Human factors in pelvic exenteration: themes in high-performing teams.

AIM: The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and postoperative phases. METHOD: Qualitative analysis of focus groups was used to capture authentic human interactions that reflect real-world multiprofessional performance. Theatre teams were treated as clusters, with a particular focus group containing participants who worked together regularly. RESULTS: Three focus groups were conducted. Four themes emerged - driving force, technical skills, nontechnical skills and operational aspects - with a total of 16 subthemes. Saturation was reached by group 2, with no new subthemes emerging after this. There was some interaction between the themes and the subthemes. Broadly speaking, driving force led to the development of specialised technical skills and nontechnical skills, which were operationalized into successful service through operational aspects. CONCLUSION: This study of teams performing pelvic exenteration is the first in the field using this methodology. It has generated rich qualitative data with authentic insights into the pragmatic aspects of developing and delivering a service. In addition, it shows how the themes are connected or 'coupled' in a network, for example technical and non-technical skills. In a complex system, 'tight coupling' leads to both high performance and adverse events. In this paper, we report the qualitative aspects of high performance by pelvic exenteration teams in a complex sociotechnical system, which depends on tight coupling of several themes.

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery.

AIM: Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery. METHOD: A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres. RESULTS: In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001). CONCLUSION: Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.

Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer.

BACKGROUND: Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer. METHODS: This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis. RESULTS: A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively. CONCLUSION: There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era.

BACKGROUND: Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers. METHODS: Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. RESULTS: Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease. CONCLUSION: This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

ANTECEDENTES: A pesar de las mejoras en los porcentajes de extirpación total del mesorrecto (total mesorectal excision, TME) en la cirugía de cáncer de recto, la disminución de los porcentajes de recidiva local y el aumento de la supervivencia a 5 años, todavía existe una gran variabilidad en la calidad del tratamiento recibido. Hasta el 30% de los cánceres de recto están localmente avanzados en el momento del diagnóstico y aproximadamente el 5-10% sobrepasarán el plano mesorrectal e invadirán las estructuras adyacentes a pesar del tratamiento neoadyuvante. Con la evolución de las resecciones ampliadas para los cánceres de recto que sobrepasan el plano de la TME, los defensores recomiendan que estas resecciones solo se realicen en centros especializados. El objetivo fue evaluar los factores pronósticos y los patrones de recidiva después de la cirugía ampliada más allá de la TME para los cánceres de recto T4. MÉTODOS: Los datos se recogieron a partir de bases de datos prospectivas de tres instituciones de alto volumen especializadas en resecciones ampliadas más allá de la TME para el cáncer de recto T4 entre 1990 y 2013. Los criterios de valoración principal fueron la supervivencia global, la recidiva local y los patrones de la primera recidiva. RESULTADOS: Se identificaron 360 pacientes. El margen de resección fue negativo (R0) en el 82,8% (n = 298) y el porcentaje de recidiva local fue de 12,5% (n = 45). El tipo de cirugía realizada (Hartmann: cociente de riesgos instantáneos, hazard ratio, HR 4,49; i.c. del 95%: 1,99-10,14; P = 0,002) y la invasión linfovascular (HR 2,02; i.c. del 95%: 1,08-3,77; P = 0,032) fueron factores predictivos independientes de recidiva local. La supervivencia global a 5 años para todos los pacientes fue del 61% (i.c. del 95%: 55-67). La incidencia acumulada a los 5 años de la primera recidiva fue de 8% para la recidiva local, 6% para la recidiva local y a distancia, y 18% para la recidiva a distancia. CONCLUSIÓN: Este estudio demuestra que un abordaje coordinado en centros especializados para cirugía más allá de la TME puede ofrecer una buena supervivencia oncológica y a largo plazo en pacientes con cáncer de recto T4.

Detection of the Bacteroides fragilis toxin gene in sheep with and without small intestinal adenocarcinoma.

Aims: To determine if presence of the Bacteroides fragilis toxin (bft) gene, a molecular marker of colonic carriage of entertoxigenic Bacteroides fragilis (ETBF) in humans, was associated with a finding of small intestinal adenocarcinomas (SIA) in sheep in New Zealand. Methods: Samples of jejunal tissue were collected from the site of tumours and from grossly normal adjacent tissue in 20 sheep, in different consignments, diagnosed with SIA based on gross examination of viscera following slaughter. Two jejunal samples were also collected from a control sheep in the same consignment that had no gross evidence of SIA. A PCR assay was used to detect the presence of the bft gene in the samples. Results: Of the sheep with SIA, the bft gene was amplified from one or both samples from 7/20 (35%) sheep, and in sheep that had no gross evidence of SIA the bft gene was amplified from at least one sample in 11/20 (55%) sheep (RR 0.61; 95% CI = 0.30-1.25; p = 0.34). Of 11 positive samples analysed, ETBF subtype bft-1 was detected in one, bft-2 was detected in 10, and none were bft-3. Conclusions and Clinical Relevance: There was a high prevalence of detection of the bft gene in both SIA-affected and non-affected sheep, but there was no apparent association between carriage of ETBF, evidenced by detection of the bft gene, and the presence of SIA. ETBF are increasingly implicated in the aetiology of human colorectal cancer, raising the possibility that sheep may provide a zoonotic reservoir of this potentially carcinogenic bacterium. Abbreviation: Bft: Bacteroides fragilis toxin; ETBF: Enterotoxigenic Bacteroides fragilis; SIA: Small intestinal adenocarcinoma.

Population-based study demonstrating an increase in colorectal cancer in young patients.

BACKGROUND: New Zealand has among the highest rates of colorectal cancer in the world and is an unscreened population. The aim of this study was to determine the trends in incidence and tumour location in the New Zealand population before the introduction of national colorectal cancer screening. METHODS: Data were obtained from the national cancer registry and linked to population data from 1995 to 2012. Incidence rates for colorectal cancer by sex, age (less than 50 years, 50-79 years, 80 years or more) and location (proximal colon, distal colon and rectum) were assessed by linear regression. RESULTS: Among patients aged under 50 years, the incidence of distal colonic cancer in men increased by 14 per cent per decade (incidence rate ratio (IRR 1·14), 95 per cent c.i. 1·00 to 1·30; P = 0·042); the incidence of rectal cancer in men increased by 18 per cent (IRR 1·18, 1·06 to 1·32; P = 0·002) and that in women by 13 per cent (IRR 1·13, 1·02 to 1·26; P = 0·023). In those aged 50-79 years, there was a reduction in incidence per decade of proximal, distal and rectal cancers in both sexes. In the group aged 80 years and over, proximal cancer incidence per decade increased by 19 per cent in women (IRR 1·19, 1·13 to 1·26; P < 0·001) and by 25 per cent in men (IRR 1·25, 1·18 to 1·32; P < 0·001); among women, the incidence of distal colonic cancer decreased by 8 per cent (IRR 0·92, 0·86 to 0·98); P = 0·012), as did that of rectal cancer (IRR 0·92, 0·86 to 0·97; P = 0·005). CONCLUSION: The increasing incidence of rectal cancer among younger patients needs to be considered when implementing screening strategies.

Meta-analysis of prophylactic mesh to prevent parastomal hernia.

BACKGROUND: Rates of parastomal hernia following stoma formation remain high. Previous systematic reviews suggested that prophylactic mesh reduces the rate of parastomal hernia; however, a larger trial has recently called this into question. The aim was to determine whether mesh placed at the time of primary stoma creation prevents parastomal hernia. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL were searched using medical subject headings for parastomal hernia, mesh and prevention. Reference lists of identified studies, clinicaltrials.gov and the WHO International Clinical Trials Registry were also searched. All randomized clinical trials were included. Two authors extracted data from each study independently using a purpose-designed sheet. Risk of bias was assessed by a tool based on that developed by Cochrane. RESULTS: Ten randomized trials were identified among 150 studies screened. In total 649 patients were included in the analysis (324 received mesh). Overall the rates of parastomal hernia were 53 of 324 (16·4 per cent) in the mesh group and 119 of 325 (36·6 per cent) in the non-mesh group (odds ratio 0·24, 95 per cent c.i. 0·12 to 0·50; P < 0·001). Mesh reduced the rate of parastomal hernia repair by 65 (95 per cent c.i. 28 to 85) per cent (P = 0·02). There were no differences in rates of parastomal infection, stomal stenosis or necrosis. Mesh type and position, and study quality did not have an independent effect on this relationship. CONCLUSION: Mesh placed prophylactically at the time of stoma creation reduced the rate of parastomal hernia, without an increase in mesh-related complications.

The long-term outcome of anti-TNF alpha therapy in perianal Crohn's disease.

BACKGROUND: The aim of the present study was to evaluate the long-term outcomes of anti-tumour necrosis factor alpha therapy in perianal Crohn's disease and identify factors predicting response to treatment. METHODS: Data from hospital clinical records and coding databases were retrospectively reviewed from a tertiary care hospital in Christchurch, New Zealand. The study included 75 adult patients with perianal Crohn's disease commenced on anti-tumour necrosis factor alpha therapy from January 2000 to December 2012. Response to treatment was determined from records relating to clinical evaluation, magnetic resonance imaging follow-up and whether further surgical intervention was required. RESULTS: 73% (55) of all patients and 38 of the 57 (67%) patients with perianal fistulas responded to anti-tumour necrosis factor alpha therapy. Patients with complex fistulas were less likely to improve as compared to patients without fistulising disease. Five of the 57 (13%) patients with perianal fistulas demonstrated complete healing on clinical evaluation; however, magnetic resonance imaging confirmed complete healing in only two. Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment [relative risk (RR) = 0.707 and 0.615, respectively; p = 0.03, p = 0.0001]. Responders were less likely to require follow-up surgery (RR = 0.658, p = 0.014) including ileostomy or proctectomy. CONCLUSIONS: Although anti-tumour necrosis factor alpha tends to improve symptoms of perianal Crohn's disease, in the long term, it rarely achieves complete healing. Perianal fistulising disease, a history of perianal abscess and antibiotic treatment are predictors of poor response to therapy.

Cohort study of mesenteric panniculitis and its relationship to malignancy.

BACKGROUND: Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure. METHODS: This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured. RESULTS: A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524). CONCLUSION: MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

Progress in the management of retrorectal tumours.

AIM: Tumours in the retrorectal space are rare and pathologically heterogeneous. The roles of imaging and preoperative biopsy, nonoperative management and the indications for surgical resection are controversial. This study investigated a series of retrorectal tumours treated in a single institution with the aim of producing a modern improved management algorithm. METHOD: A retrospective analysis was conducted of the management of all retrorectal lesions identified between 1998 and 2013 from a radiology database search. Patient demographics, presenting symptoms, imaging, biopsy, management and the results were recorded. Descriptive statistics were used and Kaplan-Meier survival analysis was performed. RESULTS: Sixty-nine patients with a confirmed retrorectal tumour were identified. The median age was 50 (36-67 interquartile range) and 42 (56%) were female. Twenty (29%) of the tumours were malignant: 4 of 41 cystic lesions were malignant (12.9%) vs. 16 of 28 solid (or heterogeneous) lesions (57.1%) (P < 0.0001). Imaging demonstrated a 95% sensitivity and 64% specificity for differentiating benign from malignant tumours. Magnetic resonance imaging (MRI) was significantly better at distinguishing between benign and malignant tumours than computed tomography (94% vs. 64%, P = 0.03). Percutaneous biopsy was performed in 16 patients and only 27 underwent resection. There was no evidence of local recurrence associated with biopsy. Solid lesions were associated with a nonsignificant decreased overall survival (P = 0.348). CONCLUSION: This study demonstrated that MRI should be the investigation of choice for retrorectal lesions. Biopsy of solid lesions is safe and useful for guiding neoadjuvant and surgical therapy. Cystic lesions without suspicious radiological features can be followed by serial imaging without resection.

Malignancy and mesenteric panniculitis.

AIM: Mesenteric panniculitis (MP) is a chronic inflammatory process of the small bowel mesentery that has been reported in conjunction with malignancy. The objectives of the present study were to identify the frequency and type of cancers that may coexist with MP and whether these can be seen on the initial diagnostic computerised tomography (CT). METHOD: A prospective database was kept of patients diagnosed with MP in the Canterbury region of New Zealand between 1 January 2003 and 31 December 2014. CT scans were independently reviewed. Clinical records were reviewed and family doctors were contacted for additional information. RESULTS: There were 302 patients with possible MP identified and 259 in whom it was confirmed on review. Seventy-eight patients had a diagnosis of malignancy, with 54 having a current cancer (59 total cancers), 33 a past cancer and nine both. Of the 59 current cancers the most common primary sites were colorectum (19), lymph nodes (17), kidney (six) and prostate (four). Fifty-four were at sites included on an abdominal CT scan. At all sites [except prostate (0/4)] there were high rates of detection on CT with 44/54 cancers visible including 20/23 gastrointestinal tract, 14/17 lymphomas and 9/9 non-prostate urogenital tract malignancies. Six people were subsequently diagnosed with cancer after the index CT. CONCLUSION: When MP occurs in association with malignancy, the commonest primary sites are large bowel, the lymph nodes and the urogenital tract. In those with MP on imaging, any cancer except prostate can usually be seen on the index CT. Further extensive investigation in asymptomatic patients is therefore likely to be of low yield.

Predictors of outcome in palliative colonic stent placement for malignant obstruction.

BACKGROUND: Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment. METHODS: Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment. RESULTS: Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful. CONCLUSION: SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

Impact of obesity on the cost of major colorectal surgery.

BACKGROUND: The incidence of obesity is increasing in New Zealand. The aim of the study was to determine whether obesity impacts on the cost of treating patients undergoing major colorectal surgery. METHODS: Between 1 February 2008 and 31 July 2009, consecutive patients undergoing major colorectal surgery at Christchurch Hospital, New Zealand, were enrolled in the study. Body mass index (BMI) and waist-to-hip ratios were assessed using standardized techniques. Patients with a high surgical risk were identified using established criteria and all patients were assessed using the Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). Cost analysis was performed using a structured query language database. Patients were analysed using accepted groupings for BMI, waist circumference and waist-to-hip ratio. RESULTS: A total of 372 patients were enrolled in the study, of whom 345 were included in the analysis. The incidence of diabetes was significantly higher with increased BMI (P = 0·002), whereas all other co-morbidities, and P-POSSUM values, did not differ between BMI groups. The groups were similar in terms of case mix. Treatment of obese patients (BMI at least 30 kg/m(2)) was significantly more expensive than that of normal weight patients (BMI 20-24·9 kg/m(2)): €10,036 versus €7390 (P = 0·005). Treatment costs for patients with a BMI of 25-29·9 kg/m(2) were next highest (€9048) followed by those for patients whose BMI was less than 20 kg/m(2) (€8884). Patients with a waist circumference above recognized standards for men and women also cost significantly more to treat (€10,063 versus €7836; P = 0·014). CONCLUSION: Excess body fat was associated with higher costs of major colorectal surgery.

Bacterial lipopolysaccharide modulates immune response in the colorectal tumor microenvironment.

Immune responses can have opposing effects in colorectal cancer (CRC), the balance of which may determine whether a cancer regresses, progresses, or potentially metastasizes. These effects are evident in CRC consensus molecular subtypes (CMS) where both CMS1 and CMS4 contain immune infiltrates yet have opposing prognoses. The microbiome has previously been associated with CRC and immune response in CRC but has largely been ignored in the CRC subtype discussion. We used CMS subtyping on surgical resections from patients and aimed to determine the contributions of the microbiome to the pleiotropic effects evident in immune-infiltrated subtypes. We integrated host gene-expression and meta-transcriptomic data to determine the link between immune characteristics and microbiome contributions in these subtypes and identified lipopolysaccharide (LPS) binding as a potential functional mechanism. We identified candidate bacteria with LPS properties that could affect immune response, and tested the effects of their LPS on cytokine production of peripheral blood mononuclear cells (PBMCs). We focused on Fusobacterium periodonticum and Bacteroides fragilis in CMS1, and Porphyromonas asaccharolytica in CMS4. Treatment of PBMCs with LPS isolated from these bacteria showed that F. periodonticum stimulates cytokine production in PBMCs while both B. fragilis and P. asaccharolytica had an inhibitory effect. Furthermore, LPS from the latter two species can inhibit the immunogenic properties of F. periodonticum LPS when co-incubated with PBMCs. We propose that different microbes in the CRC tumor microenvironment can alter the local immune activity, with important implications for prognosis and treatment response.

Clinical and genetic risk factors for perianal Crohn's disease in a population-based cohort.

OBJECTIVES: Perianal Crohn's disease (CD) affects around one-quarter of CD patients and represents a distinct disease phenotype. The objective of this study was to investigate a large population-based cohort of inflammatory bowel disease (IBD) patients to identify clinical and genetic risk factors for perianal CD. METHODS: Data were collected in the Canterbury IBD database, estimated to include 91% of all patients with IBD in Canterbury, New Zealand. Genotyping was performed for selected loci previously demonstrated to be associated with CD. Patients with perianal disease were then compared with both CD patients without perianal disease and healthy controls to assess the presence of potential phenotypic, environmental, and genetic risk factors. RESULTS: Of the 715 CD patients in the database, 190 (26.5%) had perianal disease. In all, 507 patients with genotype data available were analyzed. Perianal disease was associated with younger age at diagnosis (P < 0.0001), complicated intestinal disease (P < 0.0001), and ileal disease location (P = 0.002). There was no association with gender, ethnicity, smoking, or breast feeding. Genotype analysis revealed an association with the neutrophil cytosolic factor 4 (NCF4) gene compared with both non-perianal CD patients (odds ratio (OR): 1.47; 95% confidence interval (CI): 1.08-1.99) and healthy controls (OR: 1.47; 95% CI: 1.10-1.95). There was no association identified with other genes, including IBD5 (OR: 0.91; 95% CI: 0.69-1.20), tumor necrosis factor α (OR: 1.04; 95% CI: 0.56-1.85), and IRGM (immunity-related guanosine triphosphatase protein type M) (OR: 1.21; 95% CI: 0.80-1.82). CONCLUSIONS: This study suggests that younger age at diagnosis, complicated disease behavior, and ileal disease location are risk factors for perianal CD. In addition, this paper represents the first report of an association of the NCF4 gene with perianal disease.

Current practice in preoperative therapy and surgical management of locally advanced rectal cancer: a bi-national survey.

AIM: The Australasian colorectal surgeon's current approach to preoperative rectal cancer management was compared with international guidelines. METHOD: Members of the Colorectal Surgical Society of Australia and New Zealand were surveyed in 2010, on the use of MRI and the management of locally advanced rectal cancer. Surgeons had to decide the appropriate management in five scenarios that were developed from national guidelines. RESULTS: Of 174 invitations sent, 108 (62.1%) replies were received. Most surgeons (98.1%) had access to MRI. Ninety-three (86.1%) would use MRI routinely for staging. The majority selected a tumour-specific mesorectal resection for upper rectal cancer (58.2%) and a total mesorectal excision for distal cancer (100%). Almost all restorative operations included a covering ileostomy. One third of surgeons recommended that patients with a favourable cT3 mid-rectal tumour (N0, clear circumferential resection margins) should not have preoperative therapy and should proceed directly to surgery. When high-risk features, such as threatened resection margins or cN1 stage, were present, 5% and 15% of surgeons, respectively, would continue to treat by standard resection without preoperative therapy. CONCLUSION: Evidence-based international guidelines for the management of rectal cancer have changed little in the last 10 years. Despite this, there is a clear gap between these and clinical practice. The main variance relates to the role of radiotherapy in locally advanced rectal cancer. Despite considerable evidence that radiotherapy reduces local recurrence for all stages of rectal cancer, current practice in Australasia is for its selective use.

The process and outcomes of a nurse-led colorectal cancer follow-up clinic.

AIM: Evidence suggests that follow-up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow-up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse-led follow-up service was started in 2004. We aimed to review the results of a nurse-led colorectal cancer follow-up clinic. METHOD: Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database. RESULTS: Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow-up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow-up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis. CONCLUSION: This paper shows that a nurse-led clinic for colorectal cancer follow-up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow-up. A nurse-led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice.

Pulmonary staging in colorectal cancer: a review.

AIM: Assessment of the chest in colorectal cancer (CRC) staging is variable. The aim of this review was to look at different chest staging strategies and determine which has the greatest efficacy. METHOD: A review of studies assessing chest staging modalities for patients with CRC was performed. Modalities included chest X-ray (CXR), CT and positron emission tomography (PET). RESULTS: The majority of data consisted of case series. Two studies identified a low pick-up rate for CXR as a staging tool. Five studies showed increased detection rates of pulmonary metastases for chest CT vs CXR and abdominal CT. The clinical benefit of the increased detection rates was not clear. The incidence of indeterminate lung lesions (ILL) on staging chest CT varied from 4 to 42%. The majority (≥ 70%) of ILLs did not have any clinical significance. On CT scans, the incidence of pulmonary metastases in patients with rectal cancer ranged from 10 to 18% and in patients with colon cancer the incidence of pulmonary metastases ranged from 5-6%. The incidence of synchronous liver and pulmonary metastases compared with the overall incidence of pulmonary metastases ranged from 45 to 70%. There was no evidence reporting the superiority of PET/CT vs CT for the detection of pulmonary metastases or characterization of ILL. CONCLUSION: Studies show that chest CT scanning increases the detection rates for ILL and pulmonary metastases. The clinical benefit of the increased detection rates is not clear. There is a paucity of data assessing the optimal chest staging strategy for patients presenting with CRC.

Colorectal complications of end-stage renal failure and renal transplantation: a review.

AIM: End-stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications. METHOD: A review of the literature was performed to assess the prevalence and outcome in both benign and malignant colorectal disease. RESULTS: No prospective randomized studies assessing colorectal complications in ESRF or renal transplant were identified. Case series and case reports have described the incidence and management of benign colorectal complications. Complications included diverticulitis,infective colitis, colonic bleeding and colonic perforation. There was insufficient evidence to associated iverticular disease with adult polycystic kidney disease.Three population-based studies have shown up to a twofold increased incidence of colonic cancer but not rectal cancer for renal transplant recipients. Bowel cancer screening (as per the general population) by faecal occult blood testing appears justified for renal transplant patients; however, evidence suggests that consideration of starting screening at a younger age may be worthwhile because of an increased risk of developing colonic cancer.Two population-based studies have shown a threefold and 10-fold increased incidence of anal cancer for renal transplant recipients. A single case­control study demonstrated significant increased prevalence of anal human papilloma virus (HPV) and intraepithelial neoplasia (AIN)in patients with established renal transplants. CONCLUSIONS: Despite the lack of high-level evidence,ESRF and renal transplantation were associated with colorectal complications that could result in major morbidity and mortality. Bowel cancer screening in this patient group appears justified. The effectiveness of screening for HPV, AIN and anal cancer in renal transplant recipients remains unclear.

Routine colonoscopy following acute uncomplicated diverticulitis.

BACKGROUND: The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography. METHODS: This was a retrospective longitudinal study of patients with an initial presentation of acute uncomplicated diverticulitis on the basis of CT criteria, at a single institution between January 2004 and December 2008. RESULTS: A radiological diagnosis of acute uncomplicated diverticulitis was made in 292 patients. Some 205 patients underwent subsequent colonic evaluation or had undergone colonoscopy/CT colonography within the preceding 2 years. Colorectal polyps were present in 50 patients (24·4 per cent). Twenty patients (9·8 per cent) had hyperplastic polyps and 19 (9·3 per cent) had adenomas. Eleven patients (5·4 per cent) had advanced colonic neoplasia, including one (0·5 per cent) with a colorectal cancer. One patient had inflammatory bowel disease (IBD). The patients with colorectal cancer and IBD had clinical indicators that independently warranted colonoscopy. None of the 87 patients who did not undergo colonic evaluation had a diagnosis of colorectal cancer registered with the New Zealand Cancer Registry. CONCLUSION: The yield of advanced colonic neoplasia in this cohort was equivalent to, or less than that detected on screening asymptomatic average-risk individuals. In the absence of other indications, subsequent evaluation of the colon may not be required to confirm the diagnosis of diverticulitis.