Specialist Colorectal Surgeons Research Articles

Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England.

To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

An audit of process and outcome for emergency colectomy in England and Wales.

The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age>55years [OR 3.59 (1.05-12.21), P=0.041], female gender [OR 2.88 (1.27-6.52), P=0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P=0.007] were associated with increased mortality. There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.

Preoperative management of locally advanced rectal cancer and the role of restaging MRI: An australasian perspective

Background: Major advances in the management of locally advanced rectal cancer has led to controversies and varying clinical practices among colorectal surgeons, such as patient selection for neoadjuvant therapy and preferred regimen for neoadjuvant therapy. In addition, the role of restaging scans post-neoadjuvant therapy is still poorly established. Objectives: To examine current practice in the preoperative management of locally advanced rectal cancer in Australasia and determine the value of restaging magnetic resonance imaging (MRI). Design: Cross-sectional study (survey). Setting: Specialist colorectal surgeons in Australia and New Zealand. Participants and Methods: A web-based survey was distributed to the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) members between December 2016 and February 2017. Information on demographics, imaging modalities used for staging, indications and choice of neoadjuvant therapy, as well as utility and perceived value of restaging MRI after neoadjuvant therapy was collected. Respondents were given hypothetical scenarios to assess their management decisions based on the findings of restaging MRI scans. Sample Size: 225. Main Outcome Measures: Preferred imaging modalities for staging and restaging of rectal cancer post-neoadjuvant therapy; indications and preferred regimen for neoadjuvant therapy; and utility and perceived value of restaging scans, particularly MRI, Results: Sixty-two (27.6%) CSSANZ members responded. Main neoadjuvant therapy indications included advanced T3 tumors (80.7% for T3c; 83.9% for T3d), T4 tumors (87.1%), nodal metastases (69.4% for N1; 77.4% for N2), and an involved circumferential resection margin (CRM) (95.2%). Long-course chemoradiotherapy was preferred for neoadjuvant therapy (80.6%). The preferred initial-stage imaging modalities were MRI (100%) and computed tomography of chest, abdomen, and pelvis (CT-CAP) (100%). Fifty-six (90.3%) respondents would perform restaging scans post neoadjuvant therapy in selected patients. An involved CRM was frequently identified as a feature on restaging MRI which may affect management (78.6%), with extramural venous invasion (EMVI) (7.1%) or tumor regression grading (TRG) (26.8%) rated less significant. Conclusion: Preoperative management of locally advanced rectal cancer in Australasia is generally consistent with current guidelines. Restaging MRI after neoadjuvant therapy undoubtedly has a role for guiding patient management, but larger prospective studies are warranted to firmly establish their place in daily clinical practice. Limitations: Poor response rate, leading to a small sample size; study population limited to colorectal surgeons in Australasia; and difficult to assess how restaging scans may change management plan. Conflict of Interest: None.

Short term outcomes of emergency colorectal resections performed by colorectal versus non-colorectal specialists

Background: Emergency colorectal surgery is associated with worse outcome than elective. There is evidence that the results colorectal resections are more favourable in the hands of specialist colorectal surgeons, however; it is not clear if this applies specifically to emergency colorectal resections. The aim of this study was to assess whether emergency colorectal resections done by colorectal specialists have lower mortality and morbidity compared with non-colorectal specialists.

Current status of robotic colorectal surgery in Australasia: A questionnaire survey of consultant members of the colorectal surgical society of Australia and New Zealand

Background: There has been considerable interest worldwide in the application of a robotic operating platform in the practice of colorectal surgery. Objective: The aim of this study was to evaluate the current uptake of robotic colorectal surgery in Australia and New Zealand. Design: Survey data were obtained from the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) registry of all specialist colorectal surgeons in Australia and New Zealand. Setting: Specialist colorectal surgeons responded to the survey through e-mail contact via an official e-mail from the CSSANZ. Materials and Methods: A questionnaire was distributed to members of the CSSANZ regarding their current robotic surgical practice. Main Outcome Measures: Volume of and nature of robotic surgery being currently undertaken in Australia and New Zealand, with an emphasis on seeking to understand the surgeon and patient factors that would promote robotic practice and also any factors or barriers in the implementation of robotic colorectal surgery being performed. Sample Size: The sample size was 77. Results: Seventy-seven replies were received from a total of 227 surveys. The response rate is similar to other comparable surveys published when the laparoscopic colorectal era was introduced. Most surgeons performed minimally invasive (laparoscopic) surgery; however, only 29% performed any robotic surgery and 50% of these performed

Emergency stomas; should non-colorectal surgeons be doing it?

The aim of this study was to compare general and stoma specific short term complications in patients having stoma surgery in either an emergency or elective setting during their index hospital stay. It also compares the complications specific to a stoma carried out by surgeons with or without a specialist interest in colorectal surgery. The stoma created in emergency surgery has a high short and long term complication rate. Emergency stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient's quality of life. We retrospectively analysed data for all non-urological stomas created over the last three years in our institute. This covered the period from January 2014 to January 2017. The stoma care department kept a full database record of all patients. Besides demography we analysed the type of stoma i.e. colostomy or ileostomy, indications for the stoma, most common operation, length of stay (LOS) and short term complications based on the Clavien-Dindo classification. We also analysed the perioperative stoma related complications within the emergency cohort. A total of 199 patients had new ostomies created during the three-year period. Four patients died during the inpatient stay and were excluded from the analysis. The total number of stomas created in the emergency cohort was 60 and 135 stomas were elective procedures. The male to female ratio was 1:1.01. The average age for the emergency cohort was 6 years older than for the elective cohort. There was a statistically significant difference in length of stay between the two cohorts (T Test P Value =.02). There was a higher number of elective patients discharged in the first week compared to the emergency surgery patients. The rate of grade 3 or 4 complications was higher in the emergency cohort of patients. The rate of grade 3 or 4 complications was also much higher in patients operated by surgeons who did not have a specialist interest in colorectal surgery. The majority of grade 3 complications seen in the emergency surgery cohort and operated on by non-colorectal specialists (NCS) were stoma related, i.e retraction, necrosis and prolapse. Emergency surgery procedures are frequently bowel related. Emergency stoma surgery should not be taken as trivial procedure, non-colorectal surgeons should take advice and assistance from specialist colorectal surgeons for bowel related cases, particularly when a stoma is involved.

Barriers to the management of obstructed defaecation according to colorectal surgeons.

Obstructed defaecation (OD) has a high prevalence and high disease impact; however, patients often experience suboptimal management. This problem reflects the complex pathophysiology of OD as well as health service delivery factors. This study aimed to identify the factors that act as a barrier to effective management of OD as perceived by specialist colorectal surgeons treating this disorder. A postal questionnaire was administered to a bi-national sampling of colorectal specialists in Australia and New Zealand who were registered with their specialty society. Questions addressed variables relevant in OD management, including clinical access, decision-making, patient factors and surgeon experience and perceptions, and used Likert scales. Statistical analyses compared surgeon practice variables. The response rate was 68.5% (n=113). Most surgeons managed OD (94%), and preferred to treat OD patients themselves (87%); however, 33% of these respondents were dissatisfied with their management, 46% felt they lacked management expertise and 33% stated they had inadequate expertise in OD investigations. Clinical investigation services were more limited in private than public practice, and many surgeons lacked access to biofeedback (31%). Other barriers included heterogeneity in decision-making by surgeon age and practice location (P<0.05), dual pathologies (e.g. irritable bowel syndrome) and psychological factors, and limited uptake of multidisciplinary services and standardized (Rome) diagnostic criteria. Barriers to OD management include surgeon-specific factors, patient-specific factors and healthcare access factors. Increased utilization of pelvic floor and multidisciplinary services, increased training and standardization of OD investigations and improved access to specialist investigations and allied-health management services could improve outcomes for OD.

PWE-257 Establishing a tertiary referral service for patients with locally advanced and recurrent rectal cancer

Introduction The management of patients with locally advanced rectal cancer (LARC) and recurrent rectal cancer (RRC) (collectively referred to as Beyond TME rectal cancer) presents particular surgical challenges. It has been shown that, in carefully selected patients in centres specialising in their treatment, surgical resection can result in good outcomes. We present results from our unit, establishing a tertiary referral centre for LARC and RRC in the West Midlands, UK. The team, set up after a number of its members had worked in other high volume units, comprises specialist colorectal surgeons, radiologists, pathologists, urologists, oncologists and full MDT staff. Referrals are received through the MDT from other units within the West Midlands. Method A prospective database was set up to collect data on all referrals received for LARC and RRC. Demographic, radiological and histological data was recorded. Length of stay, short and medium term morbidity, and long-term outcome, including recurrence, were all analysed. Results A total of 34 referrals were received from October 2011 to December 2014. 7 patients were declined surgery based upon anatomical factors (e.g. extensive pelvic sidewall involvement), whilst 25 patients went on to have surgery (2 further patients’ surgery pending). Of those operated, M: F ratio 19:6 and median age was 60 years old. Surgery was for LARC (n = 11) and RRC (14). Surgery involved multi-visceral resection, according to the anatomical distribution of disease. Histology results for resection margins showed R0=19, R1=5, and R2=1. Median length of stay was 11 days. Median follow up was 12 months with 5 patients found to have further recurrence (2 R1 and 3 R0). Post-op complications were limited to 2 patients with wound infections managed with dressings, and one patient who developed hospital acquired pneumonia. One patient required nephrostomy in the post op period for ureteric stenosis on the contralateral side to a re-implanted ureter. 4 patients died within the follow up period and were all known to have recurrence. Conclusion Our initial results have shown acceptable outcomes for patients in terms of short-term morbidity and recurrence when compared to more established centres. The management of patients with LARC and RRC involves complex decision-making processes and challenging surgery. We believe this requires specialist input. As such, establishing a specialist referral unit for these cases is achievable and important in improving outcomes for this group of patients. Disclosure of interest None Declared.

The impact of surgical specialisation on survival following elective colon cancer surgery.

Reorganisation of cancer services in the UK and across Europe has led to elective surgery for colon cancer being increasingly, but not exclusively, delivered by specialist colorectal surgeons. This study examines survival after elective colon cancer surgery performed by specialist compared to non-specialist surgeons. Patients undergoing elective surgery for colon cancer in 16 hospitals between 2001 and 2004 were identified from a prospectively maintained regional audit database. Post-operative mortality (<30 days) and 5-year relative survival in those receiving surgery under the care of a specialist or non-specialist surgeon were compared. A total of 1,856 patients were included, of which, 1,367 (73.7%) were treated by a specialist and 489 (26.4%) by a non-specialist surgeon. Those treated by a specialist were more likely to be deprived, undergo surgery in a high volume unit and have higher lymph node yields than those treated by a non-specialist. Post-operative mortality was lower (4.5 versus 7.0%; P = 0.032) and 5-year relative survival was higher (72.2 versus 65.6%; P = 0.012) among those treated by a specialist surgeon. In multivariate analysis, surgery by non-specialists was independently associated with increased post-operative mortality (adjusted odds ratio (OR) 1.69; P < 0.001) and poorer 5-year relative survival (adjusted relative excess risk (RER) 1.17; P = 0.045). After exclusion of post-operative deaths, there was no difference in long-term survival (adjusted RER 1.08; P = 0.505). Five-year relative survival after elective colon cancer surgery was higher among those treated by specialist colorectal surgeons due to increased post-operative mortality among those treated by non-specialists.

All-cause 30-day postoperative mortality for older patients in highly developed countries having elective colorectal surgery: a systematic review

Background Death after surgery is an acknowledged outcome reflecting the safety of a procedure. Death rates after surgery are not often routinely collected, therefore mortality rates can be difficult to quantify. Colorectal surgery is increasingly offered to older patients. The likelihood of postoperative adverse outcomes (including death) may impact decision-making at individual, institutional or health care system levels. Objectives The objective of this review was to provide an estimate of the prevalence of all-cause 30-day postoperative mortality for older patients in highly developed countries undergoing elective colorectal surgery. Inclusion criteria Types of participants This review considered studies and reports that included patients aged 65 years and over from highly developed countries undergoing elective colorectal surgical resection. Only studies from countries with a very high Human Development Index were included. Types of interventions Studies and reports including patients having colorectal resection with or without anastamosis were included. Types of studies This review considered experimental, analytical and descriptive epidemiological study designs, including randomized controlled trials, prospective and retrospective cohort studies, case series and cross sectional studies and reports. Only studies with a minimum sample size of 150 were included. Types of outcomes This review included studies and reports that included rates of 30-day all-cause postoperative mortality. Search strategy A three-step search strategy was used in order to find published and unpublished studies and reports in the English language from 1998 to 2013. Databases searched were PubMed, Embase, Scopus, Web of Science, CINAHL, The Cochrane Central Register of Controlled Trials and the website of The Cochrane Colorectal Cancer Group. A search of the grey literature was performed, and hand searching of all retrieved articles was undertaken to identify additional studies or reports. Methodological quality Studies or reports which met the inclusion criteria were critically appraised by two independent reviewers for methodological quality using the standardized Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Any disagreements between reviewers were resolved by a third reviewer. Data collection Data was extracted from the included studies or reports using a standardized data extraction tool. The tool included details of the study type, the dates covered by the interventions, the setting and model of care, the indication for, as well as the precise intervention(s), the population age range and level of comorbidity, the outcome measure of significance to the systematic review question, and whether the study or report included any qualitative assessment of the safety or acceptability of the surgical outcome. Data synthesis Outcomes for the population of interest were identified and outcome rates over time were analysed. Sub-group analysis was undertaken for mortality rates for age groups 70 years and over, 75 years and over, and 79 years and over. Outcomes were reported separately for countries and regions. Outcome data was reported separately according to the population studied (national-level data, and also data from academic and non-academic centres). Other comparisons examined separately included laparoscopic surgery and open surgery, cancer and non-cancer surgery, rectal and colonic surgery, surgery involving only specialist colorectal surgeons and surgery where non-specialist colorectal surgeons were involved, and surgery where “enhanced recovery” models of care were identified. Any qualitative assessment of the safety or acceptability of surgical outcome was reported. Results Twenty-four studies were included in the review. Studies were reported in a range of surgical, medical and educational publications. Twenty-three of the studies were observational. Explicit postoperative mortality rates were often difficult to identify, and data was obtained through direct author contact. Postoperative mortality rates reported and discovered ranged from 0.57-11.3%. The pooled 30-day postoperative mortality rate for all patients across all included studies was 5.34%. TRUNCATED AT 600 WORDS

The First 1000 Patients on an Internet-based Colorectal Neoplasia Database Across Private and Public Medicine in Australia

Collection of multi-institutional data pertaining to the treatment of bowel cancer has been hindered by poor clinician compliance with data entry and the lack of incentive to participate. This study aimed to establish if a novel browser-based model of data collection results in complete data capture. A Web-based data collection interface was custom written, offering automated reporting modules for clinical outcome to participants and an automated reporting system for outstanding data fields, and summary reporting of surgical quality outcomes. The software was combined with a clinical feedback system incorporating fortnightly data review meetings, at the time of clinical multidisciplinary meetings. Selected were 932 consecutive patients with opt-out consent from 3 hospital sites, including public and private medicine. The primary outcomes measured were the analysis of data completeness and accuracy and ensuring that the highest-quality data were used for clinical audit of the surgical practices of Australian colorectal surgeons for the purpose of quality assurance. A total of 932 men and women, 22 to 94 years of age, treated for colorectal neoplasia were evaluated. We obtained 100% completion (>27,000 data points) of perioperative data registered by 8 specialist colorectal surgeons and a full-time database manager. Data completeness and validity are essential for clinical databases to serve the purpose of quality assurance, benchmarking, and research. The results confirm the safety and efficacy of colorectal cancer surgery in both the public and private sector in Australia. The combination of a simple multiuser interface, defined data points, automated result-reporting modules, and data-deficiency reminder module resulted in 100% data compliance in nearly 1000 clinical episodes. The unprecedented success of this model has lead to the Colorectal Surgical Society of Australia and New Zealand adopting this model for data collection for Australia and New Zealand as the binational database.

The impact of the specialist colorectal surgeons in management of emergency right colon cancer

The impact of the specialist colorectal surgeons in management of emergency right colon cancer

Modern management of colorectal cancer

Colorectal cancer affects approximately 1:20 of the population and in South Africa is largely managed by general surgeons. Management of this disease has undergone very significant changes over the last two decades. Until very recently, only two academic general surgery departments included a specialist colorectal unit, and this remains so in the majority of our universities. This has resulted in a generation of surgical graduates who are unfamiliar with, and unskilled in current best management practices for this disease. Rectal cancer is particular challenging and attracts extremely high morbidity and mortality, with poor oncological outcomes. Repeatedly, outcome has been shown to be worse in the hands of generalists, rather than specialist colorectal surgeons, of whom there are very few in the country. This review presents the most important advances of the last 20 years and highlights current controversies and frontiers.

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection. A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained. Four hundred and twenty-four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection. Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.

Complications as indicators of quality assurance after 401 consecutive colorectal cancer resections: the importance of surgeon volume in developing colorectal cancer units in India

BackgroundThe low incidence of colorectal cancer in India, coupled with absence of specialized units, contribute to lack of relevant data arising from the subcontinent. We evaluated the data of the senior author to better define the requirements that would enable development of specialized units in a country where colorectal cancer burden is increasing.MethodsWe retrospectively analyzed data of 401 consecutive colorectal resections from a prospective database of the senior author. In addition to patient demographics and types of resections, perioperative data like intraoperative blood loss, duration of surgery, complications, re-operation rates and hospital stay were recorded and analyzed.ResultsThe median age was 52 years (10-86 years). 279 were males and 122 were females. The average duration of surgery was 220.32 minutes (range 50 - 480 min). The overall complication rate was 12.2% (49/401) with a 1.2% (5/401) mortality rate. The patients having complications had an increase in their median hospital stay (from 10.5 days to 23.4 days) and the re-operation rate in them was 51%. The major complications were anastomotic leaks (2.5%) and stoma related complications (2.7%).ConclusionsThis largest ever series from India compares favorably with global standards. In a nation where colorectal cancer is on the rise, it is imperative that high volume centers develop specialized units to train future specialist colorectal surgeons. This would ensure improved quality assurance and delivery of health care even to outreach, low volume centers.

Low abdominoperineal excision rates are associated with high-workload surgeons and lower tumour height. Is further specialization needed?

Wide variation, independent of disease extent and case mix, has been observed in the rate of use of abdominoperineal excision (APE) for rectal cancer. Previous analyses have, however, been confounded by failure to adjust for the location of the tumour within the rectum. This population-based study sought to examine whether variations in tumour height explained differences in APE use. Information was obtained on all individuals who underwent a major resection for a rectal tumour diagnosed between 1998 and 2005 across the Northern and Yorkshire regions of the UK. Median distances from the dentate line were calculated for all tumours excised by APE and compared with rates of use of APE between specialists and nonspecialist surgeons and across hospital trusts. The completeness of pathological reporting of height of tumour within the rectum was variable. A low rate of APE use was associated with a lower median distance of tumours from the dentate line. Specialist colorectal cancer surgeons performed fewer APEs on patients with a tumour located lower in the rectum than nonspecialist surgeons. Variations in the height of tumour did not explain the variation in APE use. Specialist high-volume surgeons undertook fewer APEs and those they performed were closer to the dentate line than low-volume nonspecialist surgeons.

Family history? The forgotten question in high‐risk colorectal cancer patients

The aim of the study was to investigate the frequency and detail of family history recorded for patients diagnosed with potentially high-risk colorectal cancer, and to determine the proportion of these patients referred to a high-risk assessment clinic. Medical records of patients diagnosed with colorectal cancer under the age of 50 admitted to a major Sydney teaching hospital were reviewed. The proportion of records containing information about family history was calculated. Associations between recording of family history and demographic and clinical characteristics of patients were investigated. Logistic regression modelling was performed to identify significant, independent predictors of study outcomes. Of 113 patients with colorectal cancer diagnosed under the age of 50 years, 61 (54%, 95% CI: 44-63%) had an entry in their hospital medical record about family history. Family history was significantly less likely to be recorded for females, for those admitted via the Emergency Department, and for those with shorter lengths of stay. A significant family history was found in 51% of the 61 patients who had a family history recorded. Records of patients attending specialist colorectal surgeons were significantly more likely to contain information about family history than those who attended other specialists (P = 0.04). Only 14 patients (12%, 95% CI: 7-20%) were formally referred for further genetic assessment. These results suggest that family history is still being neglected in routine clinical practice, and high-risk assessment services are underutilized, implying the need for further dissemination of guidelines with regard to the recognition and management of hereditary colorectal cancer.

Outcome after Emergency Surgery for Acute Perforated Diverticulitis in 200 Cases

Background: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either by resection with primary anastomosis (PA) or Hartmann’s procedure (HP). Methods: A multicenter study was carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis Index (MPI), Hinchey score, surgeon’s experience, and the time of operation. Results: There was a tendency for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure. Conclusion: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient’s concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

The impact of surgeon and pathologist on lymph node retrieval in colorectal cancer and its impact on survival for patients with Dukes’ stage B disease

An adequate lymph node harvest is necessary for accurate Dukes' stage discrimination in colorectal cancer. The aim of this study is to identify the effect of variables, including the individual surgeon and pathologist, on lymph node harvest in a single institution. Three hundred and eighty one consecutive patients had resection for colorectal cancer, in a single unit. Factors influencing lymph node retrieval, including individual surgeon and reporting pathologist, were subjected to uni- and multivariate analysis. Actuarial survival of all patients with Dukes' stage B and C disease was then calculated and survival compared between Dukes' stage B and C at differing levels of lymph node harvest. The unit median lymph node harvest was 13 nodes/patient (95% CI 13.1-14.5). There was no difference in lymph node harvest between specialist colorectal surgeons and the pooled results of four nonspecialist consultant surgeons. However, there was a significant difference between reporting pathologists (P < 0.001). On univariate analysis, operation type, operative urgency, Dukes' stage, T-stage, reporting pathologist and use of neoadjuvant therapy in rectal cancer, were found to significantly affect lymph node retrieval. On multivariate analysis, operation type, T-stage, reporting pathologist and neoadjuvant therapy in rectal cancer remained significant variables. Patients with one or more lymph node metastasis had greater nodal harvests than those without (median 15 vs 12 P = 0.02). Survival of patients with Dukes' stage B disease was found to improve as lymph node harvest increased. Overall lymph node harvest, in this unit, varied according to the reporting pathologist but not operating surgeon. As lymph node harvest increased to 15 per patient, the probability of identifying a metastatic node increased.

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.