Demographics and macroeconomic effects in aesthetic surgery in the UK.

Media interest in aesthetic surgery is substantial and suggestions of demographic changes such as reductions in age or an increase in the number of male patients are common. In spite of this, there is no peer reviewed literature reporting demographics of a contemporary large patient cohort or of the effect of macroeconomic indicators on aesthetic surgery in the UK. In this study, computer records 13006 patients presenting between 1998 and the first quarter of 2003 at a significant aesthetic surgery centre were analysed for procedures undergone, patient age and sex. Male to female ratios for each procedure were calculated and a comparison was made between unit activity and macroeconomic indicators. The results showed that there has been no significant demographic change in the procedures studied with patient age and male to female ratio remaining constant throughout the period studied for each procedure. Comparison with macroeconomic indicators suggested increasing demand for aesthetic surgery in spite of a global recession. In conclusion, media reports of large scale demographic shifts in aesthetic surgery patients are exaggerated. The stability of unit activity in spite of falling national economic indicators suggested that some units in the UK might be relatively immune to economic vagaries. The implications for training are discussed.

Multicentre audit of death from acute pancreatitis.

A prospective audit of acute pancreatitis involving nine hospitals in the North-West Thames Region recruited 631 patients over 54 months. There were 57 deaths (9 per cent); a diagnosis had been reached in 50 patients (88 per cent) before death and in seven (12 per cent) at autopsy. Eighteen patients (32 per cent) died within the first week, usually as a result of multisystem organ failure (15 patients). Thirty-nine patients (68 per cent) died after the first week from complications related to infection (26 patients) co-morbid conditions (nine) or non-infective complications (four). Twenty-one patients (42 per cent) had been inadequately evaluated by Ranson's criteria, and only 22 (44 per cent) of 50 with a premortem diagnosis of pancreatitis had undergone computed tomography (CT). Fifteen of 26 patients who died from infection-related complications had CT and only nine underwent necrosectomy or surgical drainage. These data suggest that improved diagnosis, investigation and management of patients with acute pancreatitis is possible, and may result in improved clinical outcome.

Resource implications of head injuries on an acute surgical unit.

Head injuries are expensive and demanding in terms of resources. In the UK, most are cared for outside neurosurgical centres. In the absence of specialist rehabilitation services, patients with on-going disability add to those admitted for observation and treatment on acute surgical wards. We audited the workload pattern and financial implications related to head injuries on a general surgical unit in a central London teaching hospital. Data collected prospectively at the time of admission and derived from departmental computerized information systems included clinical outcome, hospital stay and its relationship to severity of injury and other factors. Ward, departmental (accident and emergency (A & E), intensive therapy unit (ITU), radiology, and theatre) and neurosurgical referral costs were derived. Long-term social and rehabilitation costs were not calculated. Over a 6 month period 899 patients with head injuries were treated in the A & E department, of whom 156 were admitted. Of the admitted patients 68% were classified as minor; 22% as moderate; and 10% as severe head injuries. Fifty-one per cent of adult admissions were intoxicated by alcohol. Prolonged hospital stay was related to age, severity of head injury, mechanism of injury, associated injuries and preexisting neuropsychiatric conditions (including alcoholism). Six patients died. The direct cost of these head injuries patients was estimated at 173,500 pounds, during which time they occupied 7.6% of our unit's adult inpatient capacity. Twenty-four hour observation of 76 patients with minor head injuries contributed 9700 pounds (5.6%) to this figure. Associated extracranial injuries cost a further 46,500 pounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomised controlled trial of adjuvant chemotherapy by portal-vein perfusion after curative resection for colorectal adenocarcinoma.

About half the patients treated with curative resection for colorectal cancer do not survive long-term. Adjuvant chemotherapy given during and after surgery may prevent hepatic metastases and improve patient survival. In patients with colorectal cancer, we have done a multicentre, randomised controlled trial comparing five-year survival after intraportal infusion of fluorouracil (1 g per day) plus heparin (10,000 U per day) (130 patients) or heparin alone (123) during curative resection and for 7 days thereafter, or after resection alone (145). There was no reduction in liver metastasis or increased overall survival advantage in either active-treatment arm of the study. However, patients who had stage III, Dukes' C (lymph-node-positive) tumours resected and were treated with fluorouracil plus heparin had a significant (p less than 0.03) survival advantage of about 16% compared with surgery-only controls. Further study of intraportal infusion of chemotherapeutic agent as adjuvant treatment to surgery in patients with colorectal cancer appears worthwhile.

Large bowel cancer: the effect of perioperative blood transfusion on outcome.

Perioperative blood transfusion has been reported to adversely affect survival in cancer patients, but the evidence is inconclusive and may be an epiphenomenon. From the Large Bowel Cancer Project, 961 patients who underwent curative resection and left hospital alive have been reviewed to compare the effect of perioperative blood transfusion on outcome; 591 patients (61%) had been given a blood transfusion while 370 (39%) had not been transfused. Some clinical variables were equally distributed between the two groups; ie age, sex, obstruction, perforation, tumour differentiation. Three other variables known to influence patient prognosis were not equally distributed, ie tumour site, Dukes' stage and tumour mobility. Patients with tumours of the rectum and rectosigmoid, with Dukes' stage C lesions and with some degree of tumour fixation were more likely to have received blood transfusions. Using the logrank method of multivariate analysis to allow for differences in distribution of all those variables known to affect prognosis, there was no survival disadvantage for those patients who had received perioperative blood transfusion. Furthermore, there were no overall differences between the two groups of patients in their risk of developing local tumour recurrence or distant metastases. The distribution of metastases differed: in the 'transfused' group only 37% of distant metastases were found in the liver, while 71% were found in this site in the 'not transfused' group (chi 2 = 18.46, d.f. = 1, P less than 0.001). By contrast, there was a larger proportion of patients with lung metastases in the transfused group (27% vs 11%) (chi 2 = 5.59, d.f. = 1, P less than 0.05). Therefore, these data do not support the concept of an overall deleterious effect of blood transfusion on patient survival, but suggest that blood given in the perioperative period may change the biology of the metastatic process.

Factors influencing mortality after curative resection for large bowel cancer in elderly patients.

Mortality rates from the Large Bowel Cancer Project are presented with special reference to patients older than 70 years. The in-hospital mortality rate among those who underwent curative resection for colorectal carcinoma was 7%. Unlike long-term prognosis, which is influenced by pathological features, in-hospital mortality is influenced largely by clinical factors. Age was an adverse factor (78% of deaths occurred among those aged over 70, who formed 46% of the study population), as was obstruction or perforation. 55% of deaths were due to cardiopulmonary complications. Educating patients to seek treatment early, careful preoperative assessment and postoperative monitoring of cardiopulmonary function, and, in selected patients, use of local treatments rather than wide resections may help to reduce mortality in elderly patients.

Prediction of outcome after curative resection for large bowel cancer.

Prospectively collected information on 2524 patients who had undergone "curative" resection for colorectal cancer was analysed to establish the rank-order of importance of both clinical and pathological factors affecting outcome. The patients were divided into two groups. In the first, a statistical weighting was established for each prognostic factor and those that influenced long-term survival were, in order of importance, lymph node status, tumour mobility, number of lymph nodes positive for tumour, presence of bowel obstruction, and depth of primary tumour penetration. Factors that influenced in-hospital mortality were cardiopulmonary complications, intraabdominal sepsis (without anastomotic leak), presence of bowel obstruction, and age. In the second group these mathematical weightings were applied, and the predicted and observed outcomes were in close agreement. Statistical techniques of this kind will be of value in prognosis and in analysis of the results of new treatment regimens.

Influence of tumour site on presentation, management and subsequent outcome in large bowel cancer.

To demonstrate any difference in outcome between patients with carcinoma at various sites within the large bowel, analysis of a large number of patients is necessary. From the Large Bowel Cancer Project, 4292 patients have been evaluated to compare mode of presentation, surgical management, pathological findings and outcome. Carcinoma at the splenic flexure was associated with the highest risk of obstruction (49 per cent); postoperative cardiopulmonary complications (36 per cent); in-hospital mortality (18 per cent); and the lowest age-adjusted 5-year survival (28 per cent), even after curative resection (38 per cent). This survival disadvantage was seen even in those without obstruction. Further, it was not accounted for by differences in age, sex, Dukes' stage or tumour differentiation between the various sites as stratification by these variables failed to alter significance (log rank chi 2 = 11.1; d.f. = 4; P less than 0.05). Compared with carcinoma of the left colon and rectum, tumours in the right colon were more likely to be poorly differentiated and locally advanced (in terms of fixation and penetration of the bowel wall) but were not associated with a higher risk of either distant spread at presentation or local recurrence. Age-adjusted 5-year survival following curative surgery was higher for the right colon (65 per cent) than the left (59 per cent).

Malignant large bowel obstruction.

Of 4583 patients in the Large Bowel Cancer Project, 713 (16 per cent) were obstructed. The site of greatest risk was the splenic flexure (49 per cent). Advanced stage was neither the full reason why some patients obstructed nor for their subsequent poor prospects (age-adjusted 5-year survival: not obstructed, 45 per cent; obstructed, 25 per cent). Also, there was no greater risk of vascular invasion, no heavier lymph node burden and no worse tumour differentiation in patients with obstruction. In-hospital mortality was high (23 per cent), was not reduced by either a policy of primary or staged resection and was not influenced by the site of obstruction. There was no survival advantage for either policy, but hospital stay after primary resection was half that of staged. Immediate anastomosis in the obstructed left colon had a high clinical leak rate (18 per cent versus 6 per cent elective; P less than 0.001). Both registrars and consultants had similar mortality rates for elective primary resection and for the management of obstruction itself (as evidenced by results after the first stage of a staged resection). Selection probably accounts for the very much better results achieved by consultants for primary resection in the presence of obstruction (in-hospital mortality: consultants, 13 per cent; registrars, 24 per cent).

Large bowel cancer: surgical pathology and its relationship to survival.

Modifications of Dukes' (1932) classification of rectal tumours have led to confusion. From the data of 2518 patients who had undergone curative colorectal surgery the interrelationships between tumour penetration, grade, vascular invasion and pattern of lymph node involvement have been examined and their individual relevance to survival determined. Subdivision of Dukes' A cases into those confined to the muscularis mucosae (A) and those penetrating into, but not through, the bowel wall (B1) should be abandoned. Despite interrelationships between lymph node status, grade of tumour and vascular invasion, they all contribute prognostic information independent of each other. Apical lymph node involvement, more than four lymph nodes involved and extensive primary tumours with nodal involvement all carry a bad prognosis. Although interrelated each variable is individually relevant. However, subgroups of patients with Dukes' C tumours have an observed survival significantly better than expected. When few lymph nodes are involved or the primary tumour is confined to the bowel wall but lymph nodes are involved, the expectation of life is equivalent to Dukes' B.

Covering stoma for elective anterior resection of the rectum: an outmoded operation?

A prospective multicenter study of the management of large bowel cancer recorded the results in 4,500 patients in whom 2,056 have had an elective colorectal anastomoses. Of these patients, 15.8 percent had a synchronous covering stoma to protect the anastomoses. Although the anastomotic leak rate was high in patients with a stoma, no overall differences were observed in mortality between those patients who had a covering stoma and those patients who did not (7 percent and 6.1 percent, respectively). However, when surgical policies were analyzed, clinically large and statistically significant differences were found. Some surgeons frequently used a covering stoma for low anterior resection whereas others only rarely did so. The differences in anastomotic leak and mortality were 20 percent and 7.8 percent, and 8.4 percent and 3.6 percent, respectively. We conclude that all surgeons should know their own clinical and radiologic anastomotic leak rate. If and when this figure becomes low (less than 5 percent), the covering stomas will become necessary except for the very rare and difficult case.

Local recurrence following 'curative' surgery for large bowel cancer: II. The rectum and rectosigmoid.

1988 patients with an adenocarcinoma of the rectum (1292; 65 per cent) or rectosigmoid (696; 35 per cent) have been studied. A resection (1700 patients) or polypectomy (124 patients) was performed in 1824 (92 per cent) and, of the former, 1376 patients either underwent abdominoperineal (AP) excision of the rectum (788 patients) or an anterior resection (598 patients). The in-hospital mortality was 63 patients (8 per cent) for AP and 44 (7 per cent) for anterior resection, and a curative resection had been performed in 504 (71 per cent) of those undergoing an AP, and 393 (71 per cent) of those undergoing an anterior resection. Follow-up information is available for 478 patients (95 per cent) who underwent an AP and 370 (94 per cent) who underwent an anterior resection. More patients have developed a local recurrence after an anterior resection (67; 18 per cent) than after AP (57; 12 per cent) (Logrank chi2 = 6.6, d.f. = 1, P less than 0.02) (stratified for sex and Dukes' stage). This difference is not accounted for by a lesser margin of distal clearance after an anterior resection; firstly because the margin of clearance was not different in those who did and those who did not develop a local recurrence (AP: whole group = 4.4 cm, local recurrence = 4.5 cm; anterior resection: whole group = 3.0 cm, local recurrence = 3.1 cm) and secondly because for each centimetre of distal clearance there was a consistently greater probability of recurrence for anterior resection (Logrank chi2 = 9.1, d.f. = 1, P less than 0.01) (stratified for sex, Dukes' stage and distal clearance margin).

Local recurrence following 'curative' surgery for large bowel cancer: I. The overall picture.

The Large Bowel Cancer Project is a collaborative prospective study of 4228 patients with a histologically proven adenocarcinoma, of whom 2336 (55 per cent) survived a 'curative' resection. Follow-up information is available on 2220 patients (95 per cent). Subsequently, 309 (14 per cent) have developed a local recurrence confirmed by: biopsy (127; 41 per cent), clinical examination (77; 25 per cent), X-ray (15; 5 per cent), a raised CEA (2; 1 per cent), or some other method - e.g. CT scan or a confident unbiopsied laparotomy finding (88; 29 per cent). Statistically significant factors (chi2 test, P less than 0.05) associated with local recurrence are: Dukes' classification: A 4 per cent; B 13 per cent; C 18 per cent Tumour differentiation: Well 11 per cent; Moderate 14 per cent; Poor 21 per cent Obstruction: Absent 13 per cent; Present 21 per cent Perforation: Absent 13 per cent; Present 28 per cent Tumour mobility: Freely mobile 11 per cent; Others 21 per cent Operation performed (rectal and rectosigmoid tumours): Abdomino-perineal 12 per cent; Anterior resection 18 per cent; Surgeon (Consultant only): Range less than 5 per cent to greater than 20 per cent. Stratification of the above variables altered only the statistical significance pertaining to tumour differentiation (P less than 0.1, d.f. = 2). In particular, the differences between Consultant surgeons remained.

Preoperative urography in large bowel cancer: a useless investigation?

The utility of intravenous urography (IVU) in the preoperative assessment of patients with adenocarcinoma of the large bowel has been investigated in 4226 patients derived from a prospective multicentre study entitled the Large Bowel Cancer Project. An IVU was carried out in 956 of these patients (22.6 per cent), subsequent surgery revealed unsuspected direct urinary tract involvement in 75. However, 42 (56 per cent) had shown no IVU abnormality. Twenty patients having a clinical colovesical fistula had had a preoperative IVU. Only half showed an abnormality. In the entire study group, 10 nephrectomies and 40 other concomitant urinary tract resections were performed. Four of these nephrectomies were associated with right-sided tumours. A significantly higher number of patients with a rectal primary had a preoperative IVU. The value of routine preoperative urography before large bowel cancer surgery is questioned, and other methods of determining function in the other kidney before nephrectomy should be sought.