at The Queen Elizabeth Hospital TABLE OF' CONTENTS Page No. TITLE I TABLE OX' CONTENTS II LEGEND OF TABLES VI LEGEND OF FIGURES XI SUMMARY XV DECLARATION XIX ACKNOWLEDGEMENTS XX PREFACE XXIII SECTION I AIMS I SECTION II INTRODUCTION 7 2.I Intra-operative ultrasound l1 )') Laparoscopic colorectal 20 surgery II Page No. 2.3 Advanced prognostic techniques 26 in colorectal cancer 2.4 Ambulatory anorectal surgery 35 2.5 Patient information by video 48 SECTION III METHODS, RASULTS & DISCUSSION 51 3. I INTRA.OPERATIVE ULTRASOUND 53 (i) Ultrasound detection of 55 colorectal hepatic metastases (ii) Ultrasound of the colon 76 3.2 LAPAROSCOPIC COLORECTAL 103 SURGERY (i) Laparoscopic reversal of r04 Hartmann's procedure (ii) Laparoscopic-assisted t12 colonoscopic polypectomy ilI Pase No. SECTION III (continued) (iii) Core temperature changes 118 during laparoscopic and open colorectal surgery J.J ADVANCED PROGNOSTIC TECHNIQUES IN COLORECTAL CANCER (i) Irnmunobeadreverse 134 transcriptase-polymerase chain reaction (RT-PCR) detection of free intra-peritoneal malignant cells at colorectal cancer resection 3.4 AMBULATORY ANORECTAL SURGERY (i) Day case haemorrhoidectomy 153 (ii) Pre-emptive, local 178 anaesthetic, ischio-rectal fossa block for haemorrhoidectomy IV Paee No. SECTION III (continued) (iii) Glyceryl trinitrate paste 189 versus lateral sphincterotomy in the management of chronic anal fissure 3.5 VIDEO INFORMATION (i) The impact of visual 210 information by video on pre-colonoscopy knowledge and anxiety levels SECTION IV SUMMARY AND CONCLUSIONS 227 APPENDIX 244 BIBLIOGRAPHY 249 V LEGEND OF TABLES Pase No. 2.1 .1 Published series comparing the sensitivity t6 of pre-operative investigations, operative assessment and intra-operative ultrasound in the detection of hepatic metastases at colorectal resection for adenocarcinoma. 2.r.2 Published series reporting the percentage t7 of hepatic metastases from colorectal cancer that were only detected by intra-operative ultrasound. 3.1.1.1 Follow up data for the open colectomy 70 patients who had no abnormality detected on peri-operative assessment of the liver. 3.r.1,2 Follow up data for the laparoscopic 71 colectomy patients who had no abnormality detected on peri-operative assessment of the liver. 3.1.1.3 Investigation findings and follow up 72 details for patients who had benign liver pathology detected. VI Pase No 3.1.t.4 Investigation findings and follow up data 74 for patients who had liver metastases detected by one or more of the investigation modalities. 3.2.1.I Post-operative progress following 111 laparoscopic reversal of Hartmann's procedure. 3.2.3.l Comparison of open and laparoscopic t27 operations performed in the core temperature study. 3.2.3.2 Comparison of patient details between t28 the open and laparoscopic surgery groups in the core temperature study. 3.2.3.3 Overall comparison of the minimum 129 temperature values recorded between patients undergoing open and laparoscopic colorectal surgery. 3.2.3 4 Overall comparison of the minimum 130 temperature values recorded between patients who did and did not have the Bair HuggerrM forced-air warming device applied during surgery. VII Page No. 3.2.3.5 Subgroup analysis of the minimum 131 temperature data. 3.3. 1 .1 Immunobead RT-PCR results for 151 patients who had positive results to markers of epithelial cells but not to markers of colorectal malignancy in peritoneal washings. 3.3.1.2 Immunobead RT-PCR results and 152 follow up details of patients who had positive results to markers of malignancy in peritoneal washings. 3.4.1.1 Pain scores after haemorrhoidectomy. t7r 3.4.1.2 Nausea scores after haemorrhoidectomy 175 3 .4.1 .3 Anti-emetic requirements after 176 haemorrhoidectomy. 3.4.1 3 Satisfaction ratings recorded for 177 day case haemorrhoidectomy. VIII Pase No. 3 .4.2.r Comparison of patient demographics 185 and fentanyl dose at induction in the local anaesthesia for haemorrhoidectomy randomised trial. 3 .4.2.2 Comparison of pain scores in the first 186 twenty-four hours after haemorrhoidectomy in the local anaesthesia for haemorrhoidectomy randomised trial. 3 .4.2.3 Comparison of analgesic requirements 188 in the first twenty-four hours after haemorrhoidectomy in the local anaesthesia for haemorrhoidectomy randomised trial. 3.4.3.t Patient details and outcomes for patients 205 with chronic anal fissure randomised to primary treatment by lateral sphincterotomy. 3.4.3.2 Patient details and outcomes for patients 206 with chronic anal fissure randomised to primary treatment with glyceryl trinitrate IX Pase No. 3 .5. I . I Details of patients in the information 222 video randomised trial. 3.5.1.2 Estimated first anxiety score depending 223 on sex and previous experience of colonoscopy. 3.5. I .3 Results of pre-colonoscopy knowledge 225 questionnaire. 3.5.t.4 Effect of the information video on the 226 knowledge and anxiety levels of patients with severe anxiety. X LEGEND OF FIGURES Page No. 3.1.2.1 Ultrasound of the colon: Normal colon 88 with the lumen empty. 3.1.2.2 Ultrasound of the colon: Experimental 89 assessment of normal colonic layers. 3.1.2.3 Ultrasound of the colon: Large palpable 90 cancer with the lumen empty. 3.1.2.4 Ultrasound of the colon: Impalpable cancer 9t with the lumen empty. 3.1.2.5 Ultrasound of the colon: Large cancer with 92 the empty colon immersed in a saline 'bath'. 3.L2.6 Ultrasound of the colon: Normal colon 93 with the lumen filled with fluid. 3.1.2.7 Ultrasound of the colon: Large cancer 94 with the colonic lumen filled with fluid 3.I.2.8 Ultrasound of the colon: Impalpable 95 cancer with the colonic lumen filled with fluid. 3.1.2.9 Ultrasound of the colon: 9mm polyp 96 shown with saline in the colonic lumen XI Pase No. 3.I.2.I0 Ultrasound of the colon: Image of a 97 small cancer showing invasion through muscularis mucosae. 3.1.2.11 Ultrasound of the colon: Image of a 98 large cancer with a paracolic lymph node. 3.I.2.12 Ultrasound of the colon: Small ulcer 99 remaining six days after colonoscopic polypectomy of a malignant polyp. 3.1.2.13 Ultrasound of the colon: Submucosal 100 derangement remaining five weeks after colonoscopic polypectomy of a malignant polyp. 3.1.2.L4 Ultrasound of the colon in-vivo trial: 101 Ultrasound of fluid-filled normal colon. 3.1.2.15 Ultrasound of the colon in-vivo trial: 102 Ultrasound of fluid-filled colon showing the impalpable polyp protruding into the lumen. XII Pase No. 3.2.t.1 Positions of operating theatre equipment 110 and personnel and laparoscopic ports for laparoscopic reversal of Hartmann's procedure. 3.2.3.1 Trend of core temperature change during 132 surgery for male patients. 3.2.3.2 Trend of core temperature change during 133 surgery for female patients. 3.4.1.1 Mean pain scores recorded after 172 haemorrhoidectomy illustrated graphically to show trends. 3.4.r 2 Proportion of patients recording pain t73 scores of 3 or greater (on VAS l-10) after haemorrhoidectomy. 3.4.I.3 Analgesic requirements after day case 174 haemorrhoidectomy. XIII Page No. 3.4.2.1 Trend of pain scores for the first 187 twenty-four hours after haemorrhoidectomy, comparing patients randomised to receive the full ischio-rectal fossa block with those who had infiltration of the haemorrhoidal complexes only. 3 .4.3 .t Comparison of pain scores between the 208 glyceryl trinitrate patients who had healing of their fissure by 8 weeks with those whose fissures did not heal. 3.4.3.2 Headache scores recorded by patients 209 using gylceryl trinitrate paste. 3.5.1.1 Interaction between first anxiety score 224 (7 days prior to colonoscopy) and second anxiety score (immediately prior to colonoscopy) depending on whether or not the patient watched the information video. XIV SUMMARY The impact of several technological advances and their appropriate clinical application to the field of colorectal surgery was investigated in this thesis. Intra-operative ultrasound was shown to be valuable in the assessment of the liver for hepatic metastases at the time of resection of colorectal cancer. This technology is best applied in the assessment of abnormalities that have been found on pre- operative computed tomography, rather than as the definitive screening tool itself. Laparoscopic ultrasound was found to be a difficult technique to master. Further investigation will be required in order to assess the role of laparoscopic ultrasound of the liver during laparoscopic colectomy for cancer. Intra-operative ultrasound of the colon is a technique that was developed in the two years of this thesis. Excellent images of colon and colonic neoplastic lesions were produced during a benchtop study, particularly when the colonic lumen was filled with fluid. In vivo investigation is continuing in order to assess the value of this technique in the localisation and assessment of impalpable colonic lesions for resection. Laparoscopic reversal of Hartmann's procedure and laparoscopic-assisted colonoscopic polypectomy were shown, in small series, to be feasible and safe procedures that appear to provide many of the short-term post-operative patient advantages that have been reported with other laparoscopic procedures. XV A case-controlled study of the core temperature changes during surgery showed that there is no difference in the incidence of hypothermia between laparoscopic and open colorectal surgery.