Repeat operations in patients with anal fistula, a retrospective study across England and Wales.

AIM: This article reports the frequency of repeat operations including waiting times within the National Health Service (NHS) of England and Wales. METHODS: Retrospective study on repeat operations for anal fistula (AF) performed between 1st January 2010 and 31st December 2016. Data were extracted from the national registry of data entered into Hospital Episode Statistics (HES). Patient factors (age, sex, self-declared ethnicity) and geographical location were tested for association with repeat operations and time to the second operation. RESULTS: We analysed 36,223 patients that had an operation for AF within 148 NHS trusts. The median follow-up time was 28 months. The majority of patients (67.4%) had only one operation. Eighty-five per cent of them remained under the care of a single consultant. Six per cent of the repeat surgeries occurred in at least three different treatment sites. Young age and female sex were associated with higher rates of repeat operations. Non-declared and Black or Black British ethnicity were associated with fewer operations. The median waiting time between the first and second operations was 27.4 weeks (IQR: 14.7-55.3); between the second and third 28.0 weeks (IQR: 14.7-57.0); between the third and fourth 29.0 weeks. CONCLUSION: This large real world population-based study shows that the majority of patients with AF undergo only one operation. Patients requiring multiple procedures tend to stay under the care of a small number of consultants but waiting times between operations are long. There is a geographical variation in the number of operations and the time between them.

CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital.

INTRODUCTION: The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. METHODS: A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. RESULTS: In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. CONCLUSION: In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.

CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital.

INTRODUCTION: The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. METHODS: A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. RESULTS: In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. CONCLUSION: In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.

A single-centre ten-year retrospective cohort study of malignant small bowel obstruction.

INTRODUCTION: Management of malignant small bowel obstruction (mSBO) is challenging. The decision to perform an operation evaluates the perceived chance of success against a patient's fitness for operation. The aim of this study was to characterise the mSBO patient population in a tertiary UK centre and assess the patient's treatment pathway including use and effects of palliative surgery, total parenteral nutrition (TPN), Gastrografin and dexamethasone as well as preoperative stratification. METHODS: Patients were included if they had mSBO confirmed on computed tomography imaging due to a primary or metastatic neoplasm. Data were collected on pathway and management, and Cox proportional hazard methods were utilised to observe effects on survival. RESULTS: Ninety-four patients were included, with 104 inpatient episodes. Mean age was 67.4 (SD 13.7), with 57 (60.6%) females. Most (89.4%) had only one admission for mSBO. Eighty-four (89.4%) patients died over the ten-year period, 18 (17.3%) within 30 days of admission. Fifty patients (53.1%) underwent operative management: 70% bypass, 24% stoma formation and 6% open-close laparotomies. Log rank testing of survival probability analysis was significant (p = 0.00018), with 50% survival probability at 107.32 days for operative management and 47.87 days for non-operative. DISCUSSION AND CONCLUSION: Operative management forms part of the treatment pathway for a significant proportion of patients with mSBO, offering a survival benefit, though quality of survival is not known. Case selection is good, with few open-close laparotomies. Trials of non-operative interventions such as Gastrografin and dexamethasone are not utilised fully.

Colorectal trainees in the UK struggle to meet JAG certification standards in colonoscopy by the end of their training.

AIM: Colonoscopy certification in the UK is taken in two parts - provisional and full - mandating lifetime procedure counts of 200 or 300, respectively. The aim of this study was to determine the number of procedures performed by colorectal trainees by the end of training compared with their gastroenterology peers and to determine the factors associated with achieving the 300-procedure target for full certification. METHOD: Dates of entry onto the specialist register were obtained from the General Medical Council. This list was cross-referenced with procedure counts from the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) Endoscopy Training System database to determine the number of colonoscopies and polypectomies performed during training. Factors associated with achieving 300 procedures were analysed by logistic regression. RESULTS: Procedures numbers were obtained for 234 gastroenterology and 148 colorectal surgery trainees. Over the last 5 years, the number of colonoscopies performed during training has declined for colorectal surgery trainees but increased for gastroenterology trainees. Gastroenterology trainees are more likely to achieve provisional and full certification. For trainees completing training in 2017, 19% of colorectal surgery trainees compared with 88% of gastroenterology trainees were able to reach the threshold of 300 procedures for full certification. CONCLUSION: Colorectal surgery trainees lag behind their gastroenterology counterparts in accruing endoscopy experience. This affects the ability of colorectal surgery trainees to achieve certification prior to completion of training. An urgent debate is required to decide what endoscopy training is required of a colorectal surgeon and how a robust training system can be put in place to ensure this is achieved.

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study.

AIM: Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. METHOD: Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4 weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups. RESULTS: In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12 weeks prior to surgery (418 within 4 weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications. CONCLUSION: This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.

The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database.

OBJECTIVE: The aim of this study was to determine the number of OGDs (oesophago-gastro-duodenoscopies) trainees need to perform to acquire competency in terms of successful unassisted completion to the second part of the duodenum 95% of the time. DESIGN: OGD data were retrieved from the trainee e-portfolio developed by the Joint Advisory Group on GI Endoscopy (JAG) in the UK. All trainees were included unless they were known to have a baseline experience of >20 procedures or had submitted data for <20 procedures. The primary outcome measure was OGD completion, defined as passage of the endoscope to the second part of the duodenum without physical assistance. The number of OGDs required to achieve a 95% completion rate was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine which factors were independently associated with OGD completion, a mixed effects logistic regression model was constructed with OGD completion as the outcome variable. RESULTS: Data were analysed for 1255 trainees over 288 centres, representing 243 555 OGDs. By moving average method, trainees attained a 95% completion rate at 187 procedures. By LC-Cusum analysis, after 200 procedures, >90% trainees had attained a 95% completion rate. Total number of OGDs performed, trainee age and experience in lower GI endoscopy were factors independently associated with OGD completion. CONCLUSIONS: There are limited published data on the OGD learning curve. This is the largest study to date analysing the learning curve for competency acquisition. The JAG competency requirement for 200 procedures appears appropriate.

The effects of CCR5 inhibition on regulatory T-cell recruitment to colorectal cancer.

BACKGROUND: Regulatory T cells (Treg) are enriched in human colorectal cancer (CRC) where they suppress anti-tumour immunity. The chemokine receptor CCR5 has been implicated in the recruitment of Treg from blood into CRC and tumour growth is delayed in CCR5-/- mice, associated with reduced tumour Treg infiltration. METHODS: Tissue and blood samples were obtained from patients undergoing resection of CRC. Tumour-infiltrating lymphocytes were phenotyped for chemokine receptors using flow cytometry. The presence of tissue chemokines was assessed. Standard chemotaxis and suppression assays were performed and the effects of CCR5 blockade were tested in murine tumour models. RESULTS: Functional CCR5 was highly expressed by human CRC infiltrating Treg and CCR5(high) Treg were more suppressive than their CCR5(low) Treg counterparts. Human CRC-Treg were more proliferative and activated than other T cells suggesting that local proliferation could provide an alternative explanation for the observed tumour Treg enrichment. Pharmacological inhibition of CCR5 failed to reduce tumour Treg infiltration in murine tumour models although it did result in delayed tumour growth. CONCLUSIONS: CCR5 inhibition does not mediate anti-tumour effects as a consequence of inhibiting Treg recruitment. Other mechanisms must be found to explain this effect. This has important implications for anti-CCR5 therapy in CRC.

Malignant melanoma of the gastro-intestinal tract: a case series.

BACKGROUND: Resection of gastrointestinal (GI) metastases of malignant melanoma (MM) offers a significant survival benefit. No adjuvant therapy has been shown to be effective in the treatment of these metastases. METHODS: All resections of MM affecting the GI tract at a UK University teaching hospital between October 1999 and January 2013 were identified from a pathology database. Demographic, investigative, operative and outcome data were retrieved from hospital records. Survival analysis was performed. RESULTS: Thirty patients were identified (median age 62.7 years). 3 patients underwent a second operation at a later date to resect further metastases. 6 patients (20.0%) presented with no identifiable cutaneous lesion. The average time to GI metastases was 52.0 months (range 4.9-139.8 months) for those with an identified cutaneous primary (n = 24). Two patients with initial cutaneous lesions with Breslow's thickness <1 mm developed GI metastases. Common presenting symptoms included abdominal pain (n = 8, 27.6%), GI bleeding (n = 5, 17.2%) and symptoms of GI tract obstruction (n = 4, 13.8%). CT scan was the most commonly performed investigation (96.6%). Over half of resections (54.5%, n = 18) included small bowel resection. Mortality at 2 and 5 years was 66.4% and 73.1%. Of the 3 patients who underwent a second resection of GI metastases, one is still alive after 26 months of follow up; 2 patients died after 32.8 and 18.6 months. CONCLUSIONS: Clinicians should have a low threshold for investigating GI symptoms in patients with a history of malignant melanoma even in the case of early-stage primary disease. Re-resection should be considered in patients presenting with further GI metastases.

Evaluation of serum lysyl oxidase as a blood test for colorectal cancer.

AIMS: Lysyl oxidase (LOX) expression is elevated in colorectal cancer (CRC) tissue and associated with disease progression. A blood test may form a more acceptable diagnostic test for CRC although LOX has not previously been measured in the serum. We therefore sought to determine the clinical usefulness of a serum LOX test for CRC in a symptomatic population. METHODS: Adult patients referred to a hospital colorectal clinic with bowel symptoms completed a questionnaire and provided a blood sample for serum LOX measurement. Associations between presenting symptoms, serum LOX concentrations and outcomes of investigations were tested by univariate and multivariate analyses to determine if serum LOX was clinically useful in the prediction of CRC. LOX expression in CRC and adjacent colon biopsies was evaluated by ELISA and immunohistochemistry. RESULTS: Thirty-one cases of colorectal cancer and 16 high-risk polyps were identified from a total of 962 participants. There was no association between serum LOX concentration and the presence of CRC, high-risk polyps or cancers at any site. LOX expression was significantly increased in CRC tissue compared to adjacent colon. CONCLUSION: Despite overexpression of LOX in CRC tissue, elevated serum levels could not be demonstrated. Serum LOX measurement is therefore not a clinically useful test for CRC.

Patients newly diagnosed with ulcerative colitis receive earlier treatment in surgical clinics.

AIM: The diagnosis and treatment of ulcerative colitis (UC) is traditionally the realm of gastroenterologists. However, the symptoms of UC overlap with those of bowel cancer and patients may be initially referred to colorectal surgery clinics. The aims of this study were to define which specialty most frequently diagnoses UC and to determine if there were differences in management between the two specialities. METHOD: The demographics, presenting symptoms and clinical management of patients with newly diagnosed UC were determined and compared by speciality clinic of initial referral. Histopathology reports and clinic letters were reviewed to identify patients newly diagnosed with UC at a large university teaching hospital from January 2007 to January 2012. RESULTS: Patients were more commonly referred to colorectal surgeons (74 vs 41 patients) than gastroenterologists. Patients referred to gastroenterology were younger (36.0 vs 59.6 years, P < 0.01) but there were no significant differences in gender, presenting symptoms or disease extent. Rigid sigmoidoscopy ± biopsy was more commonly performed in colorectal clinic (93.2 vs 31.7%, P < 0.01). There was a significantly shorter delay in starting disease-specific treatment for those patients referred initially to colorectal surgery (13.8 vs 33.6 days, P = 0.01). Performing rigid sigmoidoscopy in clinic was associated with starting disease-specific treatment at this visit. CONCLUSION: Patients with first presentation UC are more commonly seen in colorectal surgery clinics where rigid sigmoidoscopy is more frequently undertaken, allowing earlier commencement of UC treatment.

Assessing the value of matrix metalloproteinase 9 (MMP9) in improving the appropriateness of referrals for colorectal cancer.

BACKGROUND: A blood test may be an effective means of improving the appropriateness of referrals for symptomatic patients referred to specialist colorectal clinics. We evaluated the accuracy of a serum matrix metalloproteinase (MMP9) test in indicating colorectal cancer or its precursor conditions in a symptomatic population. METHODS: Patients aged over 18, referred urgently or routinely to secondary care following primary care presentation with colorectal symptoms completed a questionnaire and provided a blood sample for serum MMP9 estimation. Univariate analysis and logistic regression modelling investigated the association between presenting symptoms, MMP9 measurements and the diagnostic outcome of patient investigations, in order to derive the combination of factors which best predicted a high risk of malignancy. RESULTS: Data were analysed for 1002 patients. Forty-seven cases of neoplasia were identified. Age, male gender, absence of anal pain, diabetes, blood in stools, urgent referral, previous bowel polyps and previous bowel cancer were significantly associated with neoplasia. Matrix metalloproteinase 9 measurements were not found to be associated with significant colorectal pathology. CONCLUSION: This study, despite robust sampling protocols, showed no clear association between MMP9 and colorectal neoplasia. Matrix metalloproteinase 9 therefore appears to have little value as a tool to aid referral decisions in the symptomatic population.

The influence of key clinical practices on the knowledge of first year doctors about the patients under their care.

AIMS: In 2009 in the United Kingdom the 48-h working week was introduced for junior doctors. To comply with this traditional working practices have changed. This study aims to assess how much first year (FY1) doctors know about the acute surgical patients they manage and how this is influenced by changes in key working practices. METHODS: Surgical FY1s working in NHS hospitals answered 16 clinical questions about a standard acute surgical patient under their care 48 h after admission. Scores were analysed according to how long the FY1 had been looking after the patient, whether they had clerked the patient in, attended the post take ward round (PTWR), used a handover sheet to answer the questions and had sole or shared responsibility for the patient. RESULTS: Two hundred and seventy-four FY1s (92% response rate) from 36 hospitals were surveyed. The overall median score was 11/16 (inter-quartile range 8-13). Only 8.4% (23/274) FY1s had clerked in the patient and 58.4% (160/274) had attended the PTWR. Clerking patients and attending the PTWR resulted in significantly higher test scores compared to FY1s who did not perform these activities (p = < 0.001 and 0.001 respectively). The scores of the 67.2% who used a handover sheet were significantly lower than those who did not (p = 0.001). Having sole or shared responsibility and duration of care made no significant difference (p = 0.143 and p = 0.458 respectively) CONCLUSIONS: The results demonstrate that junior doctors' knowledge of their patients is significantly enhanced when they have the opportunity to perform the admission clerking and attend the PTWR. Because of working hours' restrictions this is now rare. Although use of handover sheets appears to ensure that certain key facts immediately related to the current admission are passed on, it is associated with significantly poorer wider knowledge of the patient.

The sensitivity of needle core biopsy in combination with other investigations for the diagnosis of phyllodes tumours of the breast.

BACKGROUND: The sensitivity of needle-core biopsy (NCB) in diagnosing phyllodes tumours has only been addressed by a handful of small studies. The aim of this study was to analyse the sensitivity of NCB in the diagnosis of phyllodes tumours and to compare this to the sensitivity of other commonly performed investigations. A secondary aim was to assess the effect of various patient and disease factors on the rate of false negative test results. METHODS: Pathology databases were interrogated to identify all patients with the SNOMED term M-9020 or the word phyllodes in specimen reports. Excisional specimen reports were matched to prior FNAC reports, NCB reports and imaging reports. RESULTS: Ninety-one patients had a confirmed phyllodes tumour on excision. The sensitivity of FNAC, NCB and imaging for diagnosing phyllodes tumours was 40%, 63% and 65% respectively. The sensitivity of imaging and NCB was greater for borderline and malignant lesions. Combining cytohistological and radiological tests improved sensitivity to 76%. A younger age was associated with a greater false negative rate for all tests. Borderline and malignant phyllodes tumours were significantly associated with advancing age and greater lesion size on imaging and histology. CONCLUSIONS: This is the largest report to date assessing the sensitivity of NCB in the diagnosis of phyllodes tumours. Increased sensitivity in the diagnosis of phyllodes tumours can be achieved by combining cytohistological and radiological test results. The novel association between younger age and false negative results warrants further investigation. The most likely explanation is a reluctance to diagnose phyllodes tumours in young women given the increased prevalence of cellular fibroadenomas in this age group.

Serum matrix metalloproteinase 9 and colorectal neoplasia: a community-based evaluation of a potential diagnostic test.

BACKGROUND: A blood test may be a more acceptable routine colorectal cancer (CRC) screening test than faecal occult blood test, flexible sigmoidoscopy or colonoscopy, and could be safer and cheaper. We evaluated the accuracy of a serum matrix metalloproteinase (MMP9) test for CRC in a non-presenting symptomatic population. METHODS: A cohort, aged 50-69 with lower gastrointestinal symptoms, was identified by community-based survey. Accuracy of serum MMP9 was assessed by comparison with colonoscopy. Logistic regression identified predictors of neoplasia and receiver operating characteristic curve analyses determined the cutoff to maximise the sensitivity. RESULTS: Data were available for 748 patients. Overall, 46 cases of neoplasia were identified. Univariate analysis demonstrated that demographic characteristics, behavioural factors, clinical symptoms and raised serum MMP9 concentration were all significantly associated with the presence of neoplasia. Our final logistic regression model had a sensitivity of 79% and specificity of 70%. CONCLUSION: We demonstrated a significant association between serum MMP9 concentration and the presence of neoplasia. Serum MMP9 levels are raised in those with cancer and high-risk adenomas, although MMP9 estimation is likely to have the greatest predictive utility when used as part of a panel of biomarkers. Further work is required to identify biomarkers that are sufficiently accurate for implementing into routine practice.

Herniography influences the management of patients with suspected occult herniae and patient factors can predict outcome.

PURPOSE: Patients with groin pain and no palpable hernia are a diagnostic challenge for the surgeon. It is recognised that some patients will have an occult hernia and benefit from surgical repair. Herniography remains popular in some units, as it has a high diagnostic sensitivity. METHODS: Presenting symptoms and signs were recorded, along with herniogram findings, management plan and outcome for all patients undergoing herniography between July 2004 and December 2009. Demographic factors and individual symptoms and signs were analysed for their ability to predict a positive herniogram. RESULTS: There were a total of 72 positive and 132 negative herniograms. For positive herniograms, only 41 (59%) patients underwent surgery and six (16%) patients were found not to have a hernia. The most common reasons for not proceeding to surgery were herniogram findings thought to be insignificant and the herniogram being positive on the contralateral side. For negative herniograms, despite a negative herniogram, four (3%) patients underwent surgery and a hernia was confirmed in two patients. Regarding predictive symptoms and signs, history of a groin lump and greater patient age were significantly associated with a positive herniogram and a confirmed hernia at surgery. CONCLUSIONS: After a positive herniogram, less than two-thirds of patients undergo surgery. The majority have improved symptoms on review and we, therefore, suggest a period of watchful waiting prior to herniography. Older patients and a history of a groin lump are associated with a positive herniogram and confirmed hernia at surgery, and could be used to select patients for laparoscopic exploration.

A two-millimetre free margin from invasive tumour minimises residual disease in breast-conserving surgery.

AIMS: In breast-conserving surgery, the width of free margin around a tumour to ensure adequate excision is controversial. The aim of this study was first to evaluate the frequency of residual disease in wider excision specimens in patients who undergo further surgery because of close margins of < 5 mm. Secondly, the ability of demographic and tumour-related factors to predict the close margins was appraised. PATIENTS AND METHODS: Three-hundred-and-three patients were included in the study. Patients undergoing wider excision were assessed for the presence of residual disease, and this was tested for association with the width of the initial free margin. Various factors were studied for association with close or involved margins by univariate analysis. RESULTS: Fifty-three per cent of patients were eligible for re-excision based on the need for a 5-mm clearance. With a free margin of 2 mm or more from invasive tumour, the probability of finding residual disease was 2.4%. The probability of residual disease was higher for ductal carcinoma in situ (DCIS) and did not decline with increasing the free margin width. Tumour size, lobular cancer type, vascular invasion and nodal involvement were associated with close margins. CONCLUSIONS: We suggest that a free margin of 2 mm from invasive tumour is adequate to minimise residual disease, whereas the equivalent free margin for DCIS remains unclear. Patients with large tumours and lobular cancer type should be counselled at the time of first surgery concerning the higher risk of further excision and mastectomy.

Freehand versus ultrasound-guided core biopsies of the breast: reducing the burden of repeat biopsies in patients presenting to the breast clinic.

In our breast unit a significant proportion of core biopsies are performed freehand sometimes necessitating a repeat biopsy under image guidance. The aims of this study were to establish the proportion of patients undergoing freehand core biopsies who proceeded to a repeat procedure and to determine any factors associated with a missed freehand biopsy. Four hundred and ten core biopsies over 21 months were included in the analysis. Demographic details, position and size of the lump, breast volume and lesion depth were recorded. Twenty-four percent freehand biopsies were repeated under ultrasound guidance. The histological classification of two-thirds of the repeat biopsies were upgraded, suggesting that the lesion had been previously missed. Multivariate analysis showed that missed freehand biopsies were strongly associated with deep lesions. If all lumps sited at a depth of 6mm or more were selected for US-guided core biopsy, the workload for the ultrasound department would increase by just less than a half and would have the effect of reducing the freehand biopsy miss rate by almost two-thirds. Core biopsies should be performed under ultrasound guidance. A freehand technique could be limited to superficial lesions. Depth is more predictive for a missed biopsy than lesion size or breast volume.

Seasonal variation in emergency referrals to a Surgical Assessment Unit.

OBJECTIVES: To identify any seasonal variation in the pattern of referrals to the Surgical Assessment Unit (SAU). METHODS: Admission data to the SAU were collected prospectively during two audit periods of 13 weeks each (winter 2004/2005 and summer 2005). The data were analysed comparing numbers of admissions over the two audit periods and variations in the presenting complaint. RESULTS: There were a significantly greater number of referrals to the SAU in the summer compared with winter (999 vs. 849, p = 0.026). Whilst there were no significant differences in the sex distribution of patients presenting with general surgical symptoms, a significantly greater proportion of male patients presented with urological symptoms. Additionally, a significantly greater proportion of patients presented in the summer with scrotal/testicular symptoms compared with the winter (13.9% vs. 8.5%, p = 0.02). There was no significant difference between the two periods in terms of other diagnoses. In both study periods, the SAU was busy during weekdays compared with weekends. Whilst most patients arrived in the SAU between 9 am and midnight a smaller but not insignificant number arrived outside of these hours. CONCLUSIONS: Summer compared with winter was a busy period for the SAU. This may be important in managing emergency surgical admissions. A significantly greater proportion of patients presented with scrotal/testicular symptoms during the summer, the reasons for which are unclear. The SAU diverts workload away from busy Accident & Emergency departments.

Unnecessary investigations in patients with acute pancreatitis: arterial blood sampling and serum biochemistry.

BACKGROUND: Most patients admitted with acute pancreatitis undergo arterial blood gas sampling (ABG) to calculate the modified Glasgow score (MGS) and serum amylase and liver function tests (LFTs) are requested frequently during admission. This study aims to assess the necessity of these investigations. MATERIALS & METHODS: A retrospective study of all patients attending a district general hospital with a diagnosis of acute pancreatitis (AP) between November 2005 and November 2006 was performed. Patients were identified from clinical coding data, excluding those with serum amylase levels of < 5501 U/l thereby increasing the likelihood of correct diagnosis. Demographic data and ABC reports were retrieved from the case notes. Criteria were defined for necessity of amylase and LFT requests. RESULTS: Data were retrieved for 63 patients with 227 amylase requests, 329 LFT requests, 95 ABGs and 80 MGSs. Eight ABGs were found to have PaO2 values less than 8kPa, a result that could be predicted in all cases by pulse oximeter-derived oxygen saturations of less than 95%. When the MGS excluding the PaO2 parameter was two, only one patient out of 22 (4.5%) was upgraded to a score of three due to a PaO2 of less than 8 kPa and this could have been predicted by pulse oximeter-derived oxygen saturations of 92%. The MGS excluding the PaO2 parameter was always three or more in cases where acid-base disturbance exhibited more than a mild metabolic acidosis. One hundred and sixty-two unnecessary amylase requests and 168 unnecessary LFT requests were made according to our defined criteria, equating to 2.6 unnecessary amylase requests and 2.7 unnecessary LFT requests per admission at a cost of pounds 83.40 (pounds 1.32 per admission). CONCLUSIONS: We propose not performing ABGs if the MCS excluding the PaO2 component totals two or less. Clinical judgment would have to be exercised. Unnecessary serum biochemistry requests are frequent but at little financial expense.