Colorectal resections during the COVID-19 pandemic: a national survey of practice during first lockdown

INTRODUCTION

The first wave of the COVID-19 pandemic led to an unprecedented time for the management of colorectal cancer, with uncertainty as to cancer-specific risks and the circumventing of gold standard oncological strategies. Our study aimed to acquire a snapshot of the practice of multidisciplinary team (MDT) management and variability in response to rapidly emerging guidelines.

METHODS

The survey was disseminated to 150 colorectal cancer MDTs across England and Wales taken from the National Bowel Cancer Audit data set between 15 April and 30 June 2020 for completion by colorectal surgeons.

RESULTS

Sixty-seven MDTs responded to the survey. Fifty-seven centres reported that they continued to perform colorectal cancer resections during the initial lockdown period. Fifty centres (74.6%) introduced routine preoperative COVID-19 testing and 50 (74.6%) employed full personal protective equipment for elective cases. Laparoscopic resections were continued by 25 centres (42.1%), whereas 28 (48.3%) changed to an open approach. Forty-nine (79.0%) centres reported experiencing patient-led surgical cancellations in 0-25% of their listings. If surgery was delayed significantly then 24 centres (38.7%) employed alternative neoadjuvant therapy, with short-course radiotherapy being their preferred adjunct of choice for rectal cancer. Just over 50% of the MDTs stated that they were uncomfortable or very uncomfortable with their management strategies.

CONCLUSIONS

Our study demonstrates variability in the MDT management of colorectal cancer during the initial COVID-19 lockdown, incorporating adaptive patient behaviour and initially limited data on oncological safety profiles leading to challenging decision-making.

Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to compare recurrence rates of rectal prolapse following ventral mesh rectopexy (VMR) and suture rectopexy (SR).

Methods

MEDLINE, Embase, and the Cochrane Library were searched for studies reporting on the recurrence rates of complete rectal prolapse (CRP) or intussusception (IS) after SR and VMR. Results were pooled and procedures compared; a subgroup analysis was performed comparing patients with CRP and IS who underwent VMR using biological versus synthetic meshes. A meta-analysis of studies comparing SR and VMR was undertaken. The Methodological Items for Non-Randomized Studies score, the Newcastle–Ottawa Scale, and the Cochrane Collaboration tool were used to assess the quality of studies.

Results

Twenty-two studies with 976 patients were included in the SR group and 31 studies with 1605 patients in the VMR group; among these studies, five were eligible for meta-analysis. Overall, in patients with CRP, the recurrence rate was 8.6 per cent after SR and 3.7 per cent after VMR (P < 0.001). However, in patients with IS treated using VMR, the recurrence rate was 9.7 per cent. Recurrence rates after VMR did not differ with use of biological or synthetic mesh in patients treated for CRP (4.1 versus 3.6 per cent; P = 0.789) and or IS (11.4 versus 11.0 per cent; P = 0.902). Results from the meta-analysis showed high heterogeneity, and the difference in recurrence rates between SR and VMR groups was not statistically significant (P = 0.76).

Conclusion

Although the systematic review showed a higher recurrence rate after SR than VMR for treatment of CRP, this result was not confirmed by meta-analysis. Therefore, robust RCTs comparing SR and biological VMR are required.

Laser depilation as adjuvant therapy in prevention of recurrence of pilonidal sinus disease: initial experience of a district general hospital in the UK

INTRODUCTION

Pilonidal disease is a chronic condition involving the sacrococcygeal area. It can have a significant impact on quality of life, social activities and occupation. Surgery is the mainstay of treatment. However, laser depilation has been proposed as an adjunct to surgery and has shown improved results in some studies. We present our experience of laser depilation in the treatment of pilonidal disease in a district general hospital setting in the UK.

MATERIALS AND METHODS

A prospectively maintained database of all consecutive patients who received laser depilation after elective surgery for pilonidal disease was analysed. Patients were offered a minimum of two sessions of laser depilation. The primary outcome measure was disease recurrence. Evidence of new symptoms or signs of pilonidal disease after one year from the latest surgical intervention was defined as recurrent disease. Data are presented as medians with interquartile ranges.

RESULTS

A total of 64 patients underwent laser depilation after elective surgery between 1 June 2013 and 1 June 2018; 57 were eligible for final analysis. Sixty-five per cent of patients received six or more sessions of laser treatment. There were no short- or long-term complications related to laser depilation. Patients who had more than two sessions of laser depilation showed an improved recurrence rate. Overall, recurrence rate in our series was 12% at a median follow-up of 172 weeks.

CONCLUSION

Laser depilation is a safe and effective adjunct to surgery in minimising the recurrence of pilonidal disease. Patients with primary pilonidal disease and those who are undergoing minimally invasive surgery may also benefit from adjuvant laser depilation. Further high-quality control trials are required to assess its efficacy and safety.

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

A Rare Case of Life-Threatening Bleeding Caused by a Jejunal GIST

Gastrointestinal Stromal Tumours (GISTs) are rare mesenchymal tumours that are specific to GI tract. GISTs usually associated with advanced age and have a slight male preponderance. GISTs are commonly found in stomach. Jujunal GISTs are the rarest and account for about 0.1-3% of all GI tumours [1]. The most common clinical manifestation of symptomatic GISTs includes intermittent bleeding due to mucosal ulceration. Massive, life threatening gastrointestinal (GI) bleeding is a rare occurrence. We report a rare case of bleeding Jejunal GIST in a 32-year-old female who presented with haemorrhagic shock that required resuscitative laparotomy. Histopathology and immunohistochemistry confirmed the tumour to have features of GIST with clear margins and post-operative cross-sectional imaging excluded any metastatic deposits.

Short-term outcomes of endoscopic pilonidal sinus treatment

INTRODUCTION

Endoscopic treatment for pilonidal disease was initially described by Meinero in 2013. This minimally invasive technique has both technical and aesthetic advantages. The diagnostic application helps identify the anatomy of the pilonidal disease and the operative phase ablates and cleans the infected cavity. Our aim was to study the short-term outcomes of endoscopic treatment for pilonidal disease and to evaluate complications and recurrence rates.

MATERIALS AND METHODS

A prospectively maintained database of all consecutive patients who underwent endoscopic treatment for pilonidal disease by a single surgeon in a district general hospital from 1 November 2014 to 31 March 2018 was analysed. Follow-up was available until 30 September 2018.

RESULTS

A total of 74 patients (56 men) underwent endoscopic treatment for pilonidal disease. The median age was 21 years (range 16-62 years). All patients underwent the procedure as daycase procedures, seven under local anaesthesia. There were no immediate postoperative complications and no return to theatre or readmission within 90 days. On a median follow-up of 52 weeks (range 2-114 weeks), 57 patients healed completely and 8 lost to follow-up. We achieved primary healing rates of 67% (44/66) and delayed healing rate of 77% (51/66).

CONCLUSIONS

Endoscopic treatment for pilonidal disease is a safe and effective minimally invasive technique that should be considered as first-line treatment in selected cases of pilonidal sinus disease, thereby reducing morbidity related to conventional procedures.

Video-assisted anal fistula treatment: a high volume unit initial experience

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Endoscopic pilonidal abscess treatment: a novel approach for the treatment of pilonidal abscess

INTRODUCTION Pilonidal abscess is a common surgical emergency. Conventional treatment with incision and drainage is associated with significant postoperative morbidity. We report our initial experience of using minimally invasive endoscopic technique for the treatment of pilonidal abscesses, referred to as endoscopic pilonidal abscess treatment (EPAT). MATERIALS AND METHODS A prospective database of all patients undergoing EPAT between January 2015 and March 2016 at Whiston Hospital was maintained. Data regarding patient demographics, peroperative variables and postoperative follow-up were recorded. RESULTS Nineteen patients were included, male to female ratio was 53 : 47 and median age of the cohort was 24 years (interquartile range 22-25 years). EPAT was the primary procedure for 10 patients and 9 had EPAT for recurrent pilonidal abscesses. There were no readmissions and none needed further surgery within 6 weeks of having the procedure. In all patients, complete wound healing was achieved within 6 weeks; all reported minimal postoperative pain (median postoperative visual analogue scale score 1) and immediate return to the activities of daily life. Four of the nineteen patients (21%) required definitive intervention for pilonidal disease in the follow-up period. CONCLUSIONS EPAT is a novel, minimally invasive technique for the treatment of acute pilonidal abscesses. It is safe, associated with reduced postoperative morbidity, recurrence rate and quick wound healing. Initial encouraging results require further investigations on a larger group of patients in a multicentre setting.

The significance of extramural venous invasion in R1 positive rectal cancer

BACKGROUND AND AIMS

Evidence has shown that a positive resection margin (R1) is a key determinant of subsequent local recurrence and a poor prognostic factor in rectal cancer. The aim of this study was to evaluate the outcomes and prognosticators in patients with R1 resection of rectal cancer.

MATERIAL AND METHODS

Retrospective study of all patients operatively managed within our institution between April 2008 and April 2013 for rectal cancer. Baseline demographics and multiple outcome measures recorded. Overall survival (OS), disease-free survival (DFS) and recurrence were the primary outcome measures.

RESULTS

Overall, there were 306 primary rectal cancers. Seventy-six percent were grade T3/4 tumours. OS was 30 months. R1 rate was 16 % (48 patients). Thirty-one patients underwent APR and 17 AR. In patients who responded to neoadjuvant chemotherapy (NAC), overall survival was 55 months, with no extramural venous invasion (EMV) seen in this cohort. In non-responders OS was 29 months, with EMV in 48 %. In patients who did not receive NAC, OS was 23 months, with EMV in 74 %. EMV is a strong predictor for poor survival following R1 (p = 0.001). We also found a correlation between number of positive nodes and OS/DFS (p = 0.004).

CONCLUSIONS

In this small cohort of patients with R1 positive rectal cancers, response to NAC is the strongest predictor of poor overall and disease-free survival. In patients who respond to NAC, OS and DFS has been shown to be positive, with a reduced rate of EMV.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Conservative surgery in the management of a benign ovarian cystic teratoma presenting as a rectal mass: a case report

Ovarian cystic teratomas constitute 10-15% of all ovarian tumours and are the most common ovarian neoplasms found in adolescence and during pregnancy. Nevertheless, ovarian cystic teratomas have also been described in patients aged 1-91 years. We report an unusual case of a benign ovarian cystic teratoma presenting as a rectal mass that was managed surgically using radical resection by a multidisciplinary team. This case report highlights the importance of preoperative investigations including colonoscopy and radiological investigations. A dedicated pelvic radiologist/pathologist and the involvement of a multidisciplinary team at the time of initial diagnosis and a gynaecologist and colorectal surgeon at the time of surgery will lead to an accurate diagnosis and the most appropriate treatment. Although rare, erosion of an ovarian dermoid into the rectum should be considered in young women who have an atypical presentation and are found to have a lesion in the rectum with biopsies indicating benign pathology.

Colon cancer presenting with polymyositis-A case report

INTRODUCTION

Colorectal cancer most often presents with a change in bowel habit, weight loss or with bleeding per rectum. Much less commonly, colorectal cancer may present as part of a paraneoplastic syndrome. Polymyositis is a rare disease most often considered a complement-mediated idiopathic inflammatory myopathy manifested by proximal muscle weakness. However, polymyositis may also be part of a paraneoplastic syndrome associated with an underlying malignancy. The relationship between polymyositis and malignancy is well known, but it has been suggested that tumours of the large bowel are rarely complicated by myositis.

PRESENTATION OF CASE

The authors describe a case report of an 82-year-old gentleman with a presumed musculoskeletal or neurological deficit who was subsequently diagnosed with metastatic colon cancer in the setting of progressive fatigue and muscle weakness. Concurrently, we review the current literature looking at the relationship between cancer and polymyositis.

DISCUSSION

Colorectal cancer rarely presents with symptoms such as muscle weakness, however it is important to be aware of the possibility of an underlying malignancy when seeing patients with symptoms which are suggestive of polymyositis.

CONCLUSION

The diagnosis of polymyositis in the elderly population should raise suspicion of an underlying malignancy.

Expression of cyclin D2 is an independent predictor of the development of hepatic metastasis in colorectal cancer

INTRODUCTION

Cyclin D1 has been implicated in the progression of several cancers by virtue of its influence on progression of the G1/S phase of the cell cycle. However, little is known about the possible roles of cyclin D2 and D3 in colorectal cancers (CRCs).

METHOD

We investigated the expression levels of cyclin D2 and D3 in 84 CRC specimens. Antigen expression was determined by immunohistochemical analysis of cyclin D1, D2, D3, p16INK4A and Ki67 on tissue microarrays constructed using core samples from tumour centres and margins.

RESULTS

For the whole cohort, expression of cyclin D2 at the margin was associated with vascular invasion (P = 0.039), lymph node metastasis (P = 0.020) and liver metastasis (P < 0.001). In patients with stage I and II tumours (n = 84), elevated cyclin D2 and D3 were associated with vascular invasion (P = 0.014 and 0.028 respectively), liver metastasis (P = 0.001 and 0.007 respectively) and reduced disease specific survival (Cyclin D2, P < 0.022). No association was noted between the proliferative marker Ki-67 and the D-type cyclins.

CONCLUSION

These findings suggest that cyclin D2 expression at the invasive margin of CRCs is associated with liver metastasis and may serve as a useful prognostic marker and indicator of the need for adjuvant therapy.

The role of hypoxia in recurrence following resection of Dukes' B colorectal cancer

GOALS

Tumour hypoxia has been shown to be a predictor of early distant relapse in node-negative breast and cervical cancer. The purpose of the present study was to determine the role of hypoxia in predicting patients who are at high risk of disease recurrence in Dukes B colorectal cancers.

MATERIALS AND METHODS

Archival tissue was retrieved from 52 patients who had undergone surgical resection for primary colorectal cancer. Tissue micro-arrays were constructed using tissue from the margin and the centre of the tumour. Hypoxia markers hypoxia-inducible factor (Hif)-1 alpha, vascular endothelial growth factor (VEGF), carbonic anhydrase (CA)-9 and glucose transporter (Glut)-1 were visualised using immunohistochemical detection and quantified using semi-quantitative analysis of the digitised images. Clinical details and outcome data were retrieved by case note review and collated with hypoxia markers data in a statistical database.

RESULTS

Primary colorectal cancers with a high Hif-1 alpha expression tended to have a significantly worse disease-free survival (log rank p < 0.001) and overall survival (log rank p = 0.012). VEGF was also a significant predictor of disease recurrence in primary colorectal cancers (p = 0.015). Significant correlations were also noted between Hif-1 alpha and VEGF (Pearson's p = 0.009). Glut-1 and CA-9 did not show a similar pattern with no differences in the expression pattern and no correlation observed with any of the markers. Multivariate analysis of prognostic factors showed vascular invasion (p < 0.001) and Hif-1 alpha at the tumour margin (p < 0.001) to be independent predictors for the development of liver metastases.

CONCLUSION

These results suggest an important role for Hif-1 alpha and VEGF in colorectal cancer progression, with both markers biological mechanisms directly interlinked through the hypoxic pathway. Identification of high-risk patients using the above factors will improve treatment strategies in node-negative disease and help improve patient outcome.

Accuracy in ECG lead placement among technicians, nurses, general physicians and cardiologists

The objective of the study was to determine the reliability of ECG precordial electrode placement by doctors and nurses involved in the emergency care of patients admitted with suspected cardiac diseases. A total of 120 subjects were recruited within 2 days from six hospitals. They comprised physicians, nurses and cardiac technicians involved in the clinical assessment and care of patients with suspected cardiac disease. Subjects were asked to complete a questionnaire and marked on two diagrams of the chest wall the positions they would place precordial electrodes V1-V6. This study showed wide inter-individual and inter-group variations in the placement of electrodes. Notably, V1 and V2 were frequently incorrectly positioned in the second intercostal space, especially by physicians. The correct position of V1 in the fourth right intercostal space was identified by 90% of cardiac technicians, 49% of nurses, 31% of physicians (excluding cardiologists) and--most disappointing of all--only 16% of cardiologists (p<0.001 for inter-group differences). V5 and V6 were also often mispositioned, too high on the lateral chest wall. Nurses and doctors (especially cardiologists) do not know the correct positions for ECG electrodes. Because incorrect positioning of the precordial electrodes changes the ECG significantly, patients are at risk of potentially harmful therapeutic procedures. Equally, doctors who are aware of the possibility of lead misplacement may be inclined to ignore some ECG changes that may be genuine evidence of ischaemia. The only safe solution is proper precordial electrode placement, which requires training and an environment supporting precision.

Biological characteristics and behaviour of putatively curatively resected colorectal liver metastases

AIM

To identify whether positive resection margin tumours had a more aggressive phenotype, using tumour micro-vessel density and invasive margin.

METHODS

Archival tissue was retrieved from 109 patients who had undergone resection for colorectal liver metastases. The nature of the invasive margin was determined by H&E histochemistry. MVD was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome were retrieved and collated with invasive margin and MVD data in a statistical database.

RESULTS

41/68 patients with a positive resection margin (R1) had recurrences following liver resection, while only 16/41 patients with a clear margin (R0) developed recurrences. More of the margin clear patients also developed capsulated liver metastases (56%), compared to positive resection margin patients (22%) (Chi squared test p<0.001). The stromal margin MVD in the R0 patients was 250 (11-609), compared to the R1 value of 122 (27-428) (Mann-Whitney U test p=0.01).

DISCUSSION

Positive resection margin, amongst other factors, is a predictor of poor prognosis. This appears to be in part explained by the expression of adverse tumour characteristics.

The influence of invasive growth pattern and microvessel density on prognosis in colorectal cancer and colorectal liver metastases

The nature of the invasive growth pattern and microvessel density (MVD) have been suggested to be predictors of prognosis in primary colorectal cancer (CRC) and colorectal liver metastases. The purpose of the present study was to determine whether these two histological features were interrelated and to assess their relative influence on disease recurrence and survival following surgical resection. Archival tissue was retrieved from 55 patients who had undergone surgical resection for primary CRC and matching liver metastases. The nature of the invasive margin was determined by haematoxylin and eosin (H&E) histochemistry. Microvessel density was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome data were retrieved by case note review and collated with invasive margin and MVD data in a statistical database. Primary CRCs with a pushing margin tended to form capsulated liver metastases (P<0.001) and had a significantly better disease-free survival than the infiltrative margin tumours (log rank P=0.01). Primary cancers with a high MVD tended to form high MVD liver metastases (P=0.007). Microvessel density was a significant predictor of disease recurrence in primary CRCs (P=0.006), but not liver metastases. These results suggest that primary CRCs and their liver metastases show common histological features. This may reflect common mechanisms underlying the tumour–host interaction.

National survey in the United Kingdom of prophylaxis of deep vein thrombosis for patients with fracture of the neck of the femur

Thromboprophylaxis continues to be a contentious issue because of a lack of clear answers to pertinent questions. Hence, a survey is helpful in identifying current practices. A national survey in the UK in January 2004 investigated the use of thromboprophylaxis following fracture of the neck of the femur. Responses from 723/1648 (44%) orthopaedic consultants to a postal questionnaire showed that 623 (86%) regularly undertook trauma surgery and 625 (87%) had protocols for prophylaxis of deep venous thrombosis. In all, 555 (89%) consultants followed these protocols routinely and, of these, 276 (50%) regularly used both chemical and mechanical prophylaxis, 235 (42%) used chemoprophylaxis only and 44 (8%) used mechanical prophylaxis only. Among consultants using chemoprophylaxis, 238 (46%) used low-molecular-weight heparin, 148 (30%) used aspirin, 75 (15%) used low-molecular-weight heparin and aspirin, 35 (6%) used unfractionated heparin and 15 (3%) used warfarin. However, 68 (11%) did not use any thromboprophylaxis at all for patients with fractured neck of the femur.