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Background Enhanced recovery after surgery (ERAS) is a structured programme using a multimodal, evidence-based approach to improve post-operative outcomes. Successful implementation of ERAS can be challenging. We aimed to evaluate our initial experience with colorectal ERAS and explore the perspectives of specialist doctors and nurses. Methods From 1 June 2017 to 31 December 2017, all patients who underwent elective colorectal resection and met the ERAS inclusion criteria at the Department of Colorectal Surgery, Singapore General Hospital, were included in the study. Short-term outcomes were compared between patients with >70% compliance to key ERAS components versus those with ≤70% compliance. Department staff were surveyed via questionnaire in July 2019. Results Three hundred and fifteen patients were included in study. >70% ERAS compliance rate was achieved in 84 patients (26.7%). A higher compliance rate resulted in a significantly shorter length of stay of 6 (IQR 5–8) days vs. 7 (IQR 6–9.5) days (p = 0.025) and lower readmission rate of 3.6% (n = 3) vs. 4.8% (n = 11) (p = 0.042), as well as a trend towards reduced complication rate of 15.4% (n = 13) vs. 22.0% (n = 51) and earlier return to gastrointestinal function. There was a 100% questionnaire response amongst all 12 colorectal surgeons and 5 colorectal resident nurse practitioners. Conclusion Increased adherence to the components of ERAS results in better early outcomes and may have long-term benefits on survival. Effective communication and professional support for the ERAS multi-disciplinary team, as well as understanding healthcare workers’ concerns and addressing long-standing practices, is essential for successful implementation of the programme.

The role of stem cells in the development of solid tumors remains controversial. In colorectal cancers (CRC), this is complicated by the conflicting “top-down” or “bottom-up” hypotheses of cancer initiation. We profiled the expressions of genes from the top (T) and bottom (B) crypt fractions of normal-appearing human colonic mucosa (M) at least 20 cm away from the tumor as a baseline and compared this to the genes of matched mucosa adjacent to tumors (MT) in twenty-three sporadic CRC patients. In thirteen patients, the genetic distance (M-MT) between the B fractions is smaller than the distance between the T fractions, indicating that the expressions diverge further in the top fractions (B T). Assuming that a greater genetic divergence in the top or bottom fractions indicates that position as the initiation site, it is thus equally likely that human CRC initiates from ‘top-down’ via de-differentiated colonocytes or ‘bottom-up’ via dysregulated intestinal stem cells. Dysregulated genes that persist until tumor stage are not limited to tumor suppressors or oncogenes but include metabolic and transporter genes such as CA7, PHLPP2, and AQP8.

Approximately 20% early-stage (I/II) colorectal cancer (CRC) patients develop metastases despite curative surgery. We aim to develop a formalin-fixed and paraffin-embedded (FFPE)-based predictor of metastases in early-stage, clinically-defined low risk, microsatellite-stable (MSS) CRC patients. We considered genome-wide mRNA and miRNA expression and mutation status of 20 genes assayed in 150 fresh-frozen tumours with known metastasis status. We selected 193 genes for further analysis using NanoString nCounter arrays on corresponding FFPE tumours. Neither mutation status nor miRNA expression improved the estimated prediction. The final predictor, ColoMet19, based on the top 19 genes' mRNA levels trained by Random Forest machine-learning strategy, had an estimated positive-predictive-value (PPV) of 0.66. We tested ColoMet19 on an independent test-set of 131 tumours and obtained a population-adjusted PPV of 0.67 indicating that early-stage CRC patients who tested positive have a 67% risk of developing metastases, substantially higher than the metastasis risk of 40% for node-positive (Stage III) patients who are generally treated with chemotherapy. Predicted-positive patients also had poorer metastasis-free survival (hazard ratios [HR] = 1.92, design-set; HR = 2.05, test-set). Thus, early-stage CRC patients who test positive may be considered for adjuvant therapy after surgery.

Introduction Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH. Methods From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively. Results Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26–78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5–35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure. Conclusion CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.