Diabetes in day case general and vascular surgery: A multicentre regional audit.

BACKGROUND: People with Diabetes Mellitus (DM) are at increased risk of postoperative complications if their HbA1C readings are not well controlled. In the UK, there are clear national guidelines requiring all people with DM to have HbA1C blood testing within 6months before undergoing surgery and that these readings should be below 69 mmol/mol if this is safe to achieve. The aim of this study was to determine whether hospitals in the region were compliant with the guidelines. METHODS: Data were prospectively collected from seven hospitals across the East of England region from 1st October 2017 to 31st March 2018 (6 months) in all people with DM undergoing elective day case procedures in General and Vascular surgery for benign disease. RESULTS: A total of 181 people with DM were included in the study, of whom 77.9% were male patients and the median age was 63 years. The three most commonly performed operations were laparoscopic cholecystectomy (20.9%, n = 38/181), inguinal hernia repair (20.4%, n = 37/181) and umbilical/para-umbilical hernia repair (11.0%, n = 20/181). In keeping with the national guidelines, only 86.7% (n = 157/181) of patients had an HbA1C tested within 6 months prior to their surgery date. Of the patients who had a preoperative HbA1C, 14 (n = 14/157, 8.9%) had an HbA1C ≥ 69 mmol/mol, and 12 (n = 12/14, 85.7%) of these proceeded to surgery without optimisation of their HbA1C. CONCLUSION: A significant proportion of people with diabetes undergoing elective day case procedures in our region do not have HbA1C testing within 6 months of their procedure as recommended by the national guidelines. In patients who do have a high HbA1C, the majority still undergo surgery without adequate control of their DM. Greater awareness amongst healthcare workers and robust pathways are required for this vulnerable group of patients if we are to reduce the risk of developing postoperative complication rates.

Magnetic Resonance Texture Analysis in Identifying Complete Pathological Response to Neoadjuvant Treatment in Locally Advanced Rectal Cancer.

BACKGROUND: A certain proportion of patients with locally advanced rectal cancer experience complete response after undergoing neoadjuvant chemoradiotherapy. These patients might be suitable for a conservative "watch and wait" approach, avoiding high-morbidity surgery. Texture analysis is a new modality that can assess heterogeneity in medical images by statistically analyzing gray-level intensities on a pixel-by-pixel basis. This study hypothesizes that texture analysis of magnetic resonance images can identify patients with a complete response. OBJECTIVE: This study aims to determine whether texture analysis of magnetic resonance images as a quantitative imaging biomarker can accurately identify patients with complete response. DESIGN: This is a retrospective diagnostic accuracy study. SETTINGS: This study was conducted at Colchester General Hospital, January 2003 to 2014. PATIENTS: All patients diagnosed with locally advanced rectal cancer who underwent long-course chemoradiotherapy had a posttreatment magnetic resonance scan and underwent surgery are included. INTERVENTION: Texture analysis was extracted from T2-weighted magnetic resonance images of the rectal cancer. MAIN OUTCOME MEASURES: Textural features that are able to identify complete responders were identified by a Mann-Whitney U test. Their diagnostic accuracy in identifying complete responders was determined by the area under the receiver operator characteristics curve. Cutoff values were determined by the Youden index. Pathology was the standard of reference. RESULTS: One hundred fourteen patients with first posttreatment MRI scans (6.2 weeks after completion of neoadjuvant treatment) were included. Sixty-eight patients had a second posttreatment scan (10.4 weeks). With no filtration, mean (p = 0.033), SD (p = 0.048), entropy (p = 0.007), and skewness (p = 0.000) from first posttreatment scans, and SD (p = 0.042), entropy (p = 0.014), mean of positive pixels (p = 0.032), and skewness (p = 0.000) from second posttreatment scans were all able to identify complete response. Area under the curve ranged from 0.750 to 0.88. LIMITATIONS: Texture analysis of MRI is a new modality; therefore, further studies are necessary to standardize the methodology of extraction of texture features, timing of scans, and acquisition parameters. CONCLUSIONS: Texture analysis of MRI is a potentially significant imaging biomarker that can accurately identify patients who have experienced complete response and might be suitable for a nonsurgical approach. (Cinicaltrials.gov:NCT02439086). See Video Abstract at http://links.lww.com/DCR/A760.

Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort.

INTRODUCTION: Colorectal anastomotic leaks (AL) are associated with high morbidity and mortality. Management of AL and its intra-operative decision making is often difficult. The aim of this multi-centre study is to explore different management strategies, including different surgical options, and analyse rates and patterns of failure of initial management. METHODS: All consecutive patients who had a confirmed AL after elective colorectal resections from 1st January 2014 to 31st December 2019 were included at seven hospitals across the East of England Region. Morbidity (length of stay, and failures) and mortality were compared across the different management strategies, and survival analyses were performed (Clinicaltrials.gov ID: NCT05000580). RESULTS: Across all seven hospitals, a total of 3391 elective resection were done during the study period. 201 (5.9%) consecutive patients with confirmed AL were included. The initial treatment was conservative in 102(50.7%). 19 patients (9.5%) had a radiological procedure, 80 (39.8%) of patients required surgery as an initial treatment post AL. Of those who initially did not have a surgical intervention (n = 121), 10% (n = 12/121) eventually required laparotomy, 2 additional patients required transanal drainage. Ultimately 45.8% (n = 92/201) of the whole population eventually required a laparotomy. Patients managed conservatively had a shorter LOS when compared to either radiological drainage or surgical patients. Patients with a defunctioning stoma are more likely to have a successful conservative management and shorter LOS. 90-day mortality across the entire population was 8.1%. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities or whether the leak was right or left sided. CONCLUSION: Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy and over a quarter of patients will have an end stoma.

Diagnostic accuracy of MRI in assessing tumor regression and identifying complete response in patients with locally advanced rectal cancer after neoadjuvant treatment.

BACKGROUND: The diagnostic accuracy of Magnetic Resonance Imaging (MRI) in restaging locally advanced rectal cancers (LARC) after neoadjuvant chemo-radio therapy (NCRT) has been under recent scrutiny. There is limited data on the accuracy of MRI and its timing in assessing tumor regression grade (TRG) and in identifying patients with complete response (CR). NCRT seems to cause tissue inflammation and oedema which renders reading the scans difficult for radiologist. AIM: This study aims to assess the accuracy of MRI at different time intervals after NCRT in staging TRG and in identifying CR. Inter-observer agreement between 2 blinded radiologists will also be assessed. METHOD: In this retrospective analysis, all patients diagnosed with LARC between January 2003 and 2014, who underwent long-course NCRT, who had at least one post-treatment MRI scan, and who underwent surgery with available pathology results are included. Histopathology staging is considered the reference standard. Accuracy of MRI in T staging and in TRG staging is assessed using weighted kappa. Accuracy, sensitivity, and specificity in identifying CR are calculated from a 2 × 2 contingency table. Inter-observer agreement between two-staging blinded radiologists is calculated using weighted kappa. These are calculated at 2 different time intervals after completion of NCRT. RESULTS: 114 patients were identified who had a first post-treatment MRI scan at an average of 6.2 weeks after completion of NCRT. A subgroup of 68 patients had a second post-treatment MRI at an average of 10.4 weeks. Pathology results were available for 103 patients. By the second post-treatment scan, an additional 25% of patients experienced downstaging; accuracy in T staging increased from 43% to 57.4%; accuracy in TRG staging rose from 28.2% to 38.1%; accuracy in identifying CR rose from 83.4% to 84.1%. Inter-observer agreement in T staging rose from 0.1 for first post-treatment MRI to 0.206 for second post-treatment MRI. CONCLUSION: This study advocates that restaging should occur at 10 weeks rather than the standard 6 weeks. This results in higher complete response rates and higher concordance with pathological specimens. Our results also showed that it is easier for radiologists to stage the MRI scans, resulting in higher inter-rater agreements.