Consultant Colorectal Surgeon Research Articles

FP8.8 - LumenEye XI rigid digital rectoscope in the assessment of anorectal symptoms: a sustainable substitute for outpatient flexible sigmoidoscopy?

Abstract Aims To evaluate the acceptability, safety and diagnostic yield of the LumenEye XI in the assessment of anorectal symptoms. Methods Consecutive patients with anorectal symptoms, referred to the colorectal unit by their general practitioner, had a full clinical assessment followed by endoscopic examination using the LumenEye XI by a consultant colorectal surgeon. Results 59 consecutive patients,16 being male, were examined. The median age was 59 years (range 27-90). The main reported presenting complaints were rectal bleeding (n = 18, 21.4%), proctalgia (n = 10, 15.5 %), faecal incontinence (n=12, 14.3%), obstructive defaecation (n=7, 8.3%), anorectal swelling (n = 7, 8.3%), and mucous discharge (n = 2, 2.4%). The main findings were haemorrhoids (n= 18, 22.5%), rectal prolapse and rectocoele (n=14, 17.5%), and inflammatory conditions (proctitis, anal fistula, pouchitis) (n=4, 5%). One patient was diagnosed with rectal cancer. 19 patients (23.75%) had normal findings. 13 patients (22%) were referred for further investigations. Out of the 18 patients with rectal bleeding, 16 had a definitive diagnosis made with LumenEye. The diagnoses in patients with rectal bleeding were haemorrhoids (n=15, 53.6%), inflammation (n=4, 14.3%), prolapse (n=2, 7.1%), and ulceration (n=1, 3.6%). No cause could be identified in 2 of these patients. The rectosigmoid junction was visualised in all patients who had an intact rectum (57 out of 59 patients). All patients tolerated the procedure well, with no complications. Conclusions LumenEye XI is safe and well accepted by patients with good diagnostic accuracy. It therefore offers a potential solution to helping to relieve the endoscopy burden and enable cost savings by reducing the number of outpatient flexible sigmoidoscopies.

Have changes in colorectal surgery training impacted on mortality in cancer patients? A retrospective cohort study of 51,562 procedures.

The aim of this study was to explore whether there were any differences in consultant colorectal surgeon training and adjusted 90-day postoperative colorectal cancer mortality rates (AMR). We undertook a retrospective analysis of outcomes data published on the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. A total of 51,562 procedures for patients in England diagnosed with large bowel cancer between 2010 and 2015, registered under 551 consultants were included. Consultants were split into two cohorts. The first group were the pre-Calman Trained Consultants (pre-CTr), who completed their training before 1998. The second group-the post-Calman Trained Consultants (post-CTr)-included those who received their Certificate of Completion of Training (CCT) under the Calman Training Principles (CTC, 1998-2007) and the Modernising Medical Careers Curriculum (MMC, 2008 and onwards). The outcome measure was an AMR. The pre-CTr cohort (n=84) consisted of 3.6% female colorectal consultants (n=3/84), whereas the post-CTr cohort (n=467) consisted of 14.3% female colorectal consultants (n=67/467) (p=0.006). In this cross-sectional analysis over 5 years, the average pre-CTr undertook a greater number of colorectal resections than their post-CTr peers: median procedures (interquartile range, IQR): 104 (59) vs 89 (57) respectively, p=0.008. The median AMR was significantly greater among pre-CTrs compared with post-CTrs, median AMR (IQR): 2.7% (2.0) vs 2.1% (2.9), p=0.022. These data indicate that the implementation of the MMC and Calman training principles for colorectal training is associated with a statistically lower AMR compared with other historical training periods. This merits further exploration.

28 Colorectal Cancer Resections During COVID-19: To Do or Not to Do?

IntroductionAscertaining the practice of colorectal cancer (CRC) resections during the COVID-19 pandemic in England and Wales.MethodA list of all colorectal multi-disciplinary teams (MDTs) was obtained from the National Bowel Cancer Audit (NBOCA) database. A survey was designed using Google Forms and emailed to at least one consultant colorectal surgeon of each MDT. One response per MDT was used in the analysis. All responses were anonymous. Study duration was from 15th April 2020 to 30th June 2020.ResultsSixty-eight of the 150 MDTs enlisted on the NBOCA database in England and Wales responded. 86.6% were performing CRC resections and 86% were screening patients pre-operatively for COVID-19. 84.9% were using full Personal Protective Equipment (PPE - FFP3 and eye protection) in all cases whereas 12.3% were using PPE only in suspected cases. 44.4% had resorted to open resections due to risk of laparoscopy being an aerosol generating procedure. 13.7% attributed post-operative complications to COVID-19 and 4 centres reported death due to COVID-19 related complications. 40% of MDTs used short course radiotherapy in rectal cancer patients where resections were postponed either by patient or by the team. 55% responded to feeling uncomfortable/very uncomfortable to cancel cancer resections while 31.7% were equivocal and others comfortable not to operate during the pandemic.ConclusionsThis survey demonstrates a snapshot of practice during the peak of the COVID-19 pandemic. The majority of the centres continued to perform CRC resections safely where possible. There has been obvious disruption to services and change to normal practice.

O34 Colorectal cancer resections during COVID-19: to do or not to do?

Abstract Introduction Ascertaining the practice of colorectal cancer (CRC) resections during the COVID-19 pandemic in England and Wales. Method A list of all colorectal multi-disciplinary teams (MDTs) was obtained from the National Bowel Cancer Audit (NBOCA) database. A survey was designed using Google Forms and emailed to at least one consultant colorectal surgeon of each MDT. One response per MDT was used in the analysis. All responses were anonymous. Study duration was from 15th April 2020 to 30th June 2020. Result Sixty-eight of the 150 MDTs enlisted on the NBOCA database in England and Wales responded. 86.6% were performing CRC resections and 86% were screening patients pre-operatively for COVID-19. 84.9% were using full Personal Protective Equipment (PPE—FFP3 and eye protection) in all cases whereas 12.3% were using PPE only in suspected cases. 44.4% had resorted to open resections due to risk of laparoscopy being an aerosol generating procedure. 13.7% attributed post-operative complications to COVID-19 and 4 centres reported death due to COVID-19 related complications. 40% of MDTs used short course radiotherapy in rectal cancer patients where resections were postponed either by patient or by the team. 55% responded to feeling uncomfortable/very uncomfortable to cancel cancer resections while 31.7% were equivocal and others comfortable not to operate during the pandemic. Conclusion This survey demonstrates a snapshot of practice during the peak of the COVID-19 pandemic. The majority of the centres continued to perform CRC resections safely where possible. There has been obvious disruption to services and change to normal practice. Take-home Message COVID-19 led to an unprecedented situation where safe guidance had to be implemented at short notice to enable safe surgical practice. This survey aimed to establish how colorectal MDTs in England and Wales were adapting their colorectal cancer resection practice in light of new guidance amidst the first wave of the pandemic.

The National Health Service (NHS) response to the COVID-19 pandemic: a colorectal surgeons experience in the UK.

The UK government was arguably slow to take action against the COVID-19 pandemic. However, since switching their policy from "mitigation" to "suppression", swift changes have been implemented to all aspects of life. In this unprecedented crisis healthcare has been on the battlefront across the globe. Every effort has been made in the UK to stop the National Health Service (NHS) from being overwhelmed, leading to the national slogan: "Stay at home. Protect the NHS. Save lives". In this article, a consultant general and colorectal surgeon in Southampton reports on the NHS response to the COVID-19 pandemic.

Books: Did He Save Lives? A Surgeon's Story: A Miscarriage of Justice.

David Sellu Sweetcroft Publishing, 2019, PB, 288pp, £7.19, 978-1912892327 One ordinary evening in February 2010 an experienced consultant colorectal surgeon saw his last patient of the day, a 66-year old retired builder who had developed abdominal pain shortly following an elective knee replacement. Three years later on a cold November day David Sellu was sentenced to prison for 2 and a half years for unlawfully killing John Hughes. Did He Save Lives? charts the events between these two dates that would lead to the conviction of a surgeon with a previously unblemished record of gross negligence manslaughter. Sellu’s methodical, sparse yet descriptive prose depicting the day-to-day of prison life belies the quiet horror of a life stripped of freedom, autonomy, and dignity. Born in a rural village in Sierra Leone to illiterate farmers it was not in Sellu’s destiny to become an eminent surgeon in England. Two things changed …

Where should the buck stop? Doctors, medical errors, and the justice system

Editorial, doi:10.1136/bmj.i6268 After the Court of Appeal overturned surgeon David Sellu’s conviction for manslaughter, Clare Dyer reports on fears that doctors are being unjustly criminalised When David Sellu, a respected...

PTU-032 Explant organ model testing of the ‘robotic’ colonoscope: first experience in the UK

Introduction Colonoscopy practice in the UK has improved over the past decade.1,2There remains, however, a small but significant failure rate and the use of sedation and analgesia remains the norm. There is a clear clinical need for alternatives to traditional colonoscopy. An automatic self-propelled, user-guided colonoscope has been developed that abolishes the need for sedation or analgesia in the vast majority of cases, even where traditional colonoscopy has failed or may incur excess risks.3The new model colonoscope also has a 3.1 mm working channel for diagnostic and some therapeutic options. Given that the apparatus is operated by a controller resembling those used in gaming consoles, we hypothesised that it would take little time to become familiar with controls and achieve efficient colonic intubation. Method Using an animal explant model (Erlangen-type; porcine colon) we asked a variety of operators to achieve a timed caecal intubation (total colon length 1.65 m). The Endotics colonoscopy system mark II (ECS-II) was used. Two CMT-grade doctors, two ‘JAG-independent’ SpRs, an Endoscopy nurse (non-Endoscopist), a consultant Colorectal surgeon and a Consultant Gastroenterologist were asked to try to match the performance of an expert operator (from the manufacturers). A short tutorial on the controls was given to each operator and they were allowed to intubate the simulated sigmoid-descending junction before withdrawing and conducting a timed intubation. Results The expert operator set a time of 6:21 min to reach the caecum. The experienced colonoscopists achieved a median time of 6:28 (range 6:21–6:56) with their first attempt. Subsequent attempts were not deemed necessary to improve on this. The Endoscopy nurse achieved 6:26 on first attempt. The two CMT doctors recorded times of 9:44 and 8:02 on their first attempt, then 6:48 and 6:22 on their second and 6:33 and 6:23 on their third. Withdrawal of the scope was qualitatively assessed but not timed. All operators were satisfied with image resolution. Conclusion The acquisition of operator skills to use the ECS-II was rapid and was not limited, nor hindered, by previous colonoscopy experience. Human studies have been conducted in the EU with success4,5and we expect the first UK studies to be completed soon, focussing on clinically-relevant performance indicators. Disclosure of interest None Declared. References Bowles CJ, et al. Gut 2004;53:277–83 Gavin DR, et al. Gut 2013;62:242–9 Pallotta S, et al. Poster, SIGE; 2011 Tumino E, et al. World J Gastroenterol. 2010;16:5452–6 Perri F, et al. Dig Liver Dis. 2010;42:839–43

The consequences of medical mistakes: the stakes are getting higher!

In February 2010, consultant colorectal surgeon David Sellu was referred and subsequently operated upon a patient with a perforated bowel who later died. The surgeon was found guilty of manslaughter by gross negligence and sentenced to two and a half years in prison. Roger Kirby reviews the case in detail and outlines the lessons to be learned from the tragedy.

Doctors and Manslaughter

The trial and imprisonment in November 2013 of David Sellu, a consultant general and colorectal surgeon practising at the Clementine Churchill Hospital in Harrow and Ealing Hospital NHS Trust, has sent a collective shiver down the spines of many surgeons. The judge’s sentencing remarks make a chilling read, culminating in his conviction for manslaughter and two-and-a-half years’ imprisonment.

Local recurrence after stenting for obstructing left-sided colonic cancer

Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection. A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates. In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival. SEMS was associated with an increased local recurrence rate.

A guide to cancer genetics in clinical practice

The field of cancer genetics has rapidly emerged from the early nineties after the identification of the RB1 gene, the germline monoallelic mutations of which are associated with a 90% risk of retinoblastoma. The identification of genes associated with a high risk of frequent cancers, such as breast and colorectal cancers, has rapidly led to the development of cancer genetic clinics. Although less than 5% of cancers are linked to highly predisposing gene mutations, because of the high incidence of cancers one individual among 200 is affected by cancer genetics. Thus, cancer genetics is one of the emblematic fields of personalized genomic medicine and is prone to take part in the renewed practices of genetic medicine. However, this new field, and especially the management of high-risks individuals, still needs to be translated to the clinic. Sue Clark, a consultant colorectal surgeon in charge of the polyposis registry of the UK, has edited a guide to cancer genetics published by Tfm publishing. She was joined by a number of specialists of each of the reviewed syndromes. The guide starts with two chapters introducing to the general principles of Mendelian diseases and molecular genetics, and to cancer inheritance. A third chapter is dedicated to the ethical and legal aspects of genetic testing in the field of cancer genetics. The most frequent inherited cancer syndromes are reviewed in the next 10 chapters, according to the same plan: genetics, clinical picture, diagnosis, management, and future. A last chapter is an interesting reflexion on cancer genetics centers, and the future of cancer genetics practice including the introduction of the growing body of knowledge on multifactorial cancer inheritance. Despite some data to update, such as the CHK2 gene that is not any more involved in the Li-Fraumeni syndrome, this guide is an easy and pleasant read thanks to many tables, illustrations, and key points at the end of each chapter. This guide to cancer genetics is meant for students, genetic counsellors, geneticists not specialized in cancer genetics, and clinicians managing at risk individuals searching for an introduction to the cancer genetics field. If these were Sue Clark's objectives, they have been fully accomplished▪

Doncaster third gastrointestinal anastomosis course

This excellent one day course is aimed at trainees in general surgery at core training year 1 to specialty training year 3 level. Trainees must have completed a basic surgical skills course and ideally should be doing a general surgical rotation so that the techniques covered in the course can be applied in clinical practice. The course is open to trainees from anywhere within the United Kingdom and is now becoming affiliated with the Association of Surgeons in Training. The course is run by the general surgery department of Doncaster Royal Infirmary and is led by consultant colorectal surgeon AB Harikrishnan, two consultant colleagues, and two registrars in general surgery. In future, the course will be held twice a year, with a maximum of 12 delegates on each course. Delegate numbers are limited to maintain a high trainer to trainee ratio. My course was …

PMO-254 Comparison of IBDQIP scores for two services within one trust

IntroductionThe Heart of England NHS Foundation Trust is one of the largest in England, with over 1200 beds and serves over a million people throughout north and east Birmingham and...

Measures of Outcome in Rectal Cancer Surgery

Surrey, United Kingdom Correspondence: H. S. Tilney, M.D., F.R.C.S., Consultant Colorectal Surgeon, Frimley Park Hospital NHS Foundation Trust, Surrey, United Kingdom. E-mail: [email protected]

Rectal Cancer following Abdomino-Perineal Pull-Through for Imperforate Anus

Colorectal DiseaseVolume 14, Issue 6 p. e363-e364 Case report Rectal cancer following abdomino-perineal pull-through for imperforate anus S. N. Ahmed, S. N. Ahmed Singleton Hospital, Swansea, UKSearch for more papers by this authorM. D. Evans, M. D. Evans Singleton Hospital, Swansea, UKSearch for more papers by this authorP. Bose, P. Bose Singleton Hospital, Swansea, UKSearch for more papers by this authorP. Drew, P. Drew Singleton Hospital, Swansea, UKSearch for more papers by this authorJ. Beynon, J. Beynon Singleton Hospital, Swansea, UKSearch for more papers by this authorM. Davies, M. Davies Singleton Hospital, Swansea, UKSearch for more papers by this author S. N. Ahmed, S. N. Ahmed Singleton Hospital, Swansea, UKSearch for more papers by this authorM. D. Evans, M. D. Evans Singleton Hospital, Swansea, UKSearch for more papers by this authorP. Bose, P. Bose Singleton Hospital, Swansea, UKSearch for more papers by this authorP. Drew, P. Drew Singleton Hospital, Swansea, UKSearch for more papers by this authorJ. Beynon, J. Beynon Singleton Hospital, Swansea, UKSearch for more papers by this authorM. Davies, M. Davies Singleton Hospital, Swansea, UKSearch for more papers by this author First published: 09 May 2012 https://doi.org/10.1111/j.1463-1318.2012.02876.xCitations: 2 Mark Davies, Consultant Colorectal Surgeon, Ward 4, Singleton Hospital, Sketty, Swansea SA2 8QA, UK. E-mail: mark.davies8@wales.nhs.uk Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume14, Issue6June 2012Pages e363-e364 RelatedInformation

‘The Impact of SIGN guidelines on Carotid Endarterectomy in South-East Scotland’

‘The Impact of SIGN guidelines on Carotid Endarterectomy in South-East Scotland’

Do patients require outpatient follow‐up after rapid referral double contrast barium enema?

In our hospital, patients above the age of 40 years referred with a change in bowel habit without rectal bleeding undergo a double contrast barium enema (DCBE) ideally within 2 weeks. Results of benign studies are sent to a consultant colorectal surgeon and a routine clinic visit arranged. The aim of this study was to identify whether, following DCBE, patients (i) presented at a later date with colorectal cancer and (ii) needed assessment in clinic. This is a review looking at all patients who underwent DCBE prior to routine clinic visit between January 2004 and December 2005. Hospital databases were cross-referenced to identify any patients presenting with a new diagnosis of colorectal malignancy between DCBE and April 2007. Clinic letters were reviewed to identify the number of outpatient visits prior to discharge and reasons for continued follow-up. During the study period, 521 patients (age range 31-93 years, 316 female) had DCBE prior to assessment in clinic. Diagnoses: cancer 48 (9.2%), polyps 13 (2.5%), colitis 3 (0.6%), no significant pathology 457 (87.7%). Of this latter cohort, 387 (84.7%) were discharged after one clinic visit; 54 (11.9%) attended twice and 11 (2.4%) were seen more than twice. Reasons for multiple attendances were management of haemorrhoids/anal fissure or investigations of unrelated symptoms. No new cancers were identified in this cohort between January 2004 and April 2007. Double contrast barium enema is a safe screening tool following a '2-week rule' referral with CIBH. Following a report of no significant pathology, there is no need to arrange routine follow-up.

Subcutaneous lateral internal sphincterotomy (SLIS)—a safe technique for treatment of chronic anal fissure

Subcutaneous lateral internal sphincterotomy (SLIS) is an effective treatment for fissure in ano but carries a definite risk of incontinence. The aim of this study was to assess the efficacy and complications of SLIS in patients with chronic fissure in ano. All patients presenting with a chronic anal fissure who underwent SLIS were entered into a prospective database. This is a review of these patients over 5 year's period (September 2002-2007). All operations were performed or directly supervised by a consultant colorectal surgeon. Short-term follow-up was at the first outpatient appointment (6 weeks postoperatively) and any impairment of continence was documented. During the study period of 5 years, 96 patients underwent SLIS at our institution. Median patient age was 45 years (range 19-81). The median duration of symptoms was 65 days. No fissure failed to heal after SLIS. Minor complications were noted in five patients; 85% (82/96) attended the follow-up and out of these, 6% (5/82) reported early incontinence. One patient was incontinent to flatus, one to liquid and three to solid stool. After 12 weeks of follow-up, two patients were completely symptom free, one was incontinent to flatus and two were incontinent to liquid stool. SLIS remains an effective treatment for chronic anal fissure. A small proportion of patients do suffer from faecal incontinence, which may be permanent in some cases. Careful patient selection and proper surgical training can reduce this risk.

Surgeon Volume Does Not Predict Outcomes in the Setting of Technical Credentialing: Results From a Randomized Trial of Colon Cancer

Burns, Elaine M. BSc (Hons), MBChB, MRCS Clinical Research Fellow; Mayer, Erik K. BSc (Hons), MBChB, MRCS (Eng) Clinical Research Fellow; Faiz, Omar BSc (Hons), MBBS, FRCS, MS Clinical Senior Lecturer and Honorary Consultant Colorectal Surgeon Author Information