St Mark's Hospital Research Articles

Survival and CT defined sarcopenia in patients with intestinal failure on home parenteral support

Sarcopenia occurs in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to describe the prevalence of sarcopenia in a section of our IF population using LSMI, & evaluate the effect of home parenteral support (PS) on LSMI & survival. Additionally, we aim to assess any association between LSMI, BMI & other anthropometric measurements. IF patients on PS treated at St Mark's Hospital between 1/1/2006-1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on PS & had 2 CTs: the first ≤30 days before start of HPN (pre-PS); the second ≥100 days from PS start (post-PS). Patient records were reviewed to obtain clinical & demographic information & date of death. Anthropometric measurements & BMI contemporaneous to CT scans were recorded. 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean (SD) pre-PS LSMI was 36.5 (6.8)cm2/m2. Mean BMI pre-PS was 22.1 (4.8) kg/m2. Both BMI (22.1kg/m2 to 23.5kg/m2) p<0.001) & LSMI (36.5cm2/m2 to 38.4cm2/m2) (p=0.003) increased post-PS. A positive correlation was seen between BMI & LSMI pre (r=0.47 p<0.001) & post-PS (r=0.37 p=0.003). No correlation was seen between LSMI & anthropometric measurements pre-PS (p=0.78) or post-PS (p=0.96). 11 (17%) patients died during the study period; a low LSMI pre-PS was not a risk factor for mortality (HR 0.97 p=0.55). This study is the first to look at sarcopenia & survival using CT defined LSMI (CT-LSMI) in the IF population. 83% of our cohort had a pre-PS LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI & survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI & BMI improved following PS but demonstrated that other anthropometric measurements had poor correlation with LSMI & showed no significant improvement overall after PS, confirming the known problems of inter-operator & patient variability of these measurements. Whilst we found significant correlation between LSMI & BMI, BMI significantly underestimated the presence & degree of sarcopenia. LSMI has the potential to provide an objective & reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes & utility in clinical decision making.

The impact of chromoendoscopy for surveillance of the duodenum in patients with MUTYH-associated polyposis and familial adenomatous polyposis

Duodenal polyposis and cancer have become a key issue for patients with familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP). Almost all patients with FAP will develop duodenal adenomas, and 5% will develop cancer. The incidence of duodenal adenomas in MAP appears to be lower than in FAP, but the limited available data suggest a comparable increase in the relative risk and lifetime risk of duodenal cancer. Current surveillance recommendations, however, are the same for FAP and MAP, using the Spigelman score (incorporating polyp number, size, dysplasia, and histology) for risk stratification and determination of surveillance intervals. Previous studies have demonstrated a benefit of enhanced detection rates of adenomas by use of chromoendoscopy both in sporadic colorectal disease and in groups at high risk of colorectal cancer. We aimed to assess the effect of chromoendoscopy on duodenal adenoma detection, to determine the impact on Spigelman stage and to compare this in individuals with known pathogenic mutations in order to determine the difference in duodenal involvement between MAP and FAP. A prospective study examined the impact of chromoendoscopy on the assessment of the duodenum in 51 consecutive patients with MAP and FAP in 2 academic centers in the United Kingdom (University Hospital Llandough, Cardiff, and St Mark's Hospital, London) from 2011 to2014. Enhanced adenoma detection of 3 times the number of adenomas after chromoendoscopy was demonstrated in both MAP (P= .013) and FAP (P= .002), but did not affect adenoma size. In both conditions, there was a significant increase in Spigelman stage after chromoendoscopy compared with endoscopy without dye spray. Spigelman scores and overall adenoma detection was significantly lower in MAP compared with FAP. Chromoendoscopy improved the diagnostic yield of anomas in MAP and FAP 3-fold, and in both MAP and FAP this resulted in a clinically significant upstaging in Spigelman score. Further studies are required to determine the impact of improved adenoma detection on the management and outcome of duodenal polyposis.

Post-imaging colorectal cancer or interval cancer rates after CT colonography: a systematic review and meta-analysis

CT colonography is highly sensitive for colorectal cancer, but interval or post-imaging colorectal cancer rates (diagnosis of cancer after initial negative CT colonography) are unknown, as are their underlying causes. We did a systematic review and meta-analysis of post-CT colonography and post-imaging colorectal cancer rates and causes to address this gap in understanding. We systematically searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. We included randomised, cohort, cross-sectional, or case-control studies published between Jan 1, 1994, and Feb 28, 2017, using CT colonography done according to international consensus standards with the aim of detecting cancer or polyps, and reporting post-imaging colorectal cancer rates or sufficient data to allow their calculation. We excluded studies in which all CT colonographies were done because of incomplete colonoscopy or if CT colonography was done with knowledge of colonoscopy findings. We contacted authors of component studies for additional data where necessary for retrospective CT colonography image review and causes for each post-imaging colorectal cancer. Two independent reviewers extracted data from the study reports. Our primary outcome was prevalence of post-imaging colorectal cancer 36 months after CT colonography. We used random-effects meta-analysis to estimate pooled post-imaging colorectal cancer rates, expressed using the total number of cancers and total number of CT colonographies as denominators, and per 1000 person-years. This study is registered with PROSPERO, number CRD42016042437. 2977 articles were screened and 12 studies were eligible for analysis. These studies reported data for 19 867 patients (aged 18-96 years; of 11 590 with sex data available, 6532 [56%] were female) between March, 2002, and May, 2015. At a mean of 34 months' follow-up (range 3-128·4 months), CT colonography detected 643 colorectal cancers. 29 post-imaging colorectal cancers were subsequently diagnosed. The pooled post-imaging colorectal cancer rate was 4·42 (95% CI 3·03-6·42) per 100 cancers detected, corresponding to 1·61 (1·11-2·33) post-imaging colorectal cancers per 1000 CT colonographies or 0·64 (0·44-0·92) post-imaging colorectal cancers per 1000 person-years. Heterogeneity was low (I2=0%). 17 (61%) of 28 post-imaging colorectal cancers were attributable to perceptual error and were visible in retrospect. CT colonography does not lead to an excess of post-test cancers relative to colonoscopy within 3-5 years, and the low 5-year post-imaging colorectal cancer rate confirms that the recommended screening interval of 5 years is safe. Since most post-imaging colorectal cancers arise from perceptual errors, radiologist training and quality assurance could help to reduce post-imaging colorectal cancer rates. St Mark's Hospital Foundation and the UK National Institute for Health Research via the UCL/UCLH Biomedical Research Centre.

Developing nursing leadership and specialist skills: the Burdett scholarship

Evidence-based post-registration education can greatly benefit nursing careers. The cost of continuing professional development can be prohibitive, but grants, bursaries and scholarships are available to support nurses. The Burdett Trust for Nursing established a specialist scholarship for gastrointestinal nurses. Each cohort of two scholars rotates through the specialist departments at St Mark's Hospital, London, a tertiary referral centre for intestinal and colorectal care. They also complete a residential degree-level course in stoma care, as well as specialist master classes and study days. Leadership skills and professional clinical competencies are central to the curriculum. Two previous Burdett scholars give their personal perspective on how the programme has improved their skills, confidence and career trajectories.

Use of two annual self-referral reminders and a theory-based leaflet to increase the uptake of bowel scope screening among former non-participants in London, UK: results from a randomised controlled trial

BackgroundUptake of the English Bowel Scope Screening (BSS) Programme is below the European target for acceptable participation, so that less than half of eligible adults currently benefit from the test. The aim of this study was to test the effectiveness of two self-referral reminders and a theory-based leaflet to improve uptake among former non-participants. MethodsWe performed a single-blind randomised controlled trial with three parallel arms at St Mark's Hospital, London, UK. Eligible adults were men and women who did not attend a BSS appointment at the centre within 12 months of their initial invitation. Individuals were randomised (1:1:1 ratio with simple pseudo-random allocation methods) to receive no reminder as per usual care (control), a self-referral reminder and standard information booklet (Rem-SIB), or a self-referral reminder and theory-based leaflet designed to address barriers to uptake (Rem-TBL). Individuals in both reminder groups were re-sent the self-referral reminder (with the allocated leaflet) if they had not taken part in screening within 24 months of their initial invitation. The primary outcome of the study was the proportion screened within each group 12 weeks after the delivery of the second self-referral reminder. The sample size was calculated with a standard test of difference between proportions. Analysis was by intention to treat with multivariable logistic regression on SPSS (version 24.0), with Bonferroni corrections to account for multiple comparisons. The study was approved by the Northeast Tyne and Wear South Research Ethics Service (Ref: 15/NE/0043). This trial is registered with the ISRCTN registry, number ISRCTN44293755. Findings1383 adults were randomised to control (461), Rem-SIB (461), and Rem-TBL (461). Uptake was 0·7% (n=3), 14·5% (67), and 21·5% (99), respectively. Individuals in the Rem-SIB and Rem-TBL groups were significantly more likely to attend screening than individuals in the control group (adjusted odds ratio 26·1, 95% CI 8·1–84·0; p<0·0001 vs 46·9, 14·7–149·9; p<0·0001). Individuals in the Rem-TBL group were also significantly more likely to attend screening than individuals in the Rem-SIB group (1·87, 1·3–2·6; p=0·001). InterpretationReminders that targeted non-participants improved uptake, and use of theory-based information added substantially to this strategy. Further research is needed to test whether the findings apply outside the study setting. FundingSt Mark's Hospital, Cancer Research UK

Development of a nurse-led paediatric inflammatory bowel disease service

The incidence of paediatric-onset inflammatory bowel disease (IBD) is increasing, and treatment pathways are becoming more complex. Therefore, it is necessary to develop services that are able to manage these patients appropriately with consideration of national and international guidelines. It is important to recognise children are not just small adults and their needs are different to adult patients with IBD. This article discusses the process of establishing a paediatric IBD service at Northwick Park Hospital with the support of the adult IBD nursing service at St Mark's Hospital. Both hospitals are co-located on the same site as part of the London Northwest Healthcare Trust. The new role was designed to be managed jointly by the paediatric matron and adult IBD lead nurse to ensure the appropriate aspects of both specialties were reflected in the new service.

Intimacy for patients with a stoma.

Jennie Burch, Enhanced Recovery Nurse Facilitator, St Marks Hospital, Middlesex, looks at what nurses can do to support patients after stoma formation in relation to body image and intimacy.

PTU-106 Improved Survival and Independance from Parental Nutrition for Patients with Intestinal Dysmotility

Introduction Patients receiving home parental nutrition (HPN) for intestinal dysmotility have a poor 5 years survival of 68% and independence from HPN at 5 years of 12% (Lloyd et al. 20061). Only abdominal malignancy patients fared worse. We aimed to compare the same outcomes, at the same centre 10 years since this study to see if changes in practice had impacted these outcomes. Methods An institutional database of patients referred to the Leonard Jones Intestinal Failure Unit at St Marks Hospital was interrogated for patients who started HPN between 1/1/04-1/10/15 and had the primary cause of their intestinal failure recorded as ‘dysmotility’ or ‘other’. The discharge and outpatient letters of those patients were inspected. Patients were excluded if there was any mechanical obstruction, IBD or coeliac disease prior to starting HPN or insufficient clinical information to rule these out. Measured outcomes were survival, intestinal transplant and independence from HPN. Results 159 patients were identified as potentially having dysmotility. 91 were excluded because dysmotility was not the primary cause of the intestinal failure or there was insufficient information, leaving 68 for the final analysis. The median age of this cohort was 39 years (range 16–78) and 19% were male. In total there were 471.2 years of follow up since starting HPN (median 4.4 (range 0.03–26.9)). 21 patients (31%) had a bowel resection before starting HPN. Overall survival 91%, (n = 62, 5 died on HPN, 1 off HPN), intestinal transplant 4% (n = 3, all successful), 29% (n = 17) were independent of HPN. 5 year outcomes were available for 18 patients. Survival at 5 years was 84% and independence from HPN was 40%. There were no transplants in this group. 23 patients had a diagnosis of chronic intestinal pseudo-obstruction (CIPO), 18 primary and 5 secondary, median follow up was 4.2 years. Overall survival was 91% and independence from HPN was 40%. 4 had positive histological diagnosis of neuropathy and 4 of myopathy. Both secondary CIPO (n = 5) and neuropathic bowel (n = 4) were predictive of independence from HPN compared to other dysmotility diagnoses, secondary CIPO odds ratio 0.03 (95%CI 0.0015–0.6, p Conclusion Our recent data implies improved outcomes on HPN for patients with dysmotility, particularly patients with secondary CIPO. This may be due to advances in treatment of underlying conditions. Reference 1 Lloyd DA, Vega R, Bassett P, Forbes A, Gabe SM. Survival and dependence on home parenteral nutrition: experience over a 25-year period in a UK referral centre. Alimentary Pharmacol Ther 2006;24:1231–40 Disclosure of Interest None Declared

The use of flange extenders to support patient care.

Pat Black, Senior Lecturer, St Mark's Institute of GI Nursing, St Mark's Hospital, explores one option for stoma care nurses to consider that could help improve patient confidence and comfort.

Frequency and Features of Duodenal Adenomas in Patients WithMUTYH-Associated Polyposis.

MUTYH-associated polyposis (MAP) is similar to familial adenomatous polyposis (FAP), in that it increases the risk for duodenal adenomas and cancer. Almost all patients with FAP develop duodenal adenomas and 5% develop duodenal cancer. Little is known about the prevalence of duodenal adenomas and cancer in patients with MAP, but current surveillance recommendations are the same for patients with FAP-they should begin surveillance when they are 25 years old. We aimed to assess the prevalence, extent, and progression of duodenal adenomas in patients with MAP and evaluate upper gastrointestinal tract surveillance recommendations. In a retrospective study, we collected data on all patients (n= 92) with MAP undergoing surveillance esophagogastroduodenoscopy from registries at St Mark's Hospital (London, UK) and the Academic Medical Center (Amsterdam, The Netherlands) from 2002 through 2014. We collected information on adenoma development, age at adenoma detection, interventions, and disease progression. Duodenal adenomas were detected in 31 patients (34%), at a median age of 50 years. When duodenal polyposis first was detected, it was Spigelman stages I or II in 84% of patients; most had few small polyps, without high-grade dysplasia or villous features. Subsequent esophagogastroduodenoscopy evaluation of 18 of these patients found that 14 (78%) had Spigelman stages 0 to II disease (median follow-up period, 7.8 y). Disease progressed in stage in 6 patients, over 9.5 years, because of lesion size or villous features (2 reached stage IV disease). Adenomas were down-staged in 8 patients after biopsy or polypectomy analyses, and were unchanged for 3 patients. In a data analysis from 92 patients with MAP, duodenal polyposis seemed to develop less frequently than in patients with FAP, and developed at a later age. Increasing lesion size and villous change appear to promote adenoma progression, rather than polyp number or dysplasia. It may be time to consider a new staging system for patients with MAP, to better determine disease severity and surveillance strategies.

Low-grade dysplasia in ulcerative colitis: risk factors for developing high-grade dysplasia or colorectal cancer.

OBJECTIVES:The aim of this study was to identify risk factors associated with development of high-grade dysplasia (HGD) or colorectal cancer (CRC) in ulcerative colitis (UC) patients diagnosed with low-grade dysplasia (LGD).METHODS:Patients with histologically confirmed extensive UC, who were diagnosed with LGD between 1993 and 2012 at St Mark's Hospital, were identified and followed up to 1 July 2013. Demographic, endoscopic, and histological data were collected and correlated with the development of HGD or CRC.RESULTS:A total of 172 patients were followed for a median of 48 months from the date of initial LGD diagnosis (interquartile range (IQR), 15–87 months). Overall, 33 patients developed HGD or CRC (19.1% of study population; 20 CRCs) during study period. Multivariate Cox proportional hazard analysis revealed that macroscopically non-polypoid (hazard ratio (HR), 8.6; 95% confidence interval (CI), 3.0–24.8; P<0.001) or invisible (HR, 4.1; 95% CI, 1.3–13.4; P=0.02) dysplasia, dysplastic lesions ≥1 cm in size (HR, 3.8; 95% CI, 1.5–13.4; P=0.01), and a previous history of “indefinite for dysplasia” (HR, 2.8; 95% CI, 1.2–6.5; P=0.01) were significant contributory factors for HGD or CRC development. Multifocal dysplasia (HR, 3.9; 95% CI, 1.9–7.8; P<0.001), metachronous dysplasia (HR, 3.5; 95% CI, 1.6–7.5; P=0.001), or a colonic stricture (HR, 7.4; 95% CI, 2.5–22.1; P<0.001) showed only univariate correlation to development of HGD or CRC.CONCLUSIONS:Lesions that are non-polypoid or endoscopically invisible, large (≥1 cm), or preceded by indefinite dysplasia are independent risk factors for developing HGD or CRC in UC patients diagnosed with LGD.

Management of tailgut cysts in a tertiary referral centre: a 10-year experience.

Tailgut cysts are rare congenital lesions typically presenting as presacral masses. A variable clinical presentation often leads to misdiagnosis and unsuccessful operations. A retrospective analysis was performed of tailgut cysts presenting to one surgeon at St Mark's hospital between 2003 and 2013. The patient demographic data and clinicopathological and radiological features, together with perioperative details and recurrence, were reviewed. A total of 17 patients (15 women) with a median age of 35 (21-64) years were included in the study. The mean duration of symptoms before referral was 40 months, with sepsis predominating in 12 cases. Fifteen of the patients had previously undergone surgery (mean 2.9 procedures). A posterior surgical approach was adopted in all patients with a coccygectomy performed in 13. A loop colostomy was formed in three patients. Two of them went on to have a secondary pull-through operation after an initial failed local repair of rectal injury. One case was reported to show malignant degeneration on histological examination. There was one recurrence during a median follow-up period of 13 (3-36) months. Tailgut cysts are an uncommon yet important cause of chronic perianal sepsis. Suspicion should be raised in a patient, usually female, presenting with a history of unsuccessful procedures. Diagnosis can be made by clinical assessment and MRI. Complete excision usually resolves the problem.

Factors Associated With Efficacy of Nurse-led Bowel Training of Patients With Chronic Constipation

It is not clear whether nurse-led bowel training (NBT), an individually tailored biofeedback strategy designed to improve the physiological process of defecation by operant conditioning and trial and error learning, is effective for patients with chronic constipation. We assessed the ability of NBT to reduce symptoms and increase quality of life in patients with constipation at a large tertiary medical center. We performed a retrospective analysis of data from 347 patients (median age, 50 years) who underwent a median 3 sessions of NBT for chronic constipation from January 2011 through December 2013 at St Marks Hospital in the United Kingdom. The NBT comprised a combination of sensory retraining, pelvic floor conditioning, and advice on diet and toileting behavior. Data on patient demographics (age, sex, type of constipation) were collected alongside their assessments of constipation, which were based on Patient Assessment of Constipation Quality of Life (PAC-QoL) and patient satisfaction scores. We performed binary logistic regression analysis. Each variable was tested first at the univariate level; those with significance (P < .10) were included in a multivariate model. At the end of NBT, 62.5% of the patients (217/347) reported reduced symptoms, and 40.2% of the patients (41/102) reported a reduction of at least 1 point on the PAC-QoL score. The mean PAC-QoL scores before and after NBT were 2.42 and 1.41, respectively (P = .001). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.02-2.87; P = .042), greater number of sessions (OR, 4.14; 95% CI, 2.09-8.20; P < .001), and non-irrigation (OR, 4.39; 95% CI, 1.89-10.19; P = .001) were independent predictors of patient satisfaction. Data collected immediately after patients with chronic constipation received NBT indicate that it is an effective treatment for most patients. Older patients with dyssynergic defecation benefit most from at least 4 sessions.

PTH-218 The effects of home parenteral nutrition on occupation

<h3>Introduction</h3> Home parenteral nutrition (HPN) has been shown in previous studies to reduce the quality of life¹of those receiving it. An essential part of life that provides meaning, financial security and community is occupation. The effect of HPN on a recipient’s occupation has not been looked at in detail before. This study sets out to ascertain the effect of HPN on occupation and the factors that influence a patient’s occupational status on HPN. <h3>Method</h3> We developed a questionnaire with questions about occupational status before and after starting HPN, type of work, motivation for returning to work and if HPN had impacted on their ability to work. This was completed at the outpatient clinic and also sent to patients to complete as a web-based questionnaire. The information was then compiled onto a database. The questionnaire has, so far, been carried out among patients from St Marks Hospital in London and Glasgow Royal Infirmary. <h3>Results</h3> There were 70 respondents in total (M:F 32:38, mean age 55 [20–80] years). Before starting HPN 73% patients were working, 11% were unemployed and 16% were retired; however, on HPN only 34% remained in work. The type of work was also different among those who did work with 79% in full time employment prior to HPN as well as 18% part time and 3% volunteering. Post HPN there was 42% in full time, 33% part time and 25% volunteering. The most common reason given for HPN treatment to impinge on the ability to work was ‘time needed to be on it’ (36%), ‘restricts how far from apparatus they can go’ (19%), ‘tiring’ (14%), ‘risk of complications’ (10%) and 12% stated it had ‘no impact’. For patients over 45, 91% worked prior to HPN and 49% afterwards (excluding those already retired). In patients under45, 71% worked before (bearing in mind some were under 18 before HPN) and 57% worked afterwards. In regard to gender, 43% of men (excluding those already retired) worked after HPN and only 39% of women. <h3>Conclusion</h3> Whilst HPN is an exceptionally successful treatment it does undoubtedly limit a person’s ability to work. The extent to which HPN restricts the ability to work is more pronounced in some groups such as the over 45s. How it limits the ability to work differs greatly in patients and is very subjective to the individual patient. However, identifying more common areas of difficulty opens up the opportunity to discuss these with patients and endeavour to take measures that counteract these difficulties. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Winkler MF. Quality of life in adult home parenteral nutrition patients. <i>J Parent Enteral Nutr. </i>2005;29(3):162–70. http://www.ncbi.nlm.nih.gov/pubmed/15837775(accessed 23rd April 2014)

The impact of anastomotic leak and its treatment on cancer recurrence and survival following elective colorectal cancer resection.

Anastomotic leakage is a serious complication in restorative colorectal surgery. Anastomotic leakage and its subsequent management may have long-term impact on survival. This study aims to assess the impact of colorectal anastomotic leak (AL) on overall survival (OS) and disease-free survival (DFS). A prospective database of 1,048 patients undergoing restorative colorectal cancer resections at St Mark's hospital between October 2004 and October 2013 was examined. The overall leak rate was 99/1,048 (9.4%). 43 ALs were managed conservatively with antibiotics or radiological drainage and 56 with reoperations. OS was significantly reduced in the AL group treated with a reoperation (HR 2.74, 95% CI 1.67-4.52, p < 0.001). AL was not significantly associated with worse DFS [conservatively managed AL's vs. no AL-HR 2.07 (95% CI 1.05-4.10); reoperated AL's vs. no AL-HR 1.56 (95% CI 0.81-2.99), overall p value = 0.058]. Patients who suffer anastomotic leaks requiring reoperations have worse OS compared to patients who do not leak, but there were no significant differences in DFS between patients who leaked and those who did not.

Polyposis syndromes: administrative care

The Polyposis Registry team at St Mark's Hospital, London, is made up of nurses and administrators with an ex-nurse as their day-to-day manager. The team works closely with all the consultants at the hospital, but a professor of surgery and consultant gastroenterologist act as the directors of the Registry work. Polyposis syndromes are rare, so patients are referred for specialist care from all over England, as well as occasionally from Northern Ireland, Scotland, and Wales. St Mark's Hospital cares for over 1300 patients from polyposis families whereas most general hospitals would only care for a few families. This article describes how the two administrators at St Mark's support the team and, in particular, help to care for patients who have to live with the burden of an inherited cancer syndrome. The article explains how complete integration of the administrative staff into the team enables them to relieve the nurses of many daily enquiries while reassuring patients that they will be supported.

Clinical outcomes of colo‐anal pull‐through procedure for complex rectal conditions

Pull-through with colo-anal sleeve anastomosis may be used as a last resort to avoid permanent diversion in patients with complex rectal conditions. This procedure allows the preservation of intestinal continuity by minimizing the hazards of deep dissection in an inflamed and fibrosed pelvis. A retrospective study was performed of colo-anal pull-through procedures carried out between January 1998 and December 2012 at St Mark's Hospital by one surgeon. Patients were identified from operative logbooks and their case notes were reviewed. Thirty-four patients (21 women) with a median age of 54 (21-75) years underwent the pull-through operation for complex rectal conditions involving fistulae and/or a hostile pelvis as a final attempt to restore intestinal continuity. The median length of hospital stay was 7.5 (5-45) days. Median follow-up was 23 (3-71) months. There was no peri-operative mortality. There were two (6%) outright failures. Early complications occurred in 14 (41%) patients and late complications in 10 (29%). Fistulae recurred in seven (25%) of 28 patients but with further treatment four healed, giving an overall healing rate of 89%. Normal continence was achieved in 19 (79%) of 24 patients who were evaluated. In clinically difficult rectal situations the colo-anal pull-through procedure is a suitable salvage procedure to restore intestinal continuity before considering a permanent stoma.

Study to identify the optimum surgical technique in colon cancer

BackgroundColorectal cancer is a common disease with over 41 000 new cases diagnosed every year in the UK, of which around two-thirds occur in the colon. The primary treatment for colon cancer is surgery, though outcomes vary substantially worldwide. Centres in Germany and Japan using complete mesocolic excision with central vascular ligation (CME with CVL) report some of the best outcomes after colon cancer resection in published research. We aimed to identify the optimum surgical technique for colon cancer and determine whether it could be implemented into routine practice. MethodsDigital colour photographs of consecutive colon cancer resection specimens were submitted for independent review at the University of Leeds from two UK (n=468), one German (n=136), one Japanese (n=149), and six Danish (n=263) centres. The specimens were subjected to tissue morphometry with Aperio ImageScope and given a quality score according to the plane of resection. The association to 5-year overall survival was calculated with the Kaplan-Meier method and the log rank test. A Cox's proportional hazards regression model was used to determine the independence of prognostic variables. The study was approved by the Northern and Yorkshire Research Ethics Committee. Individual patient consent was not required. FindingsAnalysis of specimens resected using conventional low tie surgery from Leeds (n=399) showed that only 127 specimens (32%) were resected in the mesocolic plane (intact mesocolon) and 95 (24%) had pronounced defects going down to the muscularis propria. There was a 15% improvement in 5-year overall survival with mesocolic plane surgery compared with muscularis propria plane surgery (hazard ratio 0·57, 95% CI 0·38–0·85; p=0·006). Plane of surgery remained an independent prognostic factor on multivariate analysis in stage III disease (0·45, 0·24–0·85; p=0·014). CME with CVL undertaken in specialist units in Germany and Japan removed more tissue between the tumour and high vascular tie than did standard surgery (median 117 mm [IQR 99–137] vs 90 [67–111], p<0·0001), and was more likely to occur in the mesocolic plane (81% vs 40%, p<0·0001). Laparoscopic CME with CVL specimens from St Mark's Hospital, UK, were not significantly different from open specimens from Germany in mesocolic plane rate and tissue morphometry. After a surgical training programme in Denmark focussing on CME with CVL, the mesocolic plane rate improved (75% after training vs 48% before, p<0·0001), amount of tissue resected between the tumour and high vascular tie increased (median 105 mm [84–129] vs 84 [67–101], p=0·006), and lymph-node yield rose (median number 28 [24–37] vs 18 [14–23], p<0·0001). InterpretationWe have shown that CME with CVL is better than conventional colon cancer surgery with respect to oncological outcomes, can be effectively done laparoscopically, and can be learned through a surgical training programme. Such programmes are easy to implement and cheap compared with the cost of modern chemotherapy. With a move towards better colon cancer surgery, around 5000 lives could potentially be saved every year in the UK and many more worldwide. FundingYorkshire Cancer Research.

Interstitial 3p25 deletion in a patient with features of 3p deletion syndrome

North West Thames Regional Genetics Service, North West London Hospitals NHS Trust, Northwick Park & St Marks Hospital, Harrow, UK Correspondence to Susan E. Holder, FRCP, MSc, North West Thames Regional Genetics Service, Level 8V, North West London Hospitals NHS Trust, Northwick Park & St Marks Hospital, Watford Road, Harrow HA1 3UJ, UK Tel: +44 20 8869 2795; fax: +44 20886 93106; e-mail: [email protected] Received June 22, 2013 Accepted October 28, 2013

Management of the malignant colorectal polyp: ACPGBI position statement

*Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK, †Torbay Hospital, Torquay, UK, ‡Department of General Surgery, Manchester Royal Infirmary, Manchester, UK, §Royal Infirmary, Glasgow, UK, ¶Department of Histopathology, Royal Bolton NHS Foundation Trust, Bolton, UK, **Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK, ††The Royal Marsden Hospital, London, UK, ‡‡Salisbury NHS Foundation Trust, Salisbury, UK and §§Department of Histopathology, University Hospital of South Manchester, Manchester, UK