Systematic review of randomised controlled trials on interventions aimed at promoting colorectal cancer screening amongst ethnic minorities

OBJECTIVES

Significant disparities exist between different ethnic groups when it comes to participation in colorectal cancer (CRC) screening programmes. A variety of interventions have been proposed to improve participation rates of ethnic minorities for CRC screening. This systematic review aims to appraise the evidence available from published randomised controlled trials (RCTs) and to identify effective interventions aimed at promoting CRC screening amongst underserved ethnic minorities.

DESIGN

We searched EmBASE, Medline, PsychInfo, Scopus and CINAHL for RCTs that analysed interventions to promote CRC screening in all ethnic minorities. CRC screening was measured as documented or self-reported screening rates. The protocol of this study was registered prospectively on PROSPERO with the registration number CRD42020216384.

RESULTS

We identified 42 relevant RCT articles, out of 1805 articles highlighted by the initial search. All except one were conducted in the US. The most frequently studied ethnic groups were African-Americans (33%), East Asians (30%), and Hispanics/Latinos (23%). In total, 7/42 (16%) RCTs had multiple arms. Interventions mainly intended to educate (52%), provide patient navigation services (21%), or provide a combination of these interventions (19%). We demonstrate that combination methods are most effective.

CONCLUSION

Many RCTs, mostly in the US, have trialed interventions aimed to increase CRC screening uptake amongst ethnic minorities to varying success. We conclude that using a combination of methods with patient navigation, education, and cultural tailoring is most effective at increasing CRC screening uptake amongst ethnic minorities. This highlights that multiple factors may hinder CRC screening and finding a one-size-fits-all solution that can be reliably implemented among different cultures and countries may be complex.

889 An Audit of Indications for Emergency Abdominal X-Rays

Background

Historically, abdominal X-rays (AXRs) have played an essential role in diagnosis of the acute abdomen. With the advent of other imaging modalities and the increasing need for efficiency in time, the utility of AXRs has been clarified by the RCR iRefer guidelines.

Aim

To assess the congruence between indications of AXR requests and the recommendations provided by the RCR iRefer guidelines.

Method

All AXRs performed over a 6-week period in the trust were identified retrospectively from our electronic database. Initial indications were subsequently compared with the current guidance and consultant radiologist reports.

Results

Out of 575 AXRs performed, 36 (6%) had no indication documented on the request. Of the remaining 539, 364 (68%) of AXRs performed met the RCR iRefer guidance. Furthermore, 496 (86%) of AXRs performed were reported as normal. 35% of AXRs that met the guidance underwent further imaging, of which 60% showed abnormality. Of those that did not meet the current criteria, abdominal pain and toxic megacolon were the most frequently documented indications.

Conclusions

One third of AXRs did not meet the RCR iRefer guidelines and were therefore requested inappropriately. Despite the remaining two thirds of requests being appropriate, over one third required further imaging in the form of CT/US. Moreover, less than one fifth of the total scans were interpreted as abnormal. This questions whether the current guidance requires revision and whether this imaging modality is over utilised with little effect on clinical outcomes.

A systematic review of ethnic disparities in the uptake of colorectal cancer screening

AIMS

Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnicity is suggested to play a role; however, there is no high-level evidence to support this. We aim to clarify the impact of Ethnicity on CRC screening uptake and our barriers to its understanding.

METHODS

A systematic review to identify studies reporting on the participation of ethnic minorities in CRC screening worldwide was performed. MEDLINE, Embase, Scopus and Google Scholar databases up until 31 May 2019 were searched. Compliance with screening according to ethnic groups and screening modality was evaluated compared to the 'White' control group.

RESULTS

Twenty-two studies were included in the review reporting on 2,084,213 patients. Substantial variation in categorisation of ethnicities (40 sub-categories), screening modality studied and confounding factors accounted for was observed. 8/15 studies for 'Blacks', 10/13 for 'Hispanics', 2/2 for 'Asians' and 1/1 for 'South East Asians' suggest a less likely or significantly decreased compliance with screening for all screening modalities (p < .05) compared to 'Whites'. Interestingly 'Japanese', 'Vietnamese' and 'Filipino' groups consistently show no difference in the uptake of CRC screening compared to the 'White' majority.

CONCLUSION

This is the only systematic review on this topic. It highlights the inconsistency in screening uptake behaviour in different ethnic minority groups and identifies barriers like variation in ethnicity categorisation, screening modality and study design utilised to understanding the intricacies of this relationship. Further collaboration and action needs to be undertaken internationally to clarify and improve inequity in the uptake of screening.

398 Abdominal X-Rays: Are They Still Relevant? a Review of Outcomes Following Emergency Abdominal Plain Films

Background

Abdominal plain films (AXR) have historically been a routine investigation in Surgical and Emergency Departments (ED), however when considering CT imaging yields significantly more diagnostic information, AXRs are ineffectual in comparison as an aid to decision making. With CT scanning and reporting readily available 24/7, are AXRs still practical?

Aim

To assess the utilisation and outcomes of emergency abdominal films.

Method

All emergency AXRs performed across the trust in a 15-day period were identified retrospectively from our electronic database and were compared with outcomes obtained from our electronic record system.

Results

248 emergency AXRs were performed, 153 Emergency Department and 95 inpatient (IP) requests. 163 (66%) were reported normal, 85 (34%) as abnormal. Of those reported as normal, 26% had further imaging (30% from ED, 17% from IP). Of those reported abnormal, 49% had no further imaging performed (62% from ED, 37% from IP). The odds ratio of admission between ED patients with a significant AXR and an insignificant AXR was 1.34 (95%CI: 0.68–2.83, p&lt;0.05).

Conclusions

One quarter of AXRs reported as normal underwent further imaging, but almost half of the AXRs with reported pathologies did not. This suggests that the usefulness of AXRs acutely is limited, as the presence or absence of abnormalities on the AXR was not a reliable predictor of further investigation nor patient outcome. We therefore suggest re-examination of their utilisation.

402 A Study to Assess Concordance Rates of Emergency Abdominal X-Ray Film Interpretation and Formal Radiological Reporting

Background

Abdominal X-rays (AXRs) were a key part of investigating acute abdominal pain prior to the advent of CT imaging. With increasing reliance on CT scanning, the utilisation and therefore reliance on the interpretation of AXRs has reduced. We investigate the concordance rates of interpretations of AXRs with the formal radiological report, along with the time taken for formal reporting.

Aim

To ascertain the concordance rates of interpretation of emergency AXRs with formal radiological reporting.

Method

All AXRs performed within the trust in a 15-day period were obtained retrospectively from our electronic imaging database. These were compared with the initial interpretations of the AXR, which was obtained from our electronic record system.

Results

248 AXRs were performed, 136 (55%) were not interpreted in the notes. Of the remaining 112, 88 (79%) of AXR interpretations were in concordance with radiological reporting. There was no difference in concordance rates between interpretation by the Emergency Department (ED) or ward-based doctors. The average time for AXRs to be reported was 1.5 days for ED, and 3 for inpatients.

Conclusions

One fifth of AXRs were incorrectly interpreted and more than half of AXRs were not interpreted at all. This brings into question not only their usefulness in general, but also the utilisation of resources to perform them. As all AXRs are reviewed by a consultant radiologist with little impact on decision making, does this still remain an effective utilisation of resources?

SP3.2.9 The concordance between emergency CT reporting in non-traumatic abdominal pain with surgical findings at laparotomy

Aims

Abdominal CT imaging is commonly used to assess the acute abdomen, and is relied upon by clinicians in decision making, often influencing the timeliness of intervention. Increased demand for CT imaging has led to departments out-sourcing reporting out of hours. The aim of this audit was to evaluate the concordance between emergency laparotomy findings and pre-operative CT reports.

Methods

115 patients underwent emergency laparotomy with a pre-operative CT scan pertinent to the clinical episode (May 2019-October 2020). 2 surgical assessors independently assessed the CT reports and laparotomy findings to determine discrepancies. Using published audit standards, discrepancies were defined as major-felt to affect patient treatment- and further classified as false positive, false negative, misdiagnosis, indeterminate; or minor and unlikely to change course of patient care.

Results

32/115 had discrepancies, 28/32 major (16/28 misdiagnosis, 4/28 false negative, 3/28 false positive, and 5/28 indeterminate). 71/115 reported by in house radiology. 19/71 discrepancies reported in house (16 major, 3 minor), 13/32 discrepancies reported by out of hours service (12 major, 1 minor). Relative risk of major discrepancies between in house radiology and out of hours service was 1.2 (p = 0.5).

Conclusions

Published audit standards are that CT reports should have &gt;90% concordance with laparotomy findings; this audit found concordance in 76%. Further analysis comparing gastrointestinal vs. non-gastrointestinal specialist radiologist to assess the impact on concordance will be performed. We aim to explore the discrepancies, and seek to identify if our imaging and operating practices can be improved.

EP.TU.991Developing as Future Leaders: A Systematic Review of Quality Improvement Training in Junior Doctors

Aims

Quality improvement (QI) training in Junior Doctors (JDs) is essential for providing High Quality Care for patients and facilitating organisational success. The aim of this study was to systematically review the evidence on QI training in JDs and determine the impact and effectiveness of training methods.

Methods

A systematic review was conducted as per PRISMA guidelines. Searches were carried out using MEDLINE, EMBASE and HMIC for English-Language articles between January 2005 to December 2019. Selected articles underwent critical appraisal using the CASP criteria by two independent reviewers. A qualitative and thematic analysis was conducted.

Results

43 studies were identified in a range of medical and surgical specialities. Common QI methodology included theoretical and project-based curricula with content focussing on PDSA cycles, root causes analyses and project development. Majority of studies reported improved knowledge, leadership skills and satisfaction. Mentorship and coaching were highly valued, but few studies adhered to this practice. Few studies demonstrated increased QI engagement. Key themes identified (i) Effectiveness of QI training (ii) Barriers to engagement (iii) Organizational culture of fostering QI.

Conclusion

There is growing mandate for training JDs in QI practices to enhance patient care. QI curricula targeting JDs have demonstrated improved knowledge and leadership skills. Nonetheless, significant barriers in QI engagement endure. Additional research is required to combat disengagement and assess sustainability of QI interventions in JDs. We further aim to introduce a pilot QI training programme for surgical JDs to enhance leadership skills.

SP1.2.3General Surgical Registrar in the Emergency Department: Developing and Evaluating a New Surgical Role

Intro

NHS Departments are experiencing unprecedented pressures with exponentially growing patient numbers and severe delays in waiting time. This directly influences bed pressures leading to cancellation of elective surgical lists to aid acute admissions. We introduce the role of a surgical registrar in emergency departments (ED) to review general surgical patients to (i) help reduce ED waiting times (ii) prevent unnecessary admissions and (iii) accelerate management plans.

Methods

This unique role was introduced in our local ED department for 3 months (Nov 2019 - Jan 2020). The shift was trialled Mon-Fri from midday to 8pm. Patient length of stay (LOS), referral times, admissions, discharges and breaches (&gt; 4hrs) were recorded.

Results

The admission rate was 24% (n 681), with a 10% reduction compared with preceding months. 75% patients were discharged following review from which 20% had outpatient investigations arranged. Average LOS at time of referral was 1hr37mins. Peak referral activity was observed on Mondays, Fridays and between 2-5pm. 98% underwent investigations and 79% received active treatments. Feedback from stakeholders, including surgical colleagues was favourable as it allowed more time spent on operative activities.

Conclusion

The NHS has some of the most challenging performance standards in the world. We introduce an innovative solution to help reduce rising clinical and financial pressures. The role of the surgical ED registrar helps reduce waiting times, escalate management and prevent unnecessary surgical admissions. Further studies are being conducted to further evaluate the sustainability of this service and extending it to neighbouring trust hospitals.

SP10.2.10Efficacy of Outpatient Appointment Reminders in Colorectal Surgery: A Prospective Analysis

Introduction

There is increasing mandate to improve attendance in outpatient clinics to support delivery of High-Quality Care. Non-attendance in Colorectal Cancer (CRC) has clinical and financial implications. Patient appointment reminders (letters, text-messages and telephone) have been implemented to reduce non-attendance. We examine the efficacy of patient appointment reminders in CRC patients.

Methods

A prospective study was conducted for 3-months in our CRC department surveying patients on their appointment reminders. Non-attending patients were surveyed via telephone to ascertain cause of non-attendance and preference of patient reminders. Data collected was analysed on SPSS.

Results

547 patients were prospectively surveyed. 19% did not receive appointments letters, from which 73% were made aware via Text message and 25% via Phone calls. 50% received letters &gt; 2 weeks’ notice. 183 patients did not attend (DNA) their appointment from which 100 were successfully surveyed through telephone. 60% of patients did not received an appointment reminder (letter), or received it following the date of their appointment. 79% patients preferred to be contacted via text messaging or an appointment app vs 13% via letters. Cost analysis releveled significant losses due to missed appointments.

Conclusion

Patient appointment reminders are fundamental in reducing non-attendance in clinics. Our study demonstrates that appointment letters are an unreliable method of patient communication. In an ever-increasing digital age, methods such as timely text-messages or an appointment app for CRC patients’ needs urgent implementation as per patient preferences. Further research is required to assess non-attendance and causality in other specialities for comparison.

1555 Comparison of Face-To-Face Versus Online Delivery of a Preparatory Course for First Year Clinical Students

Aim

The coronavirus pandemic has had a huge impact on medical education, with increasing reliance on online delivery of teaching. Sound awareness of investigations available to clinicians is an essential skill, the foundations of which are built from the first clinical year. Our aim is to evaluate whether online teaching has the same efficacy as face-to-face teaching in the context of clinical investigations teaching.

Method

We designed a case-based course using active learning methods (by means of audience participation tools) to prepare first year clinical students in interpreting key investigations (bedside, laboratory and imaging tests) with focus on surgical conditions. This course was delivered face-to-face in November 2019 and subsequently re-delivered via an online platform in November 2020. We utilised a pre- (PR) and post- (PS) confidence questionnaire and a 13-part mock single best answer examination.

Results

32 students attended the face-to-face course; 27 (84.3%) completed the PR and 21 (65.6%) completed the PS. There was a significant improvement in examination scores (56.9% to 71.7%, P < 0.01) and a significant improvement in one of the 6 confidence domains tested (interpreting abdominal radiographs, P < 0.001). 80 students attended the online course; 46 (57.5%) completed the PR and 40 (50%) completed the PS. There was a significant improvement in examination scores (58.8% to 73.2%, P < 0.001) and a significant improvement in two of the 6 confidence domains (interpreting laboratory tests and abdominal radiographs, P < 0.001 for both).

Conclusions

Online teaching is as effective as face-to-face teaching in improving knowledge and confidence in clinical investigations for first clinical year students.

1542 An Audit of Rates of Lynch Testing in Confirmed Colorectal Cancer Cases

Introduction

12% of cancers in the UK are colorectal in origin1 with 1-3% secondary to genetic mismatch repair due to Lynch syndrome2, for which the 2017 NICE guidance recommended that patients with colorectal cancer (CRC) be tested3. It increases the risk of developing other cancers such as endometrial, ovarian and small bowel1, changes the oncological treatment offered to CRC patients4,5, and prompts investigation of their relatives for the condition. In this audit we assessed our rates of trust wide Lynch testing.

Method

Patients with a diagnosis of CRC from 2017-2019 were identified from records held by our cancer services department. Histology results were obtained from an online results portal.

Results

345 were included in the analysis, 79% of which were tested for Lynch, with time taken from biopsy to results ranging from 2 to 276 days (average 45). 54% had results within 30 days, 34% between 30 and 90 days and 12% exceeded 90 days. There was no significant difference of Lynch testing rates between each year. The proportion of results returned within 30 days increased by year, with rates of 30% (2017), 55% (2018) and 71% (2019). The median days from biopsy to results also improved, from 39 to 28 and 16 days, respectively.

Conclusions

Rates and efficiency of our screening for lynch syndrome need improvement to meet the target suggested by NICE. The impact of the recent centralisation our regions pathology department on Lynch testing service provision requires further investigation.

Ethnic disparities in the uptake of colorectal cancer screening: An analysis of the West London population

AIM

Colorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.

METHOD

Results of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.

RESULTS

A total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjusted OR 1.091, p = 0.88).

CONCLUSION

This is the largest retrospective study focusing on the role of ethnicity in the uptake of CRC screening in England. Poor uptake of screening in all ethnic minorities in West London, with the exception of Asian Chinese individuals in particular, is a novel finding. A mandate to routinely collect ethnicity data, the use of a single more diverse census and further intervention are needed to understand this disparity and reduce health inequity.

698 A Systematic Review of Smartphone Applications for Enhanced Recovery After Surgery (ERAS) Following Colorectal Surgery

Introduction

Length of stay (LOS) following colorectal surgery has reduced due to enhanced recovery after surgery (ERAS) programs. Telemedicine has shown potential for patients to remotely access support, communicate progress with their medical team and enhance patient empowerment. We conducted a systematic review of smartphone applications for ERAS following colorectal surgery measuring patient outcomes and experience.

Method

The review was performed adhering to PRISMA guidelines, using search terms pertaining to ERAS, colorectal surgery, and mobile applications via electronic databases. All peer-reviewed English articles were assessed for inclusion and quality by two reviewers. A qualitative analysis was conducted to evaluate methodologies, patient experience, and outcomes.

Results

206 abstracts were identified from which 5 articles (2 RCTs and 3 cohorts) were included in the analysis. Studies surveyed patient adherence to ERAS, LOS, readmission, intra and postoperative complications. Four studies recorded patient satisfaction, whilst one assessed quality of life and application validation.

Conclusions

The review highlights paucity in the use of smartphone applications after ERAS in colorectal surgery but demonstrates high patient satisfaction levels. Service delivery in the NHS has increasingly moved to a virtual platform during the coronavirus pandemic. More research and engagement in the development and use of smartphone applications would enhance care for patients.

Incidental Gallbladder Cancer: Routine versus Selective Histological Examination After Cholecystectomy

Background  Incidental gallbladder cancer is relatively rare, with an incidence ranging between 0.19 and 5.5% of all the cholecystectomies for benign disease, and carries a poor prognosis. Currently, in the literature, there appears to be some controversy about whether all gallbladder specimens should be sent for routine histopathology. The aim of this study was to investigate the need for either routine or selective histopathological evaluation of all gallbladder specimens following cholecystectomy in our institution.

Methods  The records of all patients who underwent a cholecystectomy (laparoscopic and open) for gallstone disease over a 5-year period (between January 2011 and January 2016) were reviewed retrospectively in a single university teaching hospital. Patients with radiological evidence of gallbladder cancer preoperatively were excluded. The notes of patients with incidental gallbladder cancer were reviewed and data were collected for clinical presentation and preoperative investigations including blood tests and radiological imaging.

Results  A total of 1,473 specimens were sent for histopathological evaluation, with two patients being diagnosed with an incidental gallbladder cancer (papillary adenocarcinoma in situ and moderately differentiated invasive adenocarcinoma [stage IIIa]). The incidence rate was 0.14%. All patients with incidental gallbladder cancer had macroscopically abnormal specimens.

Conclusion  Both patients in our study who were diagnosed with incidental gallbladder cancer had macroscopic abnormalities. A selective rather than routine approach to histological evaluation of gallbladder specimens especially in those with macroscopic abnormalities should be employed. This will reduce the burden on the pathology department with potential cost savings.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Generalised purulent peritonitis and small bowel obstruction due to a spontaneously perforated ovarian dermoid cyst

We outline the narrative of a 28-year-old woman who initially presented to the emergency department with vomiting, diarrhoea, abdominal pain and fever. Blood tests revealed significantly raised inflammatory markers and acute renal failure. Initially, this was attributed to gastroenteritis due to a recent foreign travel, but further investigations and radiological imaging revealed a large right ovarian dermoid cyst with a significant amount of free intra-abdominal fluid and small bowel dilation. She underwent laparotomy, which revealed a spontaneously perforated right ovarian dermoid cyst resulting in generalised purulent peritonitis and small bowel obstruction due to bowel adherence at the perforation site. Meticulous adhesiolysis, right salpingo-oophorectomy and extensive peritoneal lavage were performed, with a good postoperative recovery. Spontaneous perforation of an ovarian dermoid cyst, without an associated torsion, is extremely rare, but it should be considered in cases of peritonitis and bowel obstruction of unclear cause with a concomitant finding of a dermoid cyst.

The multi-disciplinary team - Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's "lead clinician", and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.

Surgical Management of Patients with Neuroendocrine Neoplasms of the Appendix: Appendectomy or More

BACKGROUND

Appendiceal neuroendocrine neoplasms (ANEN) are mostly indolent tumours treated effectively with simple appendectomy. However, controversy exists regarding the necessity of oncologic right hemicolectomy (RH) in patients with histologic features suggestive of more aggressive disease. We assess the effects of current guidelines in selecting the surgical strategy (appendectomy or RH) for the management of ANEN. Methods/Aims: This is a retrospective review of all ANEN cases treated over a 14-year period at 3 referral centres and their management according to consensus guidelines of the European and the North American Neuroendocrine Tumor Societies (ENETS and NANETS, respectively). The operation performed, the tumour stage and grade, the extent of residual disease, and the follow-up outcomes were evaluated.

RESULTS

Of 14,850 patients who had appendectomies, 215 (1.45%) had histologically confirmed ANEN. Four patients had synchronous non-ANEN malignancies. One hundred and ninety-three patients had index appendectomy. Seventeen patients (7.9%) had lymph node metastases within the mesoappendix. Forty-nine patients underwent RH after appendectomy. The percentages of 30-day morbidity and mortality after RH were 2 and 0%, respectively. Twelve patients (24.5%) receiving completion RH were found to have lymph node metastases. Two patients had liver metastases, both of them synchronous. The median follow-up was 38.5 months (range 1-143). No patient developed disease recurrence. Five- and 10-year overall survival for all patients with ANEN as the only malignancy was both 99.05%.

CONCLUSIONS

The current guidelines appear effective in identifying ANEN patients at risk of harbouring nodal disease, but they question the oncological relevance of ANEN lymph node metastases. RH might present an overtreatment for a number of patients with ANEN.

The selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre

AIM

There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management.

METHOD

All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality/morbidity/Clavien-Dindo (CD) classification of morbidity, length of stay (LOS) and improvement of quality of life.

RESULTS

There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) (39.0%), rectal recurrence (RR) (22.0%), locally advanced primary colon cancer (LAPCC T3c/d-T4) (21.1%), colon cancer recurrence (CR) (12.4%), locally advanced primary anal cancer (LAPAC-failure of CRT/T3c/d-T4) (3.0%) and anal cancer recurrence (AR) (2.2%). Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The LOS varied from 13.3 to 19.9 days. RR operations had the highest morbidity (CD 1-2, 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals.

CONCLUSION

Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardized referral pathway is encouraged.

Management of tailgut cysts in a tertiary referral centre: a 10-year experience

AIM

Tailgut cysts are rare congenital lesions typically presenting as presacral masses. A variable clinical presentation often leads to misdiagnosis and unsuccessful operations.

METHOD

A retrospective analysis was performed of tailgut cysts presenting to one surgeon at St Mark's hospital between 2003 and 2013. The patient demographic data and clinicopathological and radiological features, together with perioperative details and recurrence, were reviewed.

RESULTS

A total of 17 patients (15 women) with a median age of 35 (21-64) years were included in the study. The mean duration of symptoms before referral was 40 months, with sepsis predominating in 12 cases. Fifteen of the patients had previously undergone surgery (mean 2.9 procedures). A posterior surgical approach was adopted in all patients with a coccygectomy performed in 13. A loop colostomy was formed in three patients. Two of them went on to have a secondary pull-through operation after an initial failed local repair of rectal injury. One case was reported to show malignant degeneration on histological examination. There was one recurrence during a median follow-up period of 13 (3-36) months.

CONCLUSION

Tailgut cysts are an uncommon yet important cause of chronic perianal sepsis. Suspicion should be raised in a patient, usually female, presenting with a history of unsuccessful procedures. Diagnosis can be made by clinical assessment and MRI. Complete excision usually resolves the problem.

Enhanced recovery program following colorectal resection in the elderly patient

BACKGROUND

The enhanced recovery program (ERP) aims to reduce the metabolic response to surgery, hastening recovery and shortening hospital stay. Concerns exist regarding morbidity and hospital stay in elderly patients. The present study aimed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group.

METHODS

A review was performed of a prospective database of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010. Patients were grouped into <80 years and ≥ 80 years, and perioperative data were collated. The postoperative outcomes were compared with the goals set out by the ERP protocol.

RESULTS

A total of 688 patients were included, 558 were <80 years (median: 66 years; range: 17-79 years) and 130 were ≥ 80 years (median: 83 years; range: 80-95 years). Some 96% of operations were planned laparoscopically. Median total length of hospital stay was 6 days (range: 1-108 days) for the <80 year group and 8 days (range: 1-167 days; P 0.363) for the elderly group, with a 30 day readmission rate of 8.6% for the population and no significant differences between groups. The 30 day mortality was 5%, with a significant difference between the two groups (P < 0.0001). Differences in protocol adherence were identified in the discontinuation of intravenous fluids, catheter removal, and early mobilization.

CONCLUSIONS

An enhanced recovery program is feasible for colorectal surgery patients ≥ 80 years of age, with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate. Attention to improving compliance in the postoperative phase is necessary, particularly in such high-risk patients, as such improvement may reduce the morbidity and mortality.

Screening for colorectal cancer: established and emerging modalities

It has been estimated that >95% of cases of colorectal cancer (CRC) would benefit from curative surgery if diagnosis was made at an early or premalignant polyp stage of disease. Over the past 10 years, most developed nation states have implemented mass population screening programs, which are typically targeted at the older (at-risk) age group (>50-60 years old). Conventional screening largely relies on periodic patient-centric investigation, particularly involving colonoscopy and flexible sigmoidoscopy, or else on the fecal occult blood test. These methods are compromised by either low cost-effectiveness or limited diagnostic accuracy. Advances in the development of diagnostic molecular markers for CRC have yielded an expanding list of potential new screening modalities based on investigations of patient stool (for colonocyte DNA mutations, epigenetic changes or microRNA expression) or blood specimens (for plasma DNA mutations, epigenetic changes, heteroplasmic mitochondrial DNA mutations, leukocyte transcriptome profile, plasma microRNA expression or protein and autoantibody expression). In this Review, we present a critical evaluation of the performance data and relative merits of these various new potential methods. None of these molecular diagnostic methods have yet been evaluated beyond the proof-of-principle and pilot-scale study stage and it could be some years before they replace existing methods for population screening in CRC.

The cost of postgraduate training

The Modernising Medical Careers and European Working Time Directive have led to significant changes in the working patterns and training of junior doctors. This article seeks to explore the hidden costs incurred by trainees of various specialties and grades for postgraduate training.

Laparoscopic colorectal cancer surgery in obese patients

AIM

The aim of this study was to assess the oncological and postoperative outcomes of laparoscopic colorectal cancer surgery in obese patients.

METHOD

All obese (BMI > 30) patients who underwent laparoscopic colorectal cancer surgery from January 2005 to January 2008 were compared with nonobese patients undergoing similar surgery. We recorded patient demographics, intra-operative details and postoperative morbidity and mortality.

RESULTS

Sixty-two obese and 172 nonobese patients underwent laparoscopic colorectal cancer resection. Both groups were well matched for demographic parameters. Overall mean operating times were not significantly different. Conversion to open surgery was more likely in obese patients. In particular, for rectal cancers, the conversion rate was 44% in the obese group compared with 17% in the nonobese group (P < 0.05). Postoperative morbidity was also greater in obese patients (P < 0.05). The duration of hospital stay was similar for laparoscopically completed cases (6 days obese vs 7 days nonobese), but in the obese-converted group it was 14 days (P < 0.05). The resected specimen with respect to length, resection margin and lymph node retrieval was equivalent between obese and nonobese patients. Disease-free survival and overall survival at a median follow up of 2 years were also similar.

CONCLUSIONS

Laparoscopic colorectal cancer surgery in obese patients is technically feasible and oncologically safe. Despite greater postoperative morbidity, obese patients benefit from shorter length of stay. However, a higher conversion rate, particularly for rectal cancers, should be anticipated in obese male patients.

Spontaneous bowel perforation due to norovirus: a case report

Norovirus is the leading cause of epidemic gastroenteritis worldwide but the disease is usually self-limiting and generally only causes serious health problems in the young, elderly and immunocompromised. The authors report a case of bowel perforation in an elderly Caucasian lady with confirmed infection with Norovirus genogroup II and no other presumptive cause. To the authors' knowledge this is the first such case of bowel perforation due to Norovirus. Viral gastroenteritis should be considered in the list of differentials when no obvious cause of bowel perforation can be identified to minimise morbidity and mortality.