Non-colorectal Surgeons Research Articles

Colorectal surgeons and biomedical scientists improve lymph node harvest in colorectal cancer

The aim of this study was to review lymph node retrieval from colorectal cancer resections. We examined consecutive, single colorectal cancers excised between September 1999 and February 2007. Data gathered included patient age and gender, cancer location, total number of lymph nodes and involved lymph nodes identified. The speciality of the operating surgeon was recorded. Whether a pathologist or biomedical scientist was responsible for harvesting lymph nodes from the resected specimen was also noted. A total of 1,194 patients were identified. Increased numbers of lymph nodes identified was associated with increased lymph node positivity (p<0.001, r=0.121). Biomedical scientists identified more lymph nodes (median 15, range 12-20) within specimens than consultant pathologists (median 10, range 7-13; p<0.001). Colorectal surgeons removed more lymph nodes (median 11, range 7-15) than non-colorectal surgeons (median 9, range 7-14; p=0.002). There was a significant increase in lymph node harvesting over time and this correlated with lymph node positivity. Lymph node harvest was significantly higher when the resection was performed by a colorectal surgeon and when the specimen was examined by a biomedical scientist. For accurate staging and consequent correct planning of adjuvant treatment and prognosis, resections should be performed by a colorectal surgeon and the lymph nodes harvested by a biomedical scientist.

A newly devised scoring system for prediction of mortality in patients with colorectal cancer: a prospective study

Postoperative morbidity and mortality from colorectal cancer varies widely across hospitals in the UK. We aimed to assess whether a newly developed score from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) could predict mortality from colorectal cancer surgery as accurately as the Physiology and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), or the ColoRectal POSSUM (CR-POSSUM). We analysed prospectively 618 patients with histologically confirmed colorectal cancer who had surgery to remove primary tumours done by colorectal surgeons or non-colorectal surgeons in a 3-year period. We compared observed mortality with those predicted by the ACPGBI, POSSUM, P-POSSUM, and CR-POSSUM scoring systems using the Hosmer-Lemeshow test and Receiver Operating Characteristic (ROC) curve analysis. Between April 1, 2002, and May 31, 2005, 618 consecutive patients with colorectal cancer had surgery to remove primary tumours. Overall observed 30-day mortality over the 3 years was 10.2% (95% CI 8.0-12.9). Overall predicted mortality (mean score) by use of POSSUM was 12.7% (11.7-13.7), by use of P-POSSUM was 4.4% (3.4-5.4), by use of CR-POSSUM was 9.6% (8.6-10.6), and by use of ACPGBI score was 8.1% (7.3-8.8). POSSUM overpredicted mortality, whereas P-POSSUM underpredicted mortality from colorectal-cancer surgery. CR-POSSUM was a more-accurate predictor of mortality in most analyses than was POSSUM and P-POSSUM. Although CR-POSSUM gave the closest prediction of overall mortality, analyses of subgroups of patients showed that ACPGBI score predicted overall mortality most accurately.

Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease

The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease. Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46.0 per cent) who underwent PRA and 167 (31.0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes. Mortality, surgical and medical complication rates were 4.0, 31.0 and 13.7 per cent respectively after PRA, and 23.4, 53.3 and 40.7 per cent for HP (all P < 0.001). After adjusting for the propensity score, the HP group had a 2.1- and 1.9-fold increase in medical and surgical complications respectively compared with those who had PRA, whereas the operative mortality rate was not significantly different. Non-colorectal surgeons performed a significantly higher proportion of HPs in the non-elective setting than colorectal surgeons (80.6 versus 60.4 per cent; chi(2) = 8.31, 1 d.f., P = 0.004). PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events.

Management of colorectal cancer: variations in practice in one hospital

Aims: The Royal College of Surgeons of England and the Association of Coloproctology of Great Britain and Ireland guidelines for the management of colorectal cancer were published in 1996. We audited our practice against these guidelines.Methods: Data from 211 consecutive patients undergoing colorectal cancer surgery, between September 1999 and September 2000, have been prospectively collected. Preoperative large bowel and liver imaging, assessment by colorectal specialist nurses and median number of lymph nodes resected have been compared between specialist colorectal and non-colorectal surgeons for rectal and colonic cancers. The adequacy of resection and rates of abdomino-perineal resection have been compared for rectal cancers. Following presentation of our findings, we re-audited practice between January and June 2002.Results: There was marked variation in practice within our hospital. Colorectal specialists were more likely to conform to best practice guidelines, performed fewer abdomino-perineal resections and tended to perform more extensive lymphadenectomy. Following presentation of these data, compliance with guidelines was markedly improved and the number of rectal procedures performed by non-colorectal surgeons decreased.Conclusions: The ability of audit to change practice has been demonstrated. We feel that completion of this audit cycle has improved the quality of service we provide for colorectal cancer patients in our hospital.