Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan.

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and <1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), <1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

Correlation between ASA Grade with reversal of Hartmann's procedure - a retrospective study.

Hartmann's procedure involves resecting the rectosigmoid colon, closure of the distal rectal stump, and forming an end colostomy for complicated left colon diverticulitis or malignancy. Recovery from the initial operation can, in a second stage, be followed by a reversal stage with the restoration of bowel continuity. This study aimed to assess the reversal rate and its correlation with demographic data, ASA grade, and length of hospital stay. All patients who underwent Hartmann's emergency procedure from 2014 to 2018 at Lewisham and Greenwich hospital were enrolled in this retrospective study. Data was collected from the inpatient electronic files and NELA (UK National Laparotomy Audit). 118 patients were included in the study, with 57.6% females and a median age of patients of 69 years (range 35-91). Findings of the study indicate that the most common indications for Hartmann's procedure were diverticular complications 60% (n=71) and benign perforated sigmoid or rectosigmoid cancer 16% (n=19). The average length of hospital stay was 24 days (range n=2 - 212 days). The reversal rate was 34.9% (41/118 cases). No significant difference was observed between gender and length of hospital stay in relation to the reversal rate while there was a significant correlation between age and ASA grade in relation to reversal rate; the calculated P values were recorded as (<0.000) and (<0.009) respectively. Our results show that the highest reversal rate was observed in younger and fitter (I-II) ASA grade patients. The most common medical complication from reversal of Hartmann's procedure was an anastomotic leak (n=6, 16.7%). Reversal rate of Hartmann's procedure was 34.9%. The average timeframe for reversal was within 18-20 months. There was a significant correlation between age and ASA grade in relation to reversal rate.

Establishing the need for clinical follow-up after emergency appendicectomy in the modern era: Retrospective case series of 145 patients.

INTRODUCTION: Emergency appendicectomy (EA) is a commonly performed operation, with an increasing number of EAs being performed as day-case. The aim of this study is to establish if there is a need for post-operative follow-up and if this could prevent adverse outcomes. METHODS: A retrospective analysis of patients who underwent EA at multiple centres over a six-month period was undertaken. They were contacted by telephone and a standardised questionnaire was used to ascertain post-operative outcomes, including duration of analgesia use, duration before return to normal daily activity (ADLs), surgical site infection rates (SSI) and rates of re-presentation to medical services. Patients were stratified into those who underwent laparoscopic versus open appendicectomy, smokers versus non-smokers, and body mass index (BMI). RESULTS: A total of 145 patients were included in the study. Patients undergoing open surgery (vs. laparoscopic surgery) required analgesia for significantly longer periods, with a significantly longer return to ADLs. Smokers, when compared to non-smokers experienced a significantly longer return to work/school; and significantly higher risk of SSI and re-presenting to accident & emergency; as did patients with a BMI >30 when compared to those with a BMI <30. CONCLUSION: Most patients do not need formal outpatient assessment after EA. However, there is clearly a subset of higher risk patients who may benefit from this - patients who are smokers or obese. They have prolonged recovery times, and are at greater risk of SSI. Earlier surgical outpatient follow-up of these patients could prevent adverse outcomes.

The effectiveness of a rapid-access flexible sigmoidoscopy clinic in a district hospital.

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35-86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.

Gastrointestinal stromal tumours treated before and after the advent of c-kit immunostaining.

BACKGROUND: Recently developed immunohistochemical markers have revolutionised the classification of gastrointestinal stromal tumours (GISTs) whilst tyrosine kinase inhibitors (imatinib) have had a significant impact on the treatment of advanced tumours. We review the clinicopathological features of previously resected mesenchymal tumours of the gastrointestinal tract in our institution to 1) reclassify the histological diagnosis of those stained prior to c-kit availability; 2) perform survival analysis to identify prognostic factors, and 3) to consider the implications for patients. METHODS: Clinicopathological records of patients with a diagnosis of mesenchymal tumours treated between May 1992 and April 2007 were reviewed. RESULTS: 82 patients were reviewed. 26 (32%) were reclassified as GISTs following c-kit immunostaining and a further 14 patients were treated for GIST up to April 2007 (Total: 40 patients; 21 males and 19 females, mean age 67, range 30-92 years). 36 (90%) underwent complete resection. 5-year survival of patients with GIST alone was 80%. Females had a better median survival (M: F 43 months: 73 months). CONCLUSIONS: The availability of c-kit staining allowed 32% of previously diagnosed mesenchymal tumours to be reclassified as GISTs. This may have implications for the follow-up of patients diagnosed prior to the availability of this method.

Malignant phyllodes tumor in an 11-year-old premenarchal girl.

Phyllodes tumor is uncommon in children, and the malignant form is rare. There have only been a few cases of benign phyllodes tumor reported in peripubertal children and only one malignant case. We report the second case of malignant phyllodes tumor in a premenarchal 11-year-old girl.

Open femoral hernia repair: one skin incision for all.

BACKGROUND: Femoral hernias are relatively uncommon, however they are the most common incarcerated abdominal hernia, with strangulation of a viscus carrying significant mortality. Classically three approaches are described to open femoral hernia repair: Lockwood's infra-inguinal, Lotheissen's trans-inguinal and McEvedy's high approach. Each approach describes a separate skin incision and dissection to access the femoral sac. The decision as to which approach to adopt, predominantly dependent on the suspicion of finding strangulated bowel, is often a difficult one and in our opinion an unnecessary one. METHODS: We propose a technique for open femoral hernia repair that involves a single skin incision 1 cm above the medial half of the inguinal ligament that allows all of the above approaches to the hernia sac depending on the operative findings. Thus the repair of simple femoral hernias can be performed from below the inguinal ligament. If found, inguinal hernias can be repaired. More importantly, resection of compromised bowel can be achieved by accessing the peritoneal cavity with division of the linea semilunaris 4 cm above the inguinal ligament. This avoids compromise of the inguinal canal, and with medial retraction of the rectus abdominis muscle enables access to the peritoneal cavity and compromised bowel. DISCUSSION: This simple technique minimises the preoperative debate as to which incision will allow the best approach to the femoral hernia sac, allow for alteration to a simple inguinal hernia repair if necessary, and more importantly obviate the need for further skin incisions if compromised bowel is encountered that requires resection.

Large bowel obstruction in an adult after Soave for Hirschsprung's disease in childhood.

Whereas Hirschsprung's disease is usually managed by surgery in infancy, late complications in adult life are rarely described. We report on a 36-year-old male presenting with an unusual complication after definitive treatment of Hirschsprung's disease as an infant.

Plasma volume and hematocrit changes in recurrent fainters.

The pooling of blood in the limbs is the beginning of a chain of events which brings about the reflex syncope. Observations have confirmed that the reduction of plasma volume is also a factor pathogenetically determinant in the provocation of a faint. During orthostatic stress, plasma volume shifts towards the interstitial spaces of the infra-diaphragmatic vascular network, thus, contributing greatly to the reduction in the circulating volume. The aim of the present study was to calculate whether during orthostasis there was indeed a reduction in plasma volume and to what extent in a population at high risk for fainting. A comparative study of 50 recurrent fainters and 37 controls was performed. Each group was studied both in a supine (before) and orthostatic (after) position. Blood samples were taken to determine the hematocrit and hemoglobin values. The percentage variation of these values was calculated in order to obtain the reduction in plasma volume, i. e., the expression of the amount of plasma accumulated in the interstitial spaces. A significant difference in hematocrit and hemoglobin variation (before vs. after) was found between patients and controls. Plasma volume variation before vs. after (17.1 % in patients vs. 8.6 % in controls) was then calculated using these measurements. The difference in plasma volume variation between patients and controls can be interpreted as a co-factor together with the pooling of plasma in the pathogenesis of reflex fainting. This study illustrates an easy way to evaluate the role of plasma volume reduction in the pathogenesis of vasovagal syncope.