Adapting the investigation of patients on urgent suspected cancer pathway with lower gastrointestinal symptoms across Wales during COVID-19

INTRODUCTION

The COVID-19 pandemic necessitated the introduction of revised diagnostic pathways for assessing urgent suspected cancer (USC) referrals. Combinations of faecal immunochemical testing (FIT) and minimal preparation computed tomography (CT) scans (MPCT) were used to manage referrals and prioritise access to clinical services or invasive tests. The effectiveness of these pathways across Wales is evaluated in this study.

METHODS

All consecutive patients referred from primary care on the USC pathway between 15 March and 15 June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations and timelines and patient outcomes up to 90 days following initial referral.

RESULTS

A total of 1,050 patients across eight sites in Wales were included. Of these 1,050 patients, 52.6% were female with median age 68 (21-97) years; 50.5% had first-line clinical review, of which 61.1% were virtual consultations; 49.5% had primary investigations; 26.7% of patients had FIT and 13.1% had MPCT. COVID-response pathways achieved a 29.9% reduction in use of colonoscopy as first-line investigation and 79% of patients avoided face-to-face consultations altogether during this first wave of the pandemic. Overall, 6.8% of USC referrals were diagnosed with colorectal cancer (CRC). Median timescale from diagnosis to treatment for CRC was 65 (4-175) days. The negative predictive value (NPV) for FIT in this cohort was 99.6%. MPCT as the first modality had a NPV of 99.2%.

CONCLUSION

A modified investigation pathway helped maintain cancer diagnosis rates during the pandemic with improved resource utilisation to that used prepandemic.

TP7.2.5 Surgeon measured radiological pelvic measurements as a patient selection tool for laparoscopic rectal resection – an aide in early learning curve

Introduction

Rectal resections are considered one of the most technically demanding laparoscopic procedures. This study reviews one unit’s rectal cancer resections to determine whether pelvic dimensions measured by the surgeon could aide patient selection for laparoscopic resections.

Methods

A prospectively maintained database was used to identify rectal cancer resections between April 2015 to March 2018 and patient demographics, BMI, height of tumour and operative details were in extracted. Anteroposterior (Coccygio-pubic) and transverse (interspinous) distance were measured retrospectively on linked Axial & Saggital views on staging CT scans. Tumour dimensions in the respective planes were recorded and relative proportions of tumour to pelvic dimensions calculated. These were correlated to operative approach.

Results

Our cohort comprised of 70 patients (42 men) with a median BMI of 27 and mean age of 71. While 6 operations were planned as open procedures, 64 were attempted laparoscopically. Of these, 55 were completed laparoscopically and 9 were converted (16%). There was no correlation between gender and operative approach (p = 0.2). Mean BMI for laparoscopic group 28.7 and converted group 30.0 which was not statistically significant (p = 0.32). Conversion was more likely for low tumours (89%). Median tumour to pelvic area proportion was 0.14 laparoscopic compared to 0.03 for open and 0.03 for converted suggesting that bulkier tumours are more likely to need conversion.

Discussion

None of previously identified factors such as gender and BMI predicted conversion in our cohort individually. Tumour size relative to pelvic dimensions is a simple measure a surgeon could use to guide patient selection.

SP4.1.5The use of Faecal Immunochemical Testing (FIT) and Minimal Preparation Computed Tomography (MPCT) during COVID-19 for Urgent Suspected Cancer (USC) referrals in patients with lower gastro-intestinal symptoms

Aims

The COVID-19 pandemic necessitated introduction of revised diagnostic pathways for assessing Urgent Suspected Cancer (USC) referrals. Combinations of FIT and MPCT were used to manage referrals and prioritise access to clinical services or invasive tests. The effectiveness of these pathways are evaluated in this study.

Methods

All consecutive patients referred from primary care on the USC pathway between 15^th March – 15^th June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations and timelines and patient outcomes up to 90 days following initial referral.

Results

816 patients across 8 sites in Wales were included in this initial analysis. 52.7% of patients were female with median age 69 (21 – 97) years. Of the 50.7% who had first-line clinical review, 70.5% were virtual consultations. 49.3% had primary investigations, with FIT in 31% of patients and MPCT in 18.3%. This was compliant with locally agreed pathways for 77.3% of referrals. COVID-response pathways achieved a 28.5% reduction in use of colonoscopy as first-line investigation and 84.3% of patients avoided face-to-face consultations altogether during this first wave of the pandemic.

Overall, 5.6% of USC referrals were diagnosed with CRC. Median timescale from diagnosis to treatment for CRC was 82 (4 – 175) days. The NPV for FIT in this cohort was 99.5%. MPCT as the first modality had a NPV of 99%.

Conclusion

A modified investigation pathway maintained cancer diagnosis during the pandemic with improved resource utilisation to that used previously.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial

Background

Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs.

The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision.

Methods/design

This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.

Discussion

A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions.

Trial registration

Trial Registration Number: ISRCTN 25616490. Registered on 1 January 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.

Long-term outcome of prucalopride for chronic constipation: a single-centre study

AIM

Newer 5-hydroxytryptamine agonists, such as prucalopride, have been demonstrated to be effective in the short term for treatment of chronic constipation. To date, few studies have investigated their medium- and long-term effectiveness.

METHOD

An analysis was carried out of a prospectively maintained database of all patients started on prucalopride for chronic constipation between April 2011 and April 2014. Cleveland Clinic Constipation Score (CCCS) questionnaires were administered before starting treatment with prucalopride and at the first follow-up visit to assess change in CCCS scores in 50 randomly selected patients.

RESULTS

A total of 155 patients (median age: 47 years; seven men) were started on prucalopride in this period. Of these, 16 (10%) had slow-transit constipation, 31 (20%) had obstructive defaecation syndrome and 30 (19%) had a combination of both. Of these 155 patients, 78% patients were on three or more laxatives at the time of starting prucalopride. Patients were started on 1 mg or 2 mg according to their age. The median follow-up period was 24 (range: 4-40) months. At the first follow-up visit, 106 (68%) patients reported good symptomatic improvement, whereas the remainder had no response. Third of initial responders showed decreased efficacy after a median duration of 6 months and needed regular laxatives/irrigation. Of the 50 patients who filled in the CCCS questionnaires (15 patients were nonresponders), 32 (64%) reported improved scores with a median improvement of two points per criterion.

CONCLUSION

This study provides evidence that prolonged use of prucalopride is effective in achieving a sustained benefit in the majority of patients.

Does an enhanced recovery programme add value to laparoscopic colorectal resections?

PURPOSE

Enhanced recovery programmes (ERP) are now becoming integral to the management of patients undergoing colorectal resection. The benefits of ERP in patients undergoing open colorectal resections have been well recognized; however, the value of ERP in patients undergoing laparoscopic resections is still uncertain. This study was undertaken to assess the impact of ERP in our unit where nearly 90 % of elective colorectal resections are performed laparoscopically.

METHODS

A prospectively maintained database of all patients undergoing colorectal resections between Jan 2008 to December 2012 was analysed. The ERP programme was introduced in Aug 2010. The primary outcome measure was post-operative length of stay. Secondary outcome measures were post-operative morbidity and mortality.

RESULTS

A total of 506 patients underwent major colorectal resections in the study period (282 patients since introduction of ERP). There were no demographic differences between the pre-ERP and post-ERP groups of patients. The median length of stay prior to the introduction of ERP was 6 days (right-sided resections = 6, left-sided resections = 7.5 and rectal resections = 5.5). For post-ERP, the median length of stay was 5 days (right = 5.5, left = 5 and rectal = 4). Patients who had their laparoscopic procedure converted to open had a course similar to open resections. The morbidity and mortality was lesser in the ERP group but did not reach statistical significance.

CONCLUSION

The introduction of an ERP adds additional value in laparoscopic colorectal resections, with further reductions in morbidity and length of stay.

Crohn's disease: systematic review of assessment of disease severity and its relevance to surgery

BACKGROUND

The aims of treatments for Crohn's disease are symptom control by medical or surgical means and improvement in health-related quality of life (HRQOL). A wide number of classification systems, instruments of disease activity measurement (DAM) and HRQOL are available, but few are used in routine surgical practice.

OBJECTIVE

To review the validity of DAM and HRQOL instruments and their applicability to surgically treated patients.

METHOD

A systematic literature search was undertaken to identify these instruments. Qualifying articles were used to determine the construct, content and criterion validity of the instruments identified with respect to surgically treated patients.

RESULTS

Thirteen disease activity indices and 11 HRQOL assessment tools were identified. Construct validity was demonstrated throughout but concerns of content and criterion validity were noted.

CONCLUSION

None of the current disease activity or HRQOL tools can be used without potential bias in a trial of surgical vs medical therapy as the items included favour the outcomes experienced following medical therapy. A more balanced assessment tool in the setting of a multidisciplinary trial is needed.