Need For Whole Large Bowel Investigation in Sole Change in Bowel Habit: An Analysis of 719 Patients.

Purpose/Aim of the study: Patients referred for suspected colorectal cancer typically undergo whole large bowel investigation (WLBI) as per national guidelines. Sole change in bowel habit (CIBH) with no anemia/abdominal mass at time of referral has low oncological yield following diagnostic investigations, particularly for tumors proximal to the splenic flexure. Study aims were to evaluate cancer yield of patients referred for suspected colorectal cancer presenting with sole-symptom CIBH and to assess clinical and financial feasibility of a straight-to-test flexible sigmoidoscopy (FS). Materials and methods: We analyzed all 2-week wait referrals with sole CIBH between January 2013 and 2015. Information collected included cancer yield and oncological management. Results: Overall 1831 patient referrals were made during our study time. 719 (39.3%; median age 72 years, interquartile range: 65-79.5) were identified with sole CIBH at referral and underwent subsequent WLBI. 597 (83%) patients reported predominant looser/increased frequency stool (PLS) whilst the remaining 122 (17%) had predominant hard/decreased frequency stool (PHS). Overall, 18 were diagnosed with colorectal cancer (2.5%) with a further 9 patients (1.3%) harboring non-colorectal malignancies. The PHS group yielded a significantly higher proportion of colorectal cancers than the PLS group (adjusted OR 3.24, 95% CI: 1.23-8.54; p = .02). Colonic tumors proximal to the splenic flexure are uncommon in patients with sole CIBH (0.69%). In those with PLS, one proximal malignancy (0.17%) was detected with WLBI. Conclusions: Sole CIBH without anemia/abdominal mass yields a 2.5% colorectal malignancy rate from 2-week wait referrals. Those with PLS had a 0.17% yield of proximal tumors. A straight-to-test FS in this low risk group would be clinically effective with potential annual savings of more than £50 000.

A Comparison of Emergency First Presentations of Colorectal Cancer in Under-50 and Over-50 Year-Old Patients.

Introduction: Colorectal cancer (CRC) is the second commonest malignancy related death in Western Europe with incidence increasing in young adults. 31% of UK patients with CRC present as emergencies. We compare the incidence, characteristics, management and outcomes in two cohorts presenting as CRC emergencies; under-50 and over-50 years old. Materials and Methods: Retrospective analysis was performed on 322 patients with emergency presentations of CRC over a 9-year period (January 2005-December 2013, West Suffolk Hospital, UK). Data were analyzed for demographics, symptoms, investigations, stage, grade, genetics, tumor location, management, and mortality. Results: 300 patients over 50 years old presented with CRC emergencies; 153 women (51%):147 men (49%); median age 77 years (interquartile range: 67-84). 22 patients under 50-years-old; 12 women (55%):10 men (45%); median age 43 years ([Interquartile Range (IQR)]: 35-46 years). Bowel obstruction was less common in under-50s (18.2% vs. 40.7%; p = 0.04). No over-50s had a positive family history for CRC; 7 under-50s did. A higher proportion of under-50s presented with Dukes A carcinomas (14.3% vs. 0.4%; p = 0.002), but no difference in other Dukes stages. Surgery was performed in a higher proportion of under-50s (95.5% vs. 77.0%; p = 0.04) and a higher proportion had same day surgery (71.4% vs. 28.1%; p = 0.01). Overall mortality was lower in under-50s (36.4% vs. 64.0%; p = 0.02). No significant differences occurred in in-hospital mortality (4.7% vs. 8.0%; p = 0.55), overall one-year survival (31.8% vs. 41.7%; p = 0.36), or median survival to death or study conclusion (27.1 vs. 19.6 months; p = 0.13). Conclusion: Emergency CRC had comparable outcomes between young and old cohorts, during the study time period. Younger patients were more likely to undergo operative interventions but overall survival was comparable.Our study was limited by the reporting biases intrinsic to retrospective analyses and by a small under-50 sample size. Further large-scale studies are warranted to support observations.

Iron therapy for preoperative anaemia.

BACKGROUND: Preoperative anaemia is common and occurs in 5% to 76% of patients preoperatively. It is associated with an increased risk of perioperative allogeneic blood transfusion, longer hospital stay, and increased morbidity and mortality. Iron deficiency is one of the most common causes of anaemia. Oral and intravenous iron therapy can be used to treat anaemia. Parenteral iron preparations have been shown to be more effective in conditions such as inflammatory bowel disease, chronic heart failure and postpartum haemorrhage due to rapid correction of iron stores. A limited number of studies has investigated iron therapy for the treatment of preoperative anaemia. The aim of this Cochrane Review is to summarise the evidence for iron supplementation, both enteral and parenteral, for the management of preoperative anaemia. OBJECTIVES: To evaluate the effects of preoperative iron therapy (enteral or parenteral) in reducing the need for allogeneic blood transfusions in anaemic patients undergoing surgery. SEARCH METHODS: We ran the search on 30 July 2018. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic and Embase (Ovid), CINAHL Plus (EBSCO), PubMed, and clinical trials registries, and we screened reference lists. We ran a top-up search on 28 November 2019; one study is now awaiting classification. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that compared preoperative iron monotherapy to placebo, no treatment, standard care or another form of iron therapy for anaemic adults undergoing surgery. We defined anaemia as haemoglobin values less than 13 g/dL for males and 12 g/dL for non-pregnant females. DATA COLLECTION AND ANALYSIS: Two review authors collected data and a third review author checked all collected data. Data were collected on the proportion of patients who receive a blood transfusion, the amount of blood transfused per patient (units), quality of life, ferritin levels and haemoglobin levels, measured as continuous variables at the following predetermined time points: pretreatment (baseline), preoperatively but postintervention, and postoperatively. We performed statistical analysis using the Cochrane software, Review Manager 5. We summarised outcome data in tables and forest plots. We used the GRADE approach to describe the quality of the body of evidence. MAIN RESULTS: Six RCTs, with a total of 372 participants, evaluated preoperative iron therapy to correct anaemia before planned surgery. Four studies compared iron therapy (either oral (one study) or intravenous (three studies)) with no treatment, placebo or usual care, and two studies compared intravenous iron therapy with oral iron therapy. Iron therapy was delivered over a range of periods that varied from 48 hours to three weeks prior to surgery. The 372 participants in our analysis fall far short of the 819 required - as calculated by our information size calculation - to detect a 30% reduction in blood transfusions. Five trials, involving 310 people, reported the proportion of participants who received allogeneic blood transfusions. Meta-analysis of iron therapy versus placebo or standard care showed no difference in the proportion of participants who received a blood transfusion (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.87 to 1.70; 4 studies, 200 participants; moderate-quality evidence). Only one study that compared oral versus intravenous iron therapy measured this outcome, and reported no difference in risk of transfusion between groups. There was no difference between the iron therapy and placebo/standard care groups for haemoglobin level preoperatively at the end of the intervention (mean difference (MD) 0.63 g/dL, 95% CI -0.07 to 1.34; 2 studies, 83 participants; low-quality evidence). However, intravenous iron therapy produced an increase in preoperative postintervention haemoglobin levels compared with oral iron (MD 1.23 g/dL, 95% CI 0.80 to 1.65; 2 studies, 172 participants; low-quality evidence). Ferritin levels were increased by intravenous iron, both when compared to standard care ((MD 149.00, 95% CI 25.84 to 272.16; 1 study, 63 participants; low-quality evidence) or to oral iron (MD 395.03 ng/mL, 95% CI 227.72 to 562.35; 2 studies, 151 participants; low-quality evidence). Not all studies measured quality of life, short-term mortality or postoperative morbidity. Some measured the outcomes, but did not report the data, and the studies which did report the data were underpowered. Therefore, uncertainty remains regarding these outcomes. The inclusion of new research in the future is very likely to change these results. AUTHORS' CONCLUSIONS: The use of iron therapy for preoperative anaemia does not show a clinically significant reduction in the proportion of trial participants who received an allogeneic blood transfusion compared to no iron therapy. Results for intravenous iron are consistent with a greater increase in haemoglobin and ferritin when compared to oral iron, but do not provide reliable evidence. These conclusions are drawn from six studies, three of which included very small numbers of participants. Further, well-designed, adequately powered, RCTs are required to determine the true effectiveness of iron therapy for preoperative anaemia. Two studies are currently in progress, and will include 1500 randomised participants.

A cohort investigation of anaemia, treatment and the use of allogeneic blood transfusion in colorectal cancer surgery.

INTRODUCTION: Preoperative identification and treatment of anaemia is advocated as part of Patient Blood Management due to the association of adverse outcome with the perioperative use of blood transfusion. This study aimed to establish the rate of anaemia identification, treatment and implications of this preoperative anaemia on ARBT use. METHODS: All patients who underwent elective surgery for colorectal cancer over 18 months at a single Tertiary Centre were reviewed. Electronic databases and patient casenotes were reviewed to yield required data. RESULTS: Complete data was available on 201 patients. 67% (n = 135) had haemoglobin tested at presentation. There was an inverse correlation between tumour size and initial haemoglobin (P < 0.01, Rs = -0.3). Initial haemoglobin levels were significantly lower in patients with right colonic tumours (P < 0.01). Patients who were anaemic preoperatively received a mean 0.91 units (95%CI 0-0.7) per patient which was significantly higher than non-anaemic patients (0.3 units [95%CI 0-1.3], P < 0.01). For every 1 g/dl preoperative haemoglobin increase, the likelihood of transfusion was reduced by approximately 40% (OR 0.57 [95%CI 0.458-0.708], P < 0.01). Laparoscopic surgery was associated with fewer anaemic patients transfused (P < 0.01). CONCLUSION: Haemoglobin levels should be routinely checked at diagnosis of colorectal cancer, particularly those with large or right sided lesions. Early identification of anaemia allows initiation of treatment which may reduce transfusion risk even with modest haemoglobin rises. The correct treatment of this anaemia needs to be established.

Iron therapy for pre-operative anaemia.

BACKGROUND: Pre-operative anaemia is common and occurs in up to 76% of patients. It is associated with increased peri-operative allogeneic blood transfusions, longer hospital lengths of stay and increased morbidity and mortality. Iron deficiency is one of the most common causes of this anaemia. Oral iron therapy has traditionally been used to treat anaemia but newer, safer parenteral iron preparations have been shown to be more effective in other conditions such as inflammatory bowel disease, chronic heart failure and post-partum haemorrhage. A limited number of studies look at iron therapy for the treatment of pre-operative anaemia. The aim of this Cochrane review is to summarise the evidence for use of iron supplementation, both enteral and parenteral, for the management of pre-operative anaemia. OBJECTIVES: The objective of this review is to evaluate the effects of pre-operative iron therapy (enteral or parenteral) in reducing the need for allogeneic blood transfusions in anaemic patients undergoing surgery. SEARCH METHODS: We ran the search on 25 March 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic and EMBASE (Ovid), CINAHL Plus (EBSCO), PubMed, clinical trials registries, conference abstracts, and we screened reference lists. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) which compared pre-operative iron monotherapy to placebo, no treatment, standard of care or another form of iron therapy for anaemic adults undergoing surgery. Anaemia was defined by haemoglobin values less than 13 g/dL for males and 12 g/dL for non-pregnant females. DATA COLLECTION AND ANALYSIS: Data were collected by two authors on the proportion of patients who receive a blood transfusion, amount of blood transfused per patient (units) and haemoglobin measured as continuous variables at pre-determined time-points: pre-treatment, pre-operatively but post-treatment, and post-operatively. Statistical analysis was performed using the Cochrane statistical software, Review Manager 2014. Outcome data were summarised in tables and a forest plot. MAIN RESULTS: Three prospective randomised controlled studies evaluated pre-operative iron therapy to correct anaemia (two in colorectal and one in gynaecological surgery) and included 114 patients in total. One compared oral iron versus standard care (Lidder 2007); one intravenous iron versus control (Edwards 2009); and one study compared oral versus intravenous iron (Kim 2009). Both colorectal trials reported the primary outcome (proportion of patients who received allogeneic blood transfusions) and meta-analysis showed a reduction in blood transfusions with the administration of iron therapy, but the reduction was not statistically significant (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.27 to 1.18). All studies reported haemoglobin change but data for the anaemic patients were only available for two studies (Edwards 2009 and Kim 2009). Edwards 2009 showed no difference in haemoglobin at the end of treatment pre-operatively. The intravenous versus oral iron study showed an increase in haemoglobin with intravenous iron at the end of treatment pre-operatively (MD 1.90 g/dL, 95% CI 1.16 to 2.64; participants = 56), but the results are at high risk of bias because participants with less than 80% compliance with therapy were excluded from the analysis and compliance was lower in the oral iron group due to the side-effects of treatment (Kim 2009).None of the studies reported quality of life, short- or long-term mortality or post-operative morbidity. AUTHORS' CONCLUSIONS: The use of iron therapy for pre-operative anaemia does not show a statistically significant reduction in the proportion of patients who received an allogeneic blood transfusion compared to no iron therapy. However, the 38 patients in our analysis falls far short of the 819 patients our information size calculation recommended to detect a 30% reduction in blood transfusions. Intravenous iron may be more effective than oral iron at increasing haemoglobin. However, all these conclusions are drawn from only three small randomised controlled studies. Further well designed, adequately powered randomised controlled studies are required to determine the true effectiveness of iron therapy for pre-operative anaemia.