A Askari

The impact of adjuvant chemotherapy timing on overall survival following colorectal cancer resection

BACKGROUND Several studies including two meta-analyses have showed that delay between surgery and adjuvant chemotherapy adversely impacts colorectal cancer survival. This study investigated this impact at a population level over a fifteen year period in England. METHODS The Hospital Episode Statistics database was analysed between 1997 and 2012. Colonic cancer and rectal cancer patients were collated and multivariate Cox regression analyses were undertaken to ascertain the relationship between chemotherapy delay and overall survival. RESULTS A total of 181 984 patients underwent resection without any reoperation (106 477 (58.5%) having colonic cancer and 75 507 (41.5%) having rectal cancer). In total, 30 836 (16.9%) received adjuvant chemotherapy. 9019 (49.3%), 4573 (25.0%), 2587 (14.1%), 1323 (7.2%) and 804 (4.4%) of 18 306 colonic cancer patients received within 8 weeks, 8-10 weeks, 10-12 weeks, 12-14 weeks and 14-16 weeks, respectively. Sequentially worse overall survival was observed: <8 weeks: Ref; 8-10 wks: Hazard Ratio (HR) 1.09; 10-12 wks: HR 1.13; 12-14 wks HR 1.32 and 14-16 wks: HR 1.32, p < 0.001. 5625 (44.9%), 3087 (24.6%), 1940 (15.5%), 1162 (9.3%) and 716 (5.7%) of 12 530 rectal cancer patients received within 8 weeks, 8-10 weeks, 10-12 weeks, 12-14 weeks and 14-16 weeks, respectively. Sequentially worse overall survival was observed: <8 weeks: Ref; 8-10 wks: HR 1.09; 10-12 wks: HR 1.22; 12-14 wks HR 1.23 and 14-16 wks: HR 1.31, p < 0.001. CONCLUSION Adjuvant chemotherapy delay adversely impacts colonic and rectal cancer survival. Efforts to prevent complications such as reoperation and to improve access to chemotherapy services, will improve survival in this patient cohort.

PWE-262 Patients in england with inflammatory bowel disease (IBD) who develop colorectal cancer (CRC) have shortened survival when compared with patients with sporadic CRC

Introduction Ulcerative Colitis (UC) and Crohn’s Disease (CD) are both implicated as risk factors for the development of colorectal cancer (CRC). It is unclear if this patient group has a poor survival after diagnosis. The aim of this study is to determine survival in Inflammatory Bowel Disease (IBD) associated CRC compared with sporadic CRC. Method Patients with a diagnosis of both CRC and IBD were identified from a national administrative dataset (Hospital Episode Statistics – HES). Multivariable cox proportional hazards regression analyses (adjusting for gender, age, medical comorbidity, mode of admission, operation type, chemotherapy) were used to determine survival differences. Results A total of 286,591 patients underwent surgery for CRC in England, between 1997–2012: 0.5% (n = 1,546) had UC and 0.3% (n = 776) had CD. Patients with IBD were diagnosed with CRC at a significantly younger age compared with sporadic patients (UC median age 64, CD median age 63, sporadic median age 71, p < 0.001). Long-term survival in patients with IBD was poor compared with sporadic CRC patients (HR 1.19, CI 1.12–1.26, p < 0.001). On sub-group analysis patients with UC had a 12% reduction in their survival (HR 1.12, CI 1.04–1.20, p = 0.003), whereas those with CD had a 32% reduction (HR 1.32, CI 1.20–1.45, p= <0.01). This difference in survival persisted even when adjusting for immediate post-operative mortality. Conclusion IBD associated CRC develops at a younger age than sporadic CRC with poorer long-term survival, particularly for patients with CD. The reasons for shortened survival amongst IBD patients who develop CRC are unclear. Disclosure of interest None Declared.

PTH-063 Different colectomy rates for ulcerative colitis across ethnic groups in england

Introduction Previous epidemiological studies suggest a higher rate of pan-colonic disease in South Asians (SA) compared with Caucasians. There is limited data on disease severity across ethnic groups. Refractory disease and development of dysplasia indicate aggressive disease and are both indications for colectomy. The aim of the study was to compare the risk of colectomy for ulcerative colitis (UC) in SA migrants to Caucasians. Method Patients with UC were identified from a national administrative dataset (Hospital Episode Statistics – HES) between 1997–2012 according to ICD-10 diagnosis code K51 for UC. From the cases coded for ethnicity, colectomy cases were identified according to the Office of Population Censuses and Surveys (OPCS) codes. The colectomy rate for each ethnic group was calculated as the proportion of patients who underwent colectomy from the total UC cases for that group. The median age at time of colectomy was calculated for each ethnic group. Chi-squared testing was used to determine significant differences in colectomy rate and Kruskal-Wallis test to ascertain differences in age at colectomy between ethnic groups. Results Of 212,430 UC cases, 74,988 (35.3%) were coded for ethnicity. Of these cases most were White Europeans (Caucasians) 69,208/74,988 (92.3%). The SA group consisted of: 1,954/74,988 (2.6%) Indian, 832/74,988 (1.1%) Pakistani and 129/74,988 (0.2%) Bangladeshi (Table 1). Indians had a significantly higher colectomy rate than White Europeans (10.8% vs 7.4%, p < 0.001). In contrast Pakistanis had a similar (7.0%) and Bangladeshis a significantly lower (4.7%) colectomy rate than the White European group. (7.4%, p < 0.001). SAs undergoing colectomy were significantly younger than White Europeans for each ethnic group (median age; Bangladeshis - 29 years, Pakistanis - 37 years and Indians – 41 years, compared with White Europeans – 49 years, p < 0.001).Abstract PTH-063 Table 1 Colectomy rate in UC patients by ethnicity Ethnicity White Europeans Indian Pakistani Bangladeshi No. of colectomies 5150 211 58 6 Total no. of UC cases 69208 1954 832 129 Colectomy rate (%) 7.4 10.8 7.0 4.7 Conclusion The colectomy rate is higher in Indians compared to White Europeans. Across SA ethnic groups there are differences in colectomy rate. All SA groups required a colectomy for UC at a younger age than White Europeans. These findings suggest a more aggressive phenotype in SAs and should be validated with a prospectively recruited ethnic cohort. This will also allow examination of contributing factors. Disclosure of interest None Declared.

PWE-271 Decision analysis using simulation modelling supports local excision in T1 colon cancer

Introduction Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic neoplasia. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity. This study examined the quality-of-life benefits and risks of local excision compared with results after colectomy, for low- and high-risk T1 colonic cancer. Method Decision analysis using a Markov simulation model was performed: patients were managed with either local excision (advanced therapeutic endoscopy) or colectomy. Lesions were considered high-risk according to accepted national guidelines. Probabilities and utilities were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients, with low- or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). Results In low-risk T1 colonic neoplasia, local excision increases QALE by 2.72 QALYS for fit 65-year olds (15.5% increase over surgery) and by 0.93 for unfit 80-year-olds (20.9% increase). For high-risk T1 cancers, the QALE benefit for local excision is 1.82 QALYs for fit 65-year-olds (10.5% improvement) and 0.82 for unfit 80-year-olds (18.6% improvement). In sensitivity analysis, colectomy was only preferred for 65-year-old patients, when risk of recurrence following local excision exceeded 17.3%. Conclusion Under a wide range of assumptions, for all patient cohorts, local excision is a reasonable treatment option for both low- and high-risk T1 colonic cancer. Exploration of methods to facilitate local excision of T1 colonic neoplasia appears warranted. Disclosure of interest None Declared.

PTH-343 Tube ileostomy – could it replace defunctioning loop ileostomy in elective colorectal anastomotic protection? – a systematic review and meta-analysis

Introduction Loop ileostomy for faecal diversion in elective distal colorectal anastomosis, and its subsequent reversal, are associated with significant patient morbidity and rarely even mortality. Tube ileostomy, may be an alternative technique in distal anastomosis protection, however its evidence base is not established as yet. This systematic review aims to examine differences in outcome between tube ileostomy and defunctioning ileostomy. Method A systematic literature search of MEDLINE, EMBASE, Web of Science, and Cochrane database was conducted. Studies reporting on elective left sided/colorectal anastomoses were included. Studies which reported on emergent surgery, small bowel anastomoses or tube ileostomy as a bridging procedure were excluded. The preoperative aspects, such as bowel preparation, intraoperative technique including tube size and configuration, postoperative management such as tube removal timing, nutrition delivery and complications, were assessed. Outcome measures included anastomotic leak, reoperation and stoma or tube ileostomy-related complications. Results Seven studies met the inclusion criteria. Three were case series consisting of 101 patients and four were non-randomised comparative studies consisting of 532 patients. Pooled analyses of three comparative studies, comparing tube ileostomy (n = 278) to loop ileostomy (n = 254), revealed no significant differences in anastomotic leak rates [Odds Ratio (OR) 0.85, 95% Confidence Interval (CI) 0.41 – 1.75; I2= 0%, p = 0.43].Abstract PTH-343 Figure 1 Conclusion There is a re-emergence of interest in the tube ileostomy in the elective setting, in recent years. Pooled analyses of studies comparing tube ileostomy to loop ileostomy, do not show statistically significant differences in anastomotic leak rates. Further refinement of this technique and randomised controlled studies are necessary for this technique to be routinely used by surgeons. Disclosure of interest None Declared. References Cataldo PA. Intestinal stomas: 200 years of digging. Dis Colon Rectum. 1999;42(2):137–42 Bugiantella W, Rondelli F, Mariani L, Boni M, Tassi A, Stella P, Patiti M, Ermili F, Avenia N, Mariani E. Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial. Eur J Surg Oncol. 2014;40(4):476–83

PWE-261 Elderly, ethnic minorities and socially deprived patients at high risk of requiring emergency surgery for colorectal cancer

Introduction Emergency surgery for colorectal cancer (CRC) conveys high postoperative morbidity and mortality. The aim of this study is to identify patient groups at high risk of emergency presentation and quantify their overall survival. Method All patients diagnosed with colorectal cancer between the year 1997–2011 were identified from the Hospital Episode Statistics (HES) database. Logistic regression analyses were undertaken to identify patient groups at risk of undergoing emergency surgery for colorectal cancer at first presentation. Survival plots using multivariable cox proportional hazard analyses were generated. Results Over this time period, 286,591 patients underwent resection for CRC, 69,718 (24.3%) of which were as emergencies. While, the overall rate of emergency CRC resection has significantly decreased from 29.5% in 1997 to 16.5% in 17.2% in 2011 (p < 0.001), certain patient groups continue to be at risk of undergoing colorectal cancer resection as an emergency. Elderly patients (>79 yrs old) are 55% more likely to require emergency surgery (OR 1.55, CI: 1.50–1.60, p < 0.001) compared to <55 year olds. Similarly patients from a socially deprived background are 64% more likely to undergo emergency surgery than affluent patients (OR 1.64, CI: 1.50–1.80, p < 0.001). Patients from the Black Afro-Caribbean community were also at increased risk compared to White British patients (OR 1.36, CI: 1.21–1.66, p < 0.001). Long-term survival (5-year) remains poor in patients who have emergency surgery even when adjusting for immediate (90-day) post operative mortality (emergency patients HR 1.64, CI 1.63–1.67, p < 0.001). In the screening age population (60–69 years old), there was a significant drop in emergency presentation (23.4% to 14.9%, p < 0.001) before and after the implementation in screening in 2006. Conclusion Whilst the overall rate of emergency colorectal cancer surgery is reducing, elderly patients, those from a socioeconomically deprived background and Black Afro-Caribbean patients remain at high risk of emergency attendance. Post-operative morbidity and mortality remains high in emergency presenters and 5-year survival in this patient group remains poor. Targeting screening of these high-risk patient groups is essential to reduce the number of patients attending as an emergency further. Disclosure of interest None Declared.

PWE-260 Elderly patients undergoing laparoscopic resection for colorectal cancer have better survival than patients undergoing open surgery

Introduction Elderly patients are at increased risk of death following surgery for colorectal cancer, even in the elective setting. This national study aims to examine the relationship between patient selection for laparoscopic resection and survival in an elderly cohort. Method Elderly patients (80 years and over) undergoing elective colorectal cancer resection between the years 2001–2011 were identified from the Hospital Episode Statistics (HES) database. Mortality data from Office for National Statistics (ONS) were obtained. Survival analyses using multivariable cox proportional hazard regression were carried. Confounding variables such as gender, medical comorbidity, type of operation and chemotherapy were adjusted for. Results In the time period, 5,398 elderly patients underwent elective colorectal cancer resection, of which 1,479 patients (27.4%) underwent laparoscopic resection. The mean 5-year survival in the open group was 41.0 months (95% CI 40.3–41.7) in the open group compared with 52.3 months (95% CI 51.2–53.3) in the laparoscopic group (p < 0.001). Multivariable cox hazard regression, demonstrated laparoscopic resection to have a 61% survival benefit over open surgery in elderly patients (HR 0.39, CI 0.33–0.45, p < 0.001). This survival benefit persisted, even when adjusting for immediate (90-day) post-operative mortality (HR 0.40, CI 0.32–0.44, p < 0.001). Conclusion Laparoscopic resections for colorectal cancer confer a survival advantage beyond the immediate post operative period in elderly patients. Offering this high-risk patient group elective laparoscopic resections in experienced units could help deliver better outcomes. Disclosure of interest None Declared.

PWE-273 An international comparison of clinical practice guidelines for the management of malignant colorectal polyps

Introduction Due to the varying risks of residual disease that have been reported after removal of malignant polyps, clinicians rely on clinical practice guidelines (CPGs) to inform decision-making. This study qualitatively and quantitatively compared the internationally published guidelines on the management of malignant colorectal polyps. Method A systematic literature search was undertaken to identify malignant colorectal polyp CPGs. Quantitative comparison was based on the Appraisal of Guidelines Research and Evaluation (AGREE II), a validated CPG appraisal tool which assesses 6 domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence. Histopathological risk factor assessment and treatment recommendations were further analysed for supporting levels of evidence and scientific agreement. Results Eleven International malignant colorectal polyp guidance documents were included. The AGREE assessment demonstrated significant variation in all quality domains across the CPGs. The scope and purpose domain showed the highest level of quality (median: 91%, interquartile range (IQR): 86–97%). The Applicability domain showed the lowest level of quality (median: 43%, IQR: 35–55%). Risk was attributed dichotomously (low/high risk) to malignant polyps in 8/11 CPGs and in a graded fashion in the remainder. Importantly, there were disagreements regarding which histopathological findings carried risk. Significant variation was found for degree of risk between CPGs for resection margins, tumour budding and depth of invasion. No CPG was able to provide a comprehensive analysis when multiple histopathogical risk factors are present in an MCP. The indications for local excision also demonstrated considerable variation. Conclusion There is variation in evidence interpretation and recommendations between widely used malignant colorectal polyp CPGs. Improvements in the underlying evidence base, particularly defining accurate probabilities of residual disease in the presence of multiple histopathological risk factors, are required to allow clinicians to provide personalised care to this complex patient group. Disclosure of interest None Declared.

PWE-259 Colorectal cancer (CRC) patients with inflammatory bowel disease (IBD) are at increased risk of poor outcomes post surgery in england

Introduction Colorectal cancer (CRC) patients with Ulcerative Colitis (UC) and Crohn’s Disease (CD) can be challenging to manage in the perioperative period. The aim of this study is to examine differences between Inflammatory Bowel Disease (IBD) and sporadic CRC patients in terms of the emergency admission rates, length of stay and post operative complications. Method A national study was carried out using the Hospital Episode Statistics (HES) database between the years of 1997 to 2012. Multivariable binary logistic regression was undertaken to determine whether IBD was independently associated with the development of a postoperative complication. Results During the study time period, 286,591 patient underwent colorectal cancer resection, 0.8% of which (n = 2,322) had IBD. A greater proportion of IBD patients underwent a colorectal cancer resection as an emergency than sporadic patients (UC 25.1%, CD 34.7% and sporadic 24.3%, p < 0.001). IBD patients had a significantly prolonged length of stay after elective surgery for CRC (median number of days length of stay 10 vs. 7, p = 0.001). The overall rate of serious medical complication such as myocardial infarction, stroke, pulmonary embolism was 7.8%, the overall rate of 30-day re-operation was 4.2% (n = 11,987) with a further 0.6% (n = 1,633) requiring radiological re-intervention. A diagnosis of IBD (adjusted for age, gender, comorbidity, mode of admission and type of operation) was an independent predictor of 30-day re-operation (OR 1.32, CI 1.12–1.56, p = 0.001). Conclusion IBD patients, particularly Crohn’s patients commonly have their colorectal cancer resected in an emergency setting. IBD patients are more likely to require 30-day re-intervention, irrespective of other factors. A multi-disciplinary team approach incorporating surgeons, gastroenterologists, anaesthetists and radiologists is essential in the management of these complex patients in the peri-operative period Disclosure of interest None Declared.