The use of colonic stents as a bridge to surgery in malignant colonic obstruction - A dual trust experience over 10 years.

Introduction: Worldwide colonic cancer is the third most common cancer with up to 30% of cases presenting with large bowel obstruction. Self-expanding metal stents (SEMS) have been used as a bridge to surgery (BTS) in the treatment of this malignant obstruction. We review the outcomes of SEMS as a BTS across two high volume colorectal units. Methodology: A retrospective analysis of patients undergoing colonic stenting as a bridge to surgery was performed; outcomes were compared to previously published figures on emergency colonic resections. Inclusion criteria were adults (>18 years of age) undergoing colonic stenting for colonic obstruction with a view to elective resection. Patients undergoing stenting for palliation of symptoms were excluded. Results: 39 patients were identified across both trusts over a ten-year period. 90 day mortality following BTS was found to be 3.6% and there was an 82.1% (32/39) technical success rate. 46.4% proceeded to an elective resection which was started laparoscopically. Permanent stoma rate was observed at 14.3% for elective surgery. Conclusion: Stenting for relief of acute malignant obstruction as a bridge to surgery is a viable option in select patients. Further research is required to determine oncological safety and rate of local recurrences.

Adapting an emergency general surgery service in response to the COVID-19 pandemic.

INTRODUCTION: In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes. METHODS: Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge. RESULTS: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality. CONCLUSIONS: Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.

Sucralfate paste enema: a new method of topical treatment for haemorrhagic radiation proctitis.

AIM: Rectal sucralfate has been reported to deliver clinical improvement in haemorrhagic radiation proctitis, but patients with active proctitis find the enema suspension difficult to retain thus reducing compliance and effectiveness. We describe a novel method of rectal administration via a low-volume sucralfate paste and report its results in a series of 23 patients. METHOD: Patients with rectal bleeding occurring more than 6 months after radiotherapy were shown how to prepare and self-administer sucralfate paste enemas (SPEs) twice daily for 6 weeks. The SPE was prepared using two sucralfate 1-g tablets mixed with 4.5 ml of water in an enema applicator producing a low-volume paste. The clinical response was evaluated by comparison of pre- and posttreatment clinical proctitis scores (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer). RESULTS: Eighteen male (postprostatic radiotherapy) and five female (postcervical radiotherapy) patients with a median age of 67 (32-75) years were included. The median interval between pelvic irradiation and SPE treatment was 24 (7-69) months. Twenty-two patients had full clinical scoring, of whom 16 (73%) demonstrated clinical improvement. Six (27%) had neither clinical improvement nor deterioration. Seven (32%) had resolution of all symptoms. CONCLUSION: Most patients demonstrated clinical improvement. This initial experience of the sucralfate paste enema may provide the basis for a prospective study of its effectiveness in the treatment of haemorrhagic radiation proctitis.