V.G. Matarese

Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy

AIM To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge. METHODS About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study. RESULTS Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms. CONCLUSION The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes.

OBJECTIVE The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC). METHOD FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant). RESULTS In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87). CONCLUSION Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study.

BackgroundA direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients’ and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer.ResultsAll patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis.ConclusionThis study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.

Colonoscopy surveillance in asymptomatic subjects with increased risk for colorectal cancer: clinical evaluation and cost analysis of an Italian experience.

The aim of this study was three-fold: (a) to present a surveillance plan for colorectal cancer prevention with colonoscopy, focused on first-degree relatives of colorectal cancer patients in the province of Ferrara (Italy); (b) to analyse the cost of colonoscopy at the University Hospital of Ferrara; and (c) to analyse the cost of the surveillance plan in our province. In January 2000, in the province of Ferrara, following a campaign of public sensitization, a plan of surveillance with colonoscopy was started, addressing the population at an increased risk for colorectal cancer (i.e. over 45-year-old first-degree relatives of patients with either colorectal cancer or adenomatous polyps revealed before 60 years of age). In addition, we estimated the cost of colonoscopy both at the University Hospital of Ferrara and of the surveillance plan. Between January 2000 and October 2003, 585 individuals at increased risk were interviewed. Five hundred and forty-four (94%) accepted to undergo a colonoscopy. By October 2003, 439 (81%) colonoscopies had been performed. Colonoscopy was normal in 330 individuals (75%). In 109 individuals (25%), 144 lesions were found: 35 patients (32%) had hyperplastic polyps, 66 (61%) had adenomas, and eight (7%) adenocarcinomas (six Dukes A, one Dukes B, and one Dukes C stage). Out of a total of 101 adenomas, 68 were tubular adenomas (67%), 24 tubulo-villous adenomas (24%), and nine adenomas with high-grade dysplasia (9%). The cost of colonoscopy at our hospital and the costs of the surveillance plan amounted to &U20AC;130.84 (&U20AC;169.57 with single biopsy) and &U20AC;43,103.66 (&U20AC;42 310.34/year), respectively. These data show (a) the efficacy of colonoscopy in the early diagnosis of colorectal cancer and premalignant lesions in first-degree relatives of colorectal cancer patients; (b) the low cost of colonoscopy at the centre performing the surveillance; and (c) the feasibility of screening and surveillance programmes for colorectal cancer prevention.

The first 2 years of colorectal cancer screening in Ferrara, Italy

We report on the first screening round in the District of Ferrara, a region of Emilia-Romagna, carried out between March 2005 and March 2007 to illustrate the effort of colorectal cancer (CRC) screening from administration and information to therapy and follow-up. After invitation of 38 344 persons aged 50–69 years (28.5%), 19 480 (50.8%) accepted the immunological faecal occult blood test, with 1 149 (6%) resulting positive. One thousand and one individuals (88.2%) who tested positive for immunological faecal occult blood test accepted examination by either colonoscopy (99.5%) or barium enema (0.5%). Out of 996 screenees having a colonoscopy, 231 had low-risk adenomas (23.2%) and 239 had high-risk adenomas (24%), and were treated endoscopically (96%) or surgically (4%). Ninety-one cancers were diagnosed in 9.1% of colonoscopies (Dukes stadia: A, 58.2%; B, 19.8%; C, 18.7%; D, 3.3%). Fourteen cancers (all in polyps) were treated endoscopically, and the remaining 77 were treated by surgery. One Dukes B patient and 13 of 17 Dukes C patients received adjuvant chemotherapy. Three Dukes D patients had chemotherapy only. During the 2-year study period, 87 screenees had a follow-up colonoscopy: no neoplasia was found in 35 patients initially diagnosed with cancer; low-risk adenomas were found in 31 of 52 patients with initial high-risk adenomas. In conclusion, the first CRC screening round in Ferrara was easy to organize, had a high acceptance, and detected 91 cancers (78% of which were in Dukes stages A and B, compared with only 40% in sporadic CRC in the same background population). Chemotherapy was necessary in 17 cases. This report may motivate other health authorities to initiate CRC screening campaigns.

Colonoscopic surveillance of first-degree relatives of colorectal cancer patients in a faecal occult blood screening programme

BACKGROUND In some Italian areas, colonoscopic surveillance of first-degree relatives (FDRs) of colorectal cancer (CRC) patients is provided as a part of local population-based faecal occult blood test (FOBT) screening programmes. The objective of the present study was to assess the feasibility and early results of this surveillance model. METHODS Data from district screening centres were used to evaluate the process of identification and selection of eligible FDRs (residence in the Emilia-Romagna Region, age 40-75 years, no recent colonoscopy) of screen-detected CRC patients and the detected prevalence of disease. The probability for an FDR to undergo colonoscopy and to be diagnosed with CRC and advanced adenoma was estimated using the Kaplan-Meier method. The sex- and age-standardised ratio of detected prevalence to that expected based on results from a colonoscopy screening study of the Italian general population was estimated. RESULTS Between 2005 and 2011, 9319 FDRs of 2437 screen-detected CRC patients (3.8 per patient) were identified and contacted. Their likelihood of being eligible for, and accepting, colonoscopy was 0.11 (95% confidence interval: 0.11-0.12). Among the 926 subjects undergoing colonoscopy, the prevalence of previous negative screening FOBT was 63%. Eleven CRCs (1.2%) and 100 advanced adenomas (10.8%) were detected. The standardised ratio of detected prevalence to that expected was 0.91 (95% confidence interval: 0.19-2.66) for CRC and 1.48 (1.04-2.05) for advanced adenoma. CONCLUSIONS The procedure of selection of FDRs was extremely ineffective. Due to previous negative screening tests, the prevalence of disease was less than expected. A population-based FOBT screening programme is a highly unsuitable setting for the provision of surveillance to FDRs of CRC patients.

P.1.96: COST-EFFECTIVENESS ANALYSIS OF COLORECTAL SCREENING PROGRAMME IN ITALY

Background and aim: Colorectal cancer (CRC) represents the second leading cause of cancer mortality in Europe. Evidence from several scientific studies suggests that screening for the early detection and removal of cancerous lesions can reduce its incidence and mortality and improve patients’ quality of life. The main literature on this topic refers to the American context, which is extremely different from the Italian one. The aim is to propose the results of a cost-effectiveness analysis of a screening program in Italy using as case-study the experience of a CRC screening program started in 2005 in the Province of Ferrara, to determine the full cost of the screening program and to compare the costs-effectiveness of FOBT and colonoscopy. Material and methods: A micro-costing analysis is used to identify and evaluate all the costs involved in each phase of the screening program, following an activity-based costing approach to consider all the activities carried out in the assistance process. The effectiveness of the diagnostic instrument used, FOBT combined with colonoscopy, is valued in terms of early detected lesions and years of life gained. Finally, we use the cost and effectiveness data collected to estimate the costs for year of life gained using a MISCAN-COLON Model. Results: The preliminary results show that, after the screening implementation, a huge number of new cases of hyperplasic polyps, dysplastic adenomas and carcinomas are detected. Moreover, early diagnosis allows the diagnosis of colorectal cancer at the earliest Dukes’ stages. The results of the Model show that the screening program will reduce mortality of 11% and prevent almost 1,100 deaths, with 12,741 years of life gained in a period of time of 30 years. Comparing the costs born in the first wave of the screening with the number of years potentially saved, the model shows that the incremental cost-effectiveness ratio of the program is almost €5,315 for life year. Conclusions: This study shows the economic benefits of the screening program estimated in similar studies conducted in other countries (Sonnenberg, 2000). Besides, the paper highlights the importance of implementing a screening program not only for the effects that prevention can have in clinical terms, but also for the economic impact of such a policy in terms of long-term sustainability of healthcare systems.