Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis

PURPOSE

Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.

METHODS

Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.

RESULTS

Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).

CONCLUSIONS

There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand

INTRODUCTION

Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ.

METHODS

A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported.

RESULTS

12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study.

CONCLUSION

This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.

The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

BACKGROUND

Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown.

METHODS

A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade.

RESULTS

Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Māori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Māori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology.

CONCLUSION

Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Māori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

INTRODUCTION

Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown.

METHODS

A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative.

RESULTS

Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R² = 25.8, elective cholecystectomy model R² = 50.6).

CONCLUSIONS

Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Colonic Investigation following acute diverticulitis in Northland, New Zealand

AIM

Diverticulitis is common and increasing in incidence. The risk of malignancy in those with uncomplicated diverticulitis is estimated to be 0.7%, compared with 10% in complicated diverticulitis. Newer guidelines suggest colonic investigation in patients with complicated diverticulitis only. We aim to investigate which patients in Northland undergo colonic investigation following an episode of diverticulitis, define malignancy detection rate and aid in the formulation of local guidelines.

METHODS

A retrospective review of adults admitted to Whangārei Hospital with diverticulitis between 2015 and 2019. Patients were classified as complicated or uncomplicated based on the Hinchey classification radiologically or intra-operatively. Patients were followed up to a minimum of 24 months.

RESULTS

Three hundred and forty-nine patients were included. One hundred and eighty-two (48%) patients underwent colonic investigation following admission with diverticulitis; 50 with complicated and 132 with uncomplicated disease. The rate of colonic investigation between the groups was similar, at 53% and 47% respectively. Two patients (1.1%) were found to have a colonic malignancy, both in the uncomplicated group. The performance of a colonic investigation was not associated with complicated disease, ethnicity, gender or age on univariate or multivariate analysis.

CONCLUSION

Colonic investigation following an admission for acute diverticulitis in Northland is not aligned with recently published guidelines. The rate of colonic malignancy found was low. Larger local studies are needed to guide clinicians and maximise efficiency of resource utilisation.

Characterising nationwide reasons for unplanned hospital readmission after colorectal cancer surgery

BACKGROUND

Readmissions after colorectal cancer surgery are common, despite advancements in surgical care, and have a significant impact on both individual patients and overall healthcare costs. The aim of this study was to determine the 30-and 90 days readmission rate after colorectal cancer surgery, and to investigate the risk factors and clinical reasons for unplanned readmissions.

METHOD

A multicenter, population-based study including all patients discharged after index colorectal cancer resection from 2010 to 2020 in Aotearoa New Zealand (AoNZ) was completed. The Ministry of Health National Minimum Dataset was used. Rates of readmission at 30 days and 90 days were calculated. Mixed-effect logistic regression models were built to investigate factors associated with unplanned readmission. Reasons for readmission were described.

RESULTS

Data were obtained on 16,885 patients. Unplanned 30-day and 90-day hospital readmission rates were 15.1% and 23.7% respectively. The main readmission risk factors were comorbidities, advanced disease, and postoperative complications. Hospital level variation was not present. Despite risk adjustment, R² value of models was low (30 days: 4.3%, 90 days: 5.2%). The most common reasons for readmission were gastrointestinal causes (32.1%) and wound complications (14.4%). Rates of readmission did not improve over the 11 years study period (p = 0.876).

CONCLUSION

Readmissions following colorectal resections in AoNZ are higher than other comparable healthcare systems and rates have remained constant over time. While patient comorbidities and postoperative complications are associated with readmission, the explanatory value of these variables is poor. To reduce unplanned readmissions, efforts should be focused on prevention and early detection of post-discharge complications.

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study

AIM

Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ.

METHODS

A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia.

RESULTS

Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block.

CONCLUSION

This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.

Trauma Teams in Aotearoa New Zealand-a national survey

AIMS

Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand.

METHODS

A survey was distributed using the modified Dillman's technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey.

RESULTS

Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists.

CONCLUSIONS

Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand

Background

Small intestinal Neuroendocrine Neoplasms (SI‐NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI‐NEN in Auckland, Aotearoa New Zealand (AoNZ).

Methods

A retrospective study of all patients diagnosed with a jejunal or ileal SI‐NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data.

Results

One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10‐year disease‐specific survival for all patients was 66.1% (95% CI 56.5–75.7%) and 61.8% (95% CI 51.8–71.8%), respectively. Ten‐year disease‐specific survival was 100% for stage I and II, 74% (95%CI 61.7–84.4%) for stage III and 33.9% (95%CI 16.9–35.6%) for stage IV SI‐NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92–5.5) nor distant resection (HR 1.72, 95% CI 0.63–4.7) were significantly associated with a disease‐specific or overall survival benefit.

Conclusion

This study demonstrates that stage at SI‐NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre

BACKGROUND

Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis.

METHODS

A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis.

RESULTS

Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p = 0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance.

CONCLUSION

This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

The effect of rurality and ethnicity in patients with acute cholecystitis in Northland, New Zealand

AIM

Acute cholecystitis is a common reason for emergency admission. Rurality and ethnicity are associated with poorer surgical outcomes, but data in benign disease is sparse. This study aims to assess the effect of rurality and ethnicity on the severity, management, and outcomes of acute cholecystitis.

METHODS

A five-year retrospective cohort study was conducted, including all adults admitted to Northland hospitals with acute cholecystitis. The primary cohort was identified using coding. Severity and outcome data was obtained. Severity was defined according to the Tokyo Guidelines 2018 (TG18). Primary outcomes of interest were the difference in severity of acute cholecystitis, and clinical management between groups.

RESULTS

Three hundred and seventy-seven patients were included. There were no significant differences in the severity of acute cholecystitis, rate of acute cholecystectomy, elective cholecystectomy, or non-operative management by rurality or ethnicity. Māori patients presented at a significantly younger age and were more likely to re-present while on the waiting list for elective surgery.

CONCLUSION

This study found similar clinical severity, management and outcomes comparing rural and urban patients. Māori patients presented at a significantly younger age.

Impact of rurality and ethnicity on complexity of acute diverticulitis in Northland, New Zealand

BACKGROUND

Acute diverticulitis is a common general surgical condition associated with significant costs and healthcare burden. It is unknown if rurality represents a barrier to healthcare and whether ethnic disparities exist in Northland, New Zealand. This study, therefore, aims to assess the impact of rurality and ethnicity on complexity, management, and outcomes in patients with acute diverticulitis.

METHODS

A retrospective observational study of all adults aged >18 years admitted with acute diverticulitis to any Northland District Health Board hospital between 1 January 2015 and 31 December 2019 was performed. Diverticulitis complexity was assessed using the modified Hinchey classification. The primary outcome was the effect of rurality and ethnicity on complexity of diverticulitis. Multivariable logistic regression was performed.

RESULTS

A total of 397 patients (mean age 60.3 years (standard deviation (SD) 13.8); 48.7% female) were included. Overall, 134 patients had complicated diverticulitis. Rurality nor distance from the hospital were not associated with complexity of diverticulitis or clinical outcomes (p > 0.05). Maori patients presented younger than non-Maori (mean 51 vs. 63 years, p < 0.001) but there was no difference in complications, management, or clinical outcomes (p > 0.05). On multivariable analysis, rurality status and Maori ethnicity were not associated with more complicated diverticulitis.

CONCLUSION

This study found that rurality and ethnicity were not significant predictors of the complexity of diverticulitis.

Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis

BACKGROUND

Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist.

METHODS

We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework.

RESULTS

Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation.

CONCLUSION

Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.

Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly

AIMS

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

METHOD

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

RESULTS

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

CONCLUSION

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Incidence, outcomes and effect of delayed intervention in patients with hollow viscus injury due to major trauma in the Northern region of New Zealand

BACKGROUND

Patients with hollow viscus injury (HVI) are often a cause for diagnostic uncertainty. The incidence and outcomes of patients suffering hollow viscus injury secondary to major trauma have not been previously described in New Zealand. These metrics are important to guide quality improvement and resource allocation. The aim of our study is to define the incidence, outcomes and effect of delayed intervention on patients admitted to hospital with hollow viscus injury secondary to blunt abdominal trauma in the Northern region of New Zealand.

METHODS

A 4-year multicentre retrospective study was performed in the Northern region of New Zealand between 1 July 2015 and 30 June 2019. A primary cohort of patients with confirmed hollow viscus injury secondary to blunt abdominal injury, who underwent a laparotomy, were assessed. The primary outcome measures were incidence, 30-day mortality and morbidity. Secondary outcomes included the effect of timing of surgical intervention.

RESULTS

The incidence of hollow viscus injury in the region was 2.03 per 100 000. The 30-day mortality rate was 5% and the 30-day morbidity rate was 82%. Immediate surgical intervention was carried out in 36%, early surgical intervention in 56% and delayed surgical intervention in 8%.

CONCLUSION

The incidence of hollow viscus injury is in keeping with similar studies, but with lower mortality and higher morbidity. The rate of immediate or early surgical intervention was high. These findings are important to clinicians managing patients with major trauma and those involved in planning and allocation of resources.

Effect of rurality and ethnicity in severity and outcomes in patients with acute pancreatitis

BACKGROUND

Previous studies have demonstrated a high incidence of acute pancreatitis (AP) in New Zealand, with Maori having the highest reported incidence worldwide. It is possible that barriers to healthcare exist for rural and Maori patients, leading to poorer outcomes. The aim of this study is to compare differences in severity and outcomes in patients with AP with regards to rurality and ethnicity.

METHODS

Multicentre retrospective study of all adults aged >16 years who were admitted to any hospital with AP in Northland between 1 January 2014 and 31 December 2018 was performed. Pancreatitis severity was classified using the Revised Atlanta classification. The primary outcome of interest was the difference in severity of pancreatitis with regards to rurality and ethnicity. Secondary outcomes of interest included clinical outcomes, aetiology of AP and re-presentation rates.

RESULTS

A total of 468 patients were included. There was no difference found between rural and urban or Maori and non-Maori patients with regards to disease severity, length of stay, mortality or intensive care unit admission rate. A significant difference in aetiology was found between Maori and non-Maori patients, with a higher rate of gallstone pancreatitis in Maori. There was no difference in local complications or number of re-presentations between groups.

CONCLUSION

This study showed no difference in the severity or outcomes of AP across rural and urban patients in the Northland region of New Zealand. Secondary outcomes were broadly comparable between groups, with a higher rate of gallstone pancreatitis found in Maori compared to non-Maori.

Rate and cost of representation in patients suffering from major trauma in Northland, New Zealand

INTRODUCTION

The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand.

AIM

The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland.

METHOD

We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital's clinical results reporting system and data warehouse.

RESULTS

420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days.

CONCLUSION

This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.

Association between COVID-19 public health interventions and major trauma presentation in the northern region of New Zealand

Background

The New Zealand government implemented restrictive public health interventions to eradicate Covid‐19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included.

Results

There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6–0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020.

Conclusion

This study has shown that public health interventions to prevent the spread of COVID‐19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand

Background

The New Zealand government instituted escalating public health interventions to prevent the spread of COVID‐19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity.

Results

There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length‐of‐stay, 30‐day mortality and admission diagnosis were comparable.

Conclusion

Despite a significant reduction in ED presentations, interventions for COVID‐19 did not result in a difference in the rate or severity of acute general surgical admissions.

Surgeon-performed ultrasound-guided fine needle aspiration of thyroid nodules is cost effective and efficient: evaluation of thyroid nodule assessment in a provincial New Zealand hospital

AIM

Surgeon-performed ultrasound-guided fine needle aspiration cytology (US-FNAC) and radiologist-performed US-FNAC are both accepted forms of thyroid nodule assessment. To date there have been no studies comparing cost of evaluation between these two models. The aim of this study is to compare surgeon-performed thyroid US-FNAC to radiologist-performed US-FNAC. The primary outcome of interest was cost of surgeon-performed US-FNAC compared to cost of radiologist-performed US-FNAC. Secondary outcome of interest was time to treatment decision.

METHODS

A retrospective analysis of all thyroid biopsies performed in 2016 and 2017 in a single centre were included. Costs were calculated using labour costs for SMO and allied technical personnel.

RESULTS

There were 92 patients included in the analysis. Forty-two underwent surgeon-performed US-FNAC and 50 underwent radiologist-performed US-FNAC. Mean cost in surgeon-performed US-FNAC was $653 compared to $1017 in radiologist-performed US-FNA. Time from first appointment to definitive management plan was 47 days in surgeon-performed USFNAC and 116 days in radiologist-performed US-FNAC.

CONCLUSIONS

This study demonstrates surgeon-performed US-FNAC for evaluation of thyroid nodules results in significantly lower costs and improved timeliness of care when compared to radiologist-performed US-FNAC.

Cost and resource implications of introducing intensive nodal surveillance for sentinel node positive melanoma in provincial New Zealand

AIMS

Two randomised trials have shown that immediate completion lymphadenectomy for sentinel node positive melanoma provides no long-term survival benefit; compared with a follow up regime of intensive nodal surveillance. The aim of this study was to assess the cost and resource implications of introducing this regime for patients with sentinel node positive melanoma in a provincial New Zealand hospital.

METHODS

Patients with cutaneous melanoma presenting to Northland District Health Board between 1 January 2012 and 31 December 2014 were identified. The financial and resource burden of standard treatment was assessed, including operative, outpatient and imaging interventions. Theoretical financial and resource costs of intensive nodal observation for a theoretically equivalent cohort were calculated.

RESULTS

The cost of standard treatment was $7,147 per patient and the theoretical cost of nodal observation was $5,300 per patient. Standard treatment required more operating theatre time and inpatient treatment. Nodal observation required more outpatient appointments and imaging.

CONCLUSIONS

The cost of nodal observation was lower than standard treatment than in our study. There is a shift in resource requirements from operating theatre and inpatient care to outpatient appointment and imaging. The overall resource impact is low and introduction of nodal observation appears achievable.

Counting the costs of complications in colorectal surgery

AIM

New Zealand has a high incidence of colorectal cancer. Most patients are treated with resectional surgery. There is a significant rate of complication associated with treatment. Costs of surgical treatment and effect of complications have not been previously investigated in New Zealand. The aim of this study was to define treatment costs of complications in patients undergoing resectional surgery for colorectal cancer.

METHODS

Adult patients who underwent a resectional operation for colorectal adenocarcinoma at Northland DHB between January 2011 and December 2016 were identified. Actual costs and diagnoses-related group (DRG) costs were obtained. Demographic data and information on outcomes were identified using the hospital's results reporting system CONCERTO.

RESULTS

Three hundred and ninety patients were included. One hundred and seven patients suffered a complication. Median cost per patient was $17,090. In those with complications, median cost was $28,485 compared to $14,697 in those without. Cost of complications increased as complication grade increased. Additional cost in patients with complications was on average $20,683 per patient, equating to a total of $2.2 million in this cohort.

CONCLUSION

This study has defined the costs associated with colorectal cancer resection. Complications following colorectal surgery add significant costs. Significant investment in initiatives to reduce complications is justified.

Cutaneous squamous cell carcinoma: predictors of positive and close margins and outcomes of re-excision in Northland, New Zealand

BACKGROUND

Non-melanoma skin cancer (NMSC) is the most commonly diagnosed and costly cancer in Australasia. Cutaneous squamous cell carcinoma (cSCC) accounts for approximately 25% of NMSC. A better understanding of predictors of close and positive margins following surgical excision will help guide treatment.

METHODS

A retrospective study was carried out of all primary cSCC histologically diagnosed in Northland, New Zealand in 2015. The cohort was identified by searching the regional pathology database. The primary outcome of interest was positive and close (≤1mm) margin rate following surgical excision and factors influencing them. Secondary outcomes of interest were outcomes of re-excisions.

RESULTS

A total of 1,040 cSCC were identified in 890 unique patients and 825 lesions were surgically excised. Increased odds of positive margin on surgical excision was found with increased tumour thickness (OR 1.56, 95% CI 1.24-1.96), tumours from the head and neck (OR 2.78, 95% CI 1.33-5.80) and those excised in primary care (OR 2.20, 95% CI 1.07-4.52). Increased odds of close margins was found in females (OR 2.01, 95% CI 1.3-3.2) and excision in primary care (OR 2.44 95% CI 1.5-3.98). Residual tumour was present in 13 (31.7%) patients with positive margins and 0 patients with close margins.

CONCLUSIONS

Lesions of the head and neck, those removed in primary care and with increased tumour thickness were more likely to have positive margins following surgical excision. Close margins were associated with excision in primary care and female gender. The value of re-excising tumours with close margins remains uncertain.

Risk stratification of symptomatic patients suspected of colorectal cancer using faecal and urinary markers

AIM

Faecal markers, such as the faecal immunochemical test for haemoglobin (FIT) and faecal calprotectin (FCP), have been increasingly used to exclude colorectal cancer (CRC) and colonic inflammation. However, in those with lower gastrointestinal symptoms there are considerable numbers who have cancer but have a negative FIT test (i.e. false negative), which has impeded its use in clinical practice. We undertook a study of diagnostic accuracy CRC using FIT, FCP and urinary volatile organic compounds (VOCs) in patients with lower gastrointestinal symptoms.

METHOD

One thousand and sixteen symptomatic patients with suspected CRC referred by family physicians were recruited prospectively in accordance with national referring protocol. A total of 562 patients who completed colonic investigations, in addition to providing stool for FIT and FCP as well as urine samples for urinary VOC measurements, were included in the final outcome measures.

RESULTS

The sensitivity and specificity for CRC using FIT was 0.80 [95% confidence interval (CI) 0.66-0.93] and 0.93 (CI 0.91-0.95), respectively. For urinary VOCs, the sensitivity and specificity for CRC was 0.63 (CI 0.46-0.79) and 0.63 (CI 0.59-0.67), respectively. However, for those who were FIT-negative CRC (i.e. false negatives), the addition of urinary VOCs resulted in a sensitivity of 0.97 (CI 0.90-1.0) and specificity of 0.72 (CI 0.68-0.76).

CONCLUSIONS

When applied to the FIT-negative group, urinary VOCs improve CRC detection (sensitivity rises from 0.80 to 0.97), thus showing promise as a second-stage test to complement FIT in the detection of CRC.

Counting the costs of major trauma in a provincial trauma centre

AIMS

Trauma is an important cause of morbidity and mortality in New Zealand, and also represents a significant financial and resource burden on the healthcare system. Understanding local costs and factors that affect them is important for planning of trauma services and obtaining funding for quality improvement projects. The aim of this study was to assess actual costs and influencing factors in patients treated for major trauma in Northland, New Zealand.

METHODS

Adult patients admitted to Whangarei Hospital suffering from major trauma for three years from 1 January 2015 to 31 December 2017 were identified from the hospital's prospectively maintained trauma database. Major trauma was defined as an Injury Severity Score (ISS)>12, admission to intensive care or death secondary to trauma. Patients >50 years old with isolated neck of femur fractures, hangings, poisonings and drownings were excluded. Immediate or early (<24hours) transfers to tertiary hospitals were excluded from costing analysis. Actual costs were calculated using in-house, patient-level costing utilising CostPro software. Case-weight costs, based on DRG codes used nationally, were also calculated using standard techniques. Factors affecting costs were analysed.

RESULTS

Two hundred and sixty-one patients suffering from major trauma were identified, 62 patients were transferred early leaving 199 patients for analysis. The mean ISS was 18 (IQR=14-22) and average length of stay was 8.5 days. Fifty-one percent of the cohort required intensive care and 36% underwent operative intervention in Whangarei Hospital. Total actual cost was NZ$4,614,652 with an average cost of NZ$23,189 per patient. There was a significant difference in actual vs case-weight cost for the patients in the ISS 13-24 group who formed the bulk of the cohort. There was also extremely significant difference between the costs for patients requiring either intensive care or operative intervention versus those who did not (p=0.0001).

CONCLUSIONS

This is the first study in New Zealand describing actual costs in patients suffering from major trauma and variation to case-weight costs. Intensive care admission and operative intervention have been identified as the two main drivers of cost. Further studies are needed in New Zealand, particularly in major trauma centres, to better understand the true cost of major trauma within the country.

Incidence, demographics and surgical outcomes of cutaneous squamous cell carcinoma diagnosed in Northland, New Zealand

AIM

Non-melanoma skin cancer (NMSC) is the most commonly diagnosed and most costly cancer in Australasia. Cutaneous squamous cell carcinoma (cSCC) accounts for approximately 25% of NMSC. Despite this, reporting of cSCC is not mandatory in Australasia. This creates difficulties in planning, resourcing and improving outcomes in cSCC. Previous studies in New Zealand have lacked data on ethnicity. The aim of this study was to define the incidence and demographics of cSCC diagnosed in Northland, New Zealand, including data on ethnicity.

METHODS

A 12-month retrospective study was carried out of all primary cSCC histologically diagnosed in Northland for one year. The cohort was identified by searching the Northland District Health Board pathology database. Data on outcomes and ethnicity were obtained from the hospital results system. Primary outcome of interest was the incidence of cSCC in Northland. Secondary outcomes of interest were lesion characteristics and positive margin rate.

RESULTS

1,040 cSCC were identified in 890 patients. Mean age of patients was 75. Crude incidence of primary cSCC was 668/100,000 patient years. Age standardised incidence was 305/100,000 patient years. An estimate of New Zealand incidence adjusted for age and ethnicity is 580/100,000 patient years. Overall positive margin rate in excised lesions was 9.5%.

CONCLUSION

This study has defined the rate of cSCC in a large, well defined New Zealand population, and estimated age and ethnicity adjusted incidence in New Zealand. It has demonstrated the highest incidence of cSCC in the world outside Australia. Overall positive margin rate of excised lesions was acceptable.

Clinical outcomes and effect of delayed intervention in patients with hollow viscus injury due to blunt abdominal trauma: a systematic review

INTRODUCTION

Hollow viscus injury (HVI) due to blunt abdominal trauma remains a diagnostic challenge, often presenting late and results in delayed intervention. Despite several treatment algorithms, there is currently no consensus on how to manage patients with HVI. The aim of this review was to define clinical outcomes and the effect of delayed intervention in patients with HVI due to blunt abdominal trauma. The primary outcome of interest was difference in mortality between groups.

METHODS

Based on the preferred reporting items for systematic reviews and meta-analyses statement, a literature search was performed. Studies comparing clinical outcomes in adult patients with hollow viscus injury due to blunt abdominal trauma undergoing early or delayed laparotomy were included. Two independent reviewers screened the abstracts.

RESULTS

In all, 2288 articles were retrieved. After screening, 11 studies were included. Outcomes in 3812 patients were reported. Overall mortality was 17%. Ten studies reported no difference in mortality between groups. A statistical increase in morbidity was described in five studies, and a trend to increased morbidity was seen in a further two studies. Two studies reported increased mortality in delayed intervention in isolated bowel injury.

CONCLUSIONS

This systematic review summarises the results of studies considering outcomes in patients with HVI due to blunt abdominal trauma who have early vs delayed intervention. Overall mortality was significant at 17%. If all patients with hollow viscus injury are considered, the majority of studies do not show an increase in mortality. As patients with isolated bowel injuries have higher mortality in the studies reviewed, to improve outcomes in this subset further investigation is warranted.

Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients

BACKGROUND

The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus, there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology.

AIM

To assess using faecal immunochemical test for haemoglobin (FIT) or faecal calprotectin (FCP) to detect CRC and adenoma in symptomatic patients referred from primary care.

METHODS

A total of 799 referred for urgent lower gastrointestinal investigations were prospectively recruited. Of these, 430 completed colonic investigations and returned stool samples, and were included in the final statistical analysis. Faecal immunochemical test for haemoglobin was performed on HM-JACKarc analyser (Kyowa Medex, Tokyo, Japan), and FCP by the EliA Calprotectin immunoassay (Thermo Fisher Scientific, Waltham, United States).

RESULTS

The negative predictive value (NPV) using FIT alone or both markers (FIT and FCP) in combination was similar at 99% for CRC, with a sensitivity and specificity of 84% and 93%, respectively. FIT measurements were significantly higher in left-sided colonic lesions compared with the right side; 713 vs. 94; P = 0.0203). For adenoma, the NPV using FIT alone, or both markers (FIT and FCP) in combination, was similar at 94% with a sensitivity and specificity of 69% and 56%, respectively.

CONCLUSIONS

Undetectable faecal immunochemical test for haemoglobin is sufficiently sensitive to exclude colorectal cancer, with higher values in left-sided lesions. FCP in combination does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical test for haemoglobin in primary care are required.

Contemporary characteristics of blunt abdominal trauma in a regional series from the UK

INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.

A randomized controlled trial of preoperative infiltration with bupivacaine and adrenaline in varicose vein surgery

Objectives: Clinical experience suggested that preoperative infiltration of proposed avulsion sites with bupivacaine and adrenaline reduced bleeding associated with varicose vein surgery. This hypothesis was subjected to a randomized controlled trial.

Methods: Twenty patients undergoing bilateral long saphenous vein (LSV) stripping and avulsions were randomized to have one leg infiltrated with 0.25% bupivacaine and the other with 0.25% bupivacaine with adrenaline (1 in 200,000). Following induction of general anaesthesia, 10 mL of local anaesthetic was infiltrated into the groin and 20–30 mL over the marked varicosities down the leg. Bilateral PIN stripping and hook avulsions were performed. Operative blood loss was recorded for each leg and the area of strip-site and avulsion-site bruising was determined five days postoperatively.

Results: There was no difference in the numbers of avulsions between the legs receiving adrenaline (median 12, range 4–23) and controls (median 13, range 4–25), but adrenaline significantly reduced the operative blood loss (median 41 mL, range 17–122) compared with control legs (median 79 mL, range 28–210; P < 0.001, Wilcoxon). There was also a significant reduction in postoperative avulsion-site bruising (median 45 cm2, range 13–101 compared with median 70 cm2, range 34–221; P < 0.001). There was a smaller reduction in strip-site bruising (median 50 cm2, range 14–128 compared with median 62 cm2, range 21–141; P < 0.001).

Conclusions: Preoperative infiltration with bupivacaine and adrenaline is safe and reduces bleeding and bruising associated with varicose vein surgery.

Colorectal cancer screening characteristics of patients presenting with symptoms of colorectal cancer and effect on clinical outcomes

INTRODUCTION

National colorectal cancer screening, utilising a faecal occult blood test (FOBT), is now well established in the UK. The aim of this study was to define the screening characteristics of patients presenting to secondary care with symptoms of colorectal cancer and to assess the effect of screening outcome on subsequent symptomatic presentation.

METHODS

This was a retrospective analysis of all patients of screening age presenting within one calendar year in a tertiary trust via a two-week wait (2WW) pathway owing to suspicion of colorectal cancer. Colorectal cancer related outcomes were compared between patients in the cohort who had previously accepted bowel cancer screening and patients who had previously declined bowel cancer screening. The primary endpoint was overall incidence of colorectal neoplasia. Secondary endpoints included incidence of colorectal malignancy, cancer related mortality, cancer related outcomes and polyp related outcomes.

RESULTS

Overall, 2,227 patients presented via the 2WW pathway; 955 were aged 60-75 years. Among the latter, 411 (43%) had been screened previously and had a negative FOBT, and 544 (57%) had declined screening. Incidence of colorectal neoplasia did not differ between the two groups (113 [27%] vs 143 [26%], p=0.7). Of those with a negative FOBT and subsequent symptomatic presentation, 16 (3.9%) were diagnosed with a colorectal malignancy compared with 36 (6.6%) of those who declined screening and had subsequent symptomatic presentation (relative risk: 1.7, 95% confidence interval: 0.96-3.02, p=0.08). There were no differences between the two groups with regard to TNM (tumour, lymph nodes, metastasis) stage, Dukes' stage, metastases, number of polyps or cancer related mortality (median follow-up duration: 20 months).

CONCLUSIONS

The incidence of colorectal neoplasia was similar among patients who previously had a negative FOBT and those who declined screening. There was a higher incidence of colorectal cancer detected among those who declined screening but it did not reach statistical significance. All other cancer and polyp outcomes were similar between the groups.

Utility of faecal calprotectin in inflammatory bowel disease (IBD): what cut-offs should we apply?

BACKGROUND

Faecal calprotectin (FC), a cytosolic protein released by neutrophils (S100 family) in response to inflammation, is a simple, non-invasive test that can be used to differentiate irritable bowel syndrome (IBS) with inflammatory bowel disease (IBD), where there can be considerable symptom overlap.

AIMS AND METHODS

The aims of the study were (1) to be able to predict the ability of FC to exclude IBD and determine cut-offs when in remission, (2) to investigate the effects of time and temperature on stability of FC and (3) compare three ELISA kits to measure FC: Buhlmann, PhiCal v1 and PhiCal v2. A total of 311 patients with altered bowel habit were tested for FC; 144 with IBS, 148 with IBD and 19 with other organic causes.

RESULTS

Sensitivity and specificity of FC (with PhiCal v2 kit) to distinguish between functional disorder (IBS) and IBD using cut-off 50 μg/g were 88% and 78%, respectively, with a negative predictive value of 87%. Area under the receiver operating curve was 0.84 (CI 0.78 to 0.90). For those with IBD, FC values below 250 μg/g corresponded with remission of disease with a sensitivity and specificity of 90% and 76%, respectively. Area under the receiver operating curve was 0.93 (CI 0.89 to 0.97). FC was stable once extracted and frozen for up to 2.5 months. Pearson correlation was good between Buhlmann assay and PhiCal v2 (r² = 0.95).

CONCLUSIONS

FC has up to 87% negative predictive value to exclude IBD, and cut-offs less than 250 μg/g had 90% sensitivity to determine remission in IBD. Once frozen, FC is stable and the ELISA monoclonal plates were broadly comparable.

Detection of colorectal cancer (CRC) by urinary volatile organic compound analysis

Colorectal cancer (CRC) is a leading cause of cancer related death in Europe and the USA. There is no universally accepted effective non-invasive screening test for CRC. Guaiac based faecal occult blood (gFOB) testing has largely been superseded by Faecal Immunochemical testing (FIT), but sensitivity still remains poor. The uptake of population based FOBt testing in the UK is also low at around 50%. The detection of volatile organic compounds (VOCs) signature(s) for many cancer subtypes is receiving increasing interest using a variety of gas phase analytical instruments. One such example is FAIMS (Field Asymmetric Ion Mobility Spectrometer). FAIMS is able to identify Inflammatory Bowel disease (IBD) patients by analysing shifts in VOCs patterns in both urine and faeces. This study extends this concept to determine whether CRC patients can be identified through non-invasive analysis of urine, using FAIMS. 133 patients were recruited; 83 CRC patients and 50 healthy controls. Urine was collected at the time of CRC diagnosis and headspace analysis undertaken using a FAIMS instrument (Owlstone, Lonestar, UK). Data was processed using Fisher Discriminant Analysis (FDA) after feature extraction from the raw data. FAIMS analyses demonstrated that the VOC profiles of CRC patients were tightly clustered and could be distinguished from healthy controls. Sensitivity and specificity for CRC detection with FAIMS were 88% and 60% respectively. This study suggests that VOC signatures emanating from urine can be detected in patients with CRC using ion mobility spectroscopy technology (FAIMS) with potential as a novel screening tool.

Review article: next generation diagnostic modalities in gastroenterology--gas phase volatile compound biomarker detection

BACKGROUND

The detection of airborne gas phase biomarkers that emanate from biological samples like urine, breath and faeces may herald a new age of non-invasive diagnostics. These biomarkers may reflect status in health and disease and can be detected by humans and other animals, to some extent, but far more consistently with instruments. The continued advancement in micro and nanotechnology has produced a range of compact and sophisticated gas analysis sensors and sensor systems, focussed primarily towards environmental and security applications. These instruments are now increasingly adapted for use in clinical testing and with the discovery of new gas volatile compound biomarkers, lead naturally to a new era of non-invasive diagnostics.

AIM

To review current sensor instruments like the electronic nose (e-nose) and ion mobility spectroscopy (IMS), existing technology like gas chromatography-mass spectroscopy (GC-MS) and their application in the detection of gas phase volatile compound biomarkers in medicine - focussing on gastroenterology.

METHODS

A systematic search on Medline and Pubmed databases was performed to identify articles relevant to gas and volatile organic compounds.

RESULTS

E-nose and IMS instruments achieve sensitivities and specificities ranging from 75 to 92% in differentiating between inflammatory bowel disease, bile acid diarrhoea and colon cancer from controls. For pulmonary disease, the sensitivities and specificities exceed 90% in differentiating between pulmonary malignancy, pneumonia and obstructive airways disease. These sensitivity levels also hold true for diabetes (92%) and bladder cancer (90%) when GC-MS is combined with an e-nose.

CONCLUSIONS

The accurate reproducible sensing of volatile organic compounds (VOCs) using portable near-patient devices is a goal within reach for today's clinicians.

Impact of slow transit constipation on the outcome of laparoscopic ventral rectopexy for obstructed defaecation associated with high grade internal rectal prolapse

AIM

Limited literature exists on whether slow colonic transit adversely influences the results of outlet obstruction surgery. We compared the functional results of laparoscopic ventral rectopexy (LVR) for obstructed defaecation secondary to high grade internal rectal prolapse in patients with normal and slow colonic transit.

METHOD

Consecutive patients suffering from obstructed defaecation associated with an internal rectal prolapse, who underwent an LVR between 2007 and 2011, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and colonic transit studies. Symptoms were assessed preoperatively and at 12 months after operation using a standardized questionnaire incorporating the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire, the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Quality of Life (PAC-QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

In all, 151 patients underwent LVR, 109 with normal and 42 with slow colonic transit. Preoperatively there was no significant difference between the two groups in age, sex, PAC-SYM score or FISI score. The PAC-SYM and FISI scores were significantly reduced in both groups at 12 months (P < 0.001). When comparing the change from baseline of PAC-SYM between patients with and without slow transit constipation, a significant difference was observed (P = 0.030) with changes of 58% and 40%. Quality of life (GIQLI and PAC-QOL) was equally improved in both groups. Quality of life improvement was less in patients with right colonic stasis.

CONCLUSION

Slow colonic transit has no adverse impact on function and quality of life after LVR for obstructed defaecation due to high grade internal rectal prolapse.

Survival outcome of patients with screening versus symptomatically detected colorectal cancers

AIM

The national Bowel Cancer Screening Programme has been rolled out nationwide following pilot screening in two health authorities in the UK. The aim of this study was to define overall 5-year survival of screen detected cancers and to compare the overall survival outcome of screened vs symptomatic patients over a 10-year period.

METHOD

All patients with colorectal cancer treated at one trust in patients of screening age (50-69 years) during the pilot screening programme (2000-2008) were analysed. Patients were defined as screen detected or symptomatically detected. Disease pathology and recurrence data were obtained from the hospital's computerized results reporting system and mortality was cross-matched with data from the West Midlands Cancer Intelligence Network.

RESULTS

In all, 633 patients aged 50-69 were identified in the study period; 155 patients had a screen detected cancer and 478 did not. A log-rank test completed on survival outcomes indicated that survival was significantly worse in the symptomatic group. This difference persisted if only patients treated with curative intent were considered.

CONCLUSION

Survival outcome was significantly better in the screened vs the symptomatic population in all groups and also in those treated for curative intent. There was a trend towards better survival for screen detected cancer when compared stage for stage.

Effect of season and ambient temperature on outcome of guaiac-based faecal occult blood tests performed for colorectal cancer screening

AIM

Guaiac-based faecal occult blood tests (gFOBTs) are used in the colorectal cancer screening programme. Recent data suggested that the immunological faecal occult blood test illustrated a variation in positivity according to season and ambient temperature. Our aim was to assess the effect of season and ambient temperature on the positivity rates of the gFOBT during pilot screening for colorectal cancer.

METHOD

Data from the first year of round 1 of the pilot screening programme in Coventry and Warwickshire were analysed. Patients with positive and negative gFOBT samples were included. Patients with spoilt samples or incomplete data were excluded. Of the total of 59513 patients, 30311 were men and 29202 women. Mean age was 56 years. Daily temperature data were provided by the meteorological office.

RESULTS

Median exposure of the gFOBT test card was 6 days (range 1-17). Median daily maximum temperature was 14°C. Spring and summer illustrated significantly decreased positivity rates compared with autumn and winter (Pearson's chi-squared test, P<0.001). Mean daily maximum temperature for the test card exposure showed no significant difference in positivity rates (P=0.53). Subgroup analysis revealed a significant reduction in positive samples in the >25°C subgroup (P=0.045).

CONCLUSIONS

There is a seasonal variation in positivity rates of gFOBTs with increased positivity in spring and summer months. There is no difference in positivity rates in relation to ambient temperature except in subgroup analysis where there is a significant reduction in positivity rates above 25°C.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded

AIM

Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus.

METHOD

Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5.

RESULTS

Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%.

CONCLUSION

Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

The relationship between internal rectal prolapse and internal anal sphincter function

AIM

Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function.

METHOD

Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed.

RESULTS

A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP.

CONCLUSION

This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.

What is the nature of polyps detected by the NHS bowel cancer screening pilots?

AIM

The NHS Bowel Cancer Screening Programme is currently being introduced following three rounds of pilot screening. The study outlines the important characteristics of polyps detected by pilot screening and compares the location of polyps with those of symptomatic cancers to challenge the circumstantial evidence for the adenoma carcinoma pathway.

METHOD

The first 100 patients with screen-detected polyps from University Hospitals Coventry and Warwickshire (UHCW) were identified from the colorectal cancer screening database. Important characteristics of the polyps were identified from the endoscopy reporting system and entered into a database. Polyp location was compared with the location of symptomatic cancers detected in the UHCW colorectal cancer database.

RESULTS

One hundred patients were selected for investigation and 202 polyps were detected. The average age of the patients with polyps was 61 years, 35% were under the age of 60. There were 67% male subjects. The average size of the largest polyp in each of the different patients was 13.5 mm. Eighty-five per cent of polyps were excised. Histology was available for 181 polyps of which 40% were tubulovillous, 33% tubular, 14% metaplastic and 1% villous. Eighty-eight per cent showed low-grade dysplasia and 8% high-grade one. The location of screen-detected polyps was significantly different from that of symptomatic cancers in our database, with proportionally more sigmoid and proportionally less rectal and caecal polyps detected.

CONCLUSION

The study outlines the important characteristics of screen-detected polyps. The significant difference in location of polyps from that of cancer suggests a variation in the malignancy potential of polyps depending on the location.

Are screen detected colorectal cancers asymptomatic?

OBJECTIVE

Colorectal cancer (CRC) screening aims to detect asymptomatic disease and thus provide the opportunity for early diagnosis and treatment. This study assesses the prevalence of significant symptoms in patients found to have CRC detected through the NHS National Bowel Cancer Screening Programme (NHS NBCSP) pilots.

METHOD

All patients in the NHS NBCSP pilots with a positive faecal occult blood completed a standardized symptomatology questionnaire before colonoscopy. This data was entered into the NHS BCS pilot database, data from the English arm has been analysed retrospectively.

RESULTS

There were 200 patients diagnosed with colorectal cancer. Of these, 28.5% were Dukes A, 35% Dukes B, 31% Dukes C1 and 5.5% Dukes C2. Some 81.5% reported experiencing GI symptoms. Symptoms considered significant included rectal bleeding, change in bowel habit, tenesmus and peri-anal discomfort, reported in 47.7%, 24%%, 36.5% and 15.5% of patients respectively. In addition to this, 27% reported urgency, 20.5% reported abdominal pain and 29% reported upper GI symptoms.

DISCUSSION

This data suggests a high prevalence of significant symptoms amongst patients with screening-detected CRC. It is possible that these patients would have presented via routine colorectal services if the awareness of symptoms of colorectal cancer were increased.

Does the location of screen-detected cancers differ from that seen in the unscreened population?

OBJECTIVE

It is important that screening detects cancers regardless of their location within the colon. The aim of this study was to see if the location of cancers detected by the pilot screening programme differs from that of unscreened cancers.

METHOD

The colorectal cancer dataset of University Hospital Coventry was analysed retrospectively. A 7-year period was used to include all three rounds of the pilot screening. Two groups of patients were selected, those with colorectal cancers detected by the screening programme and those detected outside of screening. The tumour location was compared in the two groups statistically (chi-squared test).

RESULTS

One thousand four hundred-ninety patients were included, 100 of whom were in the screened population and 1390 were in the unscreened population. There was no significant difference in tumour location between the two groups (P = 0.49).

CONCLUSION

This study showed that screen-detected cancers do not differ in their location from unscreened cancers and suggests that faecal occult blood testscreening detects cancer irrespective of location within the colon.