A comparative study of colorectal surgical outcome in a national audit separated by 15 years.

AIM: The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening. METHOD: Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008. RESULTS: In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period. CONCLUSION: Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

Same Surgeon: Different Centre Equals Differing Lymph Node Harvest following Colorectal Cancer Resection.

Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node (LN) retrieval in colorectal cancer (CRC) resection. Methods. The study population was 213 consecutive patients undergoing CRC resection by a single surgeon, at two units: unit one 110 operations (2002-2005) and unit two 103 (2005-2009). LN yields and case mix were compared. Results. Median LN harvests were significantly different between the two centres: unit 1: 13 nodes/patient and unit 2: 22 nodes/patient (P < .001). In unit one 42% of cases were LN positive and in unit two 48% (P = .398). There was no difference in case mix. Multivariate analysis identified unit (P < .001) and pathologist (P = .007) as independent predictors of harvest. Conclusions. A surgeon moving units can experience significantly different LN yield following CRC resection. Both units comply with national standards, but the "surgeon's results" at the two units appear to be pathologist dependent. This has implications for nodal harvest as a surrogate marker of surgical quality.

The impact of surgeon and pathologist on lymph node retrieval in colorectal cancer and its impact on survival for patients with Dukes' stage B disease.

OBJECTIVE: An adequate lymph node harvest is necessary for accurate Dukes' stage discrimination in colorectal cancer. The aim of this study is to identify the effect of variables, including the individual surgeon and pathologist, on lymph node harvest in a single institution. METHOD: Three hundred and eighty one consecutive patients had resection for colorectal cancer, in a single unit. Factors influencing lymph node retrieval, including individual surgeon and reporting pathologist, were subjected to uni- and multivariate analysis. Actuarial survival of all patients with Dukes' stage B and C disease was then calculated and survival compared between Dukes' stage B and C at differing levels of lymph node harvest. RESULTS: The unit median lymph node harvest was 13 nodes/patient (95% CI 13.1-14.5). There was no difference in lymph node harvest between specialist colorectal surgeons and the pooled results of four nonspecialist consultant surgeons. However, there was a significant difference between reporting pathologists (P < 0.001). On univariate analysis, operation type, operative urgency, Dukes' stage, T-stage, reporting pathologist and use of neoadjuvant therapy in rectal cancer, were found to significantly affect lymph node retrieval. On multivariate analysis, operation type, T-stage, reporting pathologist and neoadjuvant therapy in rectal cancer remained significant variables. Patients with one or more lymph node metastasis had greater nodal harvests than those without (median 15 vs 12 P = 0.02). Survival of patients with Dukes' stage B disease was found to improve as lymph node harvest increased. CONCLUSION: Overall lymph node harvest, in this unit, varied according to the reporting pathologist but not operating surgeon. As lymph node harvest increased to 15 per patient, the probability of identifying a metastatic node increased.

Social deprivation and outcomes in colorectal cancer.

BACKGROUND: The aim of this study was to examine the influence of social deprivation on postoperative mortality and length of stay in patients having surgery for colorectal cancer. METHODS: Data were extracted from the Association of Coloproctology of Great Britain and Ireland database of patients presenting between April 2001 and March 2002. The effect of social deprivation, measured by the Townsend score, on 30-day postoperative mortality and length of stay was evaluated by two-level hierarchical regression analysis. RESULTS: A total of 7290 (86.8 percent) patients underwent surgery. Operative mortality was 6.7 percent and median length of stay 11 days. Deprivation indices were significantly higher in patients with Dukes' 'D' cancers, undergoing emergency surgery and with higher American Society of Anesthesiologists (ASA) grades (P<0.005). Worsening deprivation was associated with higher operative mortality and longer stay (P=0.014). For each unit increase in deprivation, there was 2.9 (95 percent confidence interval 0.5 to 5.2) percent increase in 30-day mortality. On multifactorial analysis, social deprivation was an independent predictor of length of stay, but its effect on operative mortality was explained by differences in ASA grade, operative urgency and Dukes' classification. CONCLUSION: Social deprivation was an independent risk factor of postoperative length of stay and associated with higher postoperative mortality. These results have important implications for risk modelling of postoperative outcomes.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreaticography after Billroth II gastrectomy--safe provision in a district general hospital.

INTRODUCTION: Endoscopic retrograde cholangiopancreaticography (ERCP) is available in many district general hospitals in the UK. Most of the published literature on ERCP in cases with Billroth II gastrectomy reflects teaching hospital experience. The aim of this study was to evaluate this procedure in the district general hospital setting, over a 10-year period. PATIENTS AND METHODS: Details of 41 consecutive patients, whom had previously undergone Billroth II gastrectomy and were referred for ERCP were analysed for presenting symptoms and outcome of their ERCP. All procedures were carried out by a single radiologist using a conventional Olympus side-viewing duodenoscope. RESULTS: 48 examinations and 44 therapeutic procedures were carried out in 41 cases. Afferent loop intubation and cannulation of ampulla was successful in 87.5% and 98%, respectively. Two episodes of minor bleeding occurred after sphincterotomy, not requiring blood transfusion. One case of afferent loop perforation (2%) was repaired surgically. There were no cases of pancreatitis or death in this series. DISCUSSION AND CONCLUSIONS: The results show that ERCP after a Bilroth II gastrectomy can be safe and successful in the majority of cases when carried out by clinicians with a special interest, including those in a district general hospital However, experience with this procedure will diminish due to fewer indications for Billroth II gastrectomy and emergence of magnetic resonance cholangiopancreatography. It may be advisable to concentrate this technique in a few designated centres with skill and expertise.

Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer.

OBJECTIVE: To study circumferential margin involvement (CMI) in patients undergoing restorative, compared with nonrestorative, surgery for rectal cancer. DATA SOURCE: Descriptive multicentre study, using routinely collected clinical data from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Bowel Cancer Audit database. The study encompassed 1403 newly diagnosed patients with rectal cancer undergoing either restorative (anterior resection (AR)), or nonrestorative (abdominoperineal excision of rectum (APER) or Hartmann's procedure), surgery. Operations were carried out in 39 hospitals during a variable period between April 1999 to March 2002. A logistic regression analysis was used to control for variables associated with circumferential margin involvement. RESULTS: One thousand and thirty-six patients satisfied the inclusion criteria. The average CMI was 12.5% (range 0-33.3% between hospitals). CMI for anterior resection was 7.5% (n = 629) compared with a CMI of 16.7% for APER (n = 306) and a CMI of 31.7% for Hartmann's procedure (n = 101); P < or = 0.001. CMI for patients undergoing curative surgery was 7.1% (423 anterior resections, CMI 3.8% (n = 16); 181 APER, CMI 13.3% (n = 24); 29 Hartmann's procedure, CMI 17.2%). On multivariate analysis, having controlled for Dukes' stage and operative intent, the CMI was significantly different between APER and AR (odds ratio 3.3, 95%CI 2.0-5.4), but less so between Hartmann's procedure and AR (odds ratio 2.2, 95%CI 1.1-4.2). CONCLUSIONS: APER is associated with a significantly higher CMI than anterior resection. Attention to surgical technique, with a wide perineal dissection and the use of pre-operative adjuvant therapy, may reduce CMI in patients undergoing APER.

Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM).

BACKGROUND: The aim of the study was to develop a dedicated colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (CR-POSSUM) equation for predicting operative mortality, and to compare its performance with the Portsmouth (P)-POSSUM model. METHODS: Data were collected prospectively from 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001. After excluding missing data and 93 patients who did not satisfy the inclusion criteria, 4632 patients (68.2 per cent) underwent elective surgery and 2107 had an emergency operation (31.0 per cent); 2437 operations (35.9 per cent) for malignant and 4267 (62.8 per cent) for non-malignant diseases were scored. Stepwise logistic regression analysis was used to develop an age-adjusted POSSUM model and a dedicated CR-POSSUM model. A 60:40 per cent split-sample validation technique was adopted for model development and testing. Observed and expected mortality rates were compared. RESULTS: The operative mortality rate for the series was 5.7 per cent (387 of 6790 patients) (elective operations 2.8 per cent; emergency surgery 12.0 per cent). The CR-POSSUM, age-adjusted POSSUM and P-POSSUM models had similar areas under the receiver-operator characteristic curves. Model calibration was similar for CR-POSSUM and age-adjusted POSSUM models, and superior to that for the P-POSSUM model. The CR-POSSUM model offered the best overall accuracy, with an observed : expected ratio of 1.000, 0.998 and 0.911 respectively (test population). CONCLUSION: The CR-POSSUM model provided an accurate predictor of operative mortality. External validation is required in hospitals different from those in which the model was developed.

Severe panniculitis caused by homozygous ZZ alpha1-antitrypsin deficiency treated successfully with human purified enzyme (Prolastin).

Severe panniculitis caused by alpha1-antitrypsin deficiency is very rare even though the ZZ phenotype occurs in 1 : 3500 of the population of northern Europe. We describe a 33-year-old woman with rapidly progressing panniculitis and extensive skin necrosis with multiple life-threatening complications. Initial treatment followed by maintenance therapy with human purified enzyme (Prolastin, Bayer, Bridgend, U.K.) has been life-saving.

Ideal pain relief following laparoscopic cholecystectomy.

In a previous report the effectiveness of intraperitoneal bupivacaine in reducing pain following laparoscopic cholecystectomy was demonstrated. Other methods of pain relief are commonly used but none has been compared following laparoscopic cholecystectomy. In two further studies we have compared the analgesic effect of intraperitoneal bupivacaine against wound infiltration with bupivacaine, and against intraperitoneal bupivacaine with the addition of a non-steroidal anti-inflammatory drug (NSAID) in patients undergoing laparoscopic cholecystectomy. Two consecutive studies were performed. In the first, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine injected into the trocar wounds. In the second study, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity and a diclofenac suppository (100 mg) one hour before surgery. Postoperative pain was assessed with a visual analogue pain scale. There was no difference in pain scores in the two groups in either study. Intraperitoneal bupivacaine is as effective as wound infiltration. The addition of an NSAID makes no difference in the reduction of postoperative pain following laparoscopic cholecystectomy.

Surgeons' follow-up practice after resection of colorectal cancer.

Consultant surgeons in two United Kingdom Health Regions were invited to complete a questionnaire on details of their personal management of patients with colon and rectal cancer, with particular emphasis on follow-up. Replies from 140 (94%) were analysed by the surgeon's subspecialty of colorectal and gastrointestinal surgery (group 1) and all others (group 2). There was a wide variation in the duration of followup, but no difference between the two groups. More group 1 surgeons carried out investigations as a routine after colonic (P < 0.01) and rectal (P < 0.01) resection. Colonoscopy was used more frequently by group 1 (P < 0.0001) and barium enema by group 2 surgeons (P < 0.05). Investigations to detect asymptomatic metastases were used as a routine by 33.3% of surgeons, in whom there was no concordance over the choice or combination of tests and no difference between the two groups of surgeons. There is no consensus among surgeons as to the ideal duration, intensity and method of follow-up after resection for colorectal cancer and little difference between the practice of colorectal and gastrointestinal surgeons and that of other specialists, except in the use of colonoscopy and barium enema. These results reflect the continuing lack of evidence on which to base the follow-up of patients after surgery for colorectal cancer.

Colorectal cancer pathology reporting: a regional audit.

AIMS: To audit the information content of pathology reports of colorectal cancer specimens in one National Health Service region. METHODS: All reports of colorectal cancer resection specimens from the 17 NHS histopathology laboratories in Wales during 1993 were evaluated against: (a) standards previously agreed as desirable by pathologists in Wales; and (b) standards considered to be the minimum required for informed patient management. RESULTS: 1242 reports were audited. There was notable variation in the performance of different laboratories and in the completeness of reporting of individual items of information. While many items were generally well reported, only 51.5% (640/ 1242) of rectal cancer reports contained a statement on the completeness of excision at the circumferential resection margin and only 30% (373/1242) of all reports stated the number of involved lymph nodes. All of the previously agreed items were contained in only 11.3% (140/1242) of reports on colonic tumours and 4.0% (40/1242) of reports on rectal tumours. Seventy eight per cent (969/1242) of colonic carcinoma reports and 46.6% (579/ 1242) of rectal carcinoma reports met the minimum standards. CONCLUSIONS: The informational content of many routine pathology reports on colorectal cancer resection specimens is inadequate for quality patient management, for ensuring a clinically effective cancer service through audit, and for cancer registration. Template proforma reporting using nationally agreed standards is recommended as a remedy for this, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management teams.

Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit.

BACKGROUND: To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales. METHODS: Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period. RESULTS: Of 3520 patients, 3221 (91.5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17.1 per cent). Resection of the primary disease was achieved in 2859 (81.2 per cent) and this was deemed curative in 2070 (58.8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7.6 per cent (21.7 per cent for emergency/urgent and 5.5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4.9 per cent); this was 3.9 per cent after colonic resections and 7.9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent). CONCLUSION: This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.

Is an outpatient appointment required for patients referred for a minor operation under local anaesthetic?

The necessity of an outpatient (OP) consultation for patients referred for minor surgery under local anaesthetic (LA) was examined. Two separate prospective studies were performed. The first comprised 107 patients referred for minor surgery, who were assessed in the outpatient department (OPD), before being booked for minor operations. The second study comprised 106 patients whose names were placed directly on a minor operations list on the basis of the GP referral letter alone. In the first study, 97 (91 per cent) patients went on to undergo minor surgery. Five were not suitable for LA and in five an operation was considered unnecessary. Patients not suitable for LA included children, neck swellings, pre-auricular swellings and swellings described as lymph nodes. In the second study, the GP referral letters were screened to exclude the above and of 106 referrals 93 (88 per cent) underwent a minor operation. The benefit of the second study was twofold. First, 106 OP slots were available for other referrals and secondly, patients avoided the OP waiting list and did not lose time from work as a result of the OP visit. There were no adverse effects demonstrated during the second study. We believe the OP consultation can be avoided if the referral letters are carefully screened.

Intraperitoneal bupivacaine for effective pain relief after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is now widely practised. There are various methods of pain relief used but none has been assessed or compared following this procedure. We have assessed the analgesic effect of intraperitoneal bupivacaine in laparoscopic cholecystectomy. Sixty consecutive patients were randomly assigned to one of two groups. Patients in group 1 were given 20 ml of saline injected under vision into the region of the gallbladder bed. Patients in group 2 were given 20 ml of 0.25% bupivacaine in a similar fashion. Postoperative pain was assessed with a visual analogue pain scale and the site of pain was recorded. Patients in the bupivacaine group had less pain in the early postoperative period and a lower incidence of pain in the right hypochondrium. Intraperitoneal bupivacaine is a simple and effective treatment for postoperative pain after laparoscopic cholecystectomy.

Somatostatinoma of the pancreas with hypercalcaemia. A case report.

A unique case of somatostatinoma of the pancreas complicated by severe hypercalcaemia is described. Surgical resection was not possible owing to tumour extent. A dramatic and prolonged clinical and biochemical response was achieved with streptozotocin.