Aim:

ADMIRE-CD showed promising results of Mesenchymal Stem Cells (MSCs) for perianal fistulising Crohn’s Disease (PFCD), however MSC use in the UK is limited by logistical concerns and lack of long-term data. We report preliminary results of MSC treatment with stringent radiological outcomes at two UK centres.

Methods:

Patient eligibility mirrored ADMIRE-CD. Clinical and MRI follow-up occurred 6 months post-treatment. Clinical remission, response and combined (clinical and radiological) remission were defined according to ADMIRE-CD criteria. Radiological healing was also sought.

Results:

Twenty patients received MSCs (12 Female, Mean age 36.4) with 7.2 years average duration of perianal disease. Clinical follow-up data were available for 17 patients, of whom 8 demonstrated clinical remission (47%) and 3 demonstrated clinical response (18%). There was a significant improvement in mean Perianal Disease Activity Index (PDAI) scores (7.9 at baseline, 3.8 at 6-month follow-up p<0.0001). Radiological follow-up was available for 15 patients, with 7 (47%) demonstrating combined remission according to ADMIRE-CD criteria, although no patients had radiologically healed fistulae at 6 months.

Conclusion:

MSC use in the UK is feasible. Clinical and radiological outcomes at 6 months are comparable to ADMIRE-CD. However, when stringent radiological criteria are applied, complete healing was not demonstrated. Long term outcome data are awaited.

Aim:

Ileoanal pouch vaginal fistula (PVF) is a complication of restorative proctocolectomy with ileo-anal pouch anastomosis. The objective of this systematic review was to provide a consensus on the management of PVF after IPAA in ulcerative colitis.  

Method:

A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA Guidelines. Online searches of databases Medline, Embase, Cochrane Library and clinical trial registries were performed. 

Results:

27 articles were included in the study: 13 retrospective cohort studies, 2 prospective cohort studies, 8 case series, 3 case reports and a case-control study. A narrative synthesis was performed due to heterogeneity between articles. Our review included 577 PVFs, the incidence rate was 2.1-17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. 

Conclusion: 

Local interventions and abdominal approaches have a high failure rate. The results of this review will aid counselling of patients. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on management of PVF are low quality; a large prospective registry and Delphi consensus are required. 

Aim:

This study evaluated the demographics and outcomes of patients with IBD undergoing bowel resection and assessed for the potential impact of surgical subspecialisation. 

Methods:

Demographic, operative and outcome data were collected for patients undergoing a bowel resection secondary to IBD (n=913), admitted acutely to NHS trusts in the North of England between 2002-2016. The primary outcome of interest was 30-day postoperative mortality, with secondary outcomes: length of stay (LoS), stoma and anastomosis rates.

Results:

A reduction in the number of resections was noted over time (2002-06: 361 vs. 2012-16: 262, p<0.001). No change was observed for 30-day mortality over the study period (3.9%, p=0.233). LoS was unchanged (p=0.949). Laparoscopic surgery was increasingly utilised (0.6% vs. 17.2%, p<0.001) in recent years, and by colorectal subspecialists (p=0.003). More patients were managed by a colorectal consultant latterly (2002-06: 45.4% vs. 2012-16: 63.7%, p<0.001). There was no difference between colorectal and other subspecialists in mortality (p=0.156), LoS (p=0.201), stoma (p=0.629) or anastomosis (p=0.659) rates, including following multivariable adjustment.  

Conclusion:

The study demonstrated a significant reduction in the number of resections over time, increased utilisation of a laparoscopic approach and a shift towards the care of IBD surgical patients under a colorectal subspecialist.

Aim: Assessment of the therapeutic efficiency of mesenchymal stem cells (MSCs) from the rat bone marrow in the model of the inflammatory bowel disease (IBD). 

Method: Laboratory rats (n=9) were administered 30mg of dinitrobenzenesulfonic acid (DNBS) and 250μl/50% ethanol rectally. The comparison group (n=9) was given the introduction of 250μl/50% ethanol only. RNA-labeled MSCs have been injected at the peak of the clinical picture (day 4 after administration of DNBS): 1×10⁶c/kg in 0.3ml of normal saline in the tail vein (n=4) and intra-aortic (n=5) as well. Rats have been removed from the experiment on the 1^st day and day 7 after treatment.

Results: The fluorescence of RNA-labeled MSCs in the colon wall after first and seven days was prevailing after intra-aortic infusion. These rats have gained weight, got rid of diarrhea, blood in the stool and contamination around the anus as well after 7 days. The mucous membrane, the submucosa and the muscle layer of bowels were without significant pathological changes. Per contra, there was no marked relief of inflammatory after intravenous administration of MSCs.

Conclusion: MSCs of the rat bone marrow introduced into the aorta of animals with the experimental IBD provided significant reducing of intestinal inflammation by accumulating mainly in the colon wall unlike intravenous way. 

Aim

To compare post-operative outcomes following Ileal pouch anal anastomosis with and without proximal diversion.

Method

Computerised literature search, of Ovid MEDLINE and EMBASE. Full text comparative studies published between 1992 and 2019, in English language & on adult patients, who underwent Ileal pouch anal anastomosis with or without proximal stomal diversion following proctocolectomy. Main Outcome Measures were anastomotic leak, anastomosis strictures, re operations, pouch failure, intra-abdominal sepsis, small bowel obstruction/ileus and mortality.

Results

546 studies were screened.  Fourteen relevant studies (13 comparative cohorts & one RCT) included 4973 cases (1832 patients with no stomas vs 3141 with stomas).  Anastomotic strictures ((P=<0.0001) OR 0.40; 95% CI (0.26 - 0.62)) and pouch failures ((P=0.003) OR 0.54; 95% CI (0.36-0.82)) were higher in diverted than non-diverted patients.  Re-operation was more frequently required in non-diverted patients ((P value 0.02). OR 2.51; 95% CI (1.12 - 5.59)).  Heterogeneity was low in 5 out of 7 variables.

Conclusion In selected patients, diversion free IPAA is a safe procedure associated with lower anastomotic stricture and pouch failure rates than diverted IPAA. This appears to occur at the expense of a higher re-operation rate. An RCT is required to help define the selection criteria.

Aim: Success rates after conventional inflammatory bowel disease (IBD) treatments are suboptimal. The purpose of this systematic review was to provide an overview of the published studies evaluating hyperbaric oxygen therapy (HBOT) in patients with Crohn’s Disease (CD) or Ulcerative Colitis (UC).

Method: MEDLINE, Web of Science, Embase and the Cochrane Database were searched. All human (≥5 patients) and animal studies evaluating HBOT for IBD were included. 

Results: After screening 948 publications, 11 human (308 CD, 345 UC patients) and 15 animal studies were included (minimum 522 animals (unclear total amount in one study)). Clinical response rate after 5-86 HBOT sessions was 88% in UC and 81% in CD patients, with 77.7% in perineal CD. Endoscopic response rate ranged from 50-100% and radiological response was 100%. Adverse events were described in 6 out of 653 patients (0.9%). Animal studies reported less weight loss and a significantly decreased Disease Activity Index compared to controls. Furthermore, laboratory values (including inflammatory and oxidative stress markers) and histopathological features improved.

Conclusion: HBOT is a promising treatment for IBD patients with high clinical, radiological and endoscopic response rates and few adverse events. Animal studies support these findings. More research for subgroup-specific therapy is needed.

Aim: Outpatient IBD clinics at our tertiary centre were restructured to allow simultaneous assessment by both a Gastroenterologist and Surgeon, however patient perception of dual clinician presence has not been assessed. We aimed to evaluate patient perception of multi-disciplinary care in this joint IBD clinic.

Method: All patients attending the joint clinic were asked to complete an anonymised questionnaire in which they rated statements describing attitudes towards the clinic on a 5-point Likert scale, in addition to rating overall satisfaction and desired frequency of joint clinic appointments.

Results: Responses were received from 44 patients (12 male, 27 female, 5 undisclosed gender, age range 18-65, mean 41.7 years). The majority agreed that joint assessment was beneficial for decision-making, occurring without intimidation or receiving conflicting messages. Median overall satisfaction was 10 (range 8-10, 1= Not satisfied at all, 10= Very satisfied), 43% of patients preferred the joint clinic for every appointment, 41% for every treatment decision, whereas no patient stated that they never wanted a joint clinic appointment.

Conclusion: Effective IBD management requires co-ordinated care across specialties. Patients report that simultaneous medical-surgical assessment has practical and emotional benefits, without feeling overburdened or anxious by dual clinician presence. This supports streamlining IBD care in specific clinical scenarios.

Aim: The purpose of this systematic review is to analyse and evaluate the potential benefits of a laparoscopic approach on long-term pouch function, as compared to the open approach. 

Method: A comprehensive literature search was completed in March 2020. Studies that included and compared patients with UC and FAP who underwent laparoscopic versus open proctocolectomy with IPAA were incorporated into this review. 

Results: Six studies were included in this review. There were a total of 519 patients. There were 198 (38.2%) in the laparoscopic IPAA group and 321 (61.8%) in the open IPAA group. No significant differences in terms of functional outcomes were discovered between the two groups. Defecation frequency was not found to be significantly different, with an average of 7.2 bowel movements per 24 hours in the laparoscopic IPAA group, and an average of 7 bowel movements per 24 hours in the open IPAA group. There was also no significant disparity found in the reporting of faecal incontinence and urgency.

Conclusion: Laparoscopic IPAA produces similar long-term functional outcomes to the open approach. Standardisation regarding acquiring data on faecal incontinence and urgency is needed, so that these can be summated. 

Introduction: The incidence of microscopic colitis (MC) has recently increased to that of ulcerative colitis and Crohn’s disease but its diagnosis can be difficult.

Aim: To establish the incidence of MC and the diagnostic value of random mucosal biopsies.

Method:

100 consecutive patients (35 men and 65 women; median age 58.5 years, ranging from 19 to 93 years) suffering with a variety complaints but the predominant symptom of diarrhoea underwent lower intestinal endoscopy and were included into the study.  In all patients, the procedure (colonoscopy in 69 and flexible sigmoidoscopy in 31) revealed no endoscopic features of mucosal inflammation.  Findings on histological examination of random mucosal biopsies were retrospectively analysed.

Results:

Biopsies revealed MC in 9 patients. One-third (3 patients) and two-thirds (6 patients) had lymphocytic and collagenous colitis respectively in biopsies from both sides of the colon with collagenous colitis being more severe in the right colon.

Conclusion:

In patients with chronic diarrhoea and endoscopically normal mucosal appearances, biopsies offer high yield (9%) in the diagnosis of MC. Flexible sigmoidoscopy and left-sided biopsies alone are insufficient. The diagnosis of collagenous colitis can often be established only by right-sided mucosal biopsies making colonoscopy the investigation of obvious choice.

Aim To determine the impact of a strategy of steroid-avoidance and six weeks of Modulen IBD in adult patients presenting with acute small bowel Crohn’s disease followed by an interval ileocaecal resection six weeks later.

Methods Retrospective review of prospectively collected data. 

Results 17 patients included. Median age of 43 (range 26-69). 12/17 patients tolerated Modulen for six weeks, 4 were switched to Ensures and 1 a liquid diet. 5 patients underwent surgery earlier than planned of which 3 had failed Modulen. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 35.5 g/L (range 25-43) to 41.1 g/L (range 36-48). CRP levels decreased by a mean of 52.5mg/L overall. 82% of operations were performed laparoscopically. 17.6% of the cases were re-do operations. All patients avoided a stoma at the time of the operation. There were four post-operative complications: one anastomotic leak in a patient with a BMI of 42, 2 cases of paralytic ileus and one wound infection. Median length of stay was 7 days (range 3-76 days). 30-day readmission rate was 5.9%. 

Conclusion The use of Modulen appears a safe way to avoid unnecessary stoma formation with acceptable outcomes.

Aim: to assess the impact of a four-week multimodal prehabilitation program prior to elective colorectal cancer (CRC) surgery on postoperative complications, length of hospital stay, unplanned readmissions, and mortality 

Method: retrospective, single-center, observational cohort study. CRC patients (ASA > 3 and or > 65 years) attending the prehabilitation program between January 2019 and March 2020 (prehab-group) and elective CRC patients receiving standard care between January 2017 and December 2018 (control-group) were included. Univariate analysis was performed using Fisher’s Exact and Mann-Whitney U test. Multivariate logistic regression analysis was performed afterwards. 

Results: 351 patients were included (n=275 control-group, n=76 prehab-group). Baseline characteristics in both groups were comparable. The prehab- group had less complications compared to the controls (26.3% versus 40,0% , p=.032), prehabilitation was a protective factor (OR=0.5, 95% CI, 0.253-0.988, p=.046). The percentage unplanned readmission was lower in the prehab-group group (5.3% versus 16.4%, p=.014), protective factor (OR=0.313, 95% CI, 0.102-0.954, p=.041). Median hospital days of stay was 1 day shorter in the prehab-group (p=.004). Mortality did not significantly differ. 

Conclusion: the multimodal prehabilitation program in this study showed a major reduction of postoperative complications, unplanned readmissions, and hospital stay compared to standard care in patients undergoing elective colorectal cancer surgery.

Aim

Around one in six patients undergoing colorectal surgery develop major postoperative complications. Whilst the cardiopulmonary complications of smoking are known, there is limited evidence regarding the impact of smoking on postoperative outcomes in relation to colorectal surgery. The aim of this study was to assess the impact of smoking on major complications following segmental colorectal resection. 

Method

This study pooled data from two ESCP prospective multi-centre international datasets. Patients undergoing segmental colorectal resection were included. Smoking status was recorded as never, ex-smoker, or current smoker. The primary outcome was major complications (Clavien-Dindo grades III-V). A multilevel model was adjusted for potential confounding factors, and hospital and country effects. Odds ratios (OR) are reported with 95% confidence intervals (CI).

Results

Of 8575 patients included; 5366 (62.6%) had never smoked, 2022 (23.6%) were ex-smokers and 1187 (13.8%) were current smokers. After adjustment, compared to patients who never smoked, current smokers had significantly increased odds for major complications (OR 1.32, 95% CI 1.09-1.60) but ex-smokers did not (OR 1.13, 95% CI 0.96-1.33). Current smokers were at increased odds of developing anastomotic leak (OR 1.29, 95% CI 1.01-1.65) but ex-smokers were not (OR 1.05, 95% CI 0.85-1.31).

Conclusion

Smoking cessation may be a beneficial intervention in patients scheduled for elective colorectal surgery.

Aim: To re-audit rates of acute kidney injury (AKI) after elective colorectal surgery following a national quality improvement process.

Methods: Outcomes After Kidney injury in Surgery (OAKS) and Ileus Management International (IMAGINE) were prospective multicentre audits of adults undergoing consecutive elective colorectal resections in the UK and Ireland over 3‐month periods in 2015 and 2018 respectively. Centre-level results were presented as part of a locally-driven quality improvement initiative. Risk-adjusted 7-day postoperative AKI rates were calculated through multilevel logistic regression via a validated risk stratification tool.

Results: 3,133 patient records were included from OAKS (2015) and 1,784 from IMAGINE (2018). On univariate analysis, there was no significant difference (p=0.737) in 7-day AKI rates between 2015 (n=346, 11.8%) and 2018 (n=205, 11.5%). However, risk-adjusted AKI rates in 2018 were significantly lower than 2015  (-1.8%, 95% CI: -2.3% to -1.3%, p<0.001). Despite 47 centres (40.1%) reporting local feedback presentations, this was not associated with a significant difference in risk-adjusted AKI rates in 2018  (-0.7%, -2.0% to 0.6%, p=0.278).

Conclusion: Rates of AKI after elective colorectal surgery significantly reduced following a national quality improvement initiative. This may be related to increased awareness from participation or other national quality improvement initiatives, rather than feedback of centre-specific results.

Aim: This study aims to assess whether Prophylactic NGT insertion was associated with reduced rates of pneumonia, in comparison to Reactive NGT after colorectal surgery.

Method: Pre-planned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January and April 2018 were included. Those receiving NGT were divided into three groups, based on the timing of the placement: Routine (at the time of surgery); Prophylactic (after surgery, before vomiting); and Reactive (after surgery, after vomiting).

Pneumonia within 30 postoperative days was considered as primary outcome measure and it was compared between the three groups using multivariable regression analysis.

Results: 4,715 patients were included in the analysis. 1,536 (32.6%) received an NGT corresponding to 926 (60.3%) Routine, 461 (30%) Reactive and 149 (9.7%) Prophylactic. 200 patients (4.2%) developed pneumonia (No NGT: 2.7%; Routine NGT: 5.2%; Reactive NGT: 10.6%; Prophylactic NGT: 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the Prophylactic and Reactive NGT groups (OR: 1.03, 95% CI: 0.56 – 1.87, p=0.932).

Conclusion: In patients who required NGT insertion after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30 days of surgery in comparison to reactive insertion.

Aim
The Pilonidal Centre at St Mark’s Hospital was established with to improve the service, reduce post-operative complications and to classify patients’ disease in order to select the most appropriate surgical technique.

Methods
109 patients were seen in the pilonidal clinic during between November 2018 and March 2020 (male n=82). All patients were classified according to a recent classification system developed by Wysocki et al, following which they were offered curative surgery.

Results
Sixty-four consecutive patients had an operation. The remainder are awaiting surgery. Patients with more limited disease, n=37 (midline or single lateral sinus (classification 1 and 2)) were offered more limited operations in the form of Trephine or Bascom’s procedure (n=21 and n=16 respectively), resulting in fewer wound complications and more rapid recovery. Patients with more extensive disease laterally or beyond the coccyx, including recurrence after previous elective surgery, (n=27) (classification 3 to 5) were offered a cleft lift as their definitive surgery. Patients undergoing Bascom’s or Trephine procedure had significantly shorter mean time to full healing (3.1 vs 6.1 weeks, P<0.001).

Conclusion

Tailoring pilonidal treatment to the disease classification allows targeted surgery with a range of patient-specific techniques, especially in limited disease.

Aim: To report the long-term functional outcomes and quality of life (QoL) in patients after a successful redo colorectal (CRA) or coloanal anastomosis (CAA).

Method: All patients who had a successful restoration of bowel continuity following a failed primary anastomosis (2007-2018) were included. Functional outcomes and QoL were assessed using LARS; GIQLI; FSFI and IIEF5 scores.

Results: 161 patients were eligible for inclusion in this study, with long-term functional outcomes assessed in 95 patients (59%). After a median follow-up of 48 months (IQR 24-82), 49/95 patients had no or minor LARS (52%), 34/95 patients having major LARS (35%) and 12/95 patients had a stoma formed due to poor functional results (13%). In multivariate analysis, only operative interval < 36 months (OR=8.8; 95%CI [3.2-24.0]; p=0.001) and index surgery for colorectal cancer (OR=4.7; 95%CI [1.2-17.8]; p=0.024) were independently associated with a poor functional outcomes. An absence of major LARS was the only factor associated with improved QoL (p=0.001). 55% of female reported sexual dysfunction and 69% of male observed erectile dysfunction with no improvement with delay after surgery.

Conclusion: After successful redo CRA or CAA, good functional outcomes can be achieved in more than 50% of patients with a well-preserved QoL.

Aim: Graciloplasty (GP) is indicated in case of recurrent rectovaginal fistula (RVF), after failure of previous local treatments (vaginal or rectal flap). The aim of this study was to assess risk factors for GP failure performed for RVF. 

Methods: Retrospective study based on a prospective database of GP, coming from two expert centers in Bologna (Italy) and Clichy (France). 

Results: 61 patients undergoing a first GP for recurrent RVF (n=51) or ileal-vaginal fistula after ileal-pouch- anal-anastomosis (n=10), with a mean age of 42 ± 12 years were analyzed. After a mean follow-up of 56 ± 48 months, failure of GP (FGP) (persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). Two risk factors for FGP were found on univariate analysis: 1) absence of postoperative antibioprophylaxis (PAP): only 3/24 (13%) patients with FGP received PAP versus 18/37 (49%) patients with success of GP (p=0.0053); 2) postoperative perineal infection: 11/23 (48%) with FGP developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (p=0.0021).

Conclusions: Failure of Graciloplasty for rectovaginal fistula is observed in approximately 40% of the patients whatever the etiology of the fistula. This failure rate could be reduced by systematic postoperative antibioprophylaxis.

Aim: This study aimed to determine whether selective histopathological examination following appendectomy is oncologically safe.

Method: In this prospective study, all appendices removed for suspected appendicitis were systematically assessed by surgeons in 59 Dutch hospitals. Before sending all specimens for histopathological examination, the surgeon judged whether assessment by the pathologist was indicated. Primary outcome was the number of missed appendiceal neoplasms with clinical consequences benefitting the patient in case of a selective policy (upper limit 95% CI below 3:1000 considered as oncologically safe). Secondary outcomes included clinical management and outcomes.

Results: In case of a selective policy, 4966 (67.7%) of 7339 specimens would have been refrained from histopathological examination, and appendiceal neoplasms with clinical consequences would not have been diagnosed in 22 patients. Residual disease was radically removed in five patients, implying that an appendiceal neoplasm with clinical consequences benefitting the patient would have been missed in 1.01:1000 patients (upper limit 95% CI 1.61:1000). Meanwhile, ten patients experienced harm (additional resection without residual disease), whereas consequences were neither beneficial nor harmful in the remaining seven patients.

Conclusion: Selective histopathological examination following appendectomy is oncologically safe and will likely result in a reduction of costs, pathologists’ workload and unnecessary additional resections.

Aim: While during Covid-19 pandemic elective surgery was shut-down of in most settings, some referral centers were designated as surgery hubs.

Even in the enhanced recovery pathway (ERP) era patients deemed fit-for-discharge might be unable to leave hospital for often non‐medical reasons.

We sought to investigate how the pandemic scenario have impacted the quality of a long-established ERP colorectal surgery (CRS) program.

Method: We have compared short-term outcomes of two referral center for colorectal surgery during COVID-19 pandemic (group A) with the correspondent timeframe of 2019 (group B) including a special focus on length of stay (LOS) and readmission rate.

Results: Hundred and thirty-six patients underwent major colorectal surgery in group A and 173 in group B. Post-operative complications and readmission rate were comparable between the two groups.

A significantly overall shorter LOS was found in group B (p<0.001). Uncomplicated patients of group B had a shorter length of stay when compare to uncomplicated patients of group A (p=0.008). 

Conclusion: A reduction of LOS, within an long-established ERP-CRS program, was observed during the Covid-19 pandemic in comparison with the correspondent timeframe of 2019 without compromising short term outcomes.   

Aim: The Outcomes After Kidney injury in Surgery (OAKS) score stratifies patients undergoing major gastrointestinal surgery for risk of 7-day postoperative acute kidney injury (AKI). This study aimed to perform external validation in the Ileus MAnagement INternational (IMAGINE) cohort.

Methods: The IMAGINE audit included adults undergoing consecutive elective colorectal resection or stoma reversal across Europe and Australasia (January-April 2018). Multivariate logistic regression was performed using data on 7-day AKI, and the OAKS prognostic variables (age, sex, ASA grade, preoperative estimated glomerular filtration rate, open surgery, and preoperative angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers use). Discrimination and calibration (Hosmer–Lemeshow test) were assessed on prediction of patients at high-risk (>20%) of postoperative AKI. 

Results: Of 4046 patients included across 338 centres, 13.4% (n=542) developed 7-day AKI. The model discrimination was 0.67 (95% CI = 0.65-0.70), identifying high-risk patients with low sensitivity (0.28, 95% CI: 0.25-0.32) but high specificity (0.90, 95% CI = 0.89-0.91). The model demonstrated good calibration (p=0.518).

Conclusion: Discrimination of the OAKS score for patients at high-risk of postoperative AKI in this cohort is good, and remains consistent with the derivation cohort. High‐risk patients identified may represent a feasible target for interventions aimed at mitigating AKI.

Aim: Optimal oncological resection in cancers of the lower rectum often requires colostomy formation, which may negatively impact health-related quality of life (HRQoL). The Colostomy Impact (CI) score is a questionnaire dividing patients into ‘minor’ and ‘major’ CI groups to identify patients with stoma dysfunction impairing HRQoL. This study evaluates validity and reliability of the CI score internationally.

Method: Translations were performed in agreement with WHO recommendations. Cross-sectional cohorts of rectal cancer survivors with a colostomy in Australia, China, Denmark, the Netherlands, Portugal, Spain and Sweden completed the CI score, EORTC QLQ-C30, stoma specific scale of EORTC QLQ-CR29 and five anchor questions assessing colostomy impact on HRQoL.

Results: CI scores were significantly worse in patients reporting colostomy-related reduced HRQoL compared to patients reporting no impact on HRQoL and differences in EORTC scale scores between minor and major CI groups were significant and clinically relevant confirming construct validity. Assessing discriminative validity the CI score relevantly identified groups with differences in HRQoL. For reliability CI scores were equal in test and retest and intraclass correlation coefficients were moderate to excellent.

Conclusion: The CI score is valid and reliable and we encourage its use in clinical practice to identify patients requiring further attention

Aim: The gut microbiome is implicated in the development of anastomotic leaks (AL). We developed an AL mouse model to study changes in the gut microbiome following surgery, anastomoses and complications.

Method:We studied two groups: laparotomy, resection and anastomosis (R&A, n=23) and laparotomy only (n=9). Optimisation of surgical technique and mouse recovery established model consistency. Mice were sacrificed at days 3 and 7 after surgery. Intraoperative and post-operative stool and mucosal surgical site samples were taken for analysis using 16S rRNA sequencing. Surgical outcomes were assessed objectively.

Results: Beta diversity changed significantly following surgery, but no significant difference was seen in alpha diversity. Akkermansia mucinophila increased significantly (12.75% intraoperative, 26.12% post-operative) for all samples. Proteobacteria decreased significantly (34.08% intraoperative, 14.93% post-operative) for all samples. Mice that developed ALs had a lower proportion of lachnospiraceae (13.89% no leak, 4.76% leak, p<0.000) and a higher proportion of enterococcaceae (0.01% no leak, 2.18% leak, p<0.000).

Conclusion: This pilot study’s result coincide with clinical studies of anastomotic leaks outlining that Akkermansia mucinophila appears beneficial to healing. Lachnospiraceae and Enterococcaceae may be associated with leaks. This study highlights the validity of this mouse model to study of microbiome changes following surgery.

Aim: Outcome reporting of innovative colorectal surgery has historically been poor. This study aimed to review outcome reporting in IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) studies to inform the development of a core outcome sets (COS) for early phase surgical studies. 

Methods: A targeted review of IDEAL/IDEAL+Devices (IDEAL-D) studies was conducted. Studies citing IDEAL were identified using electronic searches. Records with ‘IDEAL’ in the title/abstract were selected and screened for eligibility. Outcomes from included studies were extracted verbatim including contextual information regarding outcome selection and measurement. Outcomes were categorised into a conceptual framework of domains.

Results: Of 1207 records citing IDEAL, 136 (11%) stated ‘IDEAL’ in the title/abstract. Some 48 (35%) eligible studies were included. Studies self-identified as IDEAL stage 1 (n=11), 2a (n=16), 2b (n=9), 3 (n=1), multiple stages (n=9) or did not specify stage (n=2). 1737 outcomes were grouped into 32 domains with several unique to innovation (e.g. procedure completion success/failure, modifications, surgeon’s experiences). Heterogeneity in outcome selection, measurement and reporting was observed across studies.

Conclusion: This review highlights the need to standardise outcome selection, measurement and reporting in studies of surgical innovations. Findings have informed the development of a COS through the COHESIVE study.

Aim

Emergency colorectal surgery is associated with significant mortality. Most general surgeons have a subspecialty, which forms the focus their elective work. The aim of this study is to assess the effects of consultant subspecialisation on patient outcomes following emergency colorectal resections.

Methods:

Data were requested for all emergency admissions under a general surgeon between 01/01/2002 and 31/12/2016 within the North of England. Data included demographics, diagnoses and any procedures undertaken. Patients were grouped based on their consultant’s subspecialty. The primary outcome of interest was 30-day postoperative mortality. 

Results:

Overall, 7,648 emergency colorectal resections were performed with a 30-day postoperative mortality of 13.8%. This was significantly lower if the responsible consultant was a colorectal surgeon compared with other general surgery subspecialties (11.8% vs. 15.2%, <0.001).  The colorectal specialists had a higher laparoscopy rate – 9.8% vs 6.8% (p<0.001). Stoma rates were also lower  (46.9% vs. 51.0%, p=0.001) and anastomosis rates higher (55.9% vs. 49.3%, p<0.001) amongst colorectal surgeons. On univariable analysis, patients under the care of a colorectal surgeon had a decreased postoperative mortality (OR 0.75, p<0.001), however, following multivariable adjustment, this was not statistically significant (p=0.380).

Conclusion:

These findings add to the growing body of evidence that patient outcomes may be improved by involving subspecialists in colorectal emergencies.

Aim:

The primary aim of this study was to reduce the incidence of SSI in patients undergoing elective colorectal resections by implementing an SSI bundle. Secondary outcomes included impact on length of stay (LOS), 28-day re-admission rate and rate of compliance to each element of the bundle.

Methods:

We performed a retrospective audit of consecutive patients undergoing elective colorectal resections over a 12 month period to identify the incidence of SSI in our unit. We used positive wound swab and clinically recognized infection treated with antibiotics or intervention within 30 days as a criteria for SSI.  SSI prevention bundle included, antibiotic impregnated sutures, 2% chlorohexidine skin preparation, warmed carbon dioxide during laparoscopic procedures and negative pressure wound dressings for high-risk patients.

Results:

Baseline data (n=208) revealed an SSI rate of 27.4%. In the SSI prevention bundle cohort (n=90) the recorded SSI rate is 11%. The median LOS reduced from 8 days to 6 days. Twenty-eight-day readmission rate reduced from 12% to 10.7%. Compliance rate to each bundle element was 95-100%.

Conclusion:

Our study shows that SSI rate can be reduced successfully by introduction of SSI prevention bundle.

Aim: Enhanced Recovery After Surgery (ERAS) guidelines provide a framework to improve postoperative outcomes. However, adherence to these guidelines remains challenging. The goal of this study was to investigate the association between adherence and postoperative complications, length of stay (LOS), and readmissions.

Methods: This retrospective pretest-posttest study included 265 and 301 patients undergoing colorectal resection in 13 Belgian hospitals in 2017 and 2019, respectively. Associations between outcomes and adherence to a bundle of 12 ERAS interventions were studied using multilevel regression models. 

Results: The mean overall adherence increased from 41.6%(2017) to 55.0%(2019).  Nevertheless, outcomes were not significantly different between periods. Looking across periods, LOS and postoperative complications were significantly associated with ERAS protocol adherence. Compared with patients with low adherence (<6 interventions), LOS was 1.95 (95%CI: 3.58-0.53) days shorter in patients with 6-7 interventions adhered to, and 3.32 (95%CI: 5.00-1.64) and 3.99 (95%CI: 6.34-1.65) days shorter in patients with 8-9 and 10-12 interventions, respectively. The odds ratios for postoperative complications were 0.65 (95% CI: 0.33-1.28), 0.12 (95% CI:0.03-0.38), and 0.12 (95% CI:0.23-0.59) for 6-7, 8-9 and 10-12 ERAS interventions, respectively.

Conclusion: Improvement in postoperative complications and LOS with increasing ERAS adherence indicates the benefits of implementing an ERAS bundle.

Aim: Surgeons’ subjective experience of performing new procedures play a vital role in developing innovations, but standardized measurement is lacking. This study aimed to evaluate measures of surgeon experience for use in studies of colorectal surgical innovation.

Methods: Evaluation followed modified COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) methodology. Instruments were identified by systematic reviews of early phase colorectal surgical studies and purposively sampled, targeted reviews of innovations. Content validity was appraised by two researchers independently using 45 COSMIN criteria and graded as sufficient, insufficient, indeterminate or inconsistent. Validity was assessed further with in-depth qualitative interviews with UK surgeons. 

Results: Some 8,373 abstracts were screened, of which 51 studies were included and supplemented by 71 from targeted reviews. Studies evaluated innovations such as robotics and fluorescence. 15 measurement instruments were identified. One instrument (SURG-TXL) was graded as having sufficient content validity, with others graded insufficient(N=10), indeterminate(N=2) or inconsistent content validity(N=2). In-depth interviews with eight surgeons suggest that the concepts measured by the SURG-TXL (mental demands, physical demands, task complexity, situational stress) comprehensively assess surgeons’ experience of innovation.

Conclusion: The SURG-TXL had sufficient validity to measure surgeons’ experience of colorectal innovation. Standardized use this measure may drive efficient colorectal innovation through shared learning. 

Aim: Early phase studies evaluate new technologies prior to randomised evaluation. Evaluation is limited, however, by inconsistent reporting of outcomes. This study examines outcome reporting in early phase studies of colorectal surgery.

Methods: Systematic searches identified early phase studies of procedures treating colorectal cancer. Included were a random sample of studies author-reported as ‘new’ or ‘modified’. Outcomes were extracted verbatim and categorised into domains. Outcomes were classified as ‘measured’ (where evidence that data collection had occurred) or ‘mentioned but not measured’ (where outcomes were discussed without evidence of data collection).

Results: Of 8,373 records, 816 were potentially eligible. Full-text review of a random sample of 218 studies identified 51 for inclusion. Procedures were author-reported as ‘new’ or ‘modified’ in 17 (33%) and 34 (66%) studies, respectively. Some 2073 outcomes were identified. “Anticipated disadvantages” were most frequently identified (660 (32%) outcomes identified across 50 (98%) studies). No domain was represented in all studies. Half (944, 46%) of outcomes were ‘measured’. “Surgeon/operator’s experience of the innovation” were more frequently ‘mentioned but not measured’ (207(18%) outcomes across 46 (90%) studies) than ‘measured’ (17 (2%) outcomes, 11 (22%) studies).

Conclusion: There is outcome reporting heterogeneity in early phase colorectal surgical studies. Standardisation may enable efficient evaluation of colorectal innovations.

Aim: This study aimed to investigate a comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of anastomotic leak. 

Method: Sixty consecutive patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge were included. Comprehensive testing consisted of indocyanine green fluorescent angiography, air-leak, and methylene blue tests to evaluate the perfusion and mechanical integrity of the anastomosis.   

Results: Trimodal test was positive in 16 (26.6 %) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, 2 (12.5 %) patients had clinically significant anastomotic leakage developed. Forty-four (73.4 %) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%) and 4 (9.1 %) patients had clinically relevant anastomotic leakage. 

Conclusion: Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow to reduction of ileostomy rate by two-fold. However, AL rate remains high in technically well-performed anastomoses.  

Aim: ERAS protocols are widely endorsed after colorectal surgery. This study aims to describe compliance with the individual principles of ERAS across an international setting. 

Method: A hospital-level survey was administered. This aimed to describe hospital-level compliance to 17 principles of ERAS after elective colorectal surgery. The questionnaire was mandatory for all hospitals participating in an international cohort study on colorectal surgery between October 2017 and July 2018.

Results: A total of 422 hospitals took part in the cohort study and submitted questionnaires. Most hospitals (90%) were located in Europe. The overall median compliance was 14 out of 17 items. Only 13.7% of centres were compliant with all 17 items. High compliance was noted for items: patient counseling (91%); antibiotic prophylaxis (91.5%); venous thromboembolism prophylaxis (98.8%); early mobilization (97.2%); and avoidance of hypothermia (92.5%). Lower compliance was noted for items: preoperative oral carbohydrates (55.4%), standardized anesthesia protocol, (68.6%), early oral tolerance (69.8%), avoidance of abdominal drain (64.4%) and avoidance of mechanical bowel preparation (59.3%).

Conclusion: Overall compliance with ERAS guidelines was high however there is still scope for improvement. New strategies should be considered to attain full adherence to ERAS guidelines in the management of patients undergoing elective colorectal surgery.

Aim: Outcome reporting in early phase studies of colorectal surgery is unstandardized. Mandated reporting may prevent colorectal surgeons from unknowingly repeating mistakes and avoid patient harm. This study developed a core outcome set (COS), an agreed minimum set of outcomes, to report in early phase studies of surgical innovation.

Methods: The COS were developed according to established guidance (COMET, COS-STAD). Outcomes identified from published studies, NHS policies, regulatory documentation and surgeon-innovator and patient interviews informed an international Delphi consensus survey. Patients and professionals rated the importance of each item/outcome across two survey rounds. A multi-stakeholder consensus meeting agreed the final COS.

Results: 7,666 verbatim outcomes were categorised into 32 domains. 148 professionals and 103 patients across 15 international regions completed both survey rounds. A consensus meeting convened 30 panel members, including patient representatives and professionals . Anonymised voting resulted in the inclusion and consolidation of 8 outcome domains to be included in the final COS. Domains included: procedure completion/success; modifications; expected/unexpected disadvantages, surgeon and patient experience.

Concluision: The COS and reporting guidance will promote the safe and efficient evaluation of new surgical procedures/devices by reducing outcome reporting bias and allowing real-time data synthesis to improve detection of emerging signals of promising or harmful innovations.

Aim: The objective was to compare pregnant patients and non-pregnant women of reproductive age in terms of clinical course of acute appendicitis.

Method: This was a retrospective analysis of a tertiary referral hospital database. All female patients aged between 18-45 years,  between January 2015 and December 2018 were included. The two groups were compared in terms of clinical presentation, management, and outcomes.

Results: A total of 277 patients (28 pregnant and 249 non-pregnant) included in the study. Clinical presentation was similar. In diagnostic imaging, USG was used in all pregnant patients, in addition, MRI was used at a rate of 57.1%. In non-pregnant group, CT was used at a rate of 87.9%. There was a higher negative appendectomy rate in pregnant group (21.4 and 8.8%; p: 0.038). Laparoscopic surgery was performed at a significantly higher rate in non-pregnant group (21.4 and 59.8%; p: 0.001). Both the duration of diagnosis and length of stay were longer in pregnant group. The two groups had similar rates of complicated appendicitis (71 and 10.8% p: 0.416), and overall postoperative complications (14.2 and 8.8 %, p: 0.316).

Conclusion: Although diagnostic methods and some clinical parameters of acute appendicitis are different, clinical outcomes are similar in pregnant women and non-pregnant women of reproductive age.

Aim: To explore which patient factors can predict the physical outcome of a multimodal prehabilitation programme in preoperative patients with colorectal cancer (CRC).

Methods: A retrospective, single-centre, observational cohort study, including all patients who completed the multimodal prehabilitation programme prior to colorectal tumor resection between October 2018 and March 2020 in a Dutch teaching hospital. The primary study outcome was the change in the six minute walk test (6MWT). Logistic regression was performed to identify predictors for the physical outcome of the programme. The change in 6MWT was cut-off at a moderate change of ≥50m.

Results: 89 patients were included in the data analysis. The median change in 6MWT was 36 (IQR 39) meters. The strongest predictor for a ≥50m change in 6MWT was alcohol consumption, corrected for American Society of Anaesthesiologists (ASA) grade (p=.075) The odds-ratio to improve ≥50m for patients consuming 2-6 units of alcohol per day versus patients with no alcohol consumption was 5.681 (95% CI 1.038–31.079) (p=.045).

Conclusion: Patients with moderate alcohol consumption at baseline tend to benefit more of the prehabilitation programme. This could be explained as the result of alcohol cessation. Therefore, alcohol cessation should be kept as part of the prehabilitation programme.

Aim-The application of PICO has been shown to promote healing and is associated with a reduction of surgical site infections (SSI) in abdominal surgery. Its use in closed surgical incision is encouraged by NICE, but its effect on those who also had stoma formation is less clear. The study evaluates whether its use has positive impact on patients with stoma. 

Method- Patients who underwent elective or emergency large bowel surgeries, between 2014-2018, were identified using the local database collected for national SSI surveillance. This was cross-referenced with PICO order forms. Analysed data is presented as percentages, and variable testing is performed using Chi Square test.

Results- Amongst patients with stoma, the rate of SSIs was 15.3% with 10.3% patients developing incisional SSI, while 5.3% developing organ/space SSI.  28.7% (125 out of 435) had PICO applied. The use of PICO was associated with a statistically significant reduction in the rate of incisional SSI (4.4% v 8.4%; p=0.026) but not in the rate of organ/ space SSI (2.1% v 4.5%; p=0.18). 

Conclusion-While the use of PICO appears beneficial in patients with stoma, difficulties with applying dressing in the presence of stoma may prevent better outcome.

Diverticulitis is a common cause for hospital admission. Patients are typically managed conservatively with antibiotics and then discharged with a plan for an outpatient lower gastrointestinal (LGI) endoscopy (flexible sigmoidoscopy or colonoscopy) in 6-8 weeks. This study aims to assess compliance to this guideline and assess the adenoma detection rate.

Method

All discharge summaries screened for ‘diverticulitis’ as discharge diagnosis, from Jan 2017 – April 2020 at a university teaching hospital.

Results

Total 332 patients presented with a first episode of diverticulitis, mean age 61.2 years (22-92 years). 46% (152/332) of patients underwent LGI endoscopy as an inpatient or on discharge. Median time to endoscopy was 52 days (6-868 days). 25% (84/332) received their LGI endoscopy within the 8-week target time frame. Five percent (9/152) of patients undergoing LGI endoscopy were found to have tubular adenoma with 1 patient having high grade dysplasia. No cases of malignancy were detected.

Conclusion

Over half of patients admitted with diverticulitis are not receiving a follow-up LGI endoscopy. Of those who do receive an endoscopy, there is a 5% rate of tubular adenoma.

Aim: This study describes changes in incidence, patient characteristics, management approach and outcomes for patients with bowel ischaemia over a fifteen-year period and evaluates the impact of surgical subspecialisation.

Methods: Data for emergency admissions with a diagnosis of bowel ischaemia to NHS hospitals in the North of England between 2002 and 2016 were collected, including demographics, co-morbidities, CT usage, management strategy and outcomes. Analysis was performed using chi-squared and ANOVA.

Results: The incidence of bowel ischaemia increased (2002-06: 964 vs. 2012-16: 1666 cases) with decreased 30-day mortality rates for operative (37.5% to 26.7%, p<0.001) and non-operative (45.7% to 26.8%, p<0.001) management. Fewer patients underwent operative management (56.7% to 38.7%, p<0.001). CT usage increased (44.0% to 70.3%, p<0.001) resulting in more operations being performed within 48 hours of admission (67.0% to 77.3%, p<0.001). Patients managed by gastrointestinal subspecialists, compared to non-gastrointestinal subspecialists, had comparable mortalities, however, significantly decreased length of stays and higher rates of non-operative management.

Conclusion: Ischaemic bowel is becoming more common, with increased usage of CT and improved outcomes for both operative and non-operative management. CT led to earlier operative intervention and higher rates of successful non-operative management. Subspecialist management had an impact on management and outcomes but not on mortality. 

Aim. To assess factors predicting failure of nonoperative treatment of acute complicated diverticulitis.

Method. Patients hospitalized for nonoperative treatment of complicated diverticulitis were included. Patients undergoing immediate surgery for peritonitis were excluded. Primary endpoint was the emergent sigmoidectomy for failed nonoperative treatment. CT scans were assessed by a radiologist blinded for outcome. Radiological variables included in analysis were: presence of abscess, and direction of perforation (toward small bowel, abdominal wall, pelvic wall or bladder).

Results. 158 patients were included, 26 (16%) did not respond to nonoperative treatment and underwent rescue sigmoidectomy median 3.5 days after hospital admission. By multivariate analysis, no history of deverticultis (OR 15.2, p=0.027), intraabdominal abscess (OR 8.7, p=0.005) and perforation toward small bowel (OR 39.1, p<0.001) were associated with failed nonoperative treatment. At the end of the follow-up period, 22 of 23 patients (96%) with diverticular perforation toward small bowel had undergone elective or emergent sigmoidectomy. In contrast, only 57% of patients with diverticular perforation toward retroperitoneum, abdominal wall, pelvic wall or bladder underwent surgery (p<0.001) which was elective in most cases.

Conclusion. Diverticular perforation toward small bowel is a very strong predictor of failed nonoperative treatment. It should warrant very close observation of affected patients. 

AIM
Establish the relationship between preoperative anemia in patients undergoing scheduled colorectal cancer surgery and development of postoperative complications such as infection of the surgical site, anastomotic leakage, or evisceration.
METHOD
Perioperative data collection of patients undergoing scheduled oncological colorectal surgery, with resection and anastomosis of the colon and/or rectum, between January 01, 2019 and January 01, 2020.
RESULTS
From the total 352 patients studied, an overall rate of anastomotic leakage of 8.2% was observed. Of these, 88 patients were diagnosed with anemia on preoperative tests (lower plasma hemoglobin at 11.5 g / dl), presenting anastomotic leak in 14 patients of this group, 15.9% in contrast to 5.7% of anastomotic leak in the group without anemia. In turn, the average stay in the group with anemia was 11.8 days versus 8.8 days.
CONCLUSION
In our series, preoperative anemia was an important reversible risk factor for the development of postoperative morbidity, with an anastomotic leak rate almost twice that of the control group, but this increase in morbidity may also be related to the presence of other factors of preoperative risk, typical of patients of greater complexity, studies of greater statistical complexity are necessary to reach definitive conclusions.

Aim 

There is increasing awareness of bowel dysfunction experienced by patients after rectal resection, termed 'Low Anterior Resection Syndrome' (LARS); there remains no agreement on effective treatments strategies. With a lack of treatment protocols, a nurse-led clinic has been developed. 

Method

This LARS pathway was established where assessment considers physical, emotional, and social components tailor care individually. This as a result has the potential for improving patient satisfaction and potentially yields efficiency savings for the system through more personalised commissioning and supporting people to stay well and manage their own conditions (NHS England 2016).

Results

18 patients have completed treatments, following stoma reversal 18 months previously, all experiencing LARS symptoms and treated with conservative options inclusive of trans anal irrigation. 

Satisfaction parameter (0 = Worst, 10 = Best) N=18

Improvement after clinic = 9.7

Quality of education = 9.8

Nurse relationship = 9.8

Satisfaction level

Extremely satisfied = 72%

Satisfied = 28%

Confidence in bowel management

Before = 5

After = 8.7

Conclusion

Development of the nurse-led LARS ensures all patients undergoing anterior resection are monitored from the day of surgery. A nurse provides support, advice and treatment whilst empowering patients to be actively involved in their own care. 

Aim: Surgical site infections (SSI) are common after colonic surgery. SSI can cause relevant morbidity and increase costs of care. Preoperative oral antibiotics can reduce the incidence of SSI after resection of the colon, but the role of mechanical bowel preparation (MBP) is debated. This study aims to assess the impact of a combined regimen of oral antibiotics and MBP on SSI after colonic surgery.

Method: An international, multicentre, randomized controlled trial will be conducted across Europe. Adult patients scheduled to undergo elective colonic resection between September 2020 and May 2022 will be assessed for inclusion. Patients will be randomized into one of two treatment arms: 1) preoperative oral antibiotics without MBP (control); 2) preoperative oral antibiotics with MBP (experimental). All patients will receive IV antibiotics at induction. The primary aim will be 30-day SSI, assessed by a blinded nurse. Additional endpoints include safety, morbidity/mortality, time to return of bowel function, time to complete recovery and time to discharge, long-term results. A modified intention-to-treat approach will be used.

Results Protocol: NCT04161599. Interim Analyses are planned.

Conclusion: This study will be the first to assess the efficacy and safety of preoperative oral antibiotics plus MBP to reduce SSI after colonic surgery.

Aim 

The aim of this systematic review was to assess the overall proportion of readmission and in particular dehydration related readmission after formation of a diverting ileostomy. 

Methods

A literature search was conducted from 1990-2020 reporting on overall readmission rate and readmission caused by dehydration after formation of a loop or end ileostomy. Analyses were performed using R Statistical Software Version 3.6.1

Results

The search yielded 80 studies (n=82.458 patients). Overall readmission rates within 30 days after discharge were reported by 41 studies with a pooled proportion of 21% (CI 95%,0.18.-0.23), 29 studies reported readmissions related to dehydration with a pooled proportion of 5% (95% CI, 0.03-0.08)

Four studies reported overall readmission rates in the interval between ileostomy creation and closure, with a pooled prevalence of 16% (CI95%,0.06-0.35), 7 studies showed readmission rates related to dehydration in this time interval with a pooled prevalence of 7% (95%CI,0.04-0.13). Time interval between ileostomy creation and closure ranged from 2.3 to 6.3 months.

Conclusion 

Prevalence of readmission after diverting ileostomy is high, with an overall readmission rate of 21% within 30 days after discharge. Dehydration is a leading cause for these readmissions occurring in 5% of all patients. Better monitoring, patient awareness and preventive measures are required, besides critically reviewing indications for ileostomy.

Aim: To understand attitudes towards parenthood and maternity/paternity leave in surgical careers globally.

Method: A 55-item survey, in 24 languages, consisting of common and specific questions for medical students, surgical trainees and consultants, was created online and distributed globally via social media. Questions related to compatibility of parenthood with surgical careers and workplace attitudes towards taking maternity/paternity leave. 

Results: There were 1393 (M:F, 514:829) complete responses from 65 countries, consisting of 479(34.4%) medical students; 349(25.1%) surgical trainees and 513(36.8%) consultants..

85.4% of medical students, 80.9% of trainees and 82.0% of consultants have been told/heard that a surgical career is not compatible with parenthood (no statistical difference). Females were significantly more likely to have received such comments (80.2% vs 59.5%, p<0.001). 

73.2% of the trainees and 72.3% of consultants stated that they were happy/did not mind covering colleagues for maternity/paternity leave. Over 50% of trainees and consultants reported that their workplace was supportive of their taking maternity/paternity leave. 

Conclusion: While surgical workplaces are generally reported as being supportive of taking maternity/paternity leave, an overwhelming majority have been told or heard that surgical careers are incompatible with parenthood. Female surgeons were particularly likely to receive such comments.

Aims:

Leakage following bowel anastomosis is a serious complication of colonic surgery. Novel near-infra-red (NIR) imaging techniques combined with indocyanine green (ICG) angiography demonstrate real-time perfusion of the bowel anastomosis which may improve anastomotic leak rates and outcomes. This study aims to compare the anastomotic leak rate between right hemicolectomies that had ICG-NIR intra-operative with historic control cases had not ICG-INR.

Method:

A retrospective case-control notes review was conducted of all ileum-transverse colon anastomoses performed under 4 consultant colorectal surgeons at the Queen Elizabeth Hospital, Gateshead, between 18/12/2016-15/10/2019. 

Results: 

Sixty-five and sixty-two right hemicolectomies with ileum-transverse anastomosis with ICG-INR and without ICG-INR respectively. No statistically significant difference between the two groups in terms of demographic data. 

Three (4.8%) of the anastomoses leaked in the non-ICG-INR group, while one (1.8%) leak in the ICG-INR group.

ICG-INR changed the intra-operative action plan in four patients in the ICG-INR group, none of them have had leaks. ICG-NIR was not shown to increase operation length time suggesting the use of ICG-NIR is practicable.

Conclusions: 

Findings suggest ICG-NIR reduces anastomotic leak rate and it is recommended to be incorporated as a routine practice in intra-operative ileum-transverse anastomosis assessment.

Aim: To estimate the impact of an ambulatory care pathway and Surgical Ambulatory Care Unit (SACU) implementation in care of patients with acute diverticulitis.

Method: A retrospective observational study of electronic data for patients treated for diverticulitis during 2017 and 2019 was performed. Patient demographics, inflammatory markers, admission rate and the rate of SACU attendance were recorded. SACU was established in 2016 and the ambulatory pathway initiated in 2018.

Results:In 2019, 93 patients were treated for diverticulitis, compared with 68 in 2017, respectively. There were significantly fewer admissions for diverticulitis during 2019 (p <0.00001), with 44% of patients treated within ambulatory care. The proportion of patients who re-attended the emergency department did not differ significantly between 2017 and 2019, (p =0.62). Almost all patients underwent CT during 2017, whereas in 2019, 80/93 were scanned on admission and 10/93 had had CT and/or colonoscopy within the last year.

Conclusion: There were significantly fewer admissions in 2019, following the implementation of an ambulatory pathway within the SACU. This will realize benefits in both patient care and healthcare costs. 

Aim:

Opioid prescribing rates and adverse events have risen over the last 20 years. We present Australian data analysing the prescription and consumption of opioids after discharge from colorectal procedures.

Method:

Patients who underwent elective bowel resections, ostomy formations, or restoration of bowel continuity procedures were prospectively recruited from an Australian tertiary referral centre over a 12-month period. Patients were contacted 7-10 days after hospital discharge and invited to participate in a phone survey regarding their analgesic use. 

Results:

119 patients completed the survey (approximately 80% response rate). 37% of the cohort received opioids (70% by the hospital, 30% from GPs). 7% of patients did not consume any opioids, despite receiving them from the hospital or GP. 35.42% and 59.42% of hospital-provided and GP-provided opioids went unused, respectively. Overall, the mean quantity of opioids provided was the equivalent of 29.9mg of oxycodone (range 0-250mg), whereas the mean quantity consumed was only 16.5mg of oxycodone (range 0-165mg). 

Conclusion:

We provide data from Australia demonstrating variability and over-prescription of opioids after colorectal procedures. Given that the most common prescribers of opioids in this study are hospital officers and general practitioners, we suggest that training is required to reduce the amounts of unused opioids entering the community.

Introduction:

We aimed to investigate the outcomes of elective colorectal patients referred to a prehabilitation programme and compare them to controls.

Methods 

A retrospective review of all patients who underwent colorectal surgery, over a 6-month period, was performed. Patients undergoing emergency surgery were excluded. Differences between groups were analysed by Fisher’s exact test using SPSS software (version 26.0).

Results 

A total of 177 patients were included in this study. 25 patients (median age 72.5 years) underwent prehabilitation and 152 patients (median age 66 years) did not. 

Fewer Clavien-Dindo I/II complications were recorded in the prehabilitation group (5 (20%) vs. 45 (29.5%), p = 0.472) as well as III/IV complications (1 (4%) vs. 14 (9,5%), p = 0.698). Furthermore, there were less surgical site infections in the prehabilitation group (2 (8%) vs. 35 (23%), p = 0.112) and fewer unplanned returns to theatre (1 (4%) vs. 12 (8%), p = 0.697). Length of stay was the same in both groups (median 6 days).

Conclusions 

Our findings demonstrate a trend towards reduced morbidity in prehabilitated patients. 

Aim: Tissue hypoxia leads to increased anastomotic complications following colorectal resection and anastomosis (R&A). However, healing has been shown to occur in ischemic anastomoses when intraluminal antibiotics are administered. We developed a mouse model to investigate the hypothesis that hypoxia influences anastomotic healing by altering the gut microbial profile.

Method: The study consisted of two groups: R&A (n=23) and control (laparotomy without resection, n=9). The mice were sacrificed at day 3 and day 7 after surgery. Macroscopic anastomotic healing scores and blinded histological scoring was performed. Immunohistochemical analysis was performed on anastomotic tissue to examine angiogenesis (VEGF), hypoxia (Pimonidazole) and cellular proliferation (Ki67)

Results: 

There were significant correlations between hypoxia and VEGF (r=0.6093, p=0.0007), hypoxia and Ki67 (r=0.6452, p=0.0007), as well as VEGF and Ki67 (r=0.6725, p=0.0002). There was no correlation between hypoxia and anastomotic healing scores.

Conclusion: These findings re-inforce other pre-clinical trials that show no correlation exists between hypoxia and anastomotic healing. This suggests that other factors are at play which affect anastomotic healing. Given that intraluminal antibiotics influence healing outcomes, this suggests that the gut microbial profile may influence healing, and is therefore a promising area for further investigation.

Aim: The effect of humidified, warmed carbon-dioxide (HWCO₂) on anastomotic healing and gut microbiota following colorectal surgery is unknown. HWCO₂ has the potential to influence tissue oxygenation and the gut microbiome, impacting on anastomotic healing. We aim to investigate this effect in mice.

Method: 21 mice underwent a colonic resection and anastomosis (R&A) either in room air (RA, n=11) or in HWCO₂ (n=10). A control group (no R&A, n=20) underwent a laparotomy with the same exposure (RA n = 10; HWCO₂ n = 10). Endpoints at 3 days were anastomotic strength measured by anastomotic bursting pressure (ABP) and microbiome analysis of mucosal samples by 16S rRNA sequencing.

Results: Four mice in RA developed macroscopic leaks compared to one in HWCO₂. There was no difference in ABP however changes from baseline in alpha and beta diversity were noted in RA compared to HWCO_2. The keystone species Akkermansia muciniphila changed from 3.04% to 11.25% in RA compared to 5.60% to 6.64% in HWCO₂.

Conclusion: The findings suggest a beneficial effect on both anastomotic healing and bacterial strains with HWCO₂, following colorectal surgery. This has potential clinical implications for minimally invasive approaches using HWCO₂ and open surgery utilising field flooding with CO₂

Aim: Several complications that may arise in the postoperative period of colorectal surgery, which can affect the outcome of the treatment. In addition, the great difficulty of detection and the establishment of an early diagnosis of these complications often result in worsening the clinical condition. Our aim was to study the association between the development of complications and changes in heart rate variability, as well as analytical parameters.

Method: Electrocardiographic signal and clinical markers were gathered for 73 patients, 26 of whom had postoperative complications. A statistical analysis was made  to detect differences in the values of the electrocardiographic or analytical profiles on each perioperative day.  The establishment of possible correlations was  studied. Finally, using data mining, the performance of different automatic classifiers was evaluated.

Results: There were differences in the analytical and electrocardiographic parameters on different days in consideration with the pathology. It has revealed some prominence with pre and intraoperative clinical features. Regarding to the performance of the automatic classifiers, an accuracy of 75.3% and a ROC area of 0.821 stand out in the evaluation of the statistically significant parameters from the previous analysis.

Conclusion: Therefore, the results are promising in the prediction of postoperative complications and in the future establishment of an incidence risk score.

Aim:

Compare infectious complication rate in two groups of patients with mechanical bowel preparation associated or not with oral antibiotics.

Method:

Design: Case and Controls.

Sample: Patients undergoing elective colorectal surgery.

Inclusion criteria: adults, elective colorectal surgery with anastomosis, includes reversv al ostomy, period from July 2018 to June 2019. Follow up 30 days post-surgery.

Exclusion criteria: Allergy to any of the antibiotics used, use of antibiotics 7 days before surgery.

Sampling: Non-probabilistic, consecutive

Variables: Dependent: Presence of surgical site infection and anastomotic leakage. Independent: Biodemographic profile (age, sex, BMI, comorbidities, radiotherapy, laboratory, diagnosis)

Statistics: Analytical. STATA 13.0

Results

A total of 124 patients were analysed, 62 patients in each group. Both groups are comparable. There was statistically significant difference in the reduction of superficial site infection (with OA = 2 vs alone = 11) p = 0.018 CI = 1.37-30.55 OR = 6.47. 

There was no significant reduction in leakage (OA = 0 vs. alone = 4), p = ns.

Conclusions:

The use of preoperative OA reduces the superficial infection rate. Patients who were not used OA have 6.47 higher risk of developing it. The use of OA may decrease the rate of leakage, but studies with greater number of patients are required  to establish this association.

Aim: Robotic colorectal surgery in the Philippine is emerging. This study discussed the clinicopathologic outcomes of the first robotic (R) rectal resections versus laparoscopic (L) and open (O) done during the same time period  at a single institution from March to October 2019.

Method: This is a cross-sectional study of 45 consecutive cases. Fifteen patients in each arm were compared. 

Results: The patients were mostly male (60%) with mean age of 56.04. Most of the tumors were in the low rectum (27/45;60%), locally-advanced (27/45;60%), and warranted neoadjuvant treatment (41/45;91.11%). 

The R-group had the longest operative time (438.07±124.57mins;p<0.0001), and greatest blood loss (p-0.0225). No conversion was noted.

All patients in the L-and O-groups had an R0-resection. Negative circumferential resection margin was 100%-O; 93.99%-L; 69.23%-R. All patients had adequate proximal and distal margins.

The O-group had the shortest postoperative length of stay (3.87days;p–0.0225). Postoperative-ileus (7/45;15.56%) was the most commonly encountered morbidity. One patient in the R-group underwent a trans-anal repair of an anastomotic dehiscence. No mortality was reported.

Conclusion: The   L-and O-groups had better outcomes compared to the R-group. This suggests that the proposed advantages of robotic surgery were not readily apparent. Improvements may be seen  as the program progresses through the learning curve, and with better patient selection.

AIM: To determine the diagnostic value of C-reactive protein (CRP), CD64 index on neutrophils (iCD64n) and HLA-DR monocytes (HLA-DRm) as biomarkers of postoperative infectious complications (PIC) after colorectal surgery.

Methods: 192 patients after colorectal cancer surgery and reconstructive surgery with colostoma closure were prospectively included. Blood samples were drawn to determine the values of the biomarkers on the 3 postoperative day (POD).

Results: PIC were diagnosed in 15.1% (29/192) patients. On the 3 POD ROC-analysis demonstrated that iCD64n had the best value of area under curve (AUC=0.862; p<0.001). The second was HLA-DRm with AUC=0.79 (p<0.001). CRP had the poorest diagnostic value (AUC=0.719; p<0.001). With cut-off point 1.42 for iCD64n sensitivity was 72.4%, specificity – 84.7%, positive predictive value – 26.7% and negative predictive value – 97.8%.

Conclusion: PIC after colorectal surgery are very unlikely in patients with an iCD64n below 1.42 on 3 POD. Biomarker can aid patient selection for safe and early hospital discharge.

Aim:Re-operative laparoscopic colorectal surgery is becoming increasingly common.It can be challenging procedure but its benefits can outweigh the risks in experienced hands.

Method: Systematic review of the literature reporting re-operative colorectal surgery. Retrospective and prospective cohort studies were included, with case reports being excluded.

Results: Eight studies with 275 patients (85 female, 169 male, 21 unknown gender) ,who previously had laparoscopic surgery (laparoscopic colectomies, low anterior resection, abdomino-perineal resection) were included. Indications for re-operation were either related to complications, such as bowel obstruction, bleeding, urogenital injury anastomotic leak, anastomotic stricture or malignancy related. Twenty-eight patients had complications. Eight deaths were reported and length of stay ranged from 2-70 days. Only 7 conversions to open were reported with major indications being the presence of adhesions and pelvic fibrosis.Fifty-two patients had stoma formation with 17 of them being reported to have temporary defunctioning ileostomy.

Conclusions: Re-operative laparoscopic colorectal surgery is safe when performed in centers of excellence. Management of complications, recurrence of malignancy and lateral pelvic floor dissection can be safely performed in selected patients. Complication rate is low with conversion to open procedures being relatively uncommon.

Aim: We presented a transanal resection of the fibrous stenosis by circular stapling device, which is a simple, safe and effective method to treat benign rectal anastomotic strictures. 

Method: The patient has an anastomotic stricture at the midrectum. There was no response to endoscopic dilation. Through a transanal Gelport that allowed the use of laparoscopic handpieces, the stricture was visualized and opened to the extent that the anvil was passed. A suture was attached to the tip of the anvil, and it was prevented from immigrating to the proximal. After passing the anvil, a purse-string suture was placed with laparoscopic instruments. Gelport was removed. It was pulled through the rope attached to the tip of the anvil and became accessible. After the anastomosis was performed, the anastomotic line was visualized by the transanal laparoscopy.

Results: There was no complication. The patient was discharged the first postoperative day. In follow-up, the patient's daily fecal passage was asymptomatic. There was no recurrence at the postoperative first and third month endoscopy.

Conclusion: In benign rectal anastomotic stenosis, transanal circular stapler approach is an effective and simple method and should be kept in front of more aggressive treatment options.

Aim: The goal of surgery for chronic pelvic sepsis (CPS) is to resolve pelvic inflammation while restoring intestinal continuity. The transanal pull-through procedure (TPT) achieves this by mobilizing a healthy conduit into the pelvis and creating a manual coloanal anastomosis (CAA) beyond the source of sepsis. We reviewed our single-center experience with TPT and CAA for CPS.

Methods: All patients requiring TPT from 2010 to 2018 were retrospectively reviewed using a prospective database. Morbidity and mortality were evaluated and restoration of bowel continuity at 1-year was the main endpoint.

Results: Twenty patients underwent TPT with manual CAA as a treatment. Initially, 15 patients were operated for rectal cancer. The median age was 60 (42-86) years and the median BMI was 26 (18-37) kg/m².  The median time with an ostomy before the intervention was 15 months while the median time from primary surgery to TPT was 32 months. There were no death and morbidity reached 60%, leak rate was 10%. At one year, 70% of the patients had their intestinal continuity fully restored.

Conclusion: In expert hands, the TPT procedure with CAA for CPS has acceptable morbidity and leak rates, and a bowel restoration success rate of 70% at 1-year.

Aim:

It´s important to know what patients with acute diverticulitis(AD) will have risk of complications. The utility of immuno-nutritional scores (prognostic nutritional index-PNI, neutrophil-lymphocyte ratio-NLR, platelet-lymphocyte ratio-PLR and lymphocyte-monocyte ratio-LMR) in the detection of complicated-AD (CAD) is being studied but there´s few evidence, therefore we decided to perform this study to determinate its utility as predictor of urgent-surgery in CAD.

Method:

Retrospective study,we´ve included patients with CAD, between January-2016 and December-2018.

Results:

80 patients with CAD were analysed (men:53.8%,age:65.4±14.3years). mHinchey classification: Ib 53(66.3%), II 17(21.3%), III 7(8.8%), IV 3(3.8%).LOS:7(IQR:6-9days).Urgent surgery: 34(42.5%). 

We compared Group-A(urgent-surgery) with Group-B(non-surgery). CRP, NLR, PLR and LMR values were higher and PNI lower in group-A (90.9±60.9 vs. 158.9±88.8; 8.95±7.9 vs. 10.3±6.2; 163.8±73.9 vs. 238.8±139.6; 2.37±0.85 vs. 2.82±1.9; 35.4±2.08 vs. 33.2±3.87 respectively).

In the ROC curve, the CRP, PNI, NLR, PLR and LMR had the fllowing cut-off points: <115mg/L, <35, <1, <155 and <2 respectively.We performed an analyze with this cut-off values and the needed of surgery was lower(p<0.05).

Conclusion:

The inmuno-nutritional scores are easy to perform and could be a good predictor of urgent-surgery in CAD.

Aim:

To compare our outcomes after laparoscopic peritoneal lavage (LPL) versus Hartmann's procedure (HP) and primary resection and anastomosis (PRA) in patients with complicated acute diverticulitis (CAD). 

Method:

Retrospective study, we´ve included patients with CAD, between January-2016 and December-2018.

Results:

80 patients with CAD were analysed (men:53.8%, age:65.4±14.3years). Urgent surgery group: 36 patients à men:61.1%, age:60.5 (IQR: 52-73.5 years), >70years: 33.3%. mHinchey: Ib: 33.3%, II: 36.1%, III: 22.2% and IV: 8.3%. mHinchey LPL group: Ib: 41.7%, II: 25% and III: 33.3%. LOS: 8 (IQR: 7-14.75 days). Mortality: 0%. ASA classification: I: 25%, II: 61.1%, III: 13.9%. LOS: 7(IQR:6-9days), LOS-LPL group (11.8±10.8days vs. 12.1±8.3days p>0.05).

Surgeries: HP 58.3%, PRA 8.3% and LPL 33.3%. Laparoscopic approach: 38.9%. Postoperative complications: global (53.1%), infectious (24.5%), CD≥III (16.3%). 6.1% of patients required reoperation Postoperative complications: global (63.9%), infectious (33.3%), CD≥III (19.5%), reoperations (16.7%). 

LPL vs. non-LPL postoperative complications: global (58.3% vs. 66.7% p=0>0.05), CD≥3 (16.7% vs. 20.8% p>0.05), infectious (25% vs. 37.5% p>0.05), reoperations (25% vs. 12.5% p>0.05).

Conclusion:

In our environment LPL is not related to a higher postoperative complication rate, although higher reoperation rate was seen but without statistically significant differences. Therefore, LPL for CAD could carry a high risk of failure in daily practice.

Aim

Caecal intubation rate is a quality marker for colonoscopy. Typically, 90%-95% is expected, and audited as a Key Performance Indicator (KPI). This study examines the reliability of reported completion rates.

Method

The study is a retrospective analysis of prospectively collected data. Consecutive colonoscopies done in October 2019 at a single NHS Trust were identified. Information extracted: age, sex, proposed procedure, performed procedure, extent of intubation, photographic evidence of caecal landmarks (appendiceal orifice, ileo-caecal valve and/or ileoscopy) and whether Virtual Colonography (VC) was requested.

Results

633 colonoscopies were intended. 297 females (median: 62.8; range 22-88) and 336 males (median: 66.5; range 17-92). Of these, 6 were converted to sigmoidoscopy mid procedure. Of the remainder, 29 were declared incomplete. Reported completion rate was 598/627 (95.37%). In those declared complete, 4 had no photographic evidence, and 9 required follow-up VC.

Conclusion

Mid-procedure intent change, lack of photographic evidence and/or unjustified requirement for a VC are sub-optimal outcomes. 19 further colonoscopies should have been declared incomplete, indicating a true colonoscopy completion rate of 585/633 (92.41%), a drop of 2.96%. The need to achieve the KPI, alters endoscopist behaviour inappropriately. Regular procedural checks should be implemented to ensure that reported completion rates remain a relevant quality marker.

Aim: Complete endoscopic examination of colon requires intubation of caecum beyond the ileo-caecal valve (ICV). The clearest landmark for this is appendiceal orifice. Views of ICV alone does not prove caecal intubation, as it does not require intubation of caecal pole. This study examines the reliability of reported colonoscopy completion rate.

Method: Retrospective analysis of prospectively collected data was performed. Consecutive colonoscopies done in October 2019 at a single NHS Trust were identified. Information extracted: age, sex, extent of intubation, and photographic evidence of caecal landmarks (appendiceal orifice, ICV and/or ileoscopy). 

Results: 629 colonoscopies were performed. 295 Females (median age 55.25, range 21.97-88.53) 334 males (median age 55.07, range 17.44-92.71). Colonoscopy was marked complete in 601 (reported completion rate 95.55%). Of these, 9 were post hemicolectomy, and completion confirmed by ileoscopy. Of the remaining, appendiceal orifice was not photodocumented in 67. Verifiable evidence of caecal intubation beyond the ICV is present in 562 (actual completion rate 89.34%).

Conclusion: Lack of visualisation of appendiceal orifice (where present) may indicate non-intubation of caecum. Using appendiceal orifice as the definitive end point drops the completion rate from 95.55% to a sub-par 89.34%. Photodocumentation of the appendiceal orifice should be the minimum standard.

Aim

Fistula laser-assisted closure (FiLaC) is a new approach for the treatment of anal fistula. The laser energy causes closure of the fistula tract with a radial diode laser. This retrospective study was designed to estimate safety and efficacy.

Method 

Sixty patients with anal fistula underwent the FiLaC procedure. d. A loose seton procedure was used as a bridge to laser therapy in 52 patients. The surgical procedure consisted of slow withdrawal of Laser fiber with a 12-watt laser emitting at a wavelength of 1470 nm (FiLaC device) resulting in the ablation of the fistula tract. No attempt was made to close the internal opening. The patients were followed up at 4-8 weeks interval. 

Results 

There were no intra-operative complications reported. The median duration of follow up was 10 (3–16) months. Primary healing was observed in 29(48%) patients. There were 14 (23%) failures after the operation. No patient reported incontinence postoperatively. Six(10%) patients had some minor residual symptoms and they are still awaiting further follow up. Unfortunately, 11(18%) patients were lost to follow up.

Conclusion 

There is a moderate primary success rate with the FiLaC procedure. It is a simple, safe, and effective treatment for fistula in ano.

Aim: In light of COVID-19 recommendations from the Association of Coloproctology of Great Britain and Ireland, we aimed to study patient and clinician satisfaction with a new colorectal surgery telephone clinic (TPC) in-lieu of traditional face-to-face (FTF) appointments.

Methods: We conducted patient and clinician surveys throughout June 2020. Primary outcome was patient and clinician satisfaction. Secondary outcomes included demand of patients and clinicians to continue TPC post-pandemic and views of Specialty Trainee 3+ (ST3) doctors versus consultants on TPC compared to FTF.

Results: There were clinician responses from 15 clinic sessions and 117 individual patient responses. Patients had higher satisfaction with TPC versus clinicians; 91.5% versus 66.6% reported above average experience (OR=5.35, 95% CI 1.53 to 18.75, p=0.01). Clinicians had lower demand to continue TPC post-COVID-19 versus patients, trending towards significance (60% vs 82.9%, OR=0.31, 95% CI 0.10 to 0.97, p=0.08). ST3+ doctors were more likely than consultants to find TPC inferior to FTF consultation for patient assessment (48.3% vs 23.7%, OR=3.00, 95% CI 1.17 to 7.71, p=0.03).

Conclusions: High patient satisfaction with TPC suggests it should continue to have a place in the colorectal outpatient service post-COVID-19. Clinician acceptance has been more cautious and the key to success will be appropriate case and patient selection for TPC.

Aim: 

In March 2020, NHS England issued guidelines recognising the elective component of cancer surgeries may be ‘curtailed’, due to the COVID-19 pandemic. We aimed to compare surgeons’ practice for the provision of colorectal cancer (CRC) surgery across the United Kingdom (UK), against updated Joint Royal Colleges & ACPGBI guidelines and highlight differences in practice, if any.

Method:

An online survey was conducted, which examined surgical practice across the UK against current protocols for CRC surgeries, in the COVID-19 era.

Results:

29 individual responses were received from Trusts across the UK. 23/29 (79%) surgeons ceased or saw a delay in CRC surgeries, with 3/29 (10%) yet to reintroduce them. 19/26 (73%) surgeons instructed patients to self-isolate prior to surgery, of which 5/19 (26%) correctly enforced a duration of 14 days. 10/19 (53%) participants adhered to pre-operative chest imaging guidelines, by performing a CT chest within 24 hours of surgery. 

Conclusion:

This snap shot survey highlights dramatic variations in CRC surgery practice within the UK and inconsistent adherence to protocols. In the COVID-19 era, guidelines are likely to be updated frequently and it is essential for surgeons to keep up to date with these changes, in order to maintain uniformity in practice.

AIM: To assess an impact of COVID-19 on emergency general surgical admission in a busy trauma centre during peak in the United Kingdom (UK).

METHODS: Data was collected between March and April 2020 to compare with retrospectively collected data from 2019 during the similar months. The main focus was number of diagnostic investigations and emergency surgeries performed  during the COVID peak (Group A) as compared to non-COVID period in 2019 (Group B).

RESULTS: Total number of patients admitted in Group A were 187 and 272 Group B. Only 40% patients had a COVID-19 swab and 7% of them were positive. In Group A, more patients had a diagnostic CT  abdomen as compared to Group B (p= <0.05). Additionally, 48% patients in Group A had a CT Chest as compared to 2% in Group B (p=<0.05). There was no difference in number of emergency surgeries performed in Group A and B (p= 0.12). However, 15% patients in Group A had a de-functioning stoma for bowel obstruction as main indication and one patient with positive COVID-19 swab passed away after surgery.

CONCLUSION: Significant number of patients had a diagnostic CT chest and abdomen during COVID peak in UK, however there was no difference in emergency surgical intervention rate.

Aim:

The traditional practice of requesting endoscopy procedures is paper-based which involves transfer of information via porters and is subject to delays. Other drawbacks/issues include lost forms, missed targets, delay in patient care, and also high operational cost and administrative burden. There is also lack of accountability especially in case incomplete/illegible clinical information. We created an electronic endoscopy referral system and  did an interim analysis after one month, if these issues were mitigated.

Method:

We worked in collaboration with the admissions and the information technology teams and designed a user friendly electronic referral system. The Pilot aimed to test & compare the EER process vs traditional paper referral, with aim of eliminating lost forms and reducing processing times. The pilot included 3 consultants who made 58 requests using the EER over 1 month.

Results:

There was a reduction of processing time from 5 days to median of 0.74 days, with no illegibility issues and overall led to elimination of the missing forms. It further helped in accounability, easier access to information and data-keeping.

Conclusion:

This practice highlighted that EER had a remarkable impact in reducing the factors contributing to delays and had a positive impact on patient care. 

Aim

We assessed short-term clinical and pathological outcomes in the first case-series of patients undergoing colorectal surgery using the CMR Surgical Versius robot.

Methods

We included all robotic-assisted cases and a matched cohort of laparoscopic cases over a 4-month period. We collected pathology outcomes, post-operative complications; GI-3 recovery, length of stay and 30-day readmissions. Mann-Whitney U, chi-squared test and multivariate linear regression models were applied.  

Results

28 robotic-assisted cases included robotic mobilisation ± vascular pedicle isolation. Demographics were comparable with matched laparoscopic cases (n=28, age, gender, BMI; P>0.50) with 18 right and 10 left/rectal resections in each group. Duration of robotic-assisted cases was longer (4.25vs.3 hours, P<0.001). Pathological outcomes were comparable (median 19 lymph-nodes, 0 +CRM, 0 intra-operative perforations). Two robotic cases required conversion. No significant post-operative complications (Clavien-Dindo≥3) occurred. Median time to GI-3 recovery was 3 days in each group (P=0.25) and median length of hospital stay was 4 days in each group. One patient was readmitted after robotic assisted surgery with non-specific abdominal pain requiring no intervention. 

Conclusions

CMR Versius is a safe and flexible robotic system.  The cost-effective, compact modular design with small footprint and individual arms facilitates freedom of port placement and operative flexibility and will accelerate widespread adoption of robotic-assisted colorectal surgery.

Aim: To understand maternity/paternity leave provision in surgical careers globally.

Method: A 55-item survey, in 24 languages, consisting of common and specific questions for medical students, surgical trainees and consultants, was created online and distributed globally via social media. Questions related to ease of maternity/paternity leave applications and reasons for not taking full entitlement. 

Results: There were 1393 (M:F, 514:829) complete responses from 65 countries, consisting of 349(25.1%) surgical trainees and 513(36.8%) consultants, among others. 

126(36.3%) trainees and 374(73.5%) consultants had children. Among them, 63.5% of trainees and 55.9% of consultants reported being able to take maternity leave without prejudice or that they experienced no issues with taking their full leave entitlement. 43.8% of trainees and 39.9% of consultants reported the same in respect of paternity leave. 

69% of trainees and 73.3% of consultants did not take their full leave entitlement. The most common reason among trainees was worrying about missed training opportunities (18.1%), whereas consultants were most commonly concerned about pressure from employer/senior/peers (19.8%).

Conclusion: There is gender difference in the experience of maternity/paternity leave application. More workplace support is needed in order that surgeons would feel free to utilise the full extent of their leave entitlement.

Aim: To understand the experience of parenthood during surgical careers globally.

Method: A 55-item survey, in 24 languages, consisting of common and specific questions for medical students, surgical trainees and consultants, was distributed globally via social media, with questions relating to experience of parenthood during surgical careers. 

Results: There were 1393 (F:829) complete responses from 65 countries, consisting of 479(34.4%) medical students; 349(25.1%) surgical trainees and 513(36.8%) consultants. 

520(37.3%, 20 students, 126 trainees, 374 consultants) had children. Among trainees and consultants, females were significantly less likely to have children compared with males (213/467 females, 45.6% vs 141/383 males, 36.8% without children, p=0.01). Among those with children, the time spent with children was 21-30 hours/week. Males were significantly more likely to spend 30 hours or less per week with their children compared with females (73.1% vs 50.4%, p<0.05). Both trainees (53.5%) and consultants (55.8%) reported occasionally/often feeling guilty for not spending enough time with their children.

Conclusion: Female surgeons are significantly less likely to have children. Female surgeons who have children are more likely to spend more time with their children. Surgeons often or occasionally feel guilty for not spending enough time with their children.

Aim

A nurse-led clinic for patient’s pre-stoma reversal following an anterior resection

Method

A focus for the clinic is grounded around pelvic floor exercises using a mini irrigation system. Aimed at prevention of symptoms and how to gain bowel control, actively involving patients in pre-operative preparation for stoma reversal. The pathway ensures all patients have a gastrograffin enema prior to using mini irrigation for patency of the anastomosis. All patients are tracked and supported from their initial surgery up to and after reversal of stoma. 

Results

17 pre-stoma reversal patients have been seen.  At the time of publication 5 were discharged at 6 weeks with no bowel dysfunction. A further 10 were booked for initial appointments. More data will follow. 

Satisfaction parameter (0 = Worst, 10 = Best)                N=5

Improvement since attending the clinic = 9

Quality of education from the nurse = 10

Relationship with the nurse = 10

Opinion of pelvic floor exercises after using mini irrigation = 9.4

Satisfaction level 

Extremely satisfied = 60%

Satisfied = 40%

The nursing clinic has helped 

Yes = 100%

No

Conclusion

Pelvic floor exercises using a mini irrigation system has shown to prevent symptoms after stoma reversal, more research is required

Aim: The aim of this study was to evaluate a CRP monitoring-driven discharge strategy in an homogenous group of patients undergoing laparoscopic total mesorectal excision with sphincter-saving surgery for rectal cancer (TME).

Materials and Methods: 113 patients who underwent TME had CRP monitoring on postoperative day (POD) 5. Patients were discharged on POD 6 if CRP level was ≤ 100 mg/L. Patients were matched to 123 control patients who underwent TME without CRP monitoring.

Results: Postoperative 3-months overall and severe morbidity rates were similar between groups. Mean length of hospital stay was significantly shorter in the CRP group (CRP group: 9.7 ± 14 vs controls: 11.6 ± 7 days; p < 0.001). Discharge occurred on POD 6 in 55/113 (49%) patients from CRP group vs 7/123 (6%) from controls (p < 0.001). Rehospitalization rate [CRP group: 19/113 (17%) vs controls: 13/123 (11%), p = 0.177] was similar between groups. CRP level on POD 5 had a diagnostic property to assess an anastomotic leakage with an area under the curve of 0·81.

Conclusion: In patients who underwent TME for rectal cancer, a discharge strategy based on CRP monitoring decreases significantly length of hospital stay without increasing morbidity, mortality and rehospitalisation rates.

Aim

Comprehension of complex vascular anatomy is a crucial aspect of complete mesocolic excision. We compare 3D models vs a systematic approach to CT analysis (AMIGO) on the understanding of mesenteric vascular anatomy.

Design

15 cases were included. Two GI radiology consultants reviewed each scan to confirm the vascular anatomy. Virtual 3D models were produced using a novel workflow and displayed on a web-based platform (https://skfb.ly/6OZUZ). 13 senior surgical trainees were recruited to the study. Candidates were assessed after baseline anatomical training and subsequently using the AMIGO method and 3D models.  Five cases were randomly allocated to each testing round.

Results

Both 3D and AMIGO significantly improved anatomical understanding in comparison to baseline testing. However, 3D was superior to AMIGO (3D [n=65; mean score 7.85/14] vs. AMIGO [n= 65; mean score 5.69/14; p <0.0001). For 14/15 patient cases examined, 3D was superior to using the AMIGO method. 11/13 participants demonstrated better anatomical understanding using 3D models versus AMIGO. 10/13 participants preferred 3D models in comparison to standard CT imaging.

Conclusions

3D models improve anatomical understanding of mesenteric vascular anatomy in a group of colorectal surgical trainees in comparison to a formal CT interpretation method. 3D models may be a useful planning adjunct to 2D imaging for CME surgery.  

Aim

Nodal status in colorectal cancer (CRC) is an important prognostic factor. Whether the number of retrieved and analysed lymph nodes (LN) has a direct impact on overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS) is much discussed. We present a propensity score matched analysis, eliminating biasing factors to assess the prognostic importance.

Methods

Patients operated for stage I-III CRC were identified from a prospectively maintained database. The impact of the number of LN on OS, CSS and DFS was assessed using Cox regression and propensity score analysis. 

Results

Of the 687 patients, 81.8% had 12+ LN analysed. Analysis of 12+ LN was associated with improved OS (HR=0.73; 95%CI:0.56-0.95; p=0.034) and DFS (HR=0.75; 95%CI:0.58-0.98; p=0.049) in multivariate Cox analysis. 

After adjusting for biasing factors with propensity score matching, resection of 12+ LN was significantly associated with improved OS (HR=0.59; 95%CI:0.43-0.81; p=0.002), CSS (HR=0.34; 95%CI:0.20-0.60; p<0.001) and DFS (HR=0.55; 95%CI:0.41-0.74; p<0.001) compared to patients with less than 12 LN. 

Conclusion

Eliminating biasing factors by a propensity score matching analysis revealed the importance of the number of analysed LN in patients with stage I-III CRC. Concisely, patients with at least 12 LN clearly showed an improved OS, CSS and DFS.

Aim: Estimated lymph node (LN) involvement in T1 colorectal polyp cancers can be stratified into low (4%), moderate (18%) or high (>20%) risk using histopathological markers established by Ueno et al. Although important for clinical decision-making, it may not reflect real-life clinical practice. We studied the risk of LN involvement in patients with polyp cancers and examined resultant clinical outcomes.

Method: Patients with T1 colorectal polyp cancer following polypectomy between 2013 and Nov 2019 were retrospectively analysed. Case-notes and histopathological reports were used. All patients had cancer follow-up. A proportion underwent surgery.

Results: 74 patients (34 female) were identified. Median age 71 years. Median follow-up was 42 months. Based on histopathology, 8, 50 and 16 patients were deemed low, moderate and high-risk, respectively. Resections were most common in the moderate-risk group (56%), of which 22% were LN positive. One third of high-risk patients underwent surgery but none had positive LNs. Fisher’s exact test demonstrated no association between Ueno risk groups and adverse outcomes (LN positivity, recurrence or metastatic disease).

Conclusion: Within the moderate-risk category, Ueno accurately estimates LN positivity but a stepwise increase of adverse outcomes across the risk groups was not observed. Patient counselling and fitness for surgery remain important factors when managing patients with polyp cancers.

Aim: Despite proven clinical benefits in the short-term, technical difficulties limit utilization of laparoscopy in rectal cancer surgery (RCS). Transanal Total Mesorectal Excision (taTME) overcomes many technical limitations of laparoscopic RCS. However, the costs of this procedure have not been addressed yet. We have performed a comparative cost analysis of taTME and laparoscopic TME (lapTME).

Method: Consecutive patients undergoing TME between 1 February 2014 and 31 October 2018 were selected from a prospectively maintained database and stratified, according to the type of procedure, into taTME and lapTME groups. The main outcome measure was intraoperative costs of the two procedures. Secondary outcomes were short-term outcome and cost of hospital resources to manage the postoperative course.

Results: Hundred-and-fiftytwo patients with rectal cancer (66 lapTME, 86 taTME) were included. 

TaTME surgical supplies procedure exceeded the cost of lapTME of 754,54 euros. The duration of surgery was comparable between the two approaches (p=0.50). Short-term outcomes were comparable. There was no difference in hospital resources utilization to manage postoperative course including blood test, diagnostics, consultations, and medications.

Conclusion: TaTME has higher intraoperative costs with respect to lapTME. Short-term outcomes and hospital resources to manage postoperative course are comparable.

Aim:

The superiority of robot-assisted TME over laparoscopic TME has not yet been proven. Most studies compare surgical techniques without taking into account the learning curve. This study therefore aims to compare laparoscopic TME with robot-assisted TME in patients operated by surgeons who are well beyond their learning curve.

Method:

A retrospective propensity score-matched analysis was performed for patients that were prospectively registered in the obligatory Dutch ColoRectal Audit (DCRA) and underwent a laparoscopic or a robot-assisted TME in a dedicated robot-assisted or dedicated laparoscopic centre. Patients were propensity score matched in a 1:1 ratio.

Results:

In the matched cohort, 315 patients were included per technique. Conversion was similar between groups (4.4% vs 2.5%[p=0.201]). Positive circumferential resection margin was also comparable (3.2% vs 4.4%[p=0.414]). The rate of wound infections was lower in the robot-assisted group (5.7% vs 1.9% [p=0.014]). Finally, more low anterior resections with primary anastomosis were constructed in the robot-assisted group (50.8% vs 68.3% [p<0.001]).

Conclusion:

Robot-assisted and laparoscopic TME are equally safe in terms of conversion rate and CRM-positivity. Although more primary anastomoses are constructed, the effect of more anastomoses on quality of life is yet to be investigated.

Aim: To compare short-term and oncologic outcomes transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) in patients with early rectal cancer (ERC).

Method: We conducted prospective analysis of 146 patients with ERC(T1sm1-sm3) operated between October 2011 – August 2019: TEM was performed in 92 patients, 54 were treated by TME. Short-term and oncologic outcomes of treatment were evaluated.

Results: No differences in age, anthropometric indicators, histological structure and depth of invasion of tumors were observed between two groups. TME was associated with more operating time(139(120;180) vs 40(34;50) min, р=0.00001) and POD(10(7;11) vs 7(6;9) days, р=0.00001) than TEM. There were no statistically significant differences in complication rate between TEM(6.8%(7/92)) and TME(12.7%(7/54)) groups. The average follow-up period in the TEM group was 38±23 months, in the TME group – 39±16(p=0.7). Six(6.5%) patients in the TEM group, one(1.8%) in the TME group had local recurrences(p=0.1). There were no cases of distant metastasis in both groups. Disease-free 3-year survival after TEM(92±3%) and TME(96±2%) was comparable(p=0.058).

Conclusion: TEM is comparable to TME in the treatment for early cancer in terms of complication rate and disease-free survival.

Aim

Enlarged lateral lymph nodes (LLNs) result in an increased lateral local recurrence (LLR) and lowered cancer-specific survival (CSS) rates. This study investigated the relationship between various LLN compartments and the related oncological outcomes.

 Method

This multicentre retrospective cohort study included 1216 patients with distal cT3/T4 rectal cancer without synchronous distant metastases. 741 restaging MRI-scans were reassessed and correlated to patients’ long-term oncological response. 

 Results

Multivariate analysis demonstrated that for internal iliac LLNs, pre-(chemo)radiotherapy (CRT) short-axis (SA) ≥7mm and post CRT SA of >4mm was a significant predictor for LLR compared to post-SA ≤4mm (p<0.001). Obturator LLNs with a post-SA >6mm were associated with a higher 5-year distant metastasis (DM) rate (p=0.015) and lowered CSS (p=0.002) for patients without a LLND; this difference disappeared in patients after LLND. cT-stage (p=0.033) and margin-involvement (p=0.021) were independent risk factors for metastatic disease.

 Conclusion

While enlarged internal iliac LLNs are associated with increased LLR rate, enlarged obturator LLNs are related to more advanced disease, worse 5-year DM- and CSS rates. Furthermore, LLND improves local control but seems not to impact DM. The next step is the prospective LaNoReC study; ensuring standardised CRT for LLN compartments and offering selective LLND.

AIM                                                     

Anaemia is present in 30-67% of patients with colorectal cancer(1). Correcting preoperative iron-deficiency anaemia (PIDA) can reduce the need for blood transfusion and potentially reduce hospital stay in patients undergoing major abdominal surgery(2). The aim of this study was to assess the presence and management of PIDA in patients undergoing colorectal cancer surgery.  

Method

Retrospective data was collected from patients undergoing colorectal cancer surgery to analyse perioperative haemoglobin and iron infusion rates, length of hospital stay and need for blood transfusion. Haemoglobin <130g/L was classed as anaemic.

Results

A total of 98 patients (61 male, 38 female) with a  median age of 70 years (37–91 years range) were included. Mean preoperative haemoglobin was 128g/L. Fourty three patients were anaemic with mean haemoglobin of 107g/L: 32/43 (74%) had haematinics included in their work up and 19/43 (44%) received iron infusion pre-operatively. Mean post operative day three haemoglobin was 116g/L in non-anaemic and 99g/L in  anaemic patients. Length of stay was 11.3 days in non-anaemic and 11.9 days in anaemic patients. Nine patients required blood transfusion, 5/9 had received pre-operative iron infusion.

Conclusion

PIDA is not being identified and managed adequately. An introduction of pre-operative anaemia pathway can help improve outcomes. 

Aim: There is lack of evidence regarding the patterns of failure and outcomes after margin positive resections in rectal cancer. 

Method: Retrospective analysis of the 1800 consecutive rectal resections done at a single centre from 2010 to 2018 was done. Patients who had positive pathological circumferential resection margin (pCRM) were analysed. 

Results: 105 patients with positive pCRM were identified, of which 86 were included in analysis. 84(95.3%) were operated after preoperative radiation and only 4(4.7%) patients were operated upfront. 83(96.5%) received only chemotherapy with only 2 patients receiving adjuvant chemoradiation and 1 undergoing revision surgery. Of these, 53 patients (61.6%) had recurrence with majority 29 (54.7%) having systemic relapse followed by locoregional relapse in 16 (30.2%). Of patients with locoregional relapse, only 3 could be salvaged with surgery and 1 received radiation. All of the 4 patients had systemic relapse. The median progression free survival till the subsequent recurrence was 7 months. Systemic relapse was identified mostly by asymptomatic rise of CEA levels (41.4%) while peritoneal recurrences were more often symptomatic (83.3%). Median follow up was 25 months. 2 year OS was 82.4% and DFS was 74%. 

Conclusion: Inherent aggressive disease biology drives the survival in this cohort. Intensified systemic therapy could improve the survival outcomes. 

Background: After local excision of early rectal cancer, clinical dilemmas arise when balancing risks of recurrence and treatment related morbidity. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT).

Methods: A search was conducted in PubMed, Embase and the Cochrane Library. Primary outcome was local recurrence (LR). Statistical analysis included weighted average of proportions. 

Results: Of 76 included observational cohort studies, 62 evaluated NAT, 13 cTME, and 28 aCRT. The included studies comprised 4.793 patients. The LR rate for high-risk pT1 tumors was 13.6%(95% CI 8.0-22.0) for local excision only, 4.1%(95% CI 1.7-9.4) for cTME, and 3.9%(95% CI 2.0-7.5) for aCRT. The LR rate for pT2 tumors was 28.9%(95% CI 22.3-36.4) after NAT, 4.3%(95% CI 1.4-12.5) after cTME and 14.7%(95% CI 11.2-19.0) after aCRT.

Conclusion:  Substantial risk of local recurrence has been reported for NAT, especially for high-risk pT1 and pT2 rectal cancer. Completion TME provides the lowest risk. The alternative, aCRT, showed comparable outcomes with cTME in high-risk pT1 tumors, but a higher risk in pT2 tumors. These outcomes may facilitate shared decision-making in these patients.

Aim: Defunctioning stoma is recommended after TME to decrease the severity of anastomotic leakage (AL). However, stoma itself can lead to complications. Whether the advantages of a diverting stoma outweigh the disadvantages is debated. 

Method: From 2018 to 2020, consecutive patients who underwent TME were prospectively included in a phase II trial assessing the feasibility of a tailored policy in the use of defunctioning stoma according to an AL risk stratification score. From this score, two appropriate reduction strategies have been combined : No Stoma Policy (NSP) and Early-Stoma Closure Policy (ESCP) depending on postoperative outcomes in low- and high-risk patients, respectively. Rates of stoma, AL and functional outcomes were assessed.

Results: Among 122 patients, colorectal (CRA) and coloanal (CAA) anastomosis were performed in 72 and 50 patients with 48 NSP, 23 ESCP and 51 conventional stoma closure (CSC) at 2 months. At 3 months, the rate of pelvic sepsis was 22% (27/122), 6% in NSP (3/48), 7% in ESCP (2/23) and 43% in CSC (22/51). Patients with NSP had a significant better LARS at 6 months (p=0.027).

Conclusion: Tailored policy in the use of defunctionning stoma after TME avoids stoma in 58%, is safe and provides better functional outcomes.

Aim: To investigate the epidemiology of the main subtypes of small intestinal (SI) cancer – duodenal adenocarcinoma (D-AC), duodenal neuroendocrine tumour (D-NET), jejunoileal adenocarcinoma (J/I-AC), and jejunoileal neuroendocrine tumour (J/I-NET).

Method: All patients with SI-cancer 1960–2015 were identified from the Swedish Cancer Register. Age-adjusted incidence rate (IR) with incidence rate ratios (IRR) as well as overall (OS) and net (NS) survival were calculated.

Results: Diagnosis at autopsy became less common over time while clinical diagnoses increased significantly for all four subtypes. IR was highest for J/I-NET with 9.98 clinical diagnoses per million in 2010–2015. Clinical diagnosis of D-AC increased 10-fold and surpassed J/I-AC as the second most common subtype. D-NET was by far least frequent. All subtypes except J/I-AC affected men more often. The age-distribution was similar between subtypes although AC patients were slightly older.

Survival was generally much better for patients with NET compared to AC. Both OS and NS were negatively associated with advancing age. Survival improved only for J/I-NET from 5-year NS 0.69 in the 1960s to 0.81 in 2010–2015.

Conclusion: The incidence of SI-cancer is increasing, particularly D-AC and in the elderly. Survival in SI-cancer has improved only for J/I-NET over the last decades.

Aim: Colorectal cancer (CRC) screening reduces CRC-specific mortality and has been associated with incidence rate reductions in the US population. This study aimed to determine temporal incidence trends in CRC among screening-age adults in England following the introduction of the Bowel Cancer Screening Programme in 2006.

Method: All patients aged 60-74 years diagnosed with CRC from 1974-2015 were identified from the National Cancer Registration and Analysis Service. Age-specific incidence rates were calculated for 60-64, 65-69 and 70-74 years age-groups and age-standardised rates for the entire cohort. Trends were analysed using Joinpoint regression with stratification by gender, anatomical location and deprivation quintile. 

Results: There were 473,190 new diagnoses of CRC. Following a steady increase from the mid-1970s onwards, significant incidence rate reductions were noted after 2008 in all age groups: 60-64 years (Annual Percentage Change (APC)=-1.96%), 65-69 years (APC=-5.7%) and 70-74 years (APC=-5.3%). The most pronounced reduction in incidence occurred in distal tumours (APC=-4.6%). Comparable incidence rate reductions were noted between both genders and across all deprivation quintiles.

Conclusion: The introduction of screening has been followed by a reduction in CRC incidence in the English population, which is most pronounced among adults at the upper end of the screening-age spectrum and in distal tumours.

Aim: Studies from Australia and the USA suggest a rising incidence of colorectal cancer (CRC) in younger people. Our aim was to examine early onset CRC in our unit in order to develop modified protocols targeted to this group. 

Method: CRC patients aged 50 and under were analysed from a database of over 930 patients diagnosed in our unit from 2013–2019. Patients with known heritable syndromes were excluded. 

Results: CRC in patients under 50 years rose from 2% in 2013 to 11% in 2019 (7% of all CRC). 33% of tumours were staged T4 at diagnosis with an overall mortality of 22% within 2 years of diagnosis (mode: 10 months). 23% of early onset CRC patients had rectal cancer, 47% had left sided colon cancers and 30% had cancer of the right colon. 

Conclusion: Sporadic CRC in younger people (<50 years) appears to be rising by as much as 1.5% per annum. Younger patients tend to present with more advanced cancers which may be more aggressive, leading to high mortality. The socio-economic impact of cancer in this young cohort is particularly devastating. We suggest this patient group requires modified diagnostic, treatment and surveillance protocols to improve survival.

Aim

Transanal total mesorectal excision has been suggested for resection of rectal cancer. Recently, concern has risen because of an increase in local recurrence in the implementation phase. This external audit of consecutive series of TaTME from inception in six centres in the Netherlands aims to assess the local recurrence rate in relation to experience. 

Methods

Kaplan-Meier estimated local recurrence rates and multivariate cox proportional hazard regression to assess risk factors were calculated. Primary outcome was the local recurrence rate in the initial implementation (case 1-10), continued adoption (11-40) and prolonged experience phase (41-onward).

Results

Six hundred twenty-four consecutive patients underwent a TaTME procedure for rectal cancer with a median follow up of 27 months (range 1-82). The estimated three years LR-rate was 6.6%. Cox-PH regression revealed procedural experience as an independent factor in multivariate analysis next to advanced stage (yc MRF+, pT, pN) and pelvic sepsis. Corrected analysis projected the three years LR-rate to be 9.7%, 3.3% and 3.5% for the predefined cohorts respectively.

Conclusion

This multicentre study shows a high local recurrence rate directly after implementation of TaTME which lowers to an acceptable rate when experience increases. Therefore, precautions must be implemented to reduce the unacceptable high risk at LR for units starting this technique. 

Aim: analyze the impact of R1-resections on prognosis and identify factor associated with survival.

Methods: A retrospective observational study was performed on a prospectively maintained database (2005-2017). All consecutive 135 patients with R1 specimens after resection were included and separated into 3 groups: circumferential resection margin≤1mm (CRM) due to tumor (T-CRM), involved nodes (N-CRM), or due to invasion of the distal margin (D-RM). OS, DFS, local and distant recurrences (LR and DR) were analyzed.

Results: 95 patients had low rectal tumors (70.4%). A T-CRM, N-CRM and D-RM was seen in 103 (76.3%), 42 (31.1%) and 19 (14.1%) patients respectively. 25 (18.5%) patients had >1 positive margin. At 3 years, OS was 79% [72-87], DFS was 44% [36-54], LR was 9% [4-15] and DR was 42% [33-51]. No difference was found in OS or DFS when T-CRM and N-CRM were compared (p=0.481 and p=0.4243). In multivariate analysis, adjuvant FOLFOX was associated with a better OS (HR=0.36 [0.17-0.76]). >1 positive margin was associated with a worse DFS (HR=1.99 [1.14-3.46]).

Conclusions: Impaired prognosis is encountered in patients with R1 rectal resections, especially when >1 margin is positive. Distant recurrences are 4 times more common than local recurrences. Adjuvant treatment with FOLFOX appears to improve OS.

Aim 

To compare the peri &postoperative outcomes following rectal neoplasm excision carried out by TEMS &/or TAMIS, whereby the defect is either sutured or left open

Method

A literature search of Ovid MEDLINE & EMBASE was performed. Full-text comparative studies published until November 2019, in English & of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms, were included. The main outcome measures were postoperative bleeding, infection, operative time & hospital stay.

Results

Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group & 272 in the open group). The incidence of postoperative bleeding was higher & statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured & open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67).

Conclusion

Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection & length of hospital stay were compared.

AIM: There is no consensus on the appropriate extent of oncological resection for tumours of the transverse colon. Concerns regarding tumour factors such as pattern of lymph node spread and technical factors such as anastomotic perfusion lead to a variety of procedures being performed.

METHODS: A comprehensive search for published studies examining outcomes following segmental versus extended colectomy for transverse colon tumours was performed adhering to PRISMA guidelines. 

RESULTS: Seven comparative series examining outcomes in 3,395 patients were identified. Segmental colectomy has shorter operating times (mean difference 15.80 minutes, 95% CI: -20.98 - -10.62, p<0.001) and less ileus (OR: 0.52, 95% CI: 0.33-0.81, p=0.004). There was no difference length of hospital stay (mean difference 1.53 days, 95% CI: -3.79 – 0.73, p=0.18). Extended colectomy had a lower rate of anastomotic leak (OR: 0.62, 95% CI: 0.40-0.97, p=0.04). There are less nodes retrieved in segmental colectomy (mean difference 7.60 nodes) but no difference in recurrence (OR: 0.88, 95% CI: 0.59 – 1.34, p=0.56) or overall survival (OR: 0.98, 95% CI: 0.68-1.4, p=0.9).

CONCLUSIONS: Segmental resection for transverse colon tumours is associated with less ileus but lower lymph node yields and higher leak rates. Length of stay is similar. Oncological outcomes are equivalent.

Aim: Current literature on the impact of body composition on prognosis of surgical patients still provide controversial results. The aim of this study was to evaluate the association between CT-derived body composition and long-term outcomes in colorectal cancer (CRC) patients.

Method: Pre-operative CT was available for 476 of the 799 patients who underwent surgery for stage I-III CRC between 2010 and 2017. Visceral adipose tissue area and indexed skeletal muscle area were quantified to define visceral obesity (VO) and sarcopenia, respectively.

Results: Of the 476 patients, only 13% were obese according to BMI, while 71.4% were VO and 25.9% sarcopenic. VO and sarcopenia were associated with older age at diagnosis (p<0.001), increased number of comorbidities (p=0.001) and greater Charlson Comorbidity Index (p=0.001). No differences were found in terms of pathological characteristics or surgical outcomes. Sarcopenia but not visceral obesity was associated with poorer overall survival (OS, p=0.001) and cancer-related survival (CRS, p=0.009). On multivariable analysis, sarcopenia confirmed its role as an independent predictor of OS (HR 2.28, p=0.025) and CRS (HR 3-07, p=0.036).

Conclusion: Visceral obesity does not seem to affect long-term outcomes of patients with CRC, while sarcopenia presents a negative prognostic impact on both OS and CRS.

Aim

The detection of complex colonic polyps is increasing. Size or access difficulties may restrict endoscopic removal even by expert therapeutic colonoscopists. Laparoscopic Assisted Polypectomy (LAP) may facilitate lesion removal and avoid colonic resection. Our aim was to assess outcomes of complex colonic polyps managed by LAP.

Method

A retrospective review was performed of all LAP procedures between September 2008 and October 2018. Prospective management decisions for LAP’s were made in conjunction with a Complex Polyp Multi-Disciplinary Team. 

Results

There were 55 patients treated with LAP. Median polyp size was 37.5mm with the majority (50.9%) in the caecum. Intraoperative conversion rate to bowel resection was 12.7%. Four patients (7.3%) had postoperative complications and the median length of stay was 1 day. Malignancy was histologically confirmed in 6 polyps (10.9%) of which 3 (5.5%) were unexpected. These three patients returned for uncomplicated laparoscopic bowel resections. Residual or recurrent disease occurred in 15.9% over a median follow up of 76 months. All were successfully treated endoscopically.

Conclusion

LAP avoided bowel resection in 80% of patients selected for this procedure. This technique provides a safe option with good outcomes for complex polyps where colonoscopic intervention alone is unfeasible.

Aim:  Accurate clinical diagnosis of lymph node metastases is paramount in the treatment of patients with abdominopelvic malignancy. This review assesses the diagnostic performance of deep-learning algorithms and radiomics models for lymph node metastases in abdominopelvic malignancies.

Method: The Embase, PubMed, Science Direct and IEEE Xplore databases were searched to identify eligible studies published between Jan 2009 and March 2019. Studies that reported on the accuracy of deep-learning algorithms and radiomics models for abdominopelvic malignancy by CT/MRI were selected. Estimates were pooled using random-effects meta-analysis. 

Results:  In total, 498 potentially eligible studies were identified, of which 21 were included and 17 offered enough information for a quantitative analysis. The single published deep-learning model out-performed radiomics models with a higher AUROC (0.912 vs 0.895), but both radiomics and deep-learning models outperformed the radiologist’s interpretation in isolation (0.774). Pooled results for radiomics nomograms amongst tumour subtypes demonstrated the highest AUC 0.895 (95%CI, 0.810 - 0.980) for urological malignancy, and the lowest AUC 0.798 (95%CI, 0.744 - 0.852) for colorectal malignancy.

Conclusion: Radiomics models improve the diagnostic accuracy of lymph node staging for abdominopelvic malignancies in comparison with radiologist’s assessment. Deep-learning models may further improve on this, but data remain limited.

Aim: Several studies have revealed that anastomotic leakage and resulting peritoneal infection are associated to higher recurrence rates after colorectal cancer surgery. Our hypothesis suggests that the response of residual tumor cells to the inflammation activates tumor progression and therefore recurrence. The aim was to identify differentially expressed genes by the effect of peritoneal infection, settling gene expression profiles associated to the risk of recurrence.

Method: Paired cohort study comparing patients with intra-abdominal infection after colorectal cancer surgery against patients without complications. The colorectal cancer cell line HT-29 was treated with postoperative plasma samples. The analysis was performed using the Human Gene 2.0 ST array of Affymetrix.

Results: The analysis of gene expression showed a large heterogeneity. Overexpressed (≥ 1.7 times) or inhibited (≤ 0.7) genes were identified in at least half of the patients, some of them involved in tumor progression mechanisms. This variability is consistent with a sizeable dispersion in blood cytokine expression patterns analyzed in similar cohorts.

Conclusion: The response of tumor cells to the inflammation associated to the risk of recurrence is complex and heterogeneous. The analysis of gene expression in addition to the study of other biomarkers could allow us to determine gene patterns of recurrence.

Aim: Guidance from the 2018 NHS Bowel Cancer Screening Programme (NHSBCSP) recommends histopathological reporting of key-variables for T1 colorectal polyp cancers following polypectomy. However, polyps detected and removed outside of the NHSBCSP (non-NHSBCSP polyps) are typically not reported to a similar standard and may have impact on clinical decision-making. This project aims to audit the reporting of non-NHSBCSP polyps using the gold standard NHSBCSP key-variables.

Method: 14 histopathological variables from the 2018 NHSBCSP guidelines were highlighted as key-variables to be reported. Histopathological reports for non-NHSBCSP T1 colorectal cancer polyps post-polypectomy in 2019 were identified and examined to determine inclusion of key-variables.

Results: In 2019, 14 non-NHSBCSP T1 polyps following polypectomy were identified. This created a potential 196 data points to be filled (14 reports x 14 key-variables). 136/196 (69.4%) were filled. Only 5 variables were reported 100%. Amongst others, lymphatic invasion (57%), venous invasion (71%), perineural invasion (36%), extent of local invasion (57%) and presence of a precursor lesion (7%) were incompletely recorded.

Conclusion: There is a lack of consistency in the histopathological reporting of T1 colorectal polyps. Local invasion is important to estimate local lymph node involvement. Lack of this information has the potential to impact clinical decisions due to the lack of important risk stratifying information.

Aim: The Coronavirus-19 pandemic caused the cessation of diagnostic testing for colorectal cancer. We aimed to create a novel COVID-adapted pathway at our unit to mitigate risk and maximise cancer diagnosis in patients referred with symptoms of suspected colorectal cancer.

Methods: Our “COVID-adapted pathway” integrated multiple quantitative faecal immunological tests (qFIT), to enrich for significant colorectal disease, with plain CT with prolonged oral contrast to detect gross pathology. Data was collected on presenting symptoms, blood, qFIT and CT results between 1^st April and 31^st May 2020.

Results: The total number of referrals decreased from 1140 during the same time period in 2019 to 609 during the pandemic. 422 patients (median age 64years, 220 females) were included.  Most (84.6%) were referred as ‘urgent suspicious of cancer’, with an additional 65 patients upgraded from the urgent and routine categories. We detected 13 cancers (3.1%). This was on par with a 3.2% cancer detection rate from all referrals the previous year.

Conclusion: The coronavirus pandemic led to a marked decrease in referrals and cessation of key diagnostic services. Despite this we managed to create a pathway which has captured the expected number of cancer diagnosed through the use of qFIT and plain CT.

AIM: ERAS protocols have proven to reduce morbidity and shorten recovery in patients undergoing colorectal resections. However, patients presenting more advanced disease, such as T4 cancers, are frequently excluded from ERAS protocols. Aim of this investigation was to evaluate the postoperative outcomes after application of ERAS protocol in patients undergoing surgery for T4 colorectal cancer.

METHODS: All patients with a clinical diagnosis of stage T4 colorectal cancer undergoing surgery between January 2016 to January 2020 were prospectively enrolled in the ERAS group and treated following our standard fast track protocol without exclusion. Short postoperative outcomes were compared to a control group treated with conventional care that underwent surgical resection for T4 colorectal cancer at the same center from January 2010 to December  2015. 

RESULTS:82 patients were included in the analysis of the results. Both the mean time of tollerance to a solid food diet and postoperative length of stay were significantly shorter in the ERAS group than in the comparative group (3.14±1,76 vs 4.8±1.52; p<0,0001 and 6,93±3,76 vs 9,50±4,83;p=0,0084 rispectively).

CONCLUSION : To our knowledge this is the first study analizing the feasibility of ERAS in T4 cancer patients undergoing colorectal resections. Given the results, it seems that ERAS can enhance postoperative recovery in T4 colorectal patients.

Aim: We explored the role of polypectomy and trans-anal endoscopic microsurgery (TEM/TAMIS) in patients with early rectal cancer and considered these outcomes alongside conventional major surgery, total mesorectal excision (TME).

Methods: All patients with early stage rectal cancer at our institution between 2010-2019 were included. Long-term outcomes in terms of local recurrence, survival and procedure specific morbidity were analysed. 

Results: In total, 536 patients with rectal cancer were identified, of which 112 were included being node negative early rectal cancer. Amongst these, 30 patients (27%) had polypectomy, 67(60%) TEM/TAMIS and 15(13%) TME. There were no differences in patient demographics between the three groups except for TEM/TAMIS patients being more likely to be referred from another hospital (p<0.001) and they were less active (WHO performance status p=0.04). There were no significant differences in overall survival rates and cancer specific survival between the three treatment groups. The 5-year overall survival rate for polypectomy, TEM/TAMIS or TME was 96% versus 90% and 88% respectively, (p=0.89). The 5- year cancer specific survival rate was 96%, versus 96% and 100%, respectively (p=0.74).

Conclusion: Polypectomy is an appropriate local treatment for early stage rectal cancer in selected patients. Good oncological outcomes similar to TEM/TAMIS and TME can be achieved.

Introduction

The NOSES technique allows one to remove specimen without incisions on the anterior abdominal wall and is accompanied by fewer complications by reducing the frequency of wound infections.

Materials and methods

A systematic review is carried out in accordance with PRISMA practice and recommendations.

Results

Nine comparative studies were selected from 2014 to 2019. We included 1693 patients in meta-analysis: 765 (45%) specimen was removed transanaly (NOSES) and 928 (55%) it was removed minilaparotomy (LA). The tumor size in the NOSES was smaller than in the LA group (OR=0.5, CI95% 0.2-0.8, p=0.0004). Operation time NOSES and LA were comparable (p =0.11). VAS pain was on average 2 points (OR=1.8, CI95% 1.2-2.4, p<0.00001) more pronounced in the LA. The postoperative hospital stay was less in the NOSES (OR=0.8, CI95% 0.4-1.3, p=0.0003). Morbidity after NOSES was less (OR=0.5, CI95% 0.4-0.8, p=0.0004). Wound infection was higher in the LA (OR=0.2, CI95% 0.1-0.3, p <0.00001). There were no differences in the incidence of colorectal anastomotic leakage (p=0.97, 5-year overall (p=0.74) and cancer-specific survival (p=0.76).

Conclusion

NOSES is the safe procedure and makes better conditions for the rehabilitation of the patients with rectal cancer.

Aim: to identify risk factors independently associated with anastomosis leakage (AL) of stapled colorectal anastomosis and create nomogram to determine the risk of AL before surgery.

Method: Four hundred twenty-nine consecutive patients underwent potential curative surgery for rectal cancer with stapled colorectal anastomosis at the State Scientific Centre of coloproctology, Moscow, Russia, between November 2017 and August 2019. Fluorescence angiography with indocyanine-green (ICG) used to assess the perfusion of the anastomosis in 239 patients. Risk factors of AL were identified by multivariate logistic regression analysis and used to create a nomogram.

Results: Inadequate blood supply to the sites of anastomosis according to fluorescence angiography with ICG and changes of transection line occurred in 50/239 (20.9%) cases. An anastomotic leakage was observed in 52/429 patients (12.1%). In multivariate analysis independent variables associated with AL: male sex, low anastomosis ≤6.5 cm and age ≤62.5 years. Fluorescence angiography with ICG was found as independent factor of prophylaxis of AL (OR 0.4, 95% CI: 0.2−0.8, p=0.02). These factors were included in the nomogram. The concordance index this nomogram was 0.81, that indicating well predictive ability.

Conclusion: Fluorescence angiography with ICG is a modified surgery-related factor and method of preventing of colorectal anastomosis leakage.

AIM: The role of preoperative radiation in upper rectal cancer is still under debate and current literature increasingly advices against its use. This study aimed to use meta-analytical methods to compare oncological outcomes of non-irradiated upper rectum tumours to rectosigmoid and sigmoid tumours.

METHODS: Meta-analysis was performed according to PRISMA criteria. Systematic search was done on studies comparing upper rectum to rectosigmoid and sigmoid cancers. Patients receiving neoadjuvant treatment were excluded. 

RESULTS: Seven comparative series examining outcomes in 3,942 patients were identified. There were significantly more T3/T4 tumours in the upper rectum group (OR, 1.38; 95% CI, 1.07-1.78; P = 0.01). There was no significant difference in ASA grade and lymph node positivity. Local recurrence rate was similar, however rectosigmoid and sigmoid cancers had a lower rate of total (OR, 0.76; 95% CI, 0.62-0.94; P = 0.01) and distant recurrences (OR, 0.76; 95% CI, 0.61-0.93; P = 0.009). 

CONCLUSIONS: Current evidence is not strong due to the lack of randomized controlled trials. Non-irradiated upper rectal cancers have similar local recurrence rates, but with more distant recurrences compared to rectosigmoid and sigmoid cancers.

Aim:

Recent publications regarding transanal TME performed by surgeons within their learning curve show high local recurrence rates, leading to cessation of further implementation of the technique in Norway. As evidence regarding local recurrence rates in the initial cases of robot-assisted TME is limited, this study aims to describe local recurrence rates in three Dutch centres during their initial fifty cases. 

Method:

A retrospective data analysis of the initial fifty robot-assisted TME was performed in three large Dutch centres. Baseline characteristics, overall survival, disease free survival, systemic recurrence and local recurrence were assessed at 3 years postoperatively. 

Results:

In each centre 50 patients were included since the introduction of the technique, resulting in 150 patients. Median follow up time was 43 months (IQR: 17-61]. Overall survival at 3 years was 87.1% (95%CI: 81.3%-93.3%), disease-free survival was 81.3% at 3 years (95% CI: 74.9%-88.3%), systemic recurrence was 17.7% (CI: 10.9%-23.9%) at 3 years, and local recurrence at 3 years was 3.5% (CI: 0%-6.9%). No multifocal recurrence was found.  

Conclusion:

Local recurrence rates during the initial 50 robot-assisted TME procedures appears to be low. Implementing robot-assisted TME can safely be performed, without additional cases of local recurrence during the learning curve.

Background: The faecal immunochemical test (FIT) can measure occult blood invstool and may exclude bowel cancer without need for a colonoscopy. This study investigated the diagnostic accuracy of FIT in patients with high-risk symptoms meeting NICE NG12 criteria.

Methods: Patients were eligible for recruitment if they experienced bowel symptoms meeting NICE referral criteria, and had been triaged to investigation with colonoscopy. Colonoscopy and FIT results were compared while double-blinded. Quality assurance of endoscopy and clinical data was performed by senior clinicians. External statisticians analysed anonymised data. This trial is registered on isrctn.com, ISRCTN49676259.

Findings: 9822 patients from 50 sites participated in the study, of whom 6900 (71.3%) had high-risk symptoms. The diagnoses found at colonoscopy included no disease (31%), colorectal cancer (3.3%), HRA (4.2%) and IBD (6.1%). At FIT cut-offs of 2 and 10 µg/g, referral for investigation of high-risk symptoms would be reduced by 60.7% or 79.3%. The colorectal cancer detection rate (sensitivity) was 98.4% and 92.8% at cut-offs of 2 or 10 µg/g in patients, compared to 91.5% and 84.5% in patients with low-risk symptoms.

Conclusion: FIT is an objective diagnostic tool that could guide referral and investigation of patients with high-risk bowel symptoms.

Aim: To review current evidence on neo-adjuvant chemotherapy (NACTx) only for locally advanced rectal cancer (LARC).

Methods: Twenty-four studies were identified reporting on short/long-term outcomes of NACTx for LARC. Twenty-two studies were prospective series, and two comparative. Comparative studies included a randomized-control trial (RCT) comparing NA-CTx with NA-CRT and with the combination of NA-CTx/NA-CRT, and a non-randomised study comparing NACTx to NA-CRT. Chemotherapeutic regimens were mainly 5-fluoropyrimidine and oxaliplatin-based. Rarely irinotecan or/and bevacizumab were added. 

Results: NACTx is associated with a mean anastomotic leak rate of 6.8%. In the RCT, morbidity and overall toxicity were significantly less in the NACTx group. Mean T-downstaging was 50.1%, mean N-downstaging 69.0% and mean pathologic complete response (pCR) 10.9%. The RCT showed an inferior pCR rate after NACTx than after NA-CRT, but similar rates of T downstaging. Mean LR was 8.7% and mean distant recurrence 17.9%. Satisfactory survival rates are reported by several studies.

Conclusions: NACTx seems to be an alternative to NA-CRT for patients with LARC, associated with low anastomotic leak, adequate tumour downstaging, low LR and rather high survival rates. Further data deriving from high quality studies are necessary to assess safety and efficacy of NACTx as a substitute to NA-CRT.

Aim: In early rectal cancer organ sparing treatment strategies, such as local excision have gained a more prominent position. The necessity of completion surgery is based on histopathological evaluation of risk factors. This study aimed to describe interobserver variability between pathologists and its potential impact on treatment allocation in patients with locally excised early rectal cancer. 

Methods: A prospective cohort study of TESAR trial patients was conducted(NCT02371304). Patients with either high-risk pT1 tumors or low-risk pT2 tumors were included. Both quantitative measures and histopathological risk factors were evaluated. Interobserver variability was reported by percentages and Cohen’s Kappa or intra-class coefficients. 

Results: A total of 127 patients were included. Forty-seven percent of original histopathological reports were incomplete. In 52% of the patients at least one inconsistency was reported. Interobserver agreement varied from 24%-96% or ĸ 0.154-0.951. Lymphovascular invasion and tumor budding showed agreement of 75%(ĸ=0.557) and 60%(ĸ=0.154), respectively. In almost 10% of the patients inconsistencies potentially led to a different treatment strategy. 

Conclusion: This study showed substantial interobserver variability between pathologists. Pathologists play a key role in treatment allocation in early rectal cancer and interobserver variability needs to be reduced to decrease the percentage of patients who are over- or undertreated.

Aim:

Undergoing major cancer surgery is an important decision for patients. This study assessed the effectiveness of decision-making following colorectal and oesophageal cancer surgery.

Methods

Patients who had undergone colorectal and oesophageal cancer surgery in two UK centres over two years were identified. Validated patient reported outcomes (PROs) were collected by cross sectional survey including perceived confidence in decision-making and effectiveness of risk communication (COMRADE scale), decision regret (Decisional Conflict Score; DCS), and quality of life (EORTC QLQ-PAL15). Uni- and multivariable linear regression was used to explore the relationship between PRO scores and clinical and sociodemographic variables.

Results

Some 143/244 (58%) patients returned the questionnaire. Overall, decision regret was low (median 7.81, range 0-23.4), and perceived confidence in decision-making and effectiveness of risk communication was good (median 5 (0-25) and 15 (0-25) respectively).  Higher education level was associated with reduced regret  (-0.7; CI -1.2 to -0.1;p=0.016) and a longer length of hospital stay was associated with higher regret (1;CI 0.2-1.9;p=0.014 respectively).

Conclusion

Patients perceived decision-making to be effective in this study, but those with adverse outcomes may benefit from further support

Aim: This study compares the clinical outcomes of locally advanced distal rectal cancer (LARDC) patients managed with non-operative management (NOM) following complete clinical response (cCR) and total mesorectal excision (TME) patients with pathological complete response (pCR), following neoadjuvant therapy.

Methods: All LADRC patients with cCR after neoadjuvant therapy, who were treated with NOM or      pCR after TME were enrolled into the retrospective study. The patients were analyzed primarily for local regrowth and distant metastasis and survival status.

Results: The patients in the NOM group (n=49) compared with the patients in the pCR group (n=41) revealed no differences regarding age, comorbidities, initial stage, and distance to the anal verge (p>0.05). Ten (20,41%) patients with local regrowth in the NOM group were detected on surveillance and treated with salvage surgery. Pelvic control after salvage surgery was maintained in nine patients (90%). No pelvic recurrences occurred in the pCR group, but two (5,6%) patients had distant metastasis and underwent metastasectomy. At three years, the pCR group had improved disease-free survival rates (92,68% vs 79,59%, p= 0,034), although no difference in overall survival (OS) was observed between the two groups (100% vs 97,95%, p=0,248).

Conclusion: In selected LADRC patients NOM is a promising treatment option compared to standard trimodal treatment. 

Aim: We hypothesise that biomarkers of colorectal cancer (CRC) risk can be found through molecular analysis of colorectal adenomas and there is a key role for copy number alterations (CNA).

Method: FFPE adenoma tissue from patients who subsequently developed CRC (progressors) and matched adenomas from patients who remained cancer-free for 5+ years from the date of polypectomy (non-progressors) from a single-centre hospital archive (2008-2014) were analysed using low-pass whole genome sequencing (LP-WGS), depth of >0.1x (Illumina platform) to investigate CNA burden.

Results: In this case-control study, progressors n=12 have a greater CNA burden than non-progressors n=37, with >0.05% of the genome altered in progressors and <0.01% in non-progressors, p=0.292. The number of distinct copy-number segments were analysed to compare the presence of candidate CNAs; gains were seen in chromosomes 7, 9, 12 (>25%) and losses in 18 (>10%) in the progressors. In comparison, minimal chromosomal changes were seen in non-progressors.

Conclusion: Patients who progress to CRC have a greater percentage of the genome altered when compared to non-progressors, with the majority of non-progressors having little or no genomic alterations. In the future, it is conceivable that this cost-effective test could be used to more accurately define the cohort of patients who require follow-up surveillance. 

Aims

This study investigates whether a straight-to-test colorectal cancer pathway improves attainment of the NHS England 28-day Faster Diagnosis Standard. The effect of the pathway on clinic capacity, patient satisfaction and the safety of GP-led triage are evaluated. 

Methods

This is a prospective observational study of patients managed via a straight-to-test colorectal cancer pathway between 1^st September 2019 and 19^th March 2020, with comparison to patients referred on the colorectal cancer pathway prior to its implementation from 1^st January 2019 to 30^th July 2019. Patient satisfaction was assessed with a telephone-based questionnaire.  

Results

Attainment of the 28-day target for all colorectal cancer referrals improved following establishment of the straight-to-test pathway (88% vs 81.6%, p<0.0001). Of the 515 patients who attended their straight-to-test appointment, 494 (95.9%) achieved the 28-day target. From a potential total of 548 outpatient colorectal appointments for patients on the straight-to-test pathway, 504 (92%) were avoided. Of 50 patients who undertook the satisfaction survey, 86% were satisfied with the pathway. No patient suffered an adverse event due to the straight-to-test investigations.

Conclusion

A straight-to-test pathway for suspected colorectal cancer referrals safely improves attainment of the 28-day diagnosis target and increases outpatient clinic capacity, with high patient satisfaction. 

Aim: few data are published on oncologic outcome in patients with anastomotic leak in colon cancer. Our aim was to analyse the impact of anastomotic leak (AL) on long-term outcomes after colon cancer surgery.

Method: a literature search in Cochrane Library, Embase and PubMed databases was performed using keywords “colon cancer”, “colon leakage”, “anastomotic leak”, “mortality”, “survival”. In our systemic review we included studies evaluating oncologic impact of AL. Overall survival, disease free survival, cancer-specific survival, local recurrence and distant recurrence were the outcome measures. 

Results: ten studies matching inclusion criteria were found. AL after colon resection had no significant difference on distant recurrence comparing with group of non-leak. The results showed that AL caused worse overall survival, disease free survival, cancer-specific survival and increased local recurrence.

Conclusion: Our systematic review showed that AL might be a prognostic factor of worse long-term oncologic outcome in patients undergoing colonic resection.

Aim

Quantitative faecal immunochemical test (FIT) offers the opportunity to stratify symptomatic ‘high risk’ colorectal patients for further investigation. 

Method

FIT was introduced in primary care to stratify ‘high risk’ symptomatic patients aged 60 years and above with a change in bowel habit to determine whether an urgent straight to test (STT) CT colonography (CTC) was indicated. All FIT tests were analysed using the OC-Sensor platform. A result of >4 μgHb/gFaeces, was used as the cut-off. All FIT results were cross referenced with a prospectively maintained colorectal cancer registry to determine the colorectal cancer detection rate (CRC). Data was analysed from February 2018-August 2019.

Results

The mean number of total CTC performed per month pre-FIT was 307 (range 256-340) and reduced to 263 (range 212-320) post-implementation (p = 0.0041). The number referred under the STT pathway was 213 (range 161-248) reducing to 142 (range 111-183) (p = 0.0001), however there was a corresponding rise in the number of non-STT referrals from outpatients 87 (range 69-111) to 111 (range 86-152) (p = 0.0127).

Conclusion

FIT has the potential to reduce the burden on secondary care investigations to exclude bowel cancer. Our experience has shown that a conservative FIT level of <4ug/ml has reduced numbers of STT referrals by 25%.

AIM

The aim of the study is to compare short term complications associated to intracorporeal (IA) versus extracorporeal anastomosis (EA) for minimal invasive right hemicolectomy (MIRHC).

METHOD

A retrospective study, with prospective recorded data was carried out from January 2017 to December 2019, including all patients operated with MIRHC due to neoplastic disease. Patients coverted to open surgery were excluded. Primary outcome was global morbidity. Secondary outcomes were postoperative ileum, surgical site infections and anastomotic leakage.

RESULTS

189 patients were included, of which 102 had IA. Global morbidity was higher in patients with EA (23,5% vs. 40,2%, p=0,014) and they had more medical complications (5,9% vs. 14,9%, p=0,039). None of the patients with IA had surgical wound complications (SWC), compared to 4,6% in the EA goup (p=0,029). Anastomotic leakage (AL) showed no significant differences (9,8% vs. 10,3%, p=0,55). Patients with IA had fewer postoperative ileum, without reaching significative difference (10.8% vs 20.7%, p=0,06). Multivariant analysis showed more surgical complications for EA (p=0,04) with an OR = 4,2 (95% CI: 1,06 – 12,9).

CONCLUSION

IA lowers the risk for global, medical and surgical complications with minimum risk for SWC and without increasing risk of AL. Recovery of bowel function is faster after an IA.

Aim

Quantitative faecal immunochemical test (qFIT) is NICE recommended in symptomatic patients. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method

Referrals from July 2019 and December 2019 (before and after introduction of a new 2WW referral form) were reviewed. Patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results

Of 288 2WW referrals in July, 74 people were eligible for qFIT but only 7 of these underwent testing. In July overall, 93 qFIT were performed by GPs (11 positive tests with no cancers diagnosed).

Of 222 2WW referrals in December, 18 people were eligible for qFIT, all of these people were tested. Overall, 155 qFIT were performed by GPs (18 positive results with one patient who had a positive qFIT then diagnosed with a colorectal adenoma).

There was an increase in qFIT usage by GPs, which coincided with a reduction in 2WW referrals including a reduction in qFIT-eligible 2WW referrals.

Conclusion

This audit highlights the utility of qFIT in screening symptomatic 2WW referrals. Particularly at a time where access to investigations for 2WW pathway patients has been restricted by the coronavirus pandemic. 

Aim: Side-to-end anastomosis (STE) is recommended after total mesorectal excision (TME) for rectal cancer. Because of several cases of AL on colonic stump after STE, since December 2018, we performed systematically end-to-end anastomosis (ETE) for both stapled colorectal (CRA) and manual coloanal anastomosis (CAA). The aim of this study was to assess if this new strategy changes AL and chronic pelvic sepsis rates.

Methods: All consecutive patients undergoing TME for cancer were included, with special interest on type of anastomosis and AL rate and risk of chronic AL (more than 6 months after TME).

Results: From 2006 to 2019, 518 patients underwent laparoscopic TME for low (58%) or mid (42%) rectal cancer. AL rate was 23% (91/394) after STE versus 9% (5/58) after ETE (p=0.0005). After a mean follow up of 43 months, spontaneous healing of chronic AL after stoma reversal was noted in 11/15 ETE (73%) versus 20/68 (29%) after STE (p=0.0025). 

Conclusions: Recent change of our policy after laparoscopic TME with systematic ETE (for both CRA and CAA) lead us to observe a significant drop of AL rate from 23 to 9% and a higher rate of spontaneous healing of chronic leak of 73% versus 29% after STE.

Aim: Bowel preparation in elective colorectal surgery aims to reduce surgical site infection (SSI) and anastomotic complications. This study evaluates the outcomes in patients who underwent elective rectal surgery, comparing previously used mechanical preparation only versus a bowel preparation protocol including low waste diet, oral antibiotics and mechanical preparation.

Method: Retrospective, single-center cohort study of consecutive patients with rectal cancer who underwent surgery in 2017 and 2019 (pre and post implementation of the protocol). Distribution of variables and results were analyzed using Chi-square, Mann-Whitney and t-Student tests.

Results: 65 patients were included in the study (38 in pre-protocol group vs 27 in post-protocol group). Morbidity and mortality rate were lower in post-protocol group (48.1% vs 57.9%, and 0% vs 7.9%, respectively). Postoperative ileus rate was similar in groups. Dehiscence rate was lower in post-protocol group (9.1% vs 30.4%), with significance between groups when analyzing dehiscence rate needing surgical reintervention (p = 0.047). There were statistically significant differences in the SSI rate (3.7% post-protocol vs 28.9% pre-protocol, p = 0.010).

Conclusion: Patients undergoing elective rectal surgery in which bowel preparation protocol was applied had lower SSI and dehiscence needing reintervention rates, compared to patients with mechanical preparation only. There may be other factors involved in outcome differences.

Aim: 

We conducted a single centre retrospective analysis studying the quality of life of patients on neoadjuvant long course chemoradiotherapy followed by surgery versus the W+W pathway. 

Method:

58/508 patients were consented into W+W surveillance over 7 years. 80 patients were randomly selected from the surgical arm and matched based on time of cancer diagnosis. Quality of life was measured using 2 validated questionnaires – FACT-C and FIQOL.

Results: 

The W+W group showed statistically significant improved outcomes in physical, social, emotional and functional outcomes when compared against the surgical arm using FACT-C (W+W: 119.97+/-3.74, Surgery: 111.24 +/-5.4; p<0.01). In regard to faecal incontinence, patients in the W+W arm scored higher in lifestyle (W+W: 3.66+/-0.207, Surgical arm: 3.65+/-0.24; p>0.05) and depression/self-perception (W+W: 4.06+/- 0.13, Surgical arm: 3.92+/-0.22; p>0.05). However, had poorer outcomes when it came to coping with faecal incontinence and embarrassment but overall showed no statistical significant difference against the surgical arm.

Conclusion:

The W+W pathway can be considered in those with a complete clinical response to chemoradiotherapy as it provides a better quality of life for patients as shown with FACT-C with functional outcomes favouring the W+W arm. However, a prospective study is required to validate this study.

Aim: The Quantitative faecal immunochemical test (qFIT) has been introduced as a potential triage tool for patients with symptoms suspicious for colorectal cancer. Its predictive value for detecting cancer in this group was assessed.

Methods: All symptomatic patients referred to secondary care from November 2018 were invited to complete a qFIT in parallel to their triage outcome. Patients with a qFIT result >80µg/g had investigations expedited. qFIT results, patient demographics, and colonic investigations were prospectively collected and cross-checked with the cancer database.

Results: 4968 patients submitted qFITs: 3838 (77.3%) had a qFIT level <10µg/g , 857 (17.2%) between 10 and 399µg/g and 273 (5.5%) had levels >than 400µg/g. Of those that had a completed set of investigations; 68 (2.9%) patients had cancer and 90 (4.2%) had an advanced polyp.

At thresholds of 10 µg/g, the sensitivity of detecting cancer was 79.4% and for advanced polyps was 46.7%. The negative predictive value for cancer was 98.3% decreasing to 96.1% for advanced polyps at cut-off of 400µg/g. 

Conclusions: qFIT is useful to enrich for potentially serious colorectal pathology and aid timely investigation. As a "rule-out" test, an appreciable false negative rate for cancer (20.6%) and advanced neoplasia (53.3%) should be expected.

Aim: Displacement of urogenital organs after abdominoperineal resection (APR) is an understudied issue. The aim of this study was to develop a method for quantifying this phenomenon.

Method: Patients who underwent APR for primary or recurrent rectal cancer with an evaluable pre-operative and one year post-operative CT- or MRI-scan were included from four centers (2001 - 2018). Anatomical landmarks on sagittal images were related to a coordinate system based on reference lines between fixed bony structures. The primary endpoint was the absolute displacement of the bladder backwall in millimetres.

Results: There were 205 patients included: 141 men and 64 women. The absolute displacement of the bladder backwall for men was 32 (IQR 25-45) (range 1-97) with a median displacement on the X-axis of 26 (IQR 13-39) and on the Y-axis of -8 (IQR 2- -21), and for women 35 (IQR 24-48) (range 3-75), with a median displacement on the X-axis of 29 (IQR 16-4) and on the Y-axis of -4 (IQR 15- -16) (P = 0.514).

Conclusion: This is the first study addressing and quantifying displacement of urogenital organs after APR for rectal cancer. The observed substantial displacements indicate the need for further studies on functional implications and therapeutic strategies.

Aim

Pelvimetry is a tool not routinely used in rectal cancer surgical planning, although it is well-known that a narrow pelvis can be challenging during pelvic surgery. We want to evaluate if pelvimetry parameters influence circumferential resection margin (CRM) and mesorectal quality (MQ).

Method

We have studied pelvimetric parameters and pathological outcomes in 228 patients with rectal tumors (53.1% mid, 30.7% low) who underwent radical surgery between 2017 and 2019. Mean age was 68.4 (10.3) years and 61.4% were men. Neoadjuvant treatment was performed in 64.1%. 

Results

Sphincter-sparing surgery was performed in 66.7% of them. We found association between CRM+ and higher mesorectal area (p 0.005), smaller ratio between pelvic inlet/depth (p 0.027) and higher ratio between mesorectal area/pelvic area (p 0.002); regarding MQ, there was association between incomplete MQ and shorter promontory to S3 distance (p 0.05), higher S3 to coccyx distance (p 0.044), greater verticality of the levators (0.032) and smaller mid pelvis (p 0.006) and intertuberous diameter (p 0.028).

Conclusion

Pelvimetry is a useful tool to evaluate potential difficulties during rectal surgery that can influence pathological outcomes and could help us in surgical plannig to select the most suitable approach.

Aim:

Complete mesocolic excision (CME) with central vascular ligation and D3 lymphadenectomy is a challenging technique. The objective of this work is to evaluate our initial experience with the implementation of a structured training programme of the technique in right and transverse colon cancer procedures.

Method: 

Two surgeons with expertise in laparoscopic colorectal procedures attended the ESCP Laparoscopic CME Programme in June 2019, a two-day hands-on course including operative training in cadaveric model and then a proctorship in our hospital by a faculty member. We have evaluated the initial outcomes in 29 consecutive patients during one year.

Results: 

Right or extended right colectomy was performed in 86.2% and subtotal colectomy in 13.8%. Six patients had intraoperative bleeding but no major vascular injuries, need of conversion or blood transfusion. Eleven patients had postoperative complications, with no anastomotic leakage. There were no reoperations and there was no mortality. All were R0 resections with a mean lymph node retrieval of 30.6.

Conclusion: 

A structured program facilitates the safe implementation of specific and complex surgical techniques with excellent outcomes. The proctorship was an excellent reinforcement which helped us greatly in completing the training.

Aim: To assess the pattern of apical lymph node (LN) metastases in right colon cancer.

Method: Retrospective analysis of the pathology reports of 179 consecutive patients operated for right colon adenocarcinoma at our centre between 2016 and 2018. All patients received complete mesocolic excision (CME). 

Results: The mean number of harvested LNs was 24. Pericolic LNs were harvested in 147 patients (82%), intermediate in 136 (76%), apical in 120 (67%) Lymphadenectomy of the ileocecal vessels was carried out in 177 (99%) patients; of the right colic vessels in 139 (78%); of the right branch of the middle colic vessels (MCV) in 140 (79%); and of the main trunk of the MCV in 36 (20%). Patients with positive LN were 45 (25%). Patients with positive apical LNs were 5 (3%), of which 2 had no other LN metastasis. After a median follow up of 16 months, there were no local recurrences. Distal recurrences were 12 (7%). At univariate analysis, apical LN positivity was an independent factor for disease recurrence.

Conclusion: CME allows excision of apical LNs, which are crucial for correct disease staging and prognosis.

Aim: Perioperative acquisition of covid-19 is associated with high mortality and morbidity. We have analysed the effectiveness of newly designed ‘green’ pathway for elective colorectal cancer (CRC) patients which aims to minimise risk of covid-19. 

Method: Data collected with concurrent implementation of ‘green’ pathway for all patients undergoing CRC surgery over 6 weeks. Audited standards of appropriately timed pre-operative CT chest, covid-19 swabs and shielding. Analysed impact of positive pre-operative swabs and post-operative complications. Additional risk mitigation strategies included dual consultant operating, open operating, defunctioning ileostomy for high risk anastomoses. 

Results: 49 operations performed of 56 planned. 1 cancelled due to patient being positive for covid-19, 5 due to progression of cancer on restaging CT, 1 required further medical optimisation.  All had a 2 week pre-operative swab and then shielded until the day of the operation.  48/49 had swab 2 days pre-op. CT chest performed in all, 37 (66.7%) were to restage. 4 (8%) had post-operative complication graded as ≥ 2 on Clavien-Dindo score; none of which were covid related. 1 patient tested positive for covid-19 post-operatively but remained asymptomatic. All procedures were open and performed by 2 consultants.

Conclusion: We demonstrate an effective pathway to reduce risk for patient undergoing CRC surgery during global pandemic. 

Aim: Despite the low efficacy of MRI to predict depth of invasion of early rectal cancer (ERC), management is usually based in this assessment. The aim of this study was to compare the performance of magnifying chromoendoscopy (MCE) and MRI to predict depth of invasion in ERC. 

Method: 48 consecutive patients with rectal lesions that were assessed by both MCE (Kudo pit pattern) and MRI were retrospectively reviewed, and only lesions with enbloc resection were included. MCE and MRI results were compared with the histology of the specimens.

Results: 77% of the lesions were non-invasive. MCE had classified 83% of them as non-invasive and 17% as having deep submucosal invasion. In MRI, 12% were classified as T1, 48% as T1/T2, and 40% as T2-3c. The specificity and accuracy of MCE to predict which lesions were eligible for local excision were 97% (95%CI 86-100%) and 90% (95%CI 77-96%), respectively. For MRI, 59% (95%CI 42-75%) and 58% (95%CI 43-72%), even when considering T1/T2 stages. Cohen’s kappa was 0.7 for MCE and 0.1 for MRI.

Conclusion: MCE was superior to MRI for predicting depth of invasion in ERC and its assessment should be considered when selecting lesions for local excision.

AIM: To evaluate safety, feasibility and short-term outcomes of laparoscopic complete mesocolic excision (CME) with central vascular ligation (CVL) in right–sided colon cancer compared with “traditional” laparoscopic right colectomy.

Methods: Single center retrospective observational cohort study. We retrospectively reviewed a prospective database of patients who underwent resection for right-sided colon cancer between January 2008 and February 2020. Propensity score was used to balance baseline characteristics. Two groups were matched in a 1∶1 ratio.

Results: A total of 372 cases were matched, 186 in each group. No statistically significant differences in baseline characteristics were found. Interestingly, operative time was significantly shorter [200.0 vs. 230.0 minutes, Z=-4.825 P&lt;0.001] and number of harvested lymph-nodes was higher (22 vs. 19, Z=-2.948 P&lt;0.001) in the CME group. No statistically significant differences in intraoperative blood loss and postoperative morbidity (9.1% vs. 11.8%, p = 0.202) were found. There were no significant differences in reoperation rate (1.8% vs 1.3%, P=0.557), 30-day readmission rate (0.3% vs 0.3%, P=0.966) and 90-day mortality (0% vs 0.54%, P=0.156).

Conclusions: Laparoscopic CME with CVL is technically feasible and safe. It does not seem

associated with a higher rate of complications or mortality compared with the “traditional” approach.

Aim: Controversy exists about the optimal closure technique after abdominoperineal resection (APR) for rectal cancer. Primary closure is still standard of care in the Netherlands, since biological mesh closure was demonstrated not to improve wound healing (BIOPEX-study). Use of well-vascularised tissue for filling of the perineal defect seems beneficial, and a gluteal turnover flap (GT-flap) is a promising method for this purpose. The aim of this study is to investigate whether a GT-flap improves the uncomplicated perineal wound healing after APR for rectal cancer.

Method/Results: In this single-blind multicentre randomised controlled trial, patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible. Exclusion criteria are total exenteration, sacral resection >S4/S5, and intersphincteric-APR. 160 patients will be randomised between GT-flap (experimental arm) and primary closure (control arm), with a follow-up duration of twelve months. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two.

Conclusion: The uncomplicated perineal wound healing rate is expected to increase from 65% to 85% by using the GT-flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place.

Aim: To compare the benefit of radiochemotherapy in metformin and non-metformin groups of diabetic patients with rectal cancer.

Methods: Retrospective study. All patients operated on for locally advanced rectal carcinoma who underwent neoadjuvant treatment with radiochemotherapy were included. The patients were divided into two groups: Group A (non-metformin patients) and group B (diabetic patients receiving metformin treatment). The variables analyzed were the degree of tumor regression, the complete tumor response, the number of lymphadenopathy, mortality and survival.

Results: The degree of tumor regression (HR, 1.35 (95% CI, (0.96-1.91), p = 0.132), the complete tumor response (HR, 1.08 (95% CI, (0 ), 42-2.8), p = 0.874) and mortality (HR, 1 (95% CI, (0.44-2.28), p = 0.994) was higher in group B although not significantly Survival was 92.8 months (Group A) versus 53.3 months (Group B.) Respect for the average of pathological lymphadenopathies found after neoadjuvant treatment was (HR, 5.66 (95% CI, (0, 32-100.7), p = 0.185).

Conclusion: Metformin use was associated with a higher degree of complete tumor response and a degree of tumor regression, although not significantly. However, there is no significant improvement in mortality or survival in patients receiving metformin, sometimes radiochemotherapy for rectal cancer.

Aim:To analyze the tumor related risk factors (pT1) that may influence tumor spread and long-term survival.

Methods:Retrospective observational study. All the patients underwent to surgery with a preoperative diagnosis of pT1 colorectal adenocarcinoma previously removed by colonoscopy.

Results:163 patients with pT1 staging and colorectal adenocarcinoma histology were collected They were divided into two groups (group A: No lymph node involvement in lymphadenectomy (pN-) and group B (pN +). Vascular infiltration, perineural infiltration and the presence of tumor budding were analyzed. HR=4.92(1, 06-22.95) 95% CI,p=0.031 and  p=0.001, respectively, Regarding tumor location, the HR for the ascending colon was calculated (HR=0.8(0.29-2.23) 95% CI ; p=0.662), descending colon (HR=4.92(1.06-22.95) 95% CI; p=0.031), sigma (HR=1.18(0.57-2.44) 95% CI; p=0.660 and rectum (HR=0.7(0.25-1.93) 95% CI;p=0.456. In group A the survival was 58±5 months while in group B it was 69±9 months. In both groups,no deaths were described due to disease progression or recurrence.

Conclusion:In our series we did not find significant differences in survival in either of the two groups, although we observe factors such as the degree of perineural and vascular infiltration and tumor budding as prognostic factors for the presence of lymphadenopathy.

Background: Anastomotic Leakage is a severe complication after Low Anterior Resection (LAR) for rectal cancer and most research focusses on reducing incidence and predictive factors. There is no robust data on severity and treatment strategies.

Objectives: The objective of the TENTACLE – Rectum study is 1) to investigate which factors contribute to anastomotic leakage severity and to compose an evidence based anastomotic leakage severity score and 2) to evaluate the effects of different treatment approaches.

Methods: The TENTACLE-Rectum is an international multicenter retrospective cohort study. Patients who developed anastomotic leakage after LAR for primary rectal cancer between Jan 1st 2014 and Dec 31st 2018, will be included. We aim to include 1246 patients. Primary outcome is 1-year stoma-free survival. Secondary outcomes include number of reinterventions and readmissions, total hospital stay, total time of having a stoma, type of stoma, secondary leakage related complications, mortality and hospital related costs. Regression models are used to create an evidence based anastomotic leakage severity score. Effectiveness of different treatment strategies for leakage is tested, stratified for severity score and other leakages characteristics.

Conclusion: The TENTACLE-Rectum will be the first large international collaborative study on severity and treatment of anastomotic leakage after LAR for rectal cancer, which entails an important step towards evidence-based recommendations.

Aim: The COVID19 pandemic has accelerated the need for staff to work remotely. Our aim was to demonstrate how a next generation digital platform could be used to create a virtual MDT ecosystem in order to manipulate holographic 2D and 3D images in real time. 

Method: This study involved setting up a mock virtual MDT using de-identified DICOM files from a patient who had been treated for colorectal cancer and then subsequently found to have a liver metastasis . The image file was segmented and converted into a 2D and 3D format for visualisation within Microsoft HoloLens 2 ® (smart glasses) using Holocare Solutions ® (Mixed Reality software).

Results:  A seamless cross-border pipeline was developed that involved "clinician" training, DICOM segmentation and virtual connection. We successfully performed a virtual MDT with participants able to visualise and manipulate a virtual 3D organ in real time. The digital network remotely connected sites in England and Norway.  The streaming quality was stable and HIPAA compliant. Each participant could observe others as "avatars" interacting with images within the virtual ecosystem allowing image characteristics to be highlighted.

Conclusion: We successfully conducted a virtual MDT using novel hardware and software. Our intention is to conduct a larger scale study to assess the platform's effectiveness in "Real World" MDTs.

Aim To date, there are no specific quantitative assessment regarding the use of near-infrared indocyanine green enhanced-fluorescence (ICG). Aim of the study was to evaluate the fluorescence timing as a reproducible, cost-effective parameter and to test its efficacy in predicting anastomotic leakage in colorectal surgery.

Method A cohort of 57 patients undergoing laparoscopic elective procedures for colorectal cancer was prospectively enrolled. The macro- and microperfusion were assessed by recording the timing of fluorescence appearance at the level of the iliac artery and the colonic wall, respectively. 

Results All the patients developing an anastomotic leak (AL) after surgery, had a difference between the macro- and microperfusion, identified as delta-timing (ΔT), of ≥15 seconds (p ˂ 0.0001; AUC = 0.80). This cut-off value was found to predict the AL with an odd ratio of 2.03 (95% CI: 0.18 – 23.11; p = 0.05). Cardiovascular diseases (p= 0.048), subcritical aortic stenosis (p= 0.041), BMI ≥ 27 (p= 0.008) and male gender (p= 0.017) were associated with a prolonged ΔT at multivariate analysis.

Conclusion Analysis of the fluorescence timing provides a quantitative evaluation of the tissue perfusion. A ΔT ≥ 15 seconds may be used as a real-time parameter to guide the surgical decision-making protocol.

Aim:

To compare the short-term outcomes of minimally invasive pelvic exenteration versus open pelvic exenterations at a tertiary care cancer centre in India.

Methods:

Retrospective analysis of patients who had undergone total pelvic exenterations, posterior exenterations, or supra-levator exenterations for rectal/sigmoid colon cancers over the last five years were included and the short-term outcomes were analyzed.

Results: 

149 primary tumors were included in the study. Fifty-five (37%) patients underwent MIS whereas 94 (63%) underwent open surgery. MIS approach included Laparoscopic and Robotic surgery. The mean age was 45.3 years, mean BMI was 22.7. In MIS arm, 34 patients underwent Total pelvic exenteration, 13 Posterior exenterations, six supra-levator exenterations and two underwent abdominoperineal resections with prostatectomy respectively. Mean Blood Loss was 1.1 litres vs 2.3 litres in MIS and Open Arm (p=0.043) respectively. The mean postoperative stay, total nodal yield, and CRM positivity rate were comparable. One case was converted to open. The morbidity rate of Clavien Dindo grade III or more was comparable (16% vs 20%). Only one 30-day mortality was reported in the open arm. Anastomotic and urinary conduit leaks were comparable.

Conclusion: 

MIS as compared to the open approach in pelvic exenterative surgery results in comparable outcomes with less blood loss.

Aim: This study determines the feasibility of robotic multi-visceral resection for locally advanced (T4) rectal cancers, including clinical and oncological outcomes. 

Method: This is a perspective cohort of patients who underwent total robotic total mesorectal excision of rectum with en-bloc resection of other viscera in a single UK robotic centre (2013-2018). Patient demographics, perioperative data, histopathological results, length of hospital stay (LOS), and postoperative complications were noted. 

Results: 31 patients were included (median age 74 years; (male= 19); median BMI=28.5 kg/m²; 77% of tumors were in mid and lower rectum. Seventeen patients received neoadjuvant therapy. En-bloc resected viscera included ovaries, uterus, vagina, seminal vesicle, prostate, bladder and small bowel. Seven patients had permanent stoma. Median LOS=6 days. Two patients required postoperative intensive care; 3 readmissions, primarily due to postoperative nausea and vomiting, high output stoma; R0 resection in 29 cases. One with a positive margin developed local recurrence, while the other remained disease-free at follow-up of one year; no 90-day mortality. With a median follow up of 36 months, the overall survival at 3 years was 96% and disease free survival was 84%.

Conclusion: With experience, robotic en-bloc multi-visceral resection for locally advanced rectal cancers is feasible and oncologically safe. 

Aim

Colorectal cancer (CRC) is traditionally thought of as a disease of the elderly. However, where the CRC incidence is declining among older patients, rates are steadily increasing in young adults. This study aims to highlight the outcomes for young patients with CRC.

Method

Retrospective data collection for all patients under 50 years of age diagnosed with CRC undergoing surgical management at a university teaching hospital between October 2012 and June 2018. Data sources from computer based clinical notes, radiological investigations and pathology reports. Primary endpoints are morbidity, 5-year mortality and disease-free survival (DFS). 

Results

87 patients evaluated (mean age of 40 years, range 19-49 years). 69% present with adenocarcinoma and extramural lympho-vascular invasion seen in 44.8%. Overall morbidity was 32.2%. One-third of patients required adjuvant chemotherapy. Cancer recurrence seen in 16% of patients and overall mean survival was 34-months. Mean DFS is 24.6 months. Overall 5-year survival and DFS were 72% and 59% respectively. 

Conclusion

This is a large case series of young patients presenting with CRC in the UK. CRC is often more advanced and aggressive in young patients. Current referral guidelines can result in young patients being investigated/treated for other gastrointestinal conditions before referral for CRC investigation. 

Aim

In locally advanced rectal cancer, neoadjuvant therapy has a local recurrence rate of 3-5%. In the absence of response to neoadjuvant treatment, it’s 40%. An aggressive local control with intraoperative radiotherapy (IORT) can improve the results. 

Method

It’s a retrospective observational study between the years 2012-2019 in which 40 patients have been selected for IORT. They’re local recurrences without metastatic disease, or T4 tumors in the MRI performed at the end of the neoadjuvant. The mean intraoperative dose was 11.4 Gy. 

Results 

31 men and 9 women underwent surgery, mean age 59.8 years. There was T4 rectum ADC in 86% of patients, 17% local recurrence. In all, a protective or permanent stoma was left. The resection was R0, R1 and R2 in 80%, 5% and 15% of the cases. The average operative time was 300 minutes. 60% presented Claven-Dindo complications grade <2; only 4% grade ≥3. There were no deaths in the first 30 days. Overall survival is 55% and disease-free survival is 45%. 

Conclusions 

In studies of IORT administration, recurrences should be differentiated from primary resections.

The advantage of the RIO is the administration in fields without the interposition of organs, more effective administration and a lower dose.

Aim

To evaluate the impact of consolidation chemotherapy following neoadjuvant chemoradiotherapy(NACTRT) with an assessment of the prognostic factors affecting the survival in patients who underwent pelvic exenteration for locally advanced primary colorectal adenocarcinoma. 

Methods-A retrospective analysis of a prospectively maintained database of pelvic exenteration from May 2013 to December 2018.

Results-Of the 2900 colorectal resections and 131 pelvic exenteration,100 patients underwent exenteration for primary colorectal adenocarcinoma. Of 81 patients receiving NACRT and surgery,50 received consolidation chemotherapy and 31 underwent surgery without chemotherapy.R0 resection was achieved in 90%.At a median follow up of 32 months,the 2 year disease free survival (DFS)was 61.8%;2 year and estimated 5 year overall survival (OS) was 82.6% and 62% respectively.The 2 year distant recurrence free survival was 58% in ‘consolidation chemotherapy group’ and 89% in no chemotherapy group’(p=0.025).On multivariate analysis,receiving consolidation chemotherapy (p=0.027)and LVI(p=0.001)affected the DFS.OS was significantly affected by male gender (p=0.010),hemoglobin level <12 g/dL (p=0.005),poor differentiation(p=0.013),TRG>2 (p=0.033),no adjuvant chemotherapy (p=0.007).

Conclusion-Pelvic exenteration with R0 resection and multidisciplinary treatment approach for locally advanced primary colorectal adenocarcinoma achieves excellent long-term survival.In patients,who require pelvic exenteration to achieve R0 resection following NACRT,the survival may not improve with consolidation chemotherapy

Aim

The rate of colorectal cancer (CRC) diagnosed within 3 years post colonoscopy is a key performance indicator of the quality of colonoscopy. Our aim was to quantify our post-colonoscopy CRC (PCCRC) rate and compare it with the national standard.

Method

We performed a retrospective analysis of a prospectively kept database of patients with CRC over the four years period (2016-2019). The inclusion criteria were: histological diagnosis of adenocarcinoma and clear lower gastro-intestinal endoscopy (LGIE) within three years of the diagnosis.

Results

The total of 784 patients were analysed. Twelve patients were included. Eight (67%) of CRC diagnoses were left sided. Nine patients (75%) had a curative resection, one underwent transanal endoscopic microsurgery, one chose not to have an operation, and one had metastatic cancer at the time of diagnosis. Amongst the patients who underwent a curative resection, five had extramural venous invasion (42%) and three (33%) had positive lymph nodes. In our experience, PCCRC 3 year rate was 1.5% which is within the national standards.

Conclusion

Patients with missed cancer diagnosis on LGIE are likely to present with more advanced disease. We recommend to monitor PCCRC 3 year rate and repeat LGIE in patients with persistent symptoms.

Aim: Laparoscopic surgery for small bowel neuroendocrine neoplasms (SB-NEN) is controversial, with highly selective application in guideline recommendations. The aim of this study was to evaluate surgical approach for SB-NEN at a national level.

Methods: Patients with SB-NEN diagnosed between 2005-2015 were included from the Netherlands Cancer Registry. Overall survival was assessed for laparoscopic and open approach using the Kaplan-Meier method (with Log-rank rest), and independent predictors determined by Cox proportional hazards model.

Results: In total, 482 patients were included, of whom 342 (71%) underwent open and 140 (29%) laparoscopic surgery. Patients in the open surgery group had significantly more multifocal tumours resected (24% vs. 14%), pN2 lymph nodes (15% vs. 6%) and stage IV disease (33% vs. 20%). Overall survival after open surgery was significantly shorter compared to laparoscopic surgery (3-year: 81% vs. 89%, 5-year: 71% vs. 84%, P=0.004). In multivariable analysis, age between 60-75 and above 75 years, stage IV disease and a laparoscopic approach were independently associated with overall survival, whereas tumour multifocality was not.

Conclusion: Laparoscopy was the approach in 29% of SB-NEN at a national level with selection of the most favourable patients. Laparoscopy remained independently associated with better overall survival, but residual confounding cannot be excluded. 

Aim: To evaluate the impact of primary tumour location (PTL) on oncological outcome following liver resection for colorectal liver metastases (CRLM).

Method: Consecutive patients undergoing surgery for CRLM at a single centre were retrospectively reviewed.  Kaplan-Meier survival estimates stratified by PTL and hazard ratios (HR) at 5 years post-resection using Cox regression were calculated.

Results: 205 eligible patients were identified; 158 were left sided (L-PTL; distal to the splenic flexure) and 47 right sided (R-PTL). 32.6% of left sided and sigmoid primaries had bilobar CRLM, compared to 15.9% and 21.3% of rectal and R-PTL, respectively (p=0.048). 

5-year overall survival was reduced with R-PTL compared with L-PTL (38.3% vs 53.8%, respectively; p=0.012); as was disease free survival (21.3% vs 41.1%, respectively; p=0.012).

On multivariable analysis after adjustment for demographic and oncological covariates, including primary tumour stage and adjuvant therapies, L-TPL had lower HR 0.62 (95%CI 0.39-0.98, p=0.042); whilst the presence of bilobar CRLM had a greater HR 1.61 (95%CI 1.01-2.55, p=0.044) for overall mortality. 

Conclusion: R-PTL is an independent risk factor for abbreviated overall and disease free survival in CRLM after metastasectomy. Left sided primaries appear to be associated with more frequent development of bilobar metastases, but nevertheless confer a survival advantage.   

Aim: To assess differential features between patients under the age of 50 and patients aged 50-75 operated for colorectal cancer.

Method: A retrospective review of all patients operated for colorectal adenocarcinoma during 2015-2020 in a single institution was performed, comparing patients younger than 50 years old with those on age for colorectal cancer screening, focusing on disease stage and postoperative outcomes.

Results: 207 met criteria for inclusion, 15.5% of patients on the early onset group. No differences were found in patient comorbidities. Young individuals had more transverse (22 vs. 10%, p: 0.05) and upper rectal (28 vs. 8%, p: 0.001) disease. This group was diagnosed at more advanced stage of disease. As regards to surgical treatment, young patients received more Hartmann’s procedure (16 vs. 7%, p: 0.09), had more postoperative complications (44 vs. 28%, p: 0.07) and need of re intervention (19 vs. 7%, p: 0.04). Further multivariate analysis showed same results.

Conclusion: People with early onset colorectal cancer are diagnosed at more advanced stages of their disease and present differences in tumor location. Even though they are significantly younger than those in age for screening, complications including need of re operation are more frequent in this group.

Though PET scan is 80% sensitive and specific in diagnosing reccurence, it's less effective in low volume diseases and Non-PET avid recurrences 

Aims

To assess the clinic-radiological outcome of patients with rising CEA and no structural disease in PET scan. 

Merits of addition of diagnostic laparoscopy 

Method:

All patients for which PET scan was done for elevated CEA (N=1240) were studied.

162 patients satisfying the study criteria was followed up

Results 

Among the 162 patients, median follow up was 54 months .19.7 % of patients had disease recurrence with more than 95% within two years of CEA elevation. Of all the recurrence, 84.4% failed distally. Node positive status in histopathology was the only factor significantly associated with recurrence. All the patients with local recurrence and 52% of patients with distant recurrence were given curative treatment.1/3^rd of all the recurrence were peritoneal only. Among those, performing an additional diagnostic laparoscopy salvaged 40 % of patients, while none in the group where laparoscopy was not performed.

Conclusion

The study would recommend patients with elevated CEA and negative PET scan to be kept on shorter follow up for a period of 2 years from the date of CEA elevation. Addition of an early diagnostic laparoscopy merits in salvaging an additional 6.2% patients with recurrence. 

Aim

The best way of performing the intestinal anastomosis after laparoscopic right colectomy (LRC) is controversial. The aim of our study was to evaluate our outcomes with intra- (ICA) and extra-corporeal (ECA) side-to-side ileocolic anastomosis.

Method

A descriptive, longitudinal and retrospective study was performed, including 137 consecutive patients who underwent LRC (73 with ECA and 64 with ICA) between January 2018 and June 2020, with at least one month of postoperative follow-up. Inflammatory bowel disease surgery is not included. Mean age was 73 (±10.7) years with a mean BMI of 27.9 Kg/m2. 98% of patients were ASA II or III. Both groups were similar in basic characteristics. The primary endpoint was to determine whether there were clinically relevant differences in outcomes between both anastomosis, with special interest in anastomotic leakage. 

Result

We have found differences in anastomotic leakage rate (7 vs 0, P=0.023), postoperative ileus (22 vs 10, P=0.045) and length of stay (11.6 vs 8.7, P=0.046) in favor of ICA group. No other differences were found.

Conclusion

LRC with ICA is a safe and reproducible technique, with fewer postoperative complications and a shorter length of stay. 

Aim

The COVID-19 pandemic has reduced capacity to investigate suspected colo-rectal cancer (CRC) referrals on 2 week wait (2WW) pathways. Within our unit we have restructured CRC referral pathways utilising consultant-led telephonic triage.

Method

We performed a single-centre, retrospective review of 2WW CRC referrals from 30^th March-6^th June 2020 compared against a time-matched 2019 cohort. We collected demographic and outcome data from electronic records. The primary outcome was endoscopic pick-up of CRC. Secondary measures included number discharged from the 2WW pathway without investigation, number undergoing endoscopy and cancer yield. Chi-squared test was used for dichotomous outcomes with p-values given to three decimal places.

Results

381 and 1098 patients respectively were included from 2020 and 2019. Fewer patients underwent endoscopy in 2020 (109/381 vs 884/1098; p<0.001) although with higher CRC pick-up rates (10/109 vs 21/884; p<0.001) and comparable cancer yields (10/381 vs 21/1098; p=0.403). 107 patients were discharged from the 2WW pathway without investigation after identification as low-risk in line with BSG/ACPGBI guidance. 

Conclusion

We implemented a ‘COVID model’ for 2WW CRC triage and investigation which reduces pressure on endoscopic services while maintaining a similar pre-COVID cancer yield. Long-term data is needed to investigate possible missed CRC diagnoses. This model may prove useful for future 28-day faster diagnosis standard.  

Aim: To assess potential benefits of TaTME versus laparoscopic-LAR in rectal cancer.

Method: Comparision of 17 TaTME procedures with 15 lap-LAR, performed after neoadjuvance. Years 2015-2019. Same two surgeons. Tumours<11cm from anal margin, protective ileostomy. Random distribution. Oncological variables: distance to circumferential margin; closest margin; lymph nodes; local recurrence. Surgical variables: complications; anastomotic leak; mean hospital stay; readmission. QOL variables: stoma reversal; faecal continence.

Results: Mean age: 61.6y(+/- 8.1)LAR; 69.35y(+/-8.3)TaTME. Median follow-up: 26 months[12-55]. One patient died during follow-up. No conversions to laparotomy.

Oncology: TaTME: Circumferential margin(cm) 1,84(+/-0.7); Closest margin(cm) 1,65(+/-0,8); Lymph nodes 12,6(+/-2,4);  Recurrence 1 (21months follow-up)

LAR: Circumferential margin 2,08(+/-0,9); Closest margin(cm) 1,96(+/-0,9); Lymph nodes 15(+/-5,7);  Recurrence 0.

No significant differences in anatomopathological data. None of margins affected.

Surgery: TaTME: Complications 3/17(Ileus, AUR); Leaks 3; Stay 7,9(+/-3,4); Readmission 2

                LAR: Complications 4/15(SSI, ileus, AUR, diverticulitis); Leaks 1; Stay 7,2(+/-2,8); Readmission 1

No differences observed.

QOL: Stoma reversal TaTME88,2%/LAR93,3%; Altered continence TaTME40%/LAR21,4%

No significant differences.

Conclusion: Both techniques have similar results in oncological, surgical and functional outcomes. We have not been able to demonstrate any of the benefits referred to TaTME, nor did we identify any inferiority with respect to laparoscopic-LAR.

Aim- Mean corpuscular volume (MCV) has been implicated in prediction of oncological outcomes in other cancers (e.g., esophageal), with high pre-operative MCV linked with disease recurrence. This study aimed to identify whether high MCV affects post-operative outcome and disease recurrence in colorectal cancer (CRC).

Methods- Patients undergoing elective CRC resection with curative intent in a tertiary centre between 2008 and 2019 were identified from a prospective database. Patient records were reviewed to obtain demographics, American Society of Anesthesiologists (ASA) grade, smoking and alcohol intake, tumor and pre-operative laboratory data and oncological management of each patient and inputted for regression analysis. Post-operative Clavien-Dindo (CD) score was calculated, 30-day mortality, in-hospital mortality and cancer recurrence were recorded.

Results- A total of 1293 CRCs were resected, with 89.7% of patients experiencing a hospital course without major morbidity (CD<3). The 30-day mortality rate was less than 1%, with 22 deaths overall (1.7%). There were 176 patients (13.6%) with recurrence at follow-up. Preoperative factors that predicted recurrence, CD <3 and mortality were analyzed with regression analysis. Pre-operative high MCV did not significantly predict negative post-operative or oncological outcomes.

Conclusion- MCV is not an independent prognostic factor for outcomes following elective CRC resection.

Aim: Over the past few years we have noticed increasing number of young patients diagnosed with colorectal cancer discussed in colorectal multidisciplinary team meetings . We aim to look is the incidence really rising in the younger patients aged below 40 years.

 Method: Retrospective data was collected from the Infoflex data base system at our district general hospital  for all the colorectal cancers diagnosed between January 2014- Dec 2019 and the incidence of colorectal cancers under the age of 40 years was calculated.

Results: 770 colorectal cancels we are diagnosed during the study period. 451(58.58% were male and 319(41.42%)  were female. The age range was 25 -98 years. 2.06%, 3.19%,1.14%, 0%,2.22%,2.38% patients below the age of 40 years were diagnosed with colorectal cancer in 2014,2015,2016,2017,2018 & 2019 respectively.

Conclusion: Our study does not show any increasing trend in the incidence of colorectal cancer in the younger population. One of the limitation of this study is small sample size. Probably a large sample size or analysis of colorectal registry can give us better answers.

Aim: we aimed to analyze survival of colorectal cancer patients in Lithuania.  

Method: Using population based data from the Lithuanian Cancer Registry and period analysis, we examined trends in colorectal cancer survival between 1998 and 2012 according to cancer anatomical sub-site and stage. 5-year relative survival estimates were calculated using period analysis.

Results: Overall 20 980 colorectal cancer cases reported between 1998 and 2012 were included into the study. Total number on new diagnosed colorectal cancers increased from 1998–2002 to 2008–2012 by 12.1%. The highest number of colorectal cancer were localised and proportion of these tumours increased from 33.9% to 42.0%. Number of tumour with regional metastases and advanced cancers decreased by 11.1% and 15.5%, respectively. Increased number of new cases was observed for almost all colon cancer sub-sites, with little changes in number of rectosigmoid and rectal cancers. The overall 5-year relative survival increased from 37.9% in 1998–2002 to 51.5% in 2008–2012. Positive changes in survival were evident for all disease stages and all sub-sites.

Conclusions: Although survival rates variated in colorectal cancer patients according to disease stages and sub-sites, positive changes in survival were evident for all patients in Lithuania.

AIM: to compare bowel function and oncological outcomes following these two treatment modalities. 

Methods: a total of 67 patients were included (32 with total mesorectal excision – TME group and 35 transanal local excision ± chemoradiation – LE group) from the patients who were treated 2009-2018. Patients were matched by age, cancer stage, comorbidities. Duration of operation, postoperative complications, length of hospital stay, functional and oncological outcomes were compared. Oncological outcomes were calculated using Kaplan-Meier cox diagrams and for bowel function assessment low anterior resection syndrome (LARS) score was used. 

Results: mean operation time in LE group was 58.8±45min, TME group – 121.1±42min (p< 0.05). Complications 5.7% in LE and TME groups – 15.62% (p< 0.05). 85.2 % of patients had no LARS in LE group comparing to 54.5 % in TME group (p=0.018). Minor LARS 7.4% in LE group compared to 31.8 % in TME group (p=0.018); major LARS – 7.4 % and 13.7 % respectively (0.474). Hospital stay was 2.77 days in LE group and 9.21 in TME group (p<0.05). Survival was 68.78 months in LE group and 74.81 months in TME group (p=0.964).

Conclusions: local excision ± chemoradiation is safe method for early rectal cancer comparing with a gold standard treatment. It preserves the rectum, better bowel function, gives fewer postoperative complications and shorter hospital stay. 

Aim

The COVID-19 pandemic has restructured and delayed endoscopic service delivery. qFIT (quantitative Faecal Immunochemical Test) testing may help risk stratify patients for resolution of endoscopic services.

Method

We perform a single-centre prospective study of patients awaiting endoscopy on the 2-week wait (2WW) and Bowel Cancer Screening Programme (BCSP) by 2^nd June 2020. BCSP patients were included if qFIT>120 ng/ml. Surveillance or site-check endoscopy was excluded. 2WW patients were requested to complete qFIT testing and all patients were risk stratified according to their qFIT result. Data was collected from electronic healthcare records. Outcome measures included qFIT result, diagnostics wait time (WT) and diagnostic test result.

Results

By 13^th July 2020 63/98 2WW patients had completed qFIT testing, 52/98 2WW and 35/56 BCSP patients had undergone endoscopy. In 2WW patients the median WT was 85 days with 5 patients diagnosed with CRC. In BCSP patients the median WT was 113 days with 3 patients diagnosed with CRC. 4 out of 8 patients diagnosed with CRC completed qFIT testing; all with a value >120ng/ml.