Karen Flashman

The Department of Health’s “two week standard” for bowel cancer: is it working?

Objective: To determine the effectiveness and efficiency of the Department of Health’s new general practitioner referral guidelines for bowel cancer. Design: One year prospective audit. Setting: District general hospital serving a population of 550 000. Subjects: All patients with bowel cancer; all patients referred on the basis of the two week standard and to a routine colorectal surgical outpatient clinic. Main outcome measures: Proportion of cancers referred on the basis of the two week standard and to other colorectal clinics; the proportion with the higher risk criteria and their diagnostic yields; stage of cancers diagnosed in outpatient clinics; and time to treatment. Results: A total of 249 cancers were diagnosed in the index year. Sixty five (26.1%) were referred to two week standard clinics, 40 (16.1%) to routine colorectal surgical outpatient clinics, 54 (22%) to other clinics, and 88 (35.3%) were emergencies. Thirteen patients per week were referred to the two week standard clinics and 85% (54/65) of cancers so referred were seen within two weeks. The diagnostic yield of cancer in the two week standard clinic was 9.4% (65/695) compared with 2.2% (40/1815) in the routine colorectal surgical outpatient clinic (p<0.0001). Eighty five per cent of patients with cancer referred to outpatients matched the guidelines for the two week standard clinics. Only 46% of this group were so referred. Overall, delay to treatment and Dukes’ stage were not improved in patients diagnosed in the two week standard clinics. Conclusions: Most patients with bowel cancer were not referred on the basis of the two week standard although most fulfilled the referral criteria, which had higher diagnostic yields. The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient’s journey.

Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.

Background and Objectives:The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. Methods:Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as ≥80 years, American Society of Anesthesiologists ≥3, preoperative radiotherapy, T4 tumor and BMI ≥30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. Results:A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2–33) versus 10 (1–69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02). Among the 280 (66%) “high risk” patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2–33) days in the laparoscopic group versus 11 (1–69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). Conclusion:Laparoscopic resection of colorectal cancer can achieve excellent results even in “high risk” patients and is associated with significant reductions in length of stay compared with open resection.

Major postoperative complications following elective resection for colorectal cancer decrease long-term survival but not the time to recurrence.

The aim of the study was to determine the effect of major complications after colorectal cancer surgery on survival and time to recurrence.

Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy

Aim  Preoperative short‐course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach.

Is earlier referral and investigation of bowel cancer patients presenting with rectal bleeding associated with better survival

Aim  This study was carried out to determine whether rectal bleeding is related to stage of bowel cancer and whether earlier diagnosis and treatment are associated with improved survival.

The selective use of splenic flexure mobilization is safe in both laparoscopic and open anterior resections.

Aim  Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised.

Impact of the English National Training Programme for laparoscopic colorectal surgery on training opportunities for senior colorectal trainees

BackgroundThere is growing concern that the recently introduced National Training Programme for consultants in laparoscopic colorectal surgery will have a negative impact on the training of senior colorectal trainees by minimizing the opportunities available. This study aimed to determine the impact that local implementation of the National Training Programme has had on the operating experience of senior colorectal trainees.MethodsA prospective study was conducted at a designated national training center for laparoscopic colorectal surgery based in a large district general hospital in England, United Kingdom. All patients undergoing laparoscopic colorectal surgery in our unit between October 2006–September 2008 and October 2008–September 2010 were included in the study. The study variables included number and type of procedure, patient demographics, American Society of Anesthesiology grade, body mass index, conversion rates, previous abdominal surgery, and median operating time. The main outcome measure was the number of procedures performed by senior colorectal trainees before and after commencement of National Training Programme training in October 2008.ResultsA total of 746 laparoscopic colorectal resections were performed. Senior colorectal trainees performed 175 cases before commencement of the National Training Programme and 184 cases afterward. The difference was not significant. National Training Programme consultants performed 126 cases. Data were analyzed using Fisher’s exact test and the Mann–Whitney U test. The study groups were found to be well matched. The median operating time was significantly longer after commencement of the National Training Programme. The study was limited in terms of ability to extrapolate results to smaller units wishing to participate in training programs.ConclusionImplementation of the National Training Programme in our hospital has not had a negative impact on the training opportunities for senior colorectal trainees. However, any unit wishing to participate in the National Training Programme must ensure that an adequate operative caseload and extra resources for operative lists are available for training.

Cirugía laparoscópica en el tratamiento de la enfermedad de Crohn del área ileocecal: impacto de la obesidad en los resultados postoperatorios inmediatos

INTRODUCTION The aim of our study was to analyse the short-term outcomes of laparoscopic surgery for a no medical responding ileocolic Cohns disease in a single centre according to the presence of obesity. METHODS A cross-sectional study was performed including all consecutive patients who underwent laparoscopic resection for ileocecal Crohns disease from November 2006 to November 2015. Patients were divided according to body mass index ≥ 30 kg/m2 in order to study influence of obesity in the short-term outcomes. The following variables were studied: characteristics of patients, surgical technique and postoperative results (complications, reintervention, readmission and mortality) during first 30 postoperative days. RESULTS A total of 100 patients were included (42 males) with a mean age of 39.7±15.2 years (range 18-83). The overall complication rate was 20% and only 3 patients had an anastomotic leak. Seven patients needed reoperation in the first 30 days postop (7%). The median postoperative length of hospitalization was 5.0 days. Operative time was significantly longer in patients with obesity (130 vs. 165minutes, P=.007) but there were no significant differences among the postoperative results in patients with and without obesity. CONCLUSIONS This study confirmed that laparoscopic approach for ileocecal Cohns disease is a safety and feasible technique in patients with obesity. In this last group of patients we only have to expect a longer operative time.

Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI)

The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics.

PTH-295 Diagnosis of bowel cancer; most patients don’t require whole colonic imaging (WCI); are nice guidelines misleading?

Introduction NICE guidelines imply that most patients require WCI for bowel cancer diagnosis. This and fear of missing cancer in outpatients is the major reason for over investigation of patients with bowel symptoms. Greater understanding of the way proximal bowel cancer presents is required. Method Retrospective cohort analysis using clinical data collected prospectively for 22 years (1986 to 2007) in a colorectal outpatient clinic in Portsmouth. 29005 patients were analysed to determine symptom combinations, signs and IDA according to site of the colon. Missed cancers were identified from referral back to clinic, local audit and comparison with the regional Cancer Registry. Results 1626 patients had cancer of which 1585 presented with one of three bowel symptoms (change in bowel habit, rectal bleeding or abdominal pain). Only 16% (258/1585) were cancers proximal to the sigmoid colon, of which 44% (113/258) presented with symptoms alone (no IDA, no mass), 223 (113/25191) patients would need WCI to diagnose one proximal cancer in this group. Diagnostic yield of proximal cancer in patients <60 years without a mass or IDA was 0.09% (11/11828).Abstract PTH-295 Table 1 Symptoms/signs Distal Ca*1 (Nos/%) Proximal Ca*2(Nos/%) Proximal Ca without a mass or IDA(Nos/%) NNI to diagnose a proximal ca without a mass or IDA all cancers 1326 (84%) 258 (16%) 113 (7%) 1:223 +C+B 783 (59%) 46 (18%) 22 (19%) 1:331 +C-B-A 119 ((9%) 27 (11%) 12 (11%) 1:217 +C-B+A 133 (10%) 96 (33%) 40 (35%) 1:92 +B-C-P 166 (13%) 30 (12%) 20(18%) 1:145 +B-C+P 108 (8%) 15 (6%) 6 (5%) 1:1193 +A-B-C 17 (1.3%) 44 (17%) 13 (12%) 1:119*1 Rectal and sigmoid ca;*2 Ca proximal to sigmoid; +C change in bowel habit; +B rectal bleeding; +A abdominal pain, +P perianal symptoms; +C+B, +B-C-P, +B-C+P with and without abdominal pain; NNI Number needed to investigate to diagnose one cancer Conclusion Patients without mandatory reasons for immediate WCI after a normal flexible sigmoidoscopy (particularly those aged <60 years) should be offered a treat watch and wait diagnostic strategy rather than immediate WCI. NICE guidelines may be encouraging over investigation of patients by WCI. Disclosure of interest None Declared.