Raymond Oliphant

Contribution of surgical specialization to improved colorectal cancer survival

Reorganization of colorectal cancer services has led to surgery being increasingly, but not exclusively, delivered by specialist surgeons. Outcomes from colorectal cancer surgery have improved, but the exact determinants remain unclear. This study explored the determinants of outcome after colorectal cancer surgery over time.

The impact of socio-economic circumstances on overall and grade-specific prostate cancer incidence: a population-based study.

Background:If the observed increasing incidence of prostate cancer and higher incidence in more affluent men are due to differences in diagnostic sensitivity, an excess of asymptomatic low-grade tumours might be expected.Methods:We conducted a descriptive population-based study of incident cases of prostate cancer (International Classification of Diseases version 10 codes for prostate cancer) in the West of Scotland, using the Scottish Cancer Registry data from 1991 to 2007. Socio-economic circumstances were measured using the Carstairs score, and disease grade measured using the Gleason score. Deprivation-specific European age-standardised incidence rates were calculated, and joinpoint regression analysis were used to identify significant changes in trends over time.Results:A total of 15 519 incident cases of prostate cancer were diagnosed. Incidence increased by 70% from 44 to 75 per 100 000 cases between 1991 and 2007, an average annual growth of 3.6%. Men aged <65 years experienced the largest increase in incidence. A widening socio-economic deprivation gap in incidence appeared from 1998 onwards in low-grade disease only. From 2003 to 2007, the deprivation gap (affluent to deprived) was 40.3 per 100 000 cases (P<0.001; trend), with rates 37% lower among the most deprived compared with the most affluent. This deprivation gap represents an estimated 1764 cases of prostate cancer over a 5-year period.Conclusion:Prostate cancer incidence continues to increase; an increase in low-grade disease in affluent men may suggest that prostate-specific antigen testing is responsible, but it does not explain the overall increases in all grades of disease.

The changing association between socioeconomic circumstances and the incidence of colorectal cancer: a population-based study

Background:There is emerging evidence to suggest that the association between socioeconomic circumstances and colorectal cancer incidence has changed over recent decades.Methods:We conducted a descriptive population-based study to describe the relationship between socioeconomic circumstances and the incidence of colorectal cancer in a pre-screened population. Incident cases of colorectal cancer from the West of Scotland were identified from the Scottish Cancer Registry and European age-standardised incidence rates (EASR) were calculated. Socioeconomic circumstances were measured using the area-based Scottish Index of Multiple Deprivation (SIMD).Results:In total, 14 051 incident cases of colorectal cancer were recorded from 1999 to 2007. Incidence of colorectal cancer was associated with increased deprivation in men but not among women; an association that became evident from 2005 onwards. From 2005 to 2007, the deprivation gap in incidence among men was 13.3 per 100 000 (95% confidence interval 3.2–23.4), with rates 19.5% lower among the least deprived compared with the most deprived. This deprivation gap now accounts for an estimated 75 excess cases per year of male colorectal cancer in the West of Scotland.Conclusion:Deprivation was associated with higher incidence rates of male, but not female, colorectal cancer before the implementation of a national bowel screening programme.

Validation of a modified clinical risk score to predict cancer‐specific survival for stage II colon cancer

Many patients with stage II colon cancer will die of their disease despite curative surgery. Therefore, identification of patients at high risk of poor outcome after surgery for stage II colon cancer is desirable. This study aims to validate a clinical risk score to predict cancer‐specific survival in patients undergoing surgery for stage II colon cancer. Patients undergoing surgery for stage II colon cancer in 16 hospitals in the West of Scotland between 2001 and 2004 were identified from a prospectively maintained regional clinical audit database. Overall and cancer‐specific survival rates up to 5 years were calculated. A total of 871 patients were included. At 5 years, cancer‐specific survival was 81.9% and overall survival was 65.6%. On multivariate analysis, age ≥75 years (hazard ratio (HR) 2.11, 95% confidence intervals (CI) 1.57–2.85; P<0.001) and emergency presentation (HR 1.97, 95% CI 1.43–2.70; P<0.001) were independently associated with cancer‐specific survival. Age and mode of presentation HRs were added to form a clinical risk score of 0–2. The cancer‐specific survival at 5 years for patients with a cumulative score 0 was 88.7%, 1 was 78.2% and 2 was 65.9%. These results validate a modified simple clinical risk score for patients undergoing surgery for stage II colon cancer. The combination of these two universally documented clinical factors provides a solid foundation for the examination of the impact of additional clinicopathological and treatment factors on overall and cancer‐specific survival.

Neurovasculature of high and low tie ligation of the inferior mesenteric artery

PurposeControversy exists as to whether a high or low tie ligation of the inferior mesenteric artery (IMA) is the preferred technique in surgeries of the left colon and rectum. This study aims to contribute to the discussion as to which is the more beneficial technique by investigating the neurovasculature at each site.MethodsTen embalmed cadaveric donors underwent division of the inferior mesenteric artery at the level of the low tie. The artery was subsequently ligated at the root to render a section of tissue for histological analysis of the proximal (high tie), mid and distal (low tie) segments.ResultsGanglia observed in the proximal end of seven specimens in the sample imply that there would be disruption to the innervation in a high tie procedure.ConclusionThis study suggests that a high tie should be avoided if the low tie is oncologically viable.

Surgical Ward Round Quality and Impact on Variable Patient Outcomes.

To the Editor: We read with interest the recent article by Pucher et al that describes the relationship between surgical ward round (WR) quality in the high-dependency unit setting and clinical outcomes. This pragmatic observational study examined a vital aspect of inpatient care that had previously not been studied in detail. The association of poorquality WRs with delayed diagnoses and increased preventable complications is unsurprising. Simple, cheap, and easy-to-implement interventions such as WR checklists or proforma to improve the quality of patient review could lead to significant reductions in preventable morbidity. As such, the authors should be applauded for their efforts with this study. We would like, however, to point out a few significant limitations of this study. First, the subjects involved in this study were not blinded to the presence of the nonparticipating observer and as such an element of observer effect (the Hawthorne effect) is likely to have been introduced. This source of bias could have led to participants modifying their behavior in direct response to being observed, leading to nonrepresentative WR quality being analyzed in this study. Presentation of the prestudy period patient complication rate would have been helpful to examine the influence that this source of bias had on the results presented. In addition, the authors did not make suitable comparison or adjustment for the type of surgery that patients received to help support their finding that preventable complications were higher in the poorer quality WR group. For example, a higher rate of pulmonary complications in the poorer quality WR groups could be explained if these patients underwent more thoracoabdominal procedures than those in the good-quality WR group. A more detailed comparison of patient characteristics between the highand low-quality WR groups would have been desirable. Also, the use of a retrospective case note review to obtain data on patient complications is confounded by the likelihood that those performing a less thorough WR may also be less likely to record and document postoperative complications dili-

EVALUATION OF SHORT AND LONGER-TERM SURVIVAL FOLLOWING NON-RESECTIONAL PALLIATIVE SURGERY FOR ADVANCED COLORECTAL CANCER

Introduction Palliative surgery for advanced colorectal cancer is associated with high morbidity and mortality. Non-resectional palliative surgery can be useful in the management of malignant bowel obstruction or perforation where a conservative approach can be associated with high symptom burden and imminent death. The aim of this study was to evaluate short and longer-term outcomes after non-resectional palliative surgery for advanced colorectal cancer. Methods Patients undergoing non-resectional surgery for colorectal cancer in 16 hospitals from 2001–2004 were identified from a prospectively maintained regional audit database. Post-operative mortality (<30-days) and relative survival were used to examine short and longer-term outcomes. Results A total of 225 patients were included, of which 141 (62.7%) were male. The median age at surgery was 69.3 years (s.d. 11.2; range 30.8–95.9 years). A total of 107 (47.6%) patients had rectal cancer and 160 (71.1%) had evidence of distant metastases. Ninety (40.0%) patients presented for surgery as an emergency and 135 (60.0%) presented electively. One hundred and fifty nine (70.7%) patients underwent the creation of a defunctioning proximal stoma and 63 (28.0%) had a bypass procedure. The overall post-operative mortality rate was 20.9%. Post-operative mortality was higher among emergency compared to elective presentation (36.7% versus 10.4%; p<0.001). Overall 1-year relative survival was 27.1%. One-year relative survival was higher among elective compared to emergency presentation (37.1% versus 11.9%; p<0.001). Conclusions Short and longer-term outcomes after non-resectional palliative surgery for advanced colorectal cancer are worse after emergency compared to elective presentation. Therefore, members of the palliative care team must be alert to symptoms of impending complications of advanced colorectal cancer to enable timely referral for surgical intervention on an elective rather than emergency basis.

Analysis of deaths occurring within the Nottingham trial of faecal occult blood screening for colorectal cancer

We read with interest the analysis of deaths occurring within the Nottingham trial of faecal occult blood screening for colorectal cancer performed by Whynes and colleagues,1 reported in a recent issue of Gut . While the aims of this study are to be commended, we have some concerns regarding the interpretation of ages at death and the methodology used to assign deprivation score. With respect to age at death, ‘those who participated in screening died at a more advanced age than the controls who, …