Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study.

PURPOSE: Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches. METHOD: This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers. RESULTS: Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology. CONCLUSION: Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.

Comparative study of magnetic resonance defaecography and evacuation proctography in the evaluation of obstructed defaecation.

AIM: Obstructed defaecation syndrome is a common condition of multifactorial aetiology and requires specialized evaluation. Accurate and reproducible pelvic floor imaging is imperative for multidisciplinary decision-making. Evacuation proctography (EP) and magnetic resonance defaecography (MRD) are the main imaging modalities used to assess dynamic pelvic floor function. The aim of this prospective study was to compare the findings and acceptability of MRD and EP in the same cohort of patients. METHOD: This was a prospective comparative study of MRD vs EP in 55 patients with obstructed defaecation syndrome in a single National Health Service Foundation Trust. RESULTS: Fifty-five patients were recruited and underwent both EP and MRD. Detection rates for rectocoele were similar (82% vs 73%, P = 0.227), but EP revealed a significantly higher number of trapping rectocoeles compared to MRD (75% vs 31%, P < 0.001). EP detected more rectal intussusceptions than MRD (56% vs 35%, P = 0.023). MRD appeared to underestimate the size of the identified rectocoele, although it detected a significant number of anatomical abnormalities in the middle and anterior pelvic compartment not seen on EP (1.8% enterocoele, 9% peritoneocoele and 20% cystocoele). Patients achieved higher rates of expulsion of rectal contrast during EP compared to MRD, but this difference was not significant (76% vs 64% in MRD, P = 0.092). Of the two studies, patients preferred MRD. CONCLUSIONS: MRD provides a global assessment of pelvic floor function and anatomical abnormality. MRD is better tolerated by patients but it is not as sensitive as EP in detecting trapping rectocoeles and intussusceptions.

Differences in screening vs non-screening colonoscopy: scope for improvement?

AIM: Colonoscopy performed as part of the NHS Bowel Cancer Screening Programme (BCSP) is of high standard as measured using global rating scale (GRS) criteria. Screening practitioners also provide a non-screening colonoscopy service. The current study compares colonoscopy quality indicators between screening and non-screening groups performed by a single practitioner using the GRS. METHOD: Patient details were obtained for all consecutive colonoscopies between 2007 and 2014 performed by a single screening practitioner. Data were collected retrospectively from electronic patient records; BCSP Exeter database and non-screening colonoscopies were compared. Data included patient demographics (age, gender), sedation, and the GRS data including caecal intubation, adenoma and neoplasia detection rates. RESULTS: In all, 1961 colonoscopy procedures (1067 screening and 894 non-screening) were identified; 57% were men. Mean (SD) age for all patients was 64 (± 10.4) years. Non-screening patients were younger [62 (± 14) vs 66 (± 4.8) years; P < 0.05] and were less likely to be men (51.5% vs 61.9%; P < 0.05) than their screening counterparts. Caecal intubation was more successful in screening patients [1027/1067 (96.3%)] than non-screening patients [805/894 (90%)]; P < 0.05. Adenoma detection rate was higher in the screening (46.8 ± 4.4) than non-screening (26.3 ± 11.8) group; P < 0.05. There were no differences in neoplasia detection. Polypectomy was more likely (55.5% vs 30.2%) and polyp retrieval more successful (97.5% vs 86.7%) in the screening group. CONCLUSION: Screening and non-screening colonoscopy differ in the GRS domains of completion and pathology detection. These differences need to be acknowledged when comparing screeners and non-screeners using GRS within units.

Impact of bowel cancer screening on the management of colorectal cancer.

AIM: The National Bowel Cancer Screening Programme (NBCSP) was introduced in the West Midlands in 2006. Studies, including the UK Bowel Cancer Screening Pilot, have reported an 18% reduction in mortality. This regional study assesses the impact of screening on elective and emergency colorectal cancer (CRC) surgery. METHOD: Data were extracted from the West Midlands cancer registration database for CRC diagnosed in residents of the West Midlands between 1998 and 2010. Screen-detected cancers were identified by matching to the NBCSP database. Mode of admission and intervention was obtained by matching to Hospital Episode Statistics and the classification of Interventions and Procedures code. RESULTS: Of 42,082 patients diagnosed with CRC, 30,309 received surgical treatment. From 1998 to 2005, the number of patients who underwent emergency surgery increased from 4362 to 18,357, with the proportion each year remaining constant (23.85 ± 0.95% each year). In the screening age group (60-69 years) over the same period, emergency surgery was performed in 918 of 4831 patients (19.15 ± 1.65% each year). Following the introduction of screening, the emergency surgery rate decreased each year, reaching 16% (406/2520) in all patients and 12% (101/829) in the screening age group in 2010 (P < 0.001). These changes in emergency surgery were mirrored by increases in elective surgery. CONCLUSION: The NBCSP has had a positive impact on elective and emergency surgery for CRC in the West Midlands.

Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis.

AIMS: To assess accuracy of multidetector computed tomography (MDCT) and individual radiological signs in the diagnosis of anastomotic leaks. MATERIALS AND METHODS: Patients undergoing anterior resection with a stapled anastomosis over a 2 year period were identified. Electronic and clinical records of these patients were reviewed. Unenhanced and/or enhanced MDCT was performed with intravenous and/or per-rectal contrast medium and read by a radiologist blinded to the patients' clinical details to determine the sensitivity and specificity of specific findings at MDCT for identifying leaks. RESULTS: Seventeen percent (30/170) of the anterior resections were suspected to have an anastomotic leak. Ninety-three percent (28/30) of patients underwent MDCT. Seven point six percent (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and positive and negative predictive values of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in one patient. CONCLUSIONS: Presence of peri-anastomotic air is a reliable marker of anastomotic leaks at MDCT. Leakage of rectal contrast medium is highly accurate and increases confidence of diagnosis. The appearance of the staple line itself is not accurate in assessing anastomotic integrity.

Sacral nerve stimulation for the treatment of faecal incontinence secondary to a pelvic war injury: a case report.

Faecal incontinence can be physically and socially disabling and the level of unmet need in men appears to be high. We report a case of faecal incontinence in a 29-year-old, heterosexual serviceman who sustained a trans-pelvic gunshot injury (without perineal injury) while on active duty. Despite apparently successful surgical treatment, the patient presented to our colorectal department 7 years after injury with disabling faecal incontinence. Following assessment, sacral nerve stimulation (SNS) was initiated with excellent results. We report the successful use of SNS to treat faecal incontinence resulting from a combat gunshot injury. We recommend that surgeons carefully document the anatomical position of retained ballistic fragments after gunshot or blast fragment injury and that attention should be paid to the functional results in a patient's follow-up after intestinal surgery.

Volume and accreditation, but not specialty, affect quality standards in colonoscopy.

BACKGROUND: The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy. METHODS: Data collected prospectively from a UK hospital endoscopy service between June 2007 and January 2010 were analysed. The main endpoint was the adenoma detection rate (ADR). Secondary endpoints were polyp detection rate (PDR), reported caecal intubation rate (CIR) and reported complications. Multivariable binary regression models were built to adjust for confounding patient-level and endoscopist-level variation. RESULTS: A total of 10,026 colonoscopies were included, with an overall ADR of 19.2 per cent, a CIR of 90.2 per cent and a perforation rate of 0.06 per cent. In univariable analyses, surgeons had a higher ADR and higher PDR, but lower CIR, compared with physicians. Surgeons had a significantly different case mix in terms of age, sex and indication for colonoscopy. After adjusting for this case mix in multivariable analysis, specialty was no longer a significant predictor of ADR; however, surgeons retained their higher PDR and physicians their higher CIR. Endoscopists accredited for screening and those performing more than 100 colonoscopies per year had a higher ADR. CONCLUSION: Adjusting for case mix, physicians and surgeons performed equally well in terms of ADR. Accreditation and a higher annual number of colonoscopies were more important factors in achieving quality standards.

COVID-19 opens the door for right iliac fossa pain treatment pathway.

INTRODUCTION: The COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR. METHODS: A retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups. RESULTS: The mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16-45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%. CONCLUSIONS: Greater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

Does Preoperative Diagnosis Will Change the Treatment Plan of Clear Cell Carcinoma of Endometrium Masquerading as Desmoid Tumor of Anterior Abdominal Wall?: a Case Report.

Clear cell carcinoma (CCC) of the female genital tract can arise in the ovary, endometrium, cervicovaginal region, in peritoneal and other extra pelvic sites. However, CCC involving anterior abdominal wall is a very rare entity. We are reporting a case of 55-year-old postmenopausal lady with ECOG PS-I with no comorbidity had history of cesarean section about 30 years back and presented with pain in abdomen at periumbilical region about 9 months back. She underwent evaluation at outside clinic with finding of an anterior abdominal wall swelling of size approximately 3 × 3 cm which was completely neglected by the patient. In the next period of 2 months, the swelling suddenly increased in size. CECT/PET CT showed a solid cystic mass involving anterior abdominal wall with possibility of desmoid tumor. We had decided to plan for surgical excision of the tumor. Intraoperatively we found that there was bicornuate uterus. The lesion was arising from one of the cornue of uterus and it was extended anteriorly to anterior abdominal wall with no ascites, no pelvic, or retroperitoneal lymphadenopathy. She underwent hysterectomy with bilateral salpingo-oophorectomy and defect was closed with bioabsorbable mesh. Final histopathology report was clear cell endometrial carcinoma mostly mullerian tract origin arising from endometriosis focus. Tumor cells were diffusely positive for PAX-8 and Napsin-A and negative for WT 1 with patchy positivity for P53 (wild type expression). She had received adjuvant chemotherapy and she is disease free after 2 years of completion of the treatment. Clear cell endometrial carcinoma arising from malignant transformation of an endometriosis focus to anterior abdominal wall is a very rare phenomenon and it is a difficult task to reach its final diagnosis.

CT colonography for synchronous colorectal lesions in patients with colorectal cancer: initial experience.

AIM: To assess accuracy of CT colonography (CTC) in identifying synchronous lesions in patients with colorectal carcinoma. METHODS: This study included 174 consecutive patients undergoing CTC as part of staging or primary investigation where a colorectal cancer was diagnosed between 2004 and 2007. Prone unenhanced and portal phase enhanced supine series with air or CO(2) distension were acquired using 4- or 16-slice CT (Toshiba) and read by 2D +/- 3D formats. Synchronous lesions were classified according to American College of Radiology's (ACR) polyp classification. Segmental gold standard was flexible sigmoidoscopy/colonoscopy within 1 year and/or histology of colonic resection supplemented by follow-up. Nine patients without gold standard were excluded. Sensitivity, specificity and accuracy were calculated on a per polyp, per patient and per segment basis and discrepancies analysed. RESULTS: Direct comparable data were available for 764/990 colonic segments from 165 patients. Of 41 (C2-C4) synchronous lesions on "gold standard", 33 were correctly identified on virtual colonoscopy (VC), overall per polyp sensitivity was 80.5%, with detection rates of 20/24 C3 (83.3%) and 3/3 C4 (100%) with per patient and per segment specificity of 95.4% and 99.2%, respectively. CONCLUSION: CTC is an accurate technique to assess for significant synchronous lesions in patients with colorectal cancer and is applicable for total pre-operative colonic visualisation.

Socioeconomic deprivation adversely affects survival of patients with rectal cancer.

BACKGROUND: The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer. METHODS: Data on patient demographics, mode and stage of presentation, and short- and longer-term outcomes were extracted from a database of patients with rectal cancer. Comparisons were made after stratification into quintiles of socioeconomic deprivation. RESULTS: In total 486 patients were identified. Fewer patients from the most deprived group than from the least deprived group underwent resectional surgery (79.2 versus 93 per cent; P = 0.005). Permanent stoma rates among patients who had surgery were 40.8 and 30 per cent respectively (P = 0.110). The overall 5-year survival rate was 32.8 per cent for the most deprived compared with 64.0 per cent for the least deprived patients (P < 0.001). Respective rates for those who underwent resectional surgery were 49.9 and 72 per cent (P = 0.030). CONCLUSION: In rectal cancer, socioeconomic deprivation appears to be associated with poorer outcomes and survival. This has important implications for healthcare planning.

Plasma magnesium should be monitored perioperatively in patients undergoing colorectal resection.

OBJECTIVE: Hypomagnesemia has been shown to have several clinically important sequelae. The aims of this study were: to assess the impact of bowel preparation, with sodium picosulphate (Picolax), on plasma electrolytes, with particular regard to plasma magnesium, in patients undergoing bowel preparation for colonoscopy and colorectal resection and to evaluate the influence of perioperative magnesium levels on postoperative cardiac dysrhythmias. METHOD: Sixty-one patients receiving sodium picosulphate (Picolax) bowel preparation were studied in two groups: Colonoscopy (31 patients) and Colorectal resection (30 patients). Plasma sodium, potassium, magnesium, calcium, urea, creatinine and blood haematocrit were measured in all patients prior to commencement of bowel preparation, at the time of colonoscopy or colorectal resection and 24 h postoperatively (surgery group only). Mean electrolyte and haematocrit levels were then compared. Postoperative cardiac dysrhythmias were recorded and analysed. RESULTS: No significant changes following bowel preparation were observed in plasma sodium, potassium, calcium or creatinine. Plasma urea fell following bowel preparation (colonoscopy P < 0.001, resection P = 0.004) and rose following resection (P = 0.002). Magnesium levels increased following bowel preparation in both groups (colonoscopy P < 0.001, resection P = 0.007) and fell following resection (P < 0.001). Thirty-four per cent (21/60 patients) were hypermagnesemic following bowel preparation and 20% (6/30 patients) became hypomagnesemic following surgery. Postoperative cardiac dysrhythmias were associated with lower magnesium levels at induction and postoperatively (P = 0.022 and P = 0.033). CONCLUSION: Bowel preparation with Picolax does not appear to cause significant electrolyte disturbance, except in elevating plasma magnesium. Postcolorectal resection plasma magnesium dropped significantly suggesting perioperative monitoring and replacement should be routine following colorectal surgery.

The impact of surgeon and pathologist on lymph node retrieval in colorectal cancer and its impact on survival for patients with Dukes' stage B disease.

OBJECTIVE: An adequate lymph node harvest is necessary for accurate Dukes' stage discrimination in colorectal cancer. The aim of this study is to identify the effect of variables, including the individual surgeon and pathologist, on lymph node harvest in a single institution. METHOD: Three hundred and eighty one consecutive patients had resection for colorectal cancer, in a single unit. Factors influencing lymph node retrieval, including individual surgeon and reporting pathologist, were subjected to uni- and multivariate analysis. Actuarial survival of all patients with Dukes' stage B and C disease was then calculated and survival compared between Dukes' stage B and C at differing levels of lymph node harvest. RESULTS: The unit median lymph node harvest was 13 nodes/patient (95% CI 13.1-14.5). There was no difference in lymph node harvest between specialist colorectal surgeons and the pooled results of four nonspecialist consultant surgeons. However, there was a significant difference between reporting pathologists (P < 0.001). On univariate analysis, operation type, operative urgency, Dukes' stage, T-stage, reporting pathologist and use of neoadjuvant therapy in rectal cancer, were found to significantly affect lymph node retrieval. On multivariate analysis, operation type, T-stage, reporting pathologist and neoadjuvant therapy in rectal cancer remained significant variables. Patients with one or more lymph node metastasis had greater nodal harvests than those without (median 15 vs 12 P = 0.02). Survival of patients with Dukes' stage B disease was found to improve as lymph node harvest increased. CONCLUSION: Overall lymph node harvest, in this unit, varied according to the reporting pathologist but not operating surgeon. As lymph node harvest increased to 15 per patient, the probability of identifying a metastatic node increased.

Oncology Gold Standard® practical consensus recommendations for the use of monoclonal antibodies in the management of squamous cell carcinoma of head and neck.

We present the 2017 Oncology Gold Standard Practical Consensus Recommendation for use of monoclonal antibodies in the management of advanced squamous cell carcinoma of head neck region.