521 Optimising Anaemic Patients for Colorectal Cancer Surgery: Implementation of Day-Case Iron Infusion Pathway and Closed Loop Audit of Anaemia Management in Colorectal Cancer Patients

Aim

Pre-operative anaemia is associated with increased mortality and morbidity in patients undergoing colorectal cancer (CRC) surgery. NICE recommends screening for and treating anaemia in this patient group. Our local guidelines reflect this and advocate the use of pre-operative IV iron provided to patients in the day-case unit. Through 2 audit cycles we assessed whether anaemic CRC patients were prescribed pre-operative iron infusion. Secondary outcome was the requirement of post-operative blood transfusion.

Method

Data was collected between June-August 2019 (cycle 1) and January-February 2020 (cycle 2) for patients undergoing elective CRC surgery. Data collected included haemoglobin levels pre- and post-operatively, pre-operative iron infusion and post-operative blood transfusion rates. Between the cycle’s education regarding anaemia management and further publicity of the iron infusion pathway took place within the department.

Results

In cycle 1 27.5% (11/40) of patients were anaemic; 18% (2/11) of these patients received appropriate iron infusion pre-operatively. In cycle 2 45.4% (20/44) of patients were anaemic; 60% (12/20) received iron infusion. 45% (5/11) of anaemic patients in cycle 1 had post-operative transfusion; none of these patients had pre-operative IV iron. In cycle 2 20% (4/20) of anaemic patient required post-operative transfusion; 3 out of 4 of these patients had not received pre-operative IV iron.

Conclusions

We have demonstrated how education and improved awareness of local services can increase rate of IV iron prescription and reduce the need for post-operative transfusion in anaemic CRC patients. However, these is still room for improvement in management of anaemia within this patient group.

Internal hernias: a brief review

Hernias are very familiar to a core surgical trainee in the setting of clinics and the surgical assessment unit. By definition, a hernia is an abnormal protrusion of a viscus from one compartment to another. In clinic, they are visible lumps, exhibiting a cough reflex often with a well definable history making them readily identifiable. In the acute setting, they are the third commonest cause of small bowel obstruction in the developed world. Ventral and inguinal hernias account for the majority of these with only a small proportion due to internal hernias. This article aims to educate the core surgical trainee on the anatomy and distinguishing clinical features of these rare but important types of internal abdominal hernias.

Diagnostic yield and economic implications of endoscopic colonic biopsies in patients with chronic diarrhoea

AIMS

Random colonic biopsies are recommended to exclude microscopic colitis in patients with chronic diarrhoea especially when mucosa is macroscopically normal at endoscopy. This study aimed to assess the clinical outcome and economic impact of such a policy in an unselected group of patients with macroscopically normal mucosa.

METHODS

All new patients undergoing colonoscopy for investigation of chronic diarrhoea between April and December 2009 were included. Patients were divided into two groups: macroscopically normal mucosa and macroscopically inflamed mucosa. Endoscopic findings were correlated with histology of random biopsies and haematological parameters. Symptom status and any treatment were established from follow-up. The breakdown and overall cost of random biopsies for each patient with a macroscopically normal mucosa were determined, and cost incurred per diagnosis of microscopic colitis was established.

RESULTS

Altogether 137 (90.1%) of 152 patients with chronic diarrhoea had macroscopically normal mucosa at colonoscopy. Overall incidence of microscopic colitis in the study was 1.3% (2/152); both patients belonged to the macroscopically normal mucosa group. At follow-up, both these patients had spontaneous symptom resolution without any specific treatment. The policy of undertaking random biopsies in patients with macroscopically normal mucosa incurred an extra cost of £22,057 to diagnose two cases of microscopic colitis but did not alter medical treatment.

CONCLUSIONS

In unselected patients with chronic diarrhoea and macroscopically normal mucosa, random colonic biopsies have a low diagnostic yield and incur a high cost. Continued research for predictive markers to improve patient selection for targeted biopsies is needed to develop a cost-effective investigative algorithm in chronic diarrhoea.

Terminal ileal Crohn's disease: conservative surgeon and aggressive physician?

OBJECTIVE

The timing of surgery in Crohn's disease is a matter of continuing debate, in particular early surgery for patients presenting with apparent appendicitis found to have terminal ileal Crohn's. Our aim was to assess the current strategies of UK Consultant Coloproctologists and Gastroenterologists in managing terminal ileal Crohn's disease in acute and elective settings.

METHOD

A postal questionnaire survey was sent to 460 Consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and a very similar 'medical' questionnaire sent to 1043 Consultant British Society of Gastroenterology (BSG) members.

RESULTS

247 ACPGBI members (54%) replied to the 'surgical' questionnaire. For acute terminal ileitis at presumed appendicectomy 40% would recommend doing nothing, 33% a limited ileal/ileo-caecal resection and 27% appendicectomy only. For elective management of terminal ileal Crohn's, 51% would institute medical therapy and refer to a gastroenterologist, 40% would refer directly to a gastroenterologist while 9% would follow up the patient themselves. No surgeon would perform primary resection. 398 BSG members (38%) responded to the 'medical' questionnaire. 54% would prefer their surgical colleagues to perform ileo-caecal resection acutely patients operated on for presumed appendicitis. Electively only 1.8% would refer for surgery as primary therapy. Most would institute medical therapy, with the therapeutic options varying widely.

CONCLUSIONS

There is divided opinion on managing the acute presentation of terminal ileal Crohn's disease. Surgeons appear more conservative in their approach compared to gastroenterologists. This merits further clarification before acceptance amongst the majority of physicians and particularly surgeons.