Referral guidelines for colorectal cancer--do they work?

AIMS AND METHODS: Urgent referral guidelines for patients with suspected colorectal cancer were introduced in 2000. In a district general hospital, we prospectively assessed the effect of these guidelines on the number of urgent referrals received and the number found to have cancer. RESULTS: Over the first year, 180 urgent referrals were received of whom 95 (55%) fitted the guidelines. Of these 95 patients, 24 (25%) had colorectal cancer. Conversely, only 2 of the 85 patients (2%) who did not fit the guidelines had colorectal cancer. During the same time period, a total of 145 new cancers were identified within the district of which 119 (82%) were in patients who had not been urgently referred to out-patients as suspected colorectal cancer. DISCUSSION: The guidelines are effective in that patients who fit them have a significant chance of having colorectal cancer. However, the majority of cancers are identified outside the new system. Efforts to reduce delays in diagnosis need to recognise that many patients do not have features which fit published referral criteria. Improved support for general practitioners and better access to specialist services are required to reduce delays in diagnosis.

The combination of electrically stimulated gracilis neoanal sphincter and continent colonic conduit: a step forward for total anorectal reconstruction?

PURPOSE: Patients undergoing total anorectal reconstruction for anorectal atresia or following abdominoperineal resection of the rectum do not fare as well after an electrically stimulated gracilis neoanal sphincter as patients with incontinence alone. This retrospective study reports the outcome for the combination of a continent colonic conduit or antegrade continence enema procedure with an electrically stimulated gracilis neoanal sphincter in patients with atresia or following an abdominoperineal resection of the rectum as part of total anorectal reconstruction to overcome combined incontinence and evacuatory dysfunction. METHODS: Between September 1994 and September 1999, 11 continent colonic conduits were fashioned in 11 patients with an electrically stimulated gracilis neoanal sphincter as part of total anorectal reconstruction for end-stage fecal incontinence. In addition, three patients had an antegrade continence enema procedure in situ, one of which was converted to a colonic conduit at a later stage. Five patients had a colonic conduit fashioned subsequent to an electrically stimulated gracilis neoanal sphincter, four had both procedures in a combined operation, and five had a conduit formed before an electrically stimulated gracilis neoanal sphincter (including the three with an antegrade continence enema procedure). RESULTS: Median follow-up was 53 (range, 7-98) months until July 2002 or until exit from this study group because of end stoma formation (n = 6). Seven patients (50 percent) had a successful outcome, defined as continent to solid and liquid stool. Overall, eight patients (57 percent) reported some degree of improvement in their bowel function and were successfully managed by this combination of procedures. An end stoma was formed in six patients (43 percent). CONCLUSIONS: The combination of antegrade irrigation via a colonic conduit or an antegrade continence enema procedure provides a successful outcome for some patients when incorporated into total anorectal reconstruction, provided that sepsis does not occur, thus avoiding permanent stoma formation. The combination of these procedures may represent an improvement in total anorectal reconstruction and warrants further clinical trial.