The value of auditing negative lower GI investigations preceding a final diagnosis of colorectal cancer.

OBJECTIVE: To review all preceding 'negative' large bowel investigations in patients with a final diagnosis of colorectal cancer, and to examine whether delayed diagnosis was associated with worse outcome. METHOD: Details were gathered on all patients with a new diagnosis of colorectal adenocarcinoma presenting over 4.5 years. For each patient the hospital's clinical workstation and radiology and endoscopy databases were interrogated for all flexible sigmoidoscopies, colonoscopies and barium enemas during the 5 years prior to diagnosis. RESULTS: Among the 570 patients, 28 (5%) had undergone colonoscopy and/or flexible sigmoidoscopy that had not shown colorectal cancer during the 5 years preceding final diagnosis, and a further 28 (5%) had undergone 'negative' barium enemas. Polyp surveillance might have missed four lesions destined to become malignant. Correspondingly there were three patients undergoing IBD surveillance found to have CRC, having had a negative complete colonoscopy within the preceding 5 years. Among patients undergoing de novo colonoscopy for diagnosis the true miss rate was only one patient per year. At August 2007, 29 (58%) of those with delayed diagnosis were still alive, compared with 216 (42%) of those diagnosed during initial investigation (chi2 = 5.04, P < 0.05). CONCLUSIONS: Colonoscopic miss rates are in line with previous studies. The application of simple clinical ground rules will avoid most pitfalls. The methodology described herein may assist in auditing the quality assurance of lower gastrointestinal diagnostic services. Despite the delay, late diagnosis was found to be associated with improved survival and a lower likelihood of metastatic disease.

Anxieties should not be forgotten when screening relatives of colorectal cancer patients by colonoscopy.

OBJECTIVE: Individuals with a strong family history have a high risk of developing colorectal cancer. They could well benefit from targeted screening and their increased risk warrants an invasive procedure such as colonoscopy. This study aims to assess the anxieties of symptom-free relatives offered screening by colonoscopy. METHOD: A simple questionnaire was sent to 50 consecutive people who had colorectal cancer screening by colonoscopy because of a strong family history. RESULTS: Forty-five questionnaires were answered. On assessing their anxiety levels before and after colonoscopy, 56% noticed an improvement after the test, 33% were still as anxious and 11% had raised anxiety levels despite screening. Although most of the screening colonoscopies were normal, 44% of asymptomatic relatives undergoing invasive screening had no improvement of their cancer anxieties. CONCLUSION: Screening people with a strong family history of colorectal cancer may be an efficient, cost-effective and focussed way of detecting early neoplasms rather than screening the general population. Using colonoscopy alone however, a large proportion of people still have cancer anxieties after being screened. This small study suggests that in order to attempt to alleviate anxieties, a colonoscopy alone is insufficient for some in this high-risk group.

Laparoscopic or trephine faecal diversion: is there a preferred approach and why?

BACKGROUND: Faecal diversion is often indicated in perineal sepsis and in the palliation of advanced ano-rectal malignancy. This can be performed open or laparoscopically. The aim of this study was to assess the outcome of these two approaches to stoma creation. METHODS: Prospective evaluation of laparoscopic or 'trephine' stoma creation in 49 consecutive unselected patients. RESULTS: Eighteen (37%) patients (median age 68 years) underwent a laparoscopic approach in which there were no conversions. One patient required a laparotomy for stoma mal-orientation and there were two (11%) deaths. Thirty-one patients (median age 70 years) had a trephine stoma formed with two (6%) conversions but no deaths. Thirteen (42%) of these patients had surgery performed under regional anaesthesia. There was no difference in the hospital stay between the two groups and at a mean follow-up of 16 months, 20 (41%) patients had died mainly from disease progression. CONCLUSION: Both approaches to faecal diversion give adequate results in the short term. Laparoscopic techniques should be reserved for fitter patients as a trephine stoma can be performed under regional anaesthesia.

Selective operative cholangiography and Perioperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy: a viable option for choledocholithiasis.

BACKGROUND: Most common bile duct (CBD) stones can now be removed by minimally invasive methods using pre- or postoperative endoscopic sphincterotomy. A few centers explore the bile duct laparoscopically, but not every hospital has access to the equipment for magnetic resonance (MR) cholangiopancreatography to diagnose ductal stones. This study shows the results of an alternative management option. METHODS: We did a retrospective review of perioperative endoscopic retrograde cholangiopancreatographies (ERCPs) and sphincterotomies that were performed on patients in whom choledocholithiasis had been revealed on operative cholangiogram. RESULTS: Thirteen patients underwent perioperative ERCP. Nine had successful duct clearance, three had failure to cannulate, and one was converted to an open procedure due to an anatomical problem. The combined median operating time for both procedures was 75 min and hospital stay was 2.5 days. No pancreatitis was reported. CONCLUSION: Selective operative cholangiography and perioperative ERCP during laparoscopic cholecystectomy is a viable option for the simultaneous management of CBD and gallbladder stones. Moreover, it helps to avoid unnecessary normal ERCP.

Flexible sigmoidoscopy in general practice.

OBJECTIVE: Flexible sigmoidoscopy (FS) is increasingly being accepted as the method of choice for initial investigation of rectal bleeding and other lower gastrointestinal symptoms. The aim of this study was to assess the feasibility of FS in general practice and to compare the yield, cost and efficiency of a service provided by a consultant surgeon and a General Practitioner (GP). SUBJECTS AND METHODS: A prospective study of FS was undertaken on 430 unsedated patients with symptoms suggestive of lower bowel disease in two general practices. RESULTS: The yield was comparable to hospital based data. Fifteen (3.5%) cancers were detected, of which 40% were Dukes A, and 46 (10.7%) adenomatous polyps. Cost per patient examination by a GP including capital costs, depreciation of equipment, and training was calculated to be cheaper or at least equivalent to a hospital-based service but inefficient due to the low numbers examined per month. There were no complications and no missed cancers after a minimum follow up of 2 years. CONCLUSIONS: The results suggest that FS can be safely performed by a suitably trained GP in health centres, but better utilization of equipment and value for money would be obtained by providing the service for a group of practices rather than a single practice as in this study.

Randomized trial of the addition of flexible sigmoidoscopy to faecal occult blood testing for colorectal neoplasia population screening.

BACKGROUND: Published data suggest that screening might reduce the mortality rate from colorectal neoplasia. Faecal occult blood (FOB) testing suffers from poor sensitivity and significant numbers of interval cancers, both of which should be improved by the addition of flexible sigmoidoscopy (FOS). METHODS: This prospective, randomized study aimed to assess the compliance and neoplasia yield of FOB testing and FOS compared with that of FOB testing alone. From general practitioner registers, 6371 asymptomatic patients (3124 men, 3247 women; age range 50-74 years) were invited for screening by means of FOB testing (3128 patients) performed at home, or a combination of FOB testing and FOS (3243 patients). RESULTS: Compliance with FOB testing alone was 50 per cent. In the FOB testing/FOS group, 48 per cent returned the FOB test but only 20 per cent went on to FOS. Despite the poor compliance, the neoplasia yield was four times greater in the FOB testing/FOS group. CONCLUSION: FOS increase the neoplasia yield but strategies to improve compliance must be identified for this to become a population screening test.

Can emergency general surgical referrals be reduced? A prospective study.

It has been proposed that early assessment by a senior surgeon would result in a significant reduction in the number of general surgical admissions. A prospective study of 290 surgical patients admitted to a busy district general hospital over a period of 1 calendar month has been performed to test this hypothesis. After admission, all patients were assessed by a senior surgeon who carried out triage for each patient. The commonest diagnoses in descending order of frequency were non-specific abdominal pain, appendicitis, diverticular disease, cholecystitis, head injury and pancreatitis. Twenty-two per cent of emergency admissions underwent emergency surgery. A total of 90.7% of admissions were deemed appropriate, 5.5% were deemed inappropriate and in 3.8% of cases the senior surgeon was uncertain as to whether the patient should be admitted or not. Our data fail to substantiate the claim that a significant reduction in intake size would be achieved by early assessment by a senior surgeon. Assessment by surgeons may mean sacrificing other clinical commitments, and is likely to result in a diminution in the standard of both basic and higher surgical training.

Results of endoscopic retrograde cholangio-pancreatography using a mobile image intensifier.

The results of performing endoscopic retrograde cholangio-pancreatography (ERCP) using a mobile image intensifier in a theatre or endoscopic unit are presented. Over a 2-year period, a total of 157 ERCPs were attempted in 131 patients. The procedure was successful in 146 cases (93%), with failure in 11 cases (7%). A total of 75 endoscopic sphincterotomies were attempted in 60 patients, and 69 (92%) procedures were successful, with failure to perform a sphincterotomy occurring in 6 (8%) procedures. Of the 69 successful sphincterotomies, 8 (11.6%) patients subsequently required surgery as a result of failure of stone extraction or gall bladder symptoms. There were 11 (7.5%) complications following sphincterotomy, with only one death (0.68%) attributable to the procedure. With results approaching those of specialist centres, the above method is suggested as an alternative way to expand ERCP services where X-ray department facilities are not readily available.

Feasibility of 'day case' laparoscopic cholecystectomy.

Laparoscopic cholecystectomy was offered as a day case to 15 patients (mean age 42; range 33-72 years). Three patients required overnight admission for non-operative reasons. The mean in-hospital stay for those patients successfully treated as day cases was 8.5 h and overall 12 h (range 6-28 h). In selected cases day case laparoscopic cholecystectomy is a feasible alternative to conventional inpatient management.

Cecocolic intussusception in multiple lymphomatous polyposis of the gastrointestinal tract. Report of a case.

A rare case of recurrent cecocolic intussusception in an adult patient with multiple lymphomatous polyposis of the gastrointestinal tract is presented. Clinical features, especially the difficulty in distinguishing this entity from adenomatous polyposis on colonoscopy, and histopathology are discussed. It is important that surgeons and colonoscopists be aware of this rare form of diffuse gastrointestinal lymphoma because of therapeutic implications.

Endoscopic retrograde cholangiopancreatography using a mobile image intensifier.

A method of performing endoscopic cholangiopancreatography using a mobile intensifier in a theatre or endoscopy unit setting is described. A total of 140 ERCPs were attempted in 132 patients. The examination was diagnostically successful in 114 (85%) of patients and endoscopic sphincterotomy was performed in 54 (38.5%). There were 10 (18%) complications after sphincterotomy and one postoperative death after a retroperitoneal leak. With increasing expertise, it is hoped to match the figures from specialist centres, and this method is suggested as an alternative way to expand this service where X-ray department facilities are not readily available.

Inguinal hernia repair in the elderly.

Inguinal hernia repairs were performed on 452 patients during a 14-month period. Of these patients, 116 (26%) were aged greater than 65 years. Emergency hernia repair for incarceration or strangulation was more common in the elderly (16.4%) than in those aged less than 65 years (4.4%) (P less than 0.001). Postoperative complications were significantly more common after emergency (58%) than elective repair (22%) of hernias in the elderly (P less than 0.01). There were two deaths (operative mortality 10%) following emergency repair and none after elective surgery. The average length of hospital admission was 5 days, rising to 10 days in cases suffering complications. Because of the high morbidity and mortality associated with emergency repair in the elderly, all inguinal hernias should be repaired electively unless there is an overwhelming contraindication to surgical intervention.

Submucosal versus ligation excision haemorrhoidectomy: a comparison of anal sensation, anal sphincter manometry and postoperative pain and function.

Submucosal (SM) and ligation excision (LE) haemorrhoidectomy were compared to establish whether SM is a less painful procedure and whether anal sensation is better preserved by SM, and, if so, how this relates to postoperative function. There were 18 SM and 22 LE patients. Anal sphincter manometry and anal mucosal electrosensitivity were measured pre-operatively and 6 weeks after surgery. Postoperative pain was assessed by linear analogue scale. Anal sphincter pressures which were high pre-operatively fell to normal after surgery. Neither operation affected functional sphincter length or the recto-anal inhibitory reflex. Forty per cent of patients showed ultraslow waves on sphincter motility studies. These were associated with the highest pressures and in all but three cases disappeared after surgery. There were no differences in postoperative pain scores between the two techniques but there was a wide range from no pain to very severe pain in both groups. Submucosal haemorrhoidectomy preserved anal sensation better than ligation excision but this was not reflected in improved function. There was minor leakage and soiling in 50 per cent of patients from both groups and two SM and LE patients had initial faecal incontinence. All these symptoms had resolved by 6 weeks.

An evaluation of a direct access flexible fibreoptic sigmoidoscopy service.

During a 3 year period 146 general practitioners referred 630 patients to a direct access flexible sigmoidoscopy clinic. The yield was 53.3% with significant colonic or rectal pathology in 30%. Twenty six cancers, 4 Dukes' A, and 38 patients with symptomatic adenomatous polyps were detected. Five further cancers were detected by subsequent barium enemas. The service reduced delay in diagnosing colorectal pathology but did not reduce the number of barium enemas requested by general practitioners. It is suggested that where facilities are already available, such a service to investigate rectal bleeding in patients over 40 years is of benefit both to patients and general practitioners.