Surgical management of complex ileocolonic Crohn's disease: a survey of IBD colorectal surgeons to assess variability in operative strategy.

INTRODUCTION: To explore the reported variability in the surgical management of ileocolonic Crohn' s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn's disease. METHODS: Anonymous videos demonstrating the small bowel walkthrough and anonymised patients' clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. RESULTS: Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. CONCLUSIONS: The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability.

BACKGROUND: Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough". METHODS: A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation. RESULTS: 12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%. CONCLUSION: Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease.

AIM: Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease. METHOD: After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide. RESULTS: A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described. CONCLUSIONS: A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Feasibility of intraoperative ultrasound of the small bowel during Crohn's disease surgery.

BACKGROUND: Intraoperative assessment of the extent and location of Crohn's disease is not standardised and relies on a mixture of surgeons' experience, tactile feedback and macroscopic appearance. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan of the small bowel and we here report the results of "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study". METHODS: This is a prospective single centre observational study with enrolment of all patients undergoing elective surgery for terminal ileal Crohn's disease from January 2019 to March 2020. Patients underwent laparoscopic ileocolic resection, according to a standardised technique. Ultrasound intraoperative quantitative assessment was performed according to the METRIC (MREnterography or ulTRasound in Crohn's disease) scoring guide. RESULTS: Intraoperative ultrasound was successfully performed in 6 patients from the ileocaecal valve to the proximal jejunum. The median time required was 23.5 min (range 17-37 min) as compared to 6.5 min (5-12 min) required for the macroscopic evaluation performed by the surgeon. In 3 patients, intraoperative ultrasound identified more disease than surgical evaluation. CONCLUSIONS: This feasibility study demonstrated the safety of intraoperative ultrasound and allowed the development of a standardised protocol for intraoperative ultrasound and the data collection required to inform a randomised multicentre study.

The impact of robotic total mesorectal excision on survival of patients with rectal cancer-a propensity matched analysis.

INTRODUCTION: Robotic surgery can overcome some limitations of laparoscopic total mesorectal excision (L-TME), improving the quality of the surgery. We aim to compare the medium-term oncological outcomes of L-TME vs. robotic total mesorectal excision (R-TME) for rectal cancer. METHODS: A retrospective analysis was performed including patients who underwent L-TME or R-TME between 2011 and 2017. Patients presenting with metastatic disease or R1 resection were excluded. From a total of 680 patients, 136 cases of R-TME were matched based on age, gender, stage and time of follow-up with an equal number of patients who underwent L-TME. We compared 3-year disease-free survival (DFS) and overall survival (OS). RESULTS: Major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate (7.4% vs. 16.9%, p = 0.01). The 3-year DFS rate for all stages was 69% for L-TME and 84% for R-TME (p = 0.02). For disease stage III, the 3-year DFS was significantly higher in the R-TME group. OS was also significantly superior in the robotic group for every stage, reaching 86% in stage III. In the multivariate analysis, R-TME was a significant positive prognostic factor for distant metastasis (OR 0.2 95% CI 0.1, 0.6, p = 0.001) and OS (OR 0.2 95% CI 0.07, 0.4, p = 0.000). Moreover, major complications were also found to have a negative impact on OS (OR 8.3 95% CI 3.2, 21.6, p = 0.000). CONCLUSION: R-TME for rectal cancer can achieve better oncological outcomes compared with L-TME, especially in stage III rectal cancers. However, a longer follow-up period is needed to confirm these findings.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate.

BACKGROUND: Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease. METHODS: A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes. RESULTS: One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease. CONCLUSIONS: Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI).

BACKGROUND: The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics. METHODS: This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR). RESULTS: Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them. CONCLUSION: A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.

Totally robotic rectal resection: an experience of the first 100 consecutive cases.

INTRODUCTION: Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons. AIM: The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015. METHOD: Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes. RESULTS: Sixty-six patients were male, the median age was 67 years (range-24-92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n = 74), abdominoperineal resection (n = 10), completion proctectomy (n = 9), restorative proctectomy with ileal pouch-anal anastomosis (IPAA) (n = 5) and Hartmann's procedure (n = 2). The median operating time was 240 min (range-135-456), and median blood loss was 10 ml (range 0-200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3-48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6-43). CONCLUSION: The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.

Major postoperative complications following elective resection for colorectal cancer decrease long-term survival but not the time to recurrence.

AIM: The aim of the study was to determine the effect of major complications after colorectal cancer surgery on survival and time to recurrence. METHOD: Patients having a curative colorectal cancer resection and a follow-up of at least 3 years were identified from a prospective database. Major complications were defined as Clavien-Dindo Grades 3b or 4 and their impact on time to recurrence and mortality was analysed by univariate and multivariable analysis. Postoperative death within 30 days or during the initial hospitalization (Clavien-Dindo Grade 5) was a priori excluded. RESULTS: From 2003 to 2012, 868 colorectal cancer resections resulting in 63 (7%) major postoperative complications including deaths (Clavien-Dindo ≥ 3b) were identified. After exclusion of Grade 5 complications (postoperative or in-hospital deaths), 844 resections with 39 (5%) major complications remained for analysis. Median follow-up time was 5.7 years. Using the Kaplan-Meier method, the estimated crude 5-year overall survival probability was 78% (95% CI 75-81) in the group without and 65% (95% CI 51-83) in the group with major complications (P = 0.009, log-rank test). Major complications were a significant negative predictor for overall survival (hazard ratio 2.42, 95% CI 1.41-4.14) when adjusted for sex, age, American Society of Anesthesiologists grade, tumour site (colon vs rectum), R stage and tumour stage. However, in both univariate and multivariable analysis, major complications were not a significant predictor for time to recurrence (hazard ratio 1.29, 95% CI 0.56-2.99). CONCLUSION: Non-lethal major postoperative complications seem to have a negative long-term impact on survival but not on time to recurrence.

Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy.

AIM: Preoperative short-course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. METHOD: Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow-up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. RESULTS: Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5-year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. CONCLUSION: The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.

The selective use of splenic flexure mobilization is safe in both laparoscopic and open anterior resections.

AIM: Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised. METHOD: Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009. RESULTS: Of 263 resections, SFM data were recorded in 216; 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). Eighty-eight were low anterior resections (LARs) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LARs (61%vs 29%, P<0.001), defunctioning ileostomy rates (75%vs 46%, P=0.001) and operative time (median 255 vs 185 min, P<0.001), with no differences in age, gender, body mass index, American Society of Anesthesiology score, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LARs with and without SFM or between open resections with and without SFM. CONCLUSION: Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers.

Is earlier referral and investigation of bowel cancer patients presenting with rectal bleeding associated with better survival?

AIM: This study was carried out to determine whether rectal bleeding is related to stage of bowel cancer and whether earlier diagnosis and treatment are associated with improved survival. METHOD: Eight hundred and forty-five patients were identified in the Wessex Bowel Cancer Audit (1991-1994). Presenting symptoms were identified from case notes. Outcome measures included 5-year survival, Dukes' stage, metastatic disease at surgery and time from onset of symptoms to treatment, in patients presenting with rectal bleeding or other symptoms and signs. RESULTS: Six hundred and seventy-six (80%) of 845 patient case notes were reviewed. Of these, 408 (60.4%) patients had rectal or sigmoid cancer, and 255 (62.5%) of these 408 patients, who presented with rectal bleeding, had significantly earlier stage disease than those with a change in bowel habit and/or abdominal pain (Dukes' stage A: 23.1%vs 3.6%; Dukes' stage D: 14.5%vs 23.4%; P < 0.001), fewer metastases visible at surgery (14.9%vs 22.6%; P < 0.001) and significantly better 5-year survival (54.8%vs 40.9%; P < 0.001). There was no further significant improvement in 5-year survival in patients treated within 6 months of the onset of symptoms (55.1%vs 53.5%). Hazard ratios showed that 5-year survival was independently associated with age, Dukes' stage and emergency treatment, but not with rectal bleeding, change in bowel habit, abdominal pain or delay in treatment. CONCLUSION: Bowel cancer patients presenting with rectal bleeding had earlier stage disease and significantly better survival than patients presenting with a change in bowel habit or abdominal pain. There was no reduction in 5-year survival in those patients who had a delay in treatment for > 6 months from the onset of symptoms.

Cleft closure for the treatment of pilonidal sinus disease.

AIM: Treatments for pilonidal sinus disease are numerous and prone to failure. In complex disease, the morbidity is high. In contrast with complex operations, the cleft closure procedure can be done simply and successfully with better cosmetic results. We present the results of a single-centre experience of this procedure. METHOD: One hundred and fifty patients had the operation; most were treated as a day case and many were operated under local anaesthetic. RESULTS: Primary healing occurred in 83 (60%) of 139 patients. Recurrences requiring surgery have been seen in 5.3%. The long-term cosmetic appearance has been noted to approach normality. CONCLUSION: Cleft closure is a simple and highly effective operation to treat recurrent or extensive pilonidal sinus disease.

Preoperative assessment of skeletal muscle mass during magnetic resonance enterography in patients with Crohn's disease.

Measurement of the psoas muscle area has been applied to estimate lean muscle mass as a surrogate marker of sarcopenia, but there is a paucity of evidence regarding the influence of sarcopenia on clinical outcomes following inflammatory bowel disease surgery. The aim of this study was to evaluate the association between MRI enterography defined sarcopenia and postoperative complications in patients undergoing elective ileocaecal resection for Crohn's disease. To obtain cross sectional area measurement of the psoas muscle, the freehand area tool was used to trace the margin of each psoas muscle at the level of L4, with the sum recorded as Total Psoas Area (TPA). The total cross sectional muscle area of the abdominal wall was recorded as Skeletal Muscle Area (SMA), while myosteatosis was measured by normalising the psoas muscle intensity with the mean intensity of the cerebrospinal fluid. The primary outcome was the incidence of 30-day postoperative complications in patients in the lowest quartile of TPA and SMA. 31 patients were included and ten patients (32.25%) developed postoperative complications within 30 days of surgery. The cut-off values for the lowest quartile for TPA were 11.93 cm2 in men and 9.77 cm2 in women, including a total of 8 patients (25.8%) with 5 patients in this group (62.5%) developing postoperative complications and 3 patients (37.5%) Clavien-Dindo class ≥ 3 complications. The cut-off values for the lowest quartile for SMA were 73.49 cm2 in men and 65.85 cm2 in women, with 4 patients out of 8 (50%) developing postoperative complications. Psoas muscle cross sectional area and skeletal mass area can be estimated on Magnetic Resonance Enterography as surrogate markers of sarcopenia with high inter-observer agreement.

Advantages of using a robotic stapler in rectal cancer surgery.

To compare short-term postoperative outcomes in patients undergoing robotic total mesorectal excision (TME) after the use of robotic and laparoscopic staplers. Over a 5-year period, 196 patients were divided into 2 groups according to the use of laparoscopic (LS) or robotic stapler (RS). Patient demographics and postoperative complications were compared. A total of 145 (74%) robotic TME were performed using the LS and 51 (26%) the RS. No conversions to laparoscopy or laparotomy were observed, in either group. Transection of the rectum using one or two firings was achieved in a higher proportion of RS cases (91%) compared with LS cases (60%; p < 0.001). The anastomotic leakage (AL) rate was 4% in the RS group vs. 7% in the LS group (p > 0.05). However, when three or more firings were needed for the rectal transection, the risk of AL increased (3.4% with ≤ 2 firings vs. 10.7% with ≥ 3 firings, p = 0.006). Our data confirm that multiple stapler firings for rectal transection have a major impact on AL. The robotic stapler simplifies the transaction, so that rectal division requires fewer stapler firings, with a potential reduction in the incidence of AL.

Disease stage and psychosocial outcomes in colorectal cancer.

OBJECTIVE: Disease stage is a strong predictor of cancer survival and is therefore assumed to influence psychosocial outcomes. However, existing findings are inconsistent, perhaps reflecting limited sample sizes, especially among patients with advanced disease. There has also been an emphasis on breast cancer, resulting in a focus on outcomes among women. The present study investigated associations between disease stage and psychosocial wellbeing in 128 patients (52% male, 48% female) diagnosed with colorectal cancer. METHOD: Patients diagnosed within the past year in a single hospital were invited to participate in a questionnaire study and give permission for staging information to be obtained from their medical records. The questionnaire included measures of anxiety, depression, quality of life, social support, social difficulties and quality of medical interactions. RESULTS: Patients with more advanced disease were more anxious (P < 0.01) and depressed (P < 0.001), perceived their social support as lower (P < 0.01), and had a worse quality of life (P < 0.01). Women with advanced disease had more severe colorectal symptoms (P < 0.01), and worse physical (P < 0.01) and emotional (P < 0.05) quality of life than men. CONCLUSION: Patients with advanced colorectal cancer have unmet psychosocial needs. Women may be more strongly affected by advanced disease than men.

Laparoscopic Redo Ileocolic Resection for Crohn's Disease in Patients with Previous Multiple Laparotomies.

PURPOSES:: Over 80% of patients with primary ileocolic Crohn's disease have a surgical resection within 10 years of diagnosis, and 40%-50% of them need further surgery within 15 years. Laparoscopic surgery can be challenging due to a thickened mesentery and the potential for fistulas, abscesses, and phlegmons. Aim of this study is to analyze the short-term outcomes of laparoscopic redo ileocolic resections for Crohn's disease in patients with previous multiple laparotomies. METHODS:: All patients undergoing laparoscopic surgery for ileocolic Crohn's disease from March 2006 to February 2017 were prospectively evaluated. Short term outcomes of laparoscopic ileocolic resection were compared between patients with previous multiple major surgeries and recurrent Crohn's disease, and patients undergoing surgery for the first presentation of Crohn's disease and no history of previous surgery. Conversion rate and 30-day morbidity were the primary outcomes. Reoperations, readmissions, operating time and length of stay were the secondary outcomes. RESULTS:: 29 patients with recurrent Crohn's disease and previous multiple laparotomies were included: the number of laparotomies these patients previously underwent was 2 in 19 cases (65.5%), 3 in 9 (31%), and 4 in 1 (3.5%). In total, 90 patients with no history of any previous abdominal surgery, who underwent laparoscopic ileocecal resection for Crohn's disease, represented the control group. No differences were found in morbidity and conversion rate. Operating time was longer in patients with history of previous abdominal surgery. CONCLUSION:: Laparoscopic redo ileocolic resection for Crohn's disease is feasible and safe in patients with previous multiple laparotomies at the expense of longer operating time.

Flexible sigmoidoscopy and whole colonic imaging in the diagnosis of cancer in patients with colorectal symptoms.

BACKGROUND: The aim was to identify the patients with colorectal symptoms most likely to benefit from whole colonic imaging (WCI) to diagnose colorectal cancer and those for whom flexible sigmoidoscopy (FS) may be initially sufficient. METHODS: This prospective observational study (16 years) included 16 433 newly referred patients with symptoms or signs of colorectal cancer. RESULTS: Colorectal cancer was diagnosed in 946 patients (diagnostic yield 5.8 per cent), 815 (86.2 per cent) in the rectum or sigmoid (distal) and 131 (13.8 per cent) in the proximal colon. Some 15 829 patients (96.3 per cent) presented with symptoms alone (without iron deficiency anaemia or abdominal mass). Of 787 cancers in these patients, 750 (95.3 per cent) were distal. The prevalence of proximal cancer above and below the age of 60 years was 0.4 per cent (33 of 8249) and 0.1 per cent (four of 7580) respectively. Of 16 256 patients having FS, 5665 (34.8 per cent) had WCI. Of the other 10 591, five subsequently presented with proximal cancers. FS missed ten (1.3 per cent) of 796 cancers. CONCLUSION: Patients with iron deficiency anaemia or a mass require WCI. However, in patients with symptoms alone, FS detects 95 per cent of cancers, and the diagnostic yield of WCI after FS is very low. Alternative management strategies need to be developed to avoid unnecessary investigations in this low-risk group.