Removing hospital-based triage from suspected colorectal cancer pathways: the impact and learning from a primary care-led electronic straight-to-test pathway.

BACKGROUND: The 2-week wait referral pathway for suspected colorectal cancer was introduced in England to improve time from referral from a general practitioner (GP) to diagnosis and treatment. Patients are required to be seen by a hospital clinician within 2 weeks if their symptoms meet the criteria set by the National Institute for Health and Care Excellence (NICE) and to start cancer treatment within 62 days. To achieve this, many hospitals have introduced a straight-to-test (STT) strategy requiring hospital-based triage of referrals. We describe the impact and learning from a new pathway which has removed triage and moved the process of requesting tests from hospital to GPs in primary care. METHOD: An electronic STT pathway was introduced allowing GPs to book tests supported by a decision aid based on NICE guidance eliminating the need for a standard referral form or triage process. The hospital identified referrals as being on a cancer pathway and dealt with all ongoing management. Routinely collected cancer data were used to identify time to cancer diagnosis compared with national data RESULTS: 11357 patients were referred via the new pathway over 3 years. Time from referral to diagnosis reduced from 39 to 21 days and led to a dramatic improvement in patients starting treatment within 62 days. Challenges included adapting to a change in referral criteria and developing a robust hospital system to monitor the pathway. CONCLUSION: We have changed the way patients with suspected colorectal cancer are managed within the National Health Service by giving GPs the ability to order tests electronically within a monitored cancer pathway halving time from referral to diagnosis.

Nutcracker phenomenon presenting as loin pain haematuria syndrome.

A 19-year-old female presented with bilateral severe loin pain associated with recurrent macroscopic haematuria. A provisional diagnosis of loin pain haematuria syndrome was made; the severity and frequency of pain led to referral to the pain management service. Alternative diagnoses were considered. Although previous reports of obstruction of the left renal vein have not described pain of this severity, magnetic resonance angiography was performed; it showed obstruction of the left renal vein as it passed between the superior mesenteric artery and aorta, i.e. the nutcracker phenomenon. Both pain and haematuria resolved fully after autotransplantation.

Interval biliary stent placement via percutaneous ultrasound guided cholecystostomy: another approach to palliative treatment in malignant biliary tract obstruction.

Percutaneous cholecystostomy is a minimally invasive procedure for providing gallbladder decompression, often in critically ill patients. It can be used in malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography when the intrahepatic ducts are not dilated or when stent insertion is not possible via the bile ducts. In properly selected patients, percutaneous cholecystostomy in obstructive jaundice is a simple, safe, and rapid option for biliary decompression, thus avoiding the morbidity and mortality involved with percutaneous transhepatic biliary stenting. Subsequent use of a percutaneous cholecystostomy for definitive biliary stent placement is an attractive concept and leaves patients with no external drain. To the best of our knowledge, it has only been described on three previous occasions in the published literature, on each occasion forced by surgical or technical considerations. Traditionally, anatomic/technical considerations and the risk of bile leak have precluded such an approach, but improvements in catheter design and manufacture may now make it more feasible. We report a case of successful interval metal stent placement via percutaneous cholecystostomy which was preplanned and achieved excellent palliation for the patient. The pros and cons of the procedure and approach are discussed.

Colonic vascular anomalies and colon cancer in neurofibromatosis: report of a case.

We report a case of neurofibromatosis with synchronous adenocarcinomas in the sigmoid and transverse colon. There was widespread intimal proliferation in arteries in the region of the tumors and also in the cecum. Such vascular lesions are associated with von Recklinghausen's disease. The cecal lesion produced mural thickening visible on computed tomography. This case supports a possible genetic link between neurofibromatosis and adenocarcinoma of the colon.

Multidetector CT angiography in live donor renal transplantation: experience from 156 consecutive cases at a single centre.

The performance of multidetector computed tomography (CT) angiography was assessed in the pre-operative evaluation of live renal donors. Between July 1998 and March 2006, 156 consecutive patients underwent open donor nephrectomy following pre-operative multidetector CT angiography (MDCTA). Operative notes were compared with radiological reports and discrepancies identified. MDCTA missed five of 28 accessory arteries (four visible with hindsight), accuracy of 96%. Of 30 early-branching renal arteries, eight were missed (all visible with hindsight), accuracy 95%. MDCTA missed only one of 13 venous anomalies (accuracy 97%) and also missed the only duplicated collecting system: both were undetectable with hindsight. Following modifications to image acquisition and interpretation sensitivity, negative-predictive value and accuracy were significantly increased. The results were compared with pooled data from published studies of live donor imaging. This study and previous studies of MDCTA had improved sensitivity for arterial and venous anomalies over single detector CT angiography and MR angiography. We conclude that multidetector CT angiography is an accurate modality in the pre-operative evaluation of live renal donors. Regular communication between the transplant surgeon and the radiologist is paramount to improve reporting of surgically relevant anatomy. Mechanisms should exist for auditing and improving pre-operative imaging in any live donor programme.