Assessing Guidelines on the Need for Colonoscopy After Initial Flexible Sigmoidoscopy in Young Patients With Outlet-Type Rectal Bleeding.

BACKGROUND: Although young-age-of-onset colorectal cancer is increasing in incidence, lack of screening leads to symptomatic presentation, often with rectal bleeding. Because most cancers in patients younger than 50 years are left-sided, flexible sigmoidoscopy is a reasonable way of investigating bleeding in these patients. OBJECTIVE: To predict which patients undergoing flexible sigmoidoscopy for outlet-type rectal bleeding need a full colonoscopy. DESIGN: Findings at colonoscopy were compared with published indications for colonoscopy after flexible sigmoidoscopy, which were as follows: 1) any number of advanced adenomas defined as a tubular adenoma of >9 mm diameter, a tubulovillous or villous adenoma of any size, or any adenoma with high-grade dysplasia; 2) 3 or more tubular adenomas of any size or histology; 3) any sessile serrated lesion; and 4) 20 or more hyperplastic polyps. SETTING: Charity Hospital with volunteer specialists. PATIENTS: Patients were included if they were younger than 57 years, had outlet-type rectal bleeding, and underwent flexible sigmoidoscopy at least to the descending colon followed by colonoscopy with biopsy of all resected lesions. INTERVENTIONS: Flexible sigmoidoscopy and colonoscopy with excision of all removable lesions. MAIN OUTCOME MEASURES: Findings at colonoscopy. RESULTS: There were 66 patients who had a colonoscopy between 5 and 811 days after sigmoidoscopy and also had complete data. There were 43 men and 23 women with a mean age of 39.5 years. Analysis of flexible sigmoidoscopy criteria for finding proximal high-risk lesions on colonoscopy showed a sensitivity of 76.9%, a specificity of 67.9%, a positive predictive value of 37%, a negative predictive value of 92.3%, and an accuracy of 69.7%. LIMITATIONS: A large number of exclusions for inadequate colonoscopy or inadequate data resulted in a reduced patient number in the study. CONCLUSIONS: Our criteria for follow-up colonoscopy based on the findings at initial flexible sigmoidoscopy in young patients with outlet-type rectal bleeding are reliable enough to be used in routine clinical practice, provided this is audited. See Video Abstract. GUA DE EVALUACIN PARA LA NECESIDAD DE COLONOSCOPIA DESPUS DE UNA SIGMOIDOSCOPIA FLEXIBLE INICIAL EN PACIENTES JVENES CON RECTORRAGIA: ANTECEDENTES:Si bien la edad de aparición temprana del cáncer colorrectal está aumentando en incidencia, la falta de pruebas de detección conduce a una presentación sintomática, a menudo con sangrado rectal. Debido a que la mayoría de los cánceres en pacientes menores de 50 años son del lado izquierdo, la sigmoidoscopia flexible es una forma razonable de investigar el sangrado en estos pacientes.OBJETIVO:Predecir qué pacientes sometidos a sigmoidoscopia flexible por rectorragia necesitan una colonoscopia completa.DISEÑO:Los resultados de la colonoscopia se compararon con las indicaciones publicadas para la colonoscopia después de una sigmoidoscopia flexible. Estos fueron: 1. Cualquier número de adenomas avanzados, definidos como un adenoma tubular > 9 mm, un adenoma tubulovelloso o velloso de cualquier tamaño, o cualquier adenoma con displasia de alto grado. 2. Tres o más adenomas tubulares de cualquier tamaño o histología. 3. Cualquier lesión serrada sésil. 4. Veinte o más pólipos hiperplásicos.ENTORNO CLINICO:Hospital de Caridad con especialistas voluntarios.PACIENTES:Menores de 57 años, con rectorragia, sometidos a sigmoidoscopia flexible al menos hasta el colon descendente, seguida de colonoscopia con biopsia de todas las lesiones resecadas.INTERVENCIONES:sigmoidoscopia flexible y colonoscopia con escisión de todas las lesiones removibles.PRINCIPALES MEDIDAS DE VALORACIÓN:Hallazgos en la colonoscopia.RESULTADOS:66 casos a los que se les realizó una colonoscopia entre 5 y 811 días después de la sigmoidoscopia, que también tenían datos completos. 43 hombres y 23 mujeres con una edad media de 39,5 años. El análisis de los criterios de sigmoidoscopia flexible para encontrar lesiones proximales de alto riesgo en la colonoscopia mostró una sensibilidad del 76,9 %, una especificidad del 67,9 %, un valor predictivo positivo del 37 %, un valor predictivo negativo del 92,3 % y una precisión del 69,7 %.LIMITACIONES:Gran número de exclusiones por colonoscopia inadecuada o datos inadecuados que causan un número reducido de pacientes en el estudio.CONCLUSIÓN:Nuestros criterios para la colonoscopia de seguimiento basados en los hallazgos de la sigmoidoscopia flexible inicial en pacientes jóvenes con rectorragia son lo suficientemente confiables para ser utilizados en la práctica clínica habitual, siempre que se audite. (Traducción- Dr. Ingrid Melo ).

Resurrecting New Zealand's public healthcare system or a charity hospital in every town?

Radical market-oriented health reforms in New Zealand in the early 1990s failed to deliver key financial targets, resulted in unnecessary patient deaths, adversely affected public healthcare services, induced serious tensions between clinicians and managers and encouraged a predisposition to private healthcare. A more co-operative health system was implemented in the late 1990s but remaining problems of inadequate patient access led to establishment of a charity hospital in Christchurch which, by November 2018, had registered over 18 000 patient visits. This is one indication of the need to resurrect our public healthcare system. In this paper, we discuss briefly the health reforms of the 1990s then, for discussion and debate, provide seven suggestions for how this resurrection might be achieved thereby avoiding the need for charity hospitals throughout the country.

Long-term outcomes of the australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer: the Australasian Laparoscopic Colon Cancer Study trial.

OBJECTIVE: : We report a multicentered randomized controlled trial across Australia and New Zealand comparing laparoscopic-assisted colon resection (LCR) with open colon resection (OCR) for colon cancer. BACKGROUND: : Colon cancer is a significant worldwide health issue. This trial investigated whether the short-term benefits associated with LCR for colon cancer could be achieved safely, without survival disadvantages, in our region. METHODS: : A total of 601 patients with potentially curable colon cancer were randomized to receive LCR or OCR. Primary endpoints were 5-year overall survival, recurrence-free survival, and freedom from recurrence rates, compared using an intention-to-treat analysis. RESULTS: : On April 5, 2010, 587 eligible patients were followed for a median of 5.2 years (range, 1 week-11.4 years) with 5-year confirmed follow-up data for survival and recurrence on 567 (96.6%). Significant differences between the 2 trial groups were as follows: LCR patients were older at randomization, and their pathology specimens showed smaller distal resection margins; OCR patients had some worse pathology parameters, but there were no differences in disease stages. There were no significant differences between the LCR and OCR groups in 5-year follow-up of overall survival (77.7% vs 76.0%, P = 0.64), recurrence-free survival (72.7% vs 71.2%, P = 0.70), or freedom from recurrence (86.2% vs 85.6%, P = 0.85). CONCLUSIONS: : In spite of some differences in short-term surrogate oncological markers, LCR was not inferior to OCR in direct measures of survival and disease recurrence. These findings emphasize the importance of long-term data in formulating evidence-based practice guidelines.

Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: the ALCCaS trial.

BACKGROUND: Laparoscopy has revolutionized many abdominal surgical procedures. Laparoscopic colectomy has become increasingly popular. The short- and long-term benefits and satisfactory surgical oncological treatment of colorectal cancer by laparoscopic-assisted resection remain topical. The long-term outcomes of all international randomized controlled trials are still awaited, and short-term outcomes are important in the interim. METHODS: Between January 1998 and April 2005, a multicenter, prospective, randomized clinical trial in patients with colon cancer was conducted. Six hundred and one eligible patients were recruited by 33 surgeons from 31 Australian and New Zealand centers. Patients were allocated to colectomy by either laparoscopic-assisted surgery (n = 294) or open surgery (n = 298). Patient demographics and secondary end-points, such as operative and postoperative complications, length of hospital stay, and histopathological data, will be presented in this article. Analysis was by intention-to-treat. Survival will be reported only as the study matures. RESULTS: Histopathological parameters were similar between the two groups, except in regard to distal resection margins. There was no statistically significant difference found in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in quicker return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. A statistically significant increased rate of infective complications was seen in cases converted from laparoscopic-assisted to open procedures but with no difference in reoperation or in-hospital mortality. CONCLUSIONS: Laparoscopic-assisted colonic resection gives significant improvements in return of gastrointestinal function and length of stay, with an increased operative time and no difference in the postoperative complication rate.

Treatment of duodenal adenomas with endoscopic argon plasma coagulation.

BACKGROUND: Surgical resection has been the standard treatment for duodenal adenomas. It has a high associated morbidity rate and a significant recurrence rate. The aim of this study was to evaluate endoscopic treatment of these lesions with argon plasma coagulation. METHODS: We retrospectively identified patients with non-ampullary duodenal adenomas without a polyposis syndrome and who were treated endoscopically between 1st January 1999 and 31st December 2003. Their management, follow up and outcomes were reviewed. RESULTS: Fifteen patients were included, with mean age 72 years (range 46-85 years). All were treated with at least one session of argon plasma coagulation. Initially, 13 adenomas were macroscopically cleared. Of these, eight (61%) had no recurrence during mean follow up of 40 months (26-68 months). The mean time to recurrence was 14 months (6-30 months). Eradication was possible a second time in four of five recurrent adenomas. There was one complication, of haemorrhage, from 37 sessions of argon plasma coagulation. No patient developed duodenal adenocarcinoma during the study period. CONCLUSION: Argon plasma coagulation may be safe and effective for the treatment of duodenal adenomas, but further research is required. Progression of adenomas is slow and perhaps no treatment is required.

What should be the management policy for asymptomatic inguinal hernias?

Elective surgical repair was the general policy for the treatment of asymptomatic and minimally symptomatic inguinal hernias, based on reducing the risks of possible future bowel obstruction or visceral strangulation. Two randomised controlled trials in 2006 suggested that an alternative policy of "watchful waiting" was safe and appropriate. As a result, some health authorities in the UK withdrew funding for elective surgical repair for asymptomatic hernias in 2010. The long-term follow-up results of these two trials, however, showed high rates of surgery in the watchful waiting arms due to the development of symptoms. Two recent studies have called the watchful waiting policy into question on the basis of cost-effectiveness, quality of life and mortality data. The current article shows the results of an Official Information Act request of the New Zealand Ministry of Health and the 20 District Health Boards on their current policies for the management of such hernias. The results show a range of policies, with two District Health Boards employing watchful waiting, seven with policies or health pathways that can restrict or deny access to treatment, and all District Health Boards required to comply with Ministry of Health performance indicators. It is concluded that, at least with some District Health Boards, patients with asymptomatic and minimally symptomatic inguinal hernias are given a lower priority for surgical treatment than they might merit on clinical grounds. Further research is needed to formulate appropriate policy for the management of this common disorder, and should perhaps be extended to cover other similarly common conditions.

The importance of measuring unmet healthcare needs.

Major restructuring of the health sector has been undertaken in many countries, including New Zealand and England, yet objective assessment of the outcomes has rarely been recorded. In the absence of comprehensive objective data, the success or otherwise of health reforms has been inferred from narrowly-focussed data or anecdotal accounts. A recent example relates to a buoyant King's Fund report on the quest for integrated health and social care in Canterbury, New Zealand which prompted an equally supportive editorial article in the British Medical Journal (BMJ) suggesting it may contain lessons for England's National Health Service. At the same time, a report published in the New Zealand Medical Journal expressed concerns at the level of unmet healthcare needs in Canterbury. Neither report provided objective information about changes over time in the level of unmet healthcare needs in Canterbury. We propose that the performance of healthcare systems should be measured regularly, objectively and comprehensively through documentation of unmet healthcare needs as perceived by representative segments of the population at formal interview. Thereby the success or otherwise of organisational changes to a health system and its adequacy as demographics of the population evolve, even in the absence of major restructuring of the health sector, can be better documented.

The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes.

AIM: To update activities of the Canterbury Charity Hospital (CCH) and its Trust over the 3 years 2010-2012, during which the devastating Christchurch earthquakes occurred. METHODS: Patients' treatments, establishment of new services, expansion of the CCH, staffing and finances were reviewed. RESULTS: Previously established services including general surgery continued as before, some services such as ophthalmology declined, and new services were established including colonoscopy, dentistry and some gynaecological procedures; counselling was provided following the earthquakes. Teaching and research endeavours increased. An adjacent property was purchased and renovated to accommodate the expansion. The Trust became financially self-sustaining in 2010; annual running costs of $340,000/year were maintained but were anticipated to increase soon. Of the money generously donated by the community to the Trust, 82% went directly to patient care. Although not formally recorded, hundreds of appointment request were rejected because of service unavailability or unmet referral criteria. CONCLUSIONS: This 3-year review highlights substantial, undocumented unmet healthcare needs in the region, which were exacerbated by the 2010/2011 earthquakes. We contend that the level of unmet healthcare in Canterbury and throughout the country should be regularly documented to inform planning of public healthcare services.

Ethical issues with the disclosure of surgical trial short-term data.

BACKGROUND: This paper describes the distinctions between major surgical and pharmaceutical trials and questions the application of a common ethical paradigm to guide their conduct and reporting. METHODS: Surgical trials differ from other trials in cumulative therapeutic effects, operator dependence, the clinical setting, interdependence of short- and long-term outcomes, and equipoise. A principal tenant of randomized controlled trial management is the maintenance of interim data confidentiality. Its application to complete surgical short-term data is examined across a variety of common clinical trial circumstances that influence data integrity and the reliability of conclusions regarding the benefit-to-risk profile of experimental interventions. RESULTS: Complete perioperative results describe important treatment ends that cannot influence primary outcomes. These short-term results may inform patient consent, teaching and provide valuable procedural insights to surgeons outside trial precincts. CONCLUSION: Structured experimentation standards are necessary. But, the common paradigm applied across all clinical trials and the prohibition on short term data reporting may not serve the achievement of safe and effective advancements in surgery.

Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report.

AIM: To present the early experience of establishing a community-funded and volunteer-staffed hospital in Christchurch, New Zealand. This was to provide free selected elective healthcare services to patients in the Canterbury region who were otherwise unable to access treatment in the public health system or afford private healthcare. METHODS: Data were reviewed relating to the establishment, financing, staffing and running of the Canterbury Charity Hospital. Details were provided of patients referred by their general practitioners who were seen and treated during the first two and a half years of function. RESULTS: Canterbury Charity Hospital Trust, established in 2004, completed the purchase of a residential villa in 2005 and converted it into the Canterbury Charity Hospital, which performed its first operations in 2007. By the end of December 2009, 115 volunteer health professionals and 79 non-medical volunteers had worked at the Hospital, provided a total of 966 outpatient clinic appointments, of which 609 were initial assessments, and performed 610 surgical procedures. Funding of $NZ4.3 million (end of last financial year) came from fundraising events, donations, grants and interest from investments. There has been no government funding. CONCLUSIONS: There is a substantial unmet need for elective healthcare in Canterbury, and this has, in part, been addressed by the recently established Canterbury Charity Hospital. The overwhelming community response we have experienced in Canterbury raises the question of whether the current public health system needs attention to be re-focused on unmet need. We contend that unless this occurs it might be necessary to establish charity-type hospitals elsewhere throughout the country.

Closing the audit loop is necessary to achieve compliance with evidence-based guidelines in the management of acute pancreatitis.

AIM: The aim of this study was to assess the effect of the implementation of evidence-based guidelines and subsequent feedback to surgeons in the management of acute pancreatitis. METHOD: An evidence-based Pancreatitis Proforma was developed. Data were prospectively recorded (01/06/2005-30/09/2007). Audit feedback (AFB) was performed at 9 months. A final analysis was performed comparing outcomes pre- and post-audit feedback. RESULTS: 372 patients were included. Median age (range) was 57 (12-96) years. 168 (45.2%) patients were admitted pre-AFB. Post-AFB, there was a significant increase in the number of patients whose diagnosis was made within 48 hours (135/168 (80.4%) vs 189/204 (92.6%), p<0.001) and who underwent definitive treatment for mild biliary pancreatitis (33/61 (54.1%) vs 56/70 (80.0%), p=0.002). Post-AFB there was also a significant reduction in the number of computed tomography (CT) scans performed for patients with mild acute pancreatitis (23/85 (27.1%) vs 13/99 (13.1%), p=0.018). Mortality (9/168 (5.4%) vs 3/204 (1.4%), p=0.040) also decreased. On multivariate analysis, AFB was an independent factor for change in the use of CT scans (p=0.015) and management of patients with mild biliary pancreatitis (p=0.039). CONCLUSION: For evidence-based guidelines to be effective, feedback to surgeons is necessary.

Australian and New Zealand study comparing laparoscopic and open surgeries for colon cancer in adults: organization and conduct.

This article describes the initiation and implementation of the multicentre Australia and New Zealand prospective randomized controlled clinical study comparing laparoscopic and conventional open surgical treatments of right-sided and left-sided potentially curable colon cancer (Australasian Laparoscopic Colon Cancer Study). Six hundred and one adult patients were admitted with a clinical diagnosis of a single adenocarcinoma based on a physical examination and colonoscopy, barium enema or computed tomography scan and randomly allocated to either laparoscopic or open surgery. The primary aim of the study is to compare 5-year mortality and tumour recurrence rates between the two groups. Secondary aims include comparisons of safety (intraoperative and early postoperative complications, wound site recurrence, postoperative recovery and 30-day mortality), quality of life, in-hospital costs and short-term mortality and tumour recurrence. The data for 592 patients have been collected. There are currently 3141 person years of follow up. In all 370 patients have been assessed at 5 years. This study shows that large cooperative Australia-New Zealand surgical trials can and should be carried out to address significant clinical issues. When possible, coherence with similar, concurrent international trial protocols ensures broader analyses and applicability of results. It is important to recognize that special attention to sustained funding, surgeon credentialing, clinical protocol standardization, data management, publication policy and the protection of study credibility is required from the outset. The Australasian Laparoscopic Colon Cancer Study will achieve its aims with 5-year assessments of all entered patients in March 2010.