George Ramsay

Analysis of outcome using a levator sparing technique of abdominoperineal excision of rectum and anus. Cylindrical ELAPE is not necessary in all patients

AIMS Abdominoperineal excision of rectum (APE) for cancer has a higher rate of local recurrence with a poorer outcome than stage matched anterior resection. The cylindrical excision (ELAPE) has been advocated to reduce local recurrence. However, this operation has greater morbidity and requires more post operative care. We report our outcomes from a single centre using a levator sparing dissection. METHODS All patients undergoing APE from January 2007-June 2011 were evaluated. Case notes operation notes and pathology results were reviewed for complications and staging. Follow-up data for survival and recurrence were obtained from the cancer registry, imaging and from clinic follow up. RESULTS Of all rectal cancers (n = 361), 43 had APE with curative intent. Median age was 67(IQR 59-76). Median tumour height was two centimetres from the dentate line (IQR 1-3.5 cm). Neoadjuvant chemoradiotherapy was given in 98% of APE resections with curative intent. Median post operative hospital stay was 10 days (8-15). At a median follow up of 38 months (IQR30-49) for patients undergoing curative resection, 2 patients (4.6%) had local recurrence and overall mortality was 18.6% (n = 8). CONCLUSION With adequate neoadjuvant chemoradiotherapy, a levator sparing excision of rectum remains a safe option with less morbidity and perioperative complications than has been described for ELAPE.

Impact of the Scottish Bowel Cancer Screening Programme on patient and tumour characteristics at a single centre

AIMS The Scottish National Bowel Cancer Screening Programme aims to detect asymptomatic colorectal carcinomas and improve outcomes by identifying tumours at an earlier stage. We describe the characteristics of bowel cancers diagnosed through the screening programme since it was established in June 2007 by comparison with colorectal carcinomas from all other referral sources. METHODS All patients with colorectal cancer discussed by our regional colorectal multidisciplinary team (MDT) from June 2007 to August 2011 were included. Patient and tumour characteristics were collated prospectively from MDT records. The database was then reviewed retrospectively. RESULTS During the study 209 916 (58%) of 364 759 invitations to participate in screening were accepted yielding 3895 (1.9%) positive results. The 255 (17%) screening-detected (SD) patients and 1232 (83%) other referrals (ORs) were discussed at the MDT within this period. Median age at diagnosis was 65.5 years for SD vs. 71.6 in OR (P < 0.001) with 64% vs. 53% male [SD vs. OR (P < 0.001)]. There were more left-sided tumours in SD (P = 0.005). Tumours were less advanced in SD group (P = 0.02) and more likely to undergo a laparoscopic resection (P = 0.003). Thirty (11.7%) of SD patients were dead at last follow-up compared with 458 (37.2%) of those from other sources (P < 0.001). CONCLUSIONS This cohort from a centre with an established screening programme supports the effect of screening in detecting earlier stage. Those with screen-detected tumours were more likely to survive than patients from the OR group.

Does the location of colorectal carcinoma differ between screened and unscreened populations

Aim  Screening for colorectal malignancy using faecal occult blood testing is established across the UK. In NHS Grampian the programme was introduced in 2007. Previous studies have reported no difference in anatomical locations of cancers detected by screening programmes compared with those in unscreened populations. This study aims to review the location of tumours detected in an established screening programme compared with those diagnosed through symptomatic presentation within the same population.

Urgency of referral and its impact on outcome in patients with colorectal cancer

Aim  Primary care referral for patients with bowel symptoms is triaged by general practitioners to urgent or routine based on the clinical suspicion of malignancy. Triage directly influences time to assessment and investigation. This study aimed to establish whether urgency of referral of patients with large bowel malignancy has any effect on management.

Sarcopaenia in surgical populations: A review

Sarcopaenia, or decreased muscle mass, has been the subject of a large quantity of recent literature in both medical and surgical disciplines. It has been shown, as outlined below, to be of great prognostic importance, and also may be used in certain circumstances to guide treatment. The greatest volume of research into this topic is in oncological surgical populations, in whom the prevalence of sarcopaenia has been shown to be high. However it is being increasingly studied in other patient groups. Interest in using sarcopaenia as an objective and potentially modifiable marker of frailty is increasing, especially with regards to pre-operative risk stratification and amelioration. In this review we consider the current literature regarding the cause and effect of sarcopaenia, the methods by which it may be identified and the potential ways in which it may be treated, in the interest of improving outcomes for surgical patients.

The Use of a Wound Protector as a Self Retaining Skin Retractor for SkinSparing Mastectomy and Immediate Reconstruction

Introduction: The skin sparing mastectomy allows appropriate skin closure for immediate reconstruction without threatening the oncological intent of the operation. Obtaining access to the peripheral aspects of the breast through a circum-areolar or a small incision can be difficult. Conventional retraction with metallic retractors leads to extensive point pressure on the skin flaps leading potentially to skin necrosis. Flexible Ring wound protectors are now commonplace in abdominal procedures. Here, we describe the use of the Alexis® wound retractor (Applied Medical, USA) in skin sparing mastectomies. Methodology and technique: The incision is a limited elliptical incision including the nipple-areolar complex. Skin flaps are raised circumferentially to approximately 3 cm all round and the internal ring of the medium sized Alexis® wound retractor (2.5 to 6 cm) is placed within the wound. The external component of the device is rolled inward until sufficient retraction is obtained. The dissection plane is easily visualised through the circumferential retraction obtained from the wound retractor with little additional conventional retraction and the skin sparing mastectomy is undertaken. We have also found this product helpful in axillary dissection placing small (2.5 cm) retractor with in the medium one. Discussion: We have used Alexis® retractor (Figure 1) in 30 skin sparing mastectomies and 16 axillary dissections. We have found this to be particularly useful as a retractor as the dissection plane is easily visualised. The device also provides wound protection from potential infective processes in an environment where prosthetic material is likely to be placed. The circumferential retraction allows appropriate exposure in both the breast and axilla without compromising blood supply of skin flap.

Patient consent in the post-Montgomery era: A national multi-speciality prospective study

BACKGROUND The Montgomery ruling has had a wide-ranging impact on the consent process and has been the subject of new guidelines by bodies, including the Royal College of Surgeons (RCSEng). This is the first study to examine the current standard of consent for surgical procedures at a national level. METHOD A national collaborative research model was used, with prospective data collection performed across hospitals in Scotland. Variables associated with the consent process were audited across three surgical specialities (general surgery, urology and orthopaedics) and measured against standards set by RCSEng, the Scottish Public Services Ombudsman and medical defence organisations. RESULTS A total of 289 cases were identified from 12 hospitals. The majority of patients were reviewed by a consultant surgeon in clinic (79.9%) or on the day of surgery (55.4%). The clinic consent rate was 27.0%, while a copy of the documented discussion was only provided to 4.2% of patients. On the day of surgery, the benefits, risks and alternatives to the planned procedure were discussed in less than half of cases. This rate was similar across different clinician grades, while marked variation was seen across hospitals. CONCLUSION In this prospective multi-centre study we have demonstrated wide variation in the consent processes in many surgical specialities across Scotland. Following the Montgomery ruling, we have demonstrated the current consent process in elective surgery is likely to be substandard, and may require additional steps to be taken by clinicians to ensure patients are fully informed to make decisions regarding their treatment.

Variability in the prescribing of intravenous fluids: A cross sectional multicentre analysis of clinical practice

AIMS Intravenous (IV) fluid administration continues to be a mainstay of care in General Surgery. Yet if they are prescribed incorrectly significant morbidity including electrolyte abnormalities, renal impairment and cardiac failure can develop. Despite this, it is frequently the responsibility of the most junior staff to prescribe IV fluids. We aim to analyse the understanding of IV fluid prescribing amongst junior doctors and to describe variability in clinical practice. METHODS We undertook a multicentre questionnaire study. Foundation doctors and specialty trainees were invited to undertake a two part paper-based questionnaire. Part one analysed baseline knowledge of the concentration of commonly prescribed fluids. Part two consisted of four clinical vignettes requiring a IV fluid prescribing decision by the surveyed doctor. RESULTS A total of 143 Doctors working in 8 hospitals were recruited. 65 (45.5%) doctors correctly stated the daily maintenance fluid requirements of water for an adult (25-30 mls/kg/day), while only 54 (37.8%) knew the sodium concentration of 0.9% NaCl. Lack of postgraduate experience (p = 0.011), qualifying from a medical school outside the United Kingdom (p < 0.0001) and working in one of the eight hospitals in this study (p < 0.0001) were associated with a lower knowledge level. There was limited consensus in prescribing in the responses to the 4 clinical scenarios, with 69 unique combinations of fluid choice, rate and volume prescribed. CONCLUSIONS Knowledge of the constituents of common IV fluids and routine requirement for fluid and common electrolytes is poor across junior doctors of all grades, driving large variation in clinical practice.

Can Haematology Blood Tests at Time of Diagnosis Predict Response to Neoadjuvant Treatment in Locally Advanced Rectal Cancer

Background: Outcomes in locally advanced rectal cancer are improved by neoadjuvant therapy followed by surgical resection. Some patients respond completely to preoperative treatment. Therefore, predicting the pathological response to preoperative therapy is of clinical importance. Accurate prediction would allow for tailored approaches to neoadjuvant therapy. Methods: All patients undergoing resection of rectal adenocarcinoma after neoadjuvant therapy between 2006 and 2015 were included in this cohort study. Patients were identified from a prospectively collected database and data were supplemented retrospectively with full blood count at diagnosis. Specimens resected following neoadjuvant therapy were graded according to pathological response. Follow-up data was obtained from the national registry. The primary outcome was complete pathological response. Results: Of 330 patients, 71 (21.5%) responded completely to preoperative therapy. Median age was 66 and 65% were male (n = 215). White cell count (WCC) was the most predictive marker, for predicting pCR; area under the curve (AUC) 0.666. This was higher than neutrophil/platelet ratio (AUC 0.652) or neutrophil/lymphocyte ratios (AUC = 0.437). Kaplan-Meier survival analysis showed those patients with WCC > 8 had poorer survival than those with WCC < 8 (p = 0.009). Conclusion: Routinely collected haematology samples at the point of diagnosis can assist in predicting for complete response to neoadjuvant therapy. Although novel biomarkers will have a greater predictive value, this clinically available value test could help to assist in risk stratification of patients using routinely collected laboratory tests.

Reply to: Extralevator abdomino-perineal excision (ELAPE) or abdomino-sacral amputation of the rectum (ASAR): revitalised approach for low rectal carcinoma described by Tadeusz Koszarowski in the 50s.

We thank Polkowski and colleagues for their interest in our paper. We note their results over an extended period of time utilising the Abdomino-Sacral Amputation of the Rectum (ASAR) as described in their letter. We agree with the contributors that review of outcomes from historical and current practice is vital in the ongoing attempt to improve clinical care. Indeed, this is the main reason why we sought to undertake our recent study. As we describe in our paper, in an attempt to reduce intraoperative perforation and positive circumferential resection margins, the Extralevator Abdomino-Perineal Excision (ELAPE) has become increasingly popular across Europe. Universal adoption of this technique has been advocated. In addition, it has been described as the next breakthrough in the clinical management of colorectal surgery; akin to Heald’s description of the total mesorectal excision. We felt that the published evidence for such a widespread change in practice was not convincing enough without a thorough review of our recent outcomes using a more conservative excisional approach, when this was thought to be appropriate. In our discussion, we acknowledge the short follow up period (median of 26 months) and low patient number (n 1⁄4 43). However, the evidence to adopt ELAPE stems from Holm’s original description, which has a follow up of 28 patients for 16 months. Moreover, this paper showed a local recurrence rate of 7% with a mortality rate of 28.6%. We also describe the other important papers published subsequent to Holm’s and emphasise the lack of a prolonged follow up period in any of the papers in this