Have changes in colorectal surgery training impacted on mortality in cancer patients? A retrospective cohort study of 51,562 procedures.

INTRODUCTION: The aim of this study was to explore whether there were any differences in consultant colorectal surgeon training and adjusted 90-day postoperative colorectal cancer mortality rates (AMR). METHODS: We undertook a retrospective analysis of outcomes data published on the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. A total of 51,562 procedures for patients in England diagnosed with large bowel cancer between 2010 and 2015, registered under 551 consultants were included. Consultants were split into two cohorts. The first group were the pre-Calman Trained Consultants (pre-CTr), who completed their training before 1998. The second group-the post-Calman Trained Consultants (post-CTr)-included those who received their Certificate of Completion of Training (CCT) under the Calman Training Principles (CTC, 1998-2007) and the Modernising Medical Careers Curriculum (MMC, 2008 and onwards). The outcome measure was an AMR. RESULTS: The pre-CTr cohort (n=84) consisted of 3.6% female colorectal consultants (n=3/84), whereas the post-CTr cohort (n=467) consisted of 14.3% female colorectal consultants (n=67/467) (p=0.006). In this cross-sectional analysis over 5 years, the average pre-CTr undertook a greater number of colorectal resections than their post-CTr peers: median procedures (interquartile range, IQR): 104 (59) vs 89 (57) respectively, p=0.008. The median AMR was significantly greater among pre-CTrs compared with post-CTrs, median AMR (IQR): 2.7% (2.0) vs 2.1% (2.9), p=0.022. CONCLUSIONS: These data indicate that the implementation of the MMC and Calman training principles for colorectal training is associated with a statistically lower AMR compared with other historical training periods. This merits further exploration.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Should laparoscopic reversal of Hartmann's procedure be the first line approach in all patients?

BACKGROUND/AIMS: To assess if the laparoscopic reversal of Hartmann's can be attempted in all patients, without detriment to short or long-term outcomes if the patient is subsequently converted to open. METHODS: Retrospective review of a prospectively collected database of all reversals under 8 surgeons at a single unit over 105 months, two surgeons attempting laparoscopic reversal in all patients, two pre-selecting for the laparoscopic approach and four utilising the open approach. Long-term follow-up data for re-admissions, re-operations and incisional hernia rate obtained from a postal questionnaire. RESULTS: 45 laparoscopic and 50 primary open reversals were identified. There was no difference in the mean age or previous peritonitis rate in either group. Laparoscopic conversion rate was 29% (13 patients). On intention to treat analysis, a significant difference was identified in the overall 30-day post-operative surgical morbidity (8.9% Laparoscopic-attempted vs 26.0% Open, p = 0.030). There was no difference in operating times (mean 164 vs 172 min, p = 0.896) despite the 13 patients converted to an open procedure. Mean length of stay was significantly lower in the laparoscopic-attempted group at 6.8 days (5.2-8.4) vs 14.9 days (6.4-23.7) in the open group (p = 0.001). Anastomotic leak rates were not statistically different. The median follow up was 27 months (range 6-105); 60% of patients completed a postal follow-up questionnaire. There was no difference in short-term or long-term re-admission or reoperation rates. CONCLUSIONS: Laparoscopic reversal of Hartamann's is associated with shorter hospital stay and lower morbidity even in unselected patients. Long-term outcomes are similar.

Financial impact of surgical training on hospital economics: an income analysis of 1184 out-patient clinic consultations.

INTRODUCTION: In many countries healthcare commissioning bodies (state or insurance-based) reimburse hospitals for their activity. The costs associated with post-graduate clinical training as part of this are poorly understood. This study quantified the financial revenue generated by surgical trainees in the out-patient clinic setting. METHODS: A retrospective analysis of surgical out-patient ambulatory care appointments under 6 full-time equivalent Consultants (Attendings) in one hospital over 2 months. Clinic attendance lists were generated from the Patient Access System. Appointments were categorised as: 'new', 'review' or 'procedure' as per the Department of Health Payment by Results (PbR) Outpatient Tariff (Outpatient Treatment Function Code 104; Outpatient Procedure Code OPRSI1). RESULTS: During the study period 78 clinics offered 1184 appointments; 133 of these were not attended (11.2%). Of those attended 1029 had sufficient detail for analysis (98%). 261 (25.4%) patients were seen by a trainee. Applying PbR reimbursement criteria to these gave a projected annual income of £GBP 218,712 (€EU 266,527; $USD 353,657) generated by 6 surgical trainees (Residents). This is equivalent to approximately £GBP 36,452 (€EU 44,415; $USD 58,943) per trainee annually compared to £GBP 48,732 (€EU 59,378; $USD 78,800) per Consultant. This projected yearly income off-set 95% of the trainee's basic salary. CONCLUSION: Surgical trainees generated a quarter of the out-patient clinic activity related income in this study, with each trainee producing three-quarters of that generated by a Consultant. This offers considerable commercial value to hospitals. Although this must offset productivity differences and overall running costs, training bodies should ensure hospitals offer an appropriate return. In a competitive market hospitals could be invited to compete for trainees, with preference given to those providing excellence in training.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery.

AIM: Intra-operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel. METHOD: Data were collected from a prospectively-kept database over a 12-month period from April 2008 to March 2009 and analysed retrospectively. Details concerning the documentation, visibility and accuracy of tattoos were recorded. RESULTS: Eighty-five patients (88 lesions) underwent laparoscopic resection for a benign or malignant colorectal tumour during 1 year from April 2008. Eighty-one patients underwent endoscopic visualization of the tumour as a first or second procedure. Of these 81 patients, 83 lesions were visualized endoscopically and 54 (65.1%) were tattooed in 52 patients. In the 52 patients, 36 (69%) of the tattoos were carried out on the first endoscopy. At operation the tattoo was judged to be visible and accurate in 70%, visible but inaccurate in 7% and not visible in 15%. It was significantly easier to see the tattoo in women (19/21 women vs 21/29 men; P=0.03) but there was no relationship between tattoo visibility and BMI. An accurate tattoo did not reduce the conversion rate (P=0.71). No tattoo-related complications were encountered. CONCLUSION: The practice of tattooing colorectal cancers is variable in frequency, technique and accuracy. We advocate that all colonic lesions suspicious for cancer should be tattooed during endoscopy at a defined distance below the tumour, adhering to a departmental protocol in case surgery is required.

From small acorns--developing a laparoscopic colorectal surgical service.

INTRODUCTION: Randomised controlled trials have shown that laparoscopic colorectal surgery is equal in terms of safety to open surgery. Benefits have been seen for length of stay, blood loss, immune suppression and analgesia requirements. The aim of this study was to assess the safety and feasibility of introducing laparoscopic colorectal surgery to our unit. PATIENTS AND METHODS: Prospectively collected cases of all patients undergoing laparoscopic colorectal surgery between July 2003 and July 2007 were reviewed. RESULTS: A total of 143 patients (75 males and 68 females) with a mean age of 65.8 years (range, 21-95 years) underwent surgery. Laparoscopic resection for colorectal malignancy was performed in 93 patients (65%). The conversion rate for all cases was 14.7%. Mean operative time was 203 min (range, 100-400 min), with a mean blood loss of 180 ml. The mean number of lymph nodes in malignant cases was 13.8 with clear resection margin in all but one case. The mean postoperative stay was 5.6 days (median, 4 days; range, 2-35 days). UKCCR standard for lymph node retrieval was achieved in 62.6% of cases. There were four postoperative deaths. The overall 30-day morbidity rate was 21.7%. The service is consultant-led with 9.8% of cases performed by senior trainees and 37% of procedures performed by two consultants. CONCLUSIONS: Laparoscopic colorectal surgery is technically feasible and safe in our hands. Although operative time is longer, this is counterbalanced by shorter hospital stay. The results from this series support the findings of others and continuing development of this service.

Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors.

In recent decades wide-ranging changes have occurred in medical school curricula. Time spent studying gross anatomy has declined amidst controversy as to how, what, and when teaching is best delivered. This reduced emphasis has led to concerns amongst clinicians that a new generation of doctors are leaving medical school with insufficient anatomical knowledge. Previous studies have established that medical students value their anatomy teaching during medical school. None have sought to establish views on the sufficiency of this teaching. We investigate the opinions of newly qualified doctors at a UK medical school and relate these opinions to career intentions and academic performance in the setting of a traditional dissection and prosection-based course. Overall nearly half of respondents believe they received insufficient anatomy teaching. A substantial proportion called for the integration of anatomy teaching throughout the medical school course. Trainees intent on pursuing a surgical career were more likely to believe anatomy teaching was insufficient than those pursuing a nonsurgical career; however, overall there was no statistical difference in relation to the mean for any individual career group. This study adds to the current debates in anatomical sciences education, indicating that overall, regardless of career intentions, new doctors perceive the need for greater emphasis on anatomical teaching.

A prospective audit of early pain and patient satisfaction following out-patient band ligation of haemorrhoids.

INTRODUCTION: Information regarding early morbidity, pain and patient satisfaction following band ligation of haemorrhoids is limited. This is the first report to address these issues specifically. PATIENTS AND METHODS: A total of 183 patients underwent the procedure over a 10-month period. Prospective data were collected using a detailed structured questionnaire regarding symptoms, analgesia requirements and patient satisfaction in the following week. RESULTS: The response rate was 74% (135/183). Pain scores were highest 4 h following the procedure. At 1 week, 75% of patients were pain-free, with 9 (7%) still experiencing moderate-to-severe pain. About 65% required oral analgesia, most frequently on the day of procedure. Rectal bleeding occurred in 86 patients (65%) on the day after banding, persisting in 32 (24%) at 1 week. Vaso-vagal symptoms occurred in 41 patients (30%) and were commonest at the time of banding. Eighty patients (59%) were satisfied with their experience and would undergo the procedure again. Patients requiring oral analgesia and those experiencing bleeding or vaso-vagal symptoms were significantly less likely to be satisfied with the procedure. Only 57% of the patients surveyed would recommend the procedure to a friend. CONCLUSIONS: Data from this large cohort of patients suggest that discomfort and bleeding may persist for a week or more following banding of haemorrhoids. Patients should be aware of this in order to make an informed decision as to whether to undergo the procedure, and surgeons should investigate ways of reducing it. Patient satisfaction may be further improved by more accurate counselling regarding the incidence of specific complications.

Current concepts in immunotherapy for the treatment of colorectal cancer.

Immunotherapy could have a role in the therapy of colorectal cancer as there is now convincing evidence that the immune system can specifically recognize and destroy malignant cells. The MAb 17-1A has been used in advanced and primary disease, along with newer agents such as anti-epidermal growth factor receptor (EGFR) antibody. Immunotherapy with autologous tumour cell vaccine, genetic modification of immunostimulatory cytokines, suicide genes and TAAs as discussed. The multiplicity of peptide and carbohydrate antigens which can be potential targets for immunotherapy are also discussed. These include MUC1, Thomsen-Friedenreich and Sialosyl-Tn antigens and HER2 / neu. Active specific immunotherapy with the anti-idiotypic antibodies CEAVac and 105AD7, along with DC vaccines, is being currently used in adjuvant clinical trials. 105AD7 has been shown to cause significantly greater apoptosis of tumour cells in colorectal cancer patients, while CEAVac generated T cell proliferative anti-CEA responses. Dendritic cells pulsed with tumour mRNA or TAAs currently are being assessed in clinical trials. The role of HSPs in the anti-tumour immune response is discussed. Non-specific immunotherapeutic agents used in clinical trials with chemotherapeutic regimens have not shown any definitive benefit. Tumour progression may occur as result of escape from the host anti-cancer immune response. Better understanding of mechanisms of tumour evasion could explain why immunotherapy trials in patients have not shown better results. These include down-regulation of immune responses by the tumour, altered expression of MHC and/or TAAs by tumour cells, altered expression of adhesion molecules by tumour and/or DCs and usurpation of the immune response to the advantage of the cancer.

Randomized double-blind phase II survival study comparing immunization with the anti-idiotypic monoclonal antibody 105AD7 against placebo in advanced colorectal cancer.

The cancer vaccine 105AD7 is an anti-idiotypic monoclonal antibody that mimics the tumour-associated antigen 791T/gp72 (CD55, Decay Accelerating Factor) on colorectal cancer cells. Phase I studies in patients with advanced disease confirmed that 105AD7 is non-toxic, and that T cell responses could be generated. A prospective, randomized, double-blind, placebo-controlled survival study in patients with advanced colorectal cancer was performed. 162 patients were enrolled between April 1994 and October 1996. Patients attended at trial entry, and at 6 and 12 weeks, where they received 105AD7 or placebo. Study groups were comparable in terms of patient demographics, and time from diagnosis of advanced colorectal cancer (277.1 v 278.6 days). Baseline disease was similar, with 50% of patients having malignancy in at least 2 anatomic sites. Compliance with treatment was poor, with only 50% of patients receiving 3 planned vaccinations. Median survival from randomization date was 124 and 184 days in 105AD7 and placebo arms respectively (P = 0.38), and 456 and 486 days from the date of diagnosis of advanced disease (P = 0.82). 105AD7 vaccination does not prolong survival in patients with advanced colorectal cancer. The reasons for lack of efficacy are unclear, but may reflect the high tumour burden in the patient population, and poor compliance with immunization. Further vaccine studies should concentrate on patients with minimal residual disease.

Long-term results of surgical decompression of thoracic outlet compression syndrome.

BACKGROUND: Thoracic outlet compression syndrome is characterised by a variety of symptoms relating to compression of the neurovascular bundle. Though no one test is specific for the syndrome, relief of symptoms may be obtained following surgery in up to 99% of cases. PATIENTS AND METHODS: The notes of 118 patients operated on in 126 operations by a single surgeon using a supraclavicular approach were reviewed. Symptoms, pre-operative investigations, and complications were all documented. Outcome at 6 weeks, 6, 12 and 24 months follow-up was also recorded. In addition, 61 patients were contacted by telephone, in order to assess current level of symptoms. RESULTS: Symptoms were predominantly motor, sensory or vasomotor, and were present for a mean of 19.6 months prior to surgery. Complications were rare, but included a pneumothorax requiring a chest drain (n = 1) and infraclavicular anaesthesia (n = 13). The mean duration of hospital stay was 2.1 days. At 6 weeks follow up, 86.5% of patients reported either an improvement, or complete resolution of their symptoms. Sixty-one patients were contactable, a mean of 55 months following decompression. Of these, 44 (72.1%) were either improved or asymptomatic. CONCLUSION: Decompression for thoracic outlet compression syndrome through a supraclavicular approach encompassing first rib resection leads to good long-term results with few complications.

Surgical management of infantile hypertrophic pyloric stenosis--can it be performed by general surgeons?

INTRODUCTION: Debate exists as to whether IHPS can be treated in district general hospitals as effectively as in specialist paediatric surgical units. AIM: To review the surgical treatment of IHPS in babies admitted to a district general hospital under the care of two consultant general surgeons with a paediatric surgical interest. PATIENTS AND METHODS: The case notes of 66 babies operated on for IHPS over a 42 month period between April 1995 and September 1998 were retrospectively reviewed. Demographics, operative details, hospital stay, and overall complications were all documented. RESULTS: Peri-operative complications occurred in 2 patients, both requiring omental patches for duodenal perforation. Nine patients had 1 or 2 episodes of postoperative vomiting; 4 had either a wound or urinary tract infection; and 1 baby developed an incisional hernia. There was no mortality. DISCUSSION: The complication rate seen in this series is comparable to that of specialist centres, and supports current guidelines suggesting that IHPS can be managed by general surgeons with a paediatric surgical interest in a district general hospital.

Laparoscopic colorectal cancer surgery.

BACKGROUND: A number of controversies exist in the laparoscopic treatment of colorectal cancer, and thus the technique has so far failed to gain widespread acceptance throughout the United Kingdom. This review aims to discuss these issues in the context of ongoing published trials, assessing both purported advantages and disadvantages. METHODS: The United States National Library of Medicine Medline database, and the Bath Information Data Service (BIDS) were searched using keywords related to laparoscopic colorectal cancer surgery. Recent surgical journals were also reviewed for relevant publications. Attempts have been made to quote only the most recent work from institutions with multiple publications using the same group of patients, in order to present the most coherent picture. The data are presented as randomized controlled trials, nonrandomized controlled studies, and series comprising more than 10 patients. CONCLUSIONS: This review confirms that laparoscopic colorectal cancer surgery is technically feasible. In addition patients lose less blood, have less immunosuppression, and have shorter postoperative ileus, in-patient stay, and require less analgesia. However, concerns still remain as to the development of port-site metastases, the longer operating times, and the overall cost of the equipment. In view of these concerns, the place of laparoscopically assisted colorectal cancer surgery is likely to remain controversial for some years yet. Randomized, controlled trials are as yet too few to provide definitive answers to all these issues.

Vaccine-induced apoptosis: a novel clinical trial end point?

The functional end point of immunotherapy is to induce tumor regression. Because immune effector mechanisms usually result in apoptosis, the aim of this study was to determine whether measurement of tumor apoptosis ex vivo is a good end point to evaluate the efficacy of cancer vaccines. A prototype vaccine, 105AD7, was administered to colorectal cancer patients before resection of their primary tumors. There was a significant increase in apoptosis of tumor cells within immunized patients compared with control patients as assessed by immunohistochemistry (P = 0.005; n = 16) or by flow cytometry (P = 0.003; n = 34). Preoperative immunization and measurement of tumor cell apoptosis may be a valuable clinical end point for evaluation of new vaccine and other biological approaches.