Upper gastrointestinal training in the UK and Ireland: a Roux Group Study.

INTRODUCTION: Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I. METHODS: A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability. RESULTS: A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage. CONCLUSIONS: Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Comparison of robotic vs laparoscopic left-sided colorectal cancer resections.

Robotic assisted surgery (RAS) has become increasingly adopted in colorectal cancer surgery. This study aims to compare robotic and laparoscopic approaches to left sided colorectal resections in terms of surgical outcomeswith no formal enhanced recovery programme. All patients undergoing robotic or laparoscopic left sided or rectal (high and low anterior resection) cancer surgery at a single tertiary referral centre over 3 years were included.A total of 184 consecutive patients from July 2017 to December 2020 were included in this study, with 40.2% (n=74/184) undergoing RAS. The median age at time of surgery was 68 years (IQR 60-73 years). RAS had a significantly shorter length of median stay of 3 days, compared to 5 days in the conventional laparoscopic surgery (CLS) group (p<0.001). RAS had a significantly lower rate of conversion to open surgery (0% vs 16.4%, p<0.001). The median operative time was also shorter in RAS (308 minutes), compared to CLS (326 minutes, p=0.019). The overall rate of any complication was 16.8%, with the RAS experiencing a lower complication rate (12.2% vs 20.0%, p=0.041). There was no significant difference in anastomotic leak rates between the two groups (4.0% vs 5.5%, p=0.673), or in terms of complete resection (R0) (robotic 98.6%, laparoscopic 100%, p=0.095). Robotic left sided colorectal surgery delivers equivalent oncological resection compared to laparoscopic approaches, with the added benefits of reduced length of stay and lower rates of conversion to open surgery. This has both clinical and healthcare economic benefits.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19.

INTRODUCTION: Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients. METHODS: A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK. RESULTS: Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19. CONCLUSION: With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.

INTRODUCTION: Diverticular disease is one of the most frequent reasons for attending emergency departments and surgical causes of hospital admission. In the past decade, many surgical and gastroenterological societies have published guidelines for the management of diverticular disease. The aim of the present study was to appraise the methodological quality of these guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. METHODS: PubMed, Embase, Cochrane Library and Google Scholar databases were searched systematically. The methodological quality of the guidelines was appraised independently by five appraisers using the AGREE II instrument. FINDINGS: A systematic search of the literature identified 12 guidelines. The median overall score of all guidelines was 68%. Across all guidelines, the highest score of 85% was demonstrated in the domain 'Scope and purpose'. The domains 'Clarity and presentation' and 'Editorial independence' both scored a median of 72%. The lowest scores were demonstrated in the domains 'Stakeholder involvement' and 'Applicability' at 46% and 40%, respectively. Overall, the National Institute for Health and Care Excellence (NICE) guidelines performed consistently well, scoring 100% in five of six domains; NICE was one of the few guidelines that specifically reported stakeholder involvement, scoring 97%. Generally, the domain of 'Stakeholder involvement' ranked poorly with seven of twelve guidelines scoring below 50%, with the worst score in this domain demonstrated by Danish guidelines at 25%. CONCLUSION: Six of twelve guidelines (NICE, American Society of Colon & Rectal Surgeons (ASCRS), European Society of Coloproctology (ESCP), American Gastroenterological Association, German Society of Gastroenterology/German Society for General and Visceral Surgery (German), Netherlands Society of Surgery) scored above 70%. Only three, NICE, ASCRS and ESCP, scored above 75% and were voted unanimously by the appraisers for use as they are. Therefore, use of AGREE II may help improve the methodological quality of guidelines and their future updates.

Diversion, resection, or stenting as a bridge to surgery for acute neoplastic left-sided colonic obstruction: a systematic review and network meta-analysis of studies with curative intent.

INTRODUCTION: The debate on the best surgical management strategy for acute malignant left-sided colonic obstruction is ongoing. Decompressing colostomy (DC) and stenting as a bridge to surgery (SBTS) are the currently proposed alternative approaches to emergency colectomy (EC). However, the results of a traditional meta-analysis were inconclusive. Therefore, a network meta-analysis (NMA) was conducted to compare the three approaches for acute left-sided colonic obstruction. METHODS: A systematic literature search of Embase, PubMed, Google Scholar and the Cochrane library was performed. A traditional meta-analysis and subsequent NMA were conducted. FINDINGS: A significantly greater number of primary anastomoses were performed in the DC cohort than in the EC and SBTS cohorts. The 90-day mortality rate was significantly lower in the DC cohort than in the EC and SBTS cohorts. Higher costs were associated with the SBTS cohort (by US$2,000) than with the EC cohort. The locoregional recurrence rate was higher for the SBTS cohort than for the EC cohort. CONCLUSIONS: Evidence from the first NMA suggests there may be some clinical advantages associated with DC as an alternative approach to the EC and SBTS approaches for adequately selected patients with malignant large bowel obstruction.

Ultrahigh-figure-of-merit refractive index sensor based on the Rayleigh anomaly resonance.

We investigate an all-metal and simple-fabrication grating with an ultranarrow band absorption spectrum in the telecom window range. The influences of structure parameters on the absorption characteristics are investigated. For the best design, the absorption efficiency reaches 94% under normal incidence, with the full width at half-maximum of only 0.17 nm. We demonstrate that this ultranarrow band absorption is the result of the dominant excitation of the Rayleigh anomaly mode. The corresponding figure of merit is calculated to be 8530RIU-1. The applied procedure has the potential to also be used in designing high-performance reflection-based sensors in other wavelength ranges.

Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK.

INTRODUCTION: Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England. MATERIALS AND METHODS: An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background. RESULTS: A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents. CONCLUSION: There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.

Long-term oncological outcomes following completely minimally invasive esophagectomy versus open esophagectomy.

Open esophagectomy (OE) for esophageal and gastroesophageal junctional cancers is associated with high morbidity. Completely minimally invasive esophagectomy (CMIE) techniques have evolved over the last two decades and significantly reduce surgical trauma compared to open surgery. Despite this, long-term oncological outcomes following CMIE compared to OE remain unclear. This systematic review and meta-analysis aimed to compare overall 5-year survival (OFS) and disease-free 5-year survival (DFFS) between CMIE and OE. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials was conducted. The PROSPERO database was also searched for studies comparing OFS and DFFS between CMIE and OE. The Newcastle Ottawa Scale was used to assess study quality for included studies. Overall, seven studies (containing 949 patients: 527 OE and 422 CMIE) were identified from screening. On pooled meta-analysis, there was no significant difference in OFS or DFFS between CMIE and OE cohorts ([odds ratio 1.12; 95% CI: 0.85 to 1.48; P = 0.41] and [odds ratio 1.34; 95% CI: 0.81-2.22; P = 0.25] respectively). Sensitivity and subgroup analysis with high-quality studies, three highest sample sized studies, and three most recent studies also revealed no difference in long-term oncological outcomes between the two operative groups. This review demonstrates long-term oncological outcomes following CMIE appear equivalent to OE based on amalgamation of existing published literature. Limited high-level evidence comparing OFS and DFFS between CMIE and OE exists. Further research with a randomized controlled trial is required to clinically validate these findings.

The association of age with the clinicopathological characteristics and prognosis of colorectal cancer: a UK single-centre retrospective study.

INTRODUCTION: Colorectal cancer (CRC) is uncommon in patients under the age of 40 years and its association with poor histological features and survival is uncertain. This study aimed to evaluate age-related differences in clinicopathological features and prognosis in patients diagnosed with CRC. METHOD: A single-centre retrospective review of all patients diagnosed with CRC between 2004 and 2013 was performed. Patients were stratified into three age groups: (1) 18-40 years, (2) 41-60 years and (3)> 60 years. Clinicopathological characteristics and outcomes were compared between the three groups. RESULTS: A total of 1328 patients were included, of whom 57.2% were men. There were 28 (2.1%) patients in group 1, 287 (21.6%) in group 2 and 1013 (76.3%) in group 3. Group 1 had the highest proportion of rectal tumours (57.1% in group 1, 50.2% in group 2 and 31.9% in group 3; P < 0.001). Tumour histology and disease stage were comparable between the groups. Group 1 had significantly worse disease-free survival (DFS) than the two older groups (44%, 78% and 77%, respectively; P = 0.022). Multivariate analysis demonstrated that age was not an independent prognostic factor whereas Stage III disease [hazard ratio (HR) 4.42; 95% CI 2.81-6.94; P < 0.001] and neoadjuvant chemotherapy (HR 1.65; 95% CI 1.06-2.58; P = 0.026) were associated with increased risk of recurrence. CONCLUSION: Patients under the age of 40 are more likely to present with rectal cancer and have comparable histological features than the older groups. Despite higher rates of adjuvant and neoadjuvant treatment, the young group were found to have worse DFS.

Obesity surgery and risk of cancer.

BACKGROUND: Obesity increases the risk of several types of cancer. Whether bariatric surgery influences the risk of obesity-related cancer is not clear. This study aimed to uncover the risk of hormone-related (breast, endometrial and prostate), colorectal and oesophageal cancers following obesity surgery. METHODS: This national population-based cohort study used data from the Hospital Episode Statistics database in England collected between 1997 and 2012. Propensity matching on sex, age, co-morbidity and duration of follow-up was used to compare cancer risk among obese individuals undergoing bariatric surgery (gastric bypass, gastric banding or sleeve gastrectomy) and obese individuals not undergoing such surgery. Conditional logistic regression provided odds ratios (ORs) with 95 per cent confidence intervals. RESULTS: In the study period, from a cohort of 716 960 patients diagnosed with obesity, 8794 patients who underwent bariatric surgery were matched exactly with 8794 obese patients who did not have surgery. Compared with the no-surgery group, patients who had bariatric surgery exhibited a decreased risk of hormone-related cancers (OR 0·23, 95 per cent c.i. 0·18 to 0·30). This decrease was consistent for breast (OR 0·25, 0·19 to 0·33), endometrium (OR 0·21, 0·13 to 0·35) and prostate (OR 0·37, 0·17 to 0·76) cancer. Gastric bypass resulted in the largest risk reduction for hormone-related cancers (OR 0·16, 0·11 to 0·24). Gastric bypass, but not gastric banding or sleeve gastrectomy, was associated with an increased risk of colorectal cancer (OR 2·63, 1·17 to 5·95). Longer follow-up after bariatric surgery strengthened these diverging associations. CONCLUSION: Bariatric surgery is associated with decreased risk of hormone-related cancers, whereas gastric bypass might increase the risk of colorectal cancer.

A newly emerged focus of zoonotic cutaneous leishmaniasis in South-western Iran.

Leishmaniasis is rising in many countries, including Iran, due to climate change, refugee crises, urbanization and etc. The aim of this study was to explore the epidemiology, extent and identity of Leishmania species in a newly emerged focus in Abdanan County, Ilam Province, South-western Iran. This study was performed as a descriptive cross-sectional study by a systematic house-to-house approach. The Leishmania species was identified by RFLP-PCR and sequencing. Altogether, 46799 individuals consisting of 22907 (48.9) female and 23892 (51.1%) male were interviewed and physically examined for the presence of skin lesions. Overall, the incidence rate was 0.34% (n = 160). All age groups were affected and the incidence rate was the highest in <10 years of age group (0.49%) and the lowest in >50 years old individuals (0.15%), although there was no significant difference regarding the sex and age. The majority of patients had one lesion (47.5%) on hands (56%) and most of the cases occurred in Abdanan city (%54) in summer. Based on the RFLP-PCR analysis, all the Leishmania isolates were L. major of single genotype. A newly emerged focus of zoonotic CL caused by L. major occurred in South-western of Iran. Multiple risk factors created this epidemic area. Further studies on the vector and reservoir are crucial needed to provide evidences to select the prophylactic and therapeutic measures for future control strategies.

Restorative surgery after colectomy for ulcerative colitis in England and Sweden: observations from a comparison of nationwide cohorts.

AIM: A longstanding disparity exists between the approaches to restorative surgery after colectomy for patients with ulcerative colitis (UC) in England and Sweden. This study aims to compare rates of colectomy and restorative surgery in comparable national cohorts. METHOD: The English Hospital Episode Statistics (HES) and Swedish National Patient Register (NPR) were interrogated between 2002 and April 2012. Patients with two diagnostic episodes for UC (age ≥ 15 years) were included. Patients were excluded if they had an episode of inflammatory bowel disease or colectomy before 2002. The cumulative incidences of colectomy and restorative surgery were calculated using the Kaplan-Meier method. RESULTS: A total of 98 691 patients were included in the study, 76 129 in England and 22 562 in Sweden. The 5-year cumulative incidence of all restorative surgery after colectomy in England was 33% vs 46% in Sweden (P-value < 0.001). Of the patients undergoing restorative surgery, 92.3% of English patients had a pouch vs 38.8% in Sweden and 7.7% vs 59.1% respectively had an ileorectal anastomosis (IRA). The 5-year cumulative incidence of colectomy in this study cohort was 13% in England and 6% in Sweden (P-value < 0.001). CONCLUSION: Following colectomy for UC only one-third of English patients and half of Swedish patients underwent restorative surgery. In England nearly all these patients underwent pouches, in Sweden a less significant majority underwent IRAs. It is surprising to demonstrate this discrepancy in a comparable cohort of patients from similar healthcare systems. The causes and consequences of this international variation in management are not fully understood and require further investigation.

Population-based cohort study of surgical myotomy and pneumatic dilatation as primary interventions for oesophageal achalasia.

BACKGROUND: The aim of this national population-based cohort study was to compare rates of reintervention after surgical myotomy versus sequential pneumatic dilatation for the primary management of oesophageal achalasia. METHODS: Patients with oesophageal achalasia diagnosed between 2002 and 2012, and without an intervention in the preceding 5 years were identified from the Hospital Episode Statistics database. Patients were divided into two groups based on the primary treatment, and propensity score matching was used to compensate for differences in baseline characteristics. RESULTS: Some 14 705 patients were diagnosed with oesophageal achalasia, of whom 7487 (50·9 per cent) received interventional treatment: 1742 (23·3 per cent) surgical myotomy, 4534 (60·6 per cent) pneumatic dilatation and 1211 (16·2 per cent) endoscopic botulinum toxin injection. As age increased, the proportion of patients receiving myotomy decreased and the proportion undergoing dilatation increased. Patients who underwent surgical myotomy were younger (mean age 44·8 years versus 58·5 years among those who had pneumatic dilatation; P < 0·001), a greater proportion had a Charlson co-morbidity index score of 0 (90·1 versus 87·7 per cent; P = 0·003) and they were more commonly men (55·6 versus 51·8 per cent; P = 0·020). Following propensity score matching, the safety of the two initial treatment approaches was equivalent, with no difference in incidence of oesophageal perforation (1·3 and 1·4 per cent after myotomy and dilatation respectively; P = 0·750). However, dilatation was associated with increased need for reintervention (59·6 versus 13·8 per cent; P < 0·001) and frequency of reinterventions (mean 0·34 versus 0·06 per year; P < 0·001). CONCLUSION: Surgical myotomy was associated with a lower rate of reintervention and could be offered as primary treatment in patients with oesophageal achalasia who are fit for surgery. For those unfit for surgery, pneumatic dilatation may provide symptomatic relief with approximately 60 per cent of patients requiring reintervention.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK.

BACKGROUND: Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS: In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS: Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION: This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions.

BACKGROUND: In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions. METHODS: The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997-2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed. RESULTS: Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia. CONCLUSION: Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.

Natural history of anorectal sepsis.

BACKGROUND: Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation. METHODS: The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation. RESULTS: A total of 165 536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158 713 (95·9 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4·1 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20·2 per 100 000. The rate of subsequent fistula formation following an abscess was 15·5 per cent (23 012 of 148 286) in idiopathic cases and 41·6 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26·7 per cent coded concurrently as ulcerative colitis; 47·2 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67·5 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3·51; P < 0·001), ulcerative colitis (HR 1·82; P < 0·001), female sex (HR 1·18; P < 0·001), age at time of first abscess 41-60 years (HR 1·85 versus less than 20 years; P < 0·001), and intersphincteric (HR 1·53; P < 0·001) or ischiorectal (HR 1·48; P < 0·001) abscess location compared with perianal. Some 2·9 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14 months. CONCLUSION: The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.

Risk of metachronous colorectal cancer following colectomy in Lynch syndrome: a systematic review and meta-analysis.

AIM: Lynch syndrome (LS) accounts for 2-4% of all colorectal cancer (CRC) cases, and is associated with an increased risk of developing metachronous colorectal cancer (mCRC). The role of extended colectomy in LS CRC is controversial. There are limited studies comparing the risk of mCRC following segmental colectomy and extended colectomy. The objective of this systematic review is to evaluate the risk of developing mCRC following segmental and extended colectomy for LS CRC and endoscopic compliance. METHOD: A systematic review of major databases was performed using predefined terms. All original articles published in English comparing the risk of mCRC in LS patients after segmental and extended colectomy from 1950 to January 2016 were included. RESULTS: The search retrieved 324 studies. Six studies involving 871 patients met the inclusion criteria. Of these, 705 (80.9%) underwent segmental colectomy and 166 (19.1%) extended colectomy. Average follow-up was 91.2 months. The mCRC rate was 22.8% and 6% in the segmental and extended colectomy groups, respectively. The segmental group were over four times more likely to develop mCRC (OR 4.02, 95% CI: 2.01-8.04, P < 0.0001). mCRC occurred in patients after segmental colectomy despite 1-2-yearly postoperative endoscopic surveillance. CONCLUSION: This result suggests that extended colectomy reduces the risk of mCRC by over four-fold compared with segmental colectomy. mCRC occurred in the segmental group despite postoperative endoscopic surveillance. This needs to be borne in mind when deciding on the appropriate surgical management of LS patients with CRC. We recommend that extended colectomy should be considered for patients with confirmed LS CRC.

The Impact of Patient Demographics, Anatomy, Comorbidities, and Peri-operative Planning on the Primary Functional Maturation of Autogenous Radiocephalic Arteriovenous Fistula.

OBJECTIVES: The aim of this study was to evaluate the collective and/or independent impact of patient demographics, comorbidities, anatomical factors, and peri-operative parameters on the primary functional maturation of RCAVFs. This study also aimed to identify the range and best cut off value for each variable and evaluate the likelihood, significance and percentage of primary functional maturation of RCAVFs. METHODS: This was a prospective consecutive single centre cohort study over a 4 year period; it was conducted on patients with the intention-to-treat using a radiocephalic arteriovenous fistula (RCAVF) (Brescia-Cimino). During this period 548 vascular access procedures, inclusive of RCAVF, were performed. Variables included patient demographics (age, gender), anatomical variance (cephalic vein, radial artery diameter, laterality), comorbidities (diabetes mellitus, ischaemic heart disease, congestive cardiac failure, hypertension), aetiology of renal failure, and anaesthesia type (local versus general anaesthesia). RESULTS: Of the total, 324 patients, cephalic vein diameter > 1.5 mm (OR 4.57, 95% CI, 2.42-8.63, p < .001) (non-augmented) and radial artery diameter > 1.6 mm (OR 12.26, 95% CI, 6.27-23.97, p < .001) were found to be independently associated with the primary functional maturation of 86% in the RCAVF formation. CONCLUSION: Of all the variables, cephalic vein and radial artery diameter are independently associated with the primary functional maturation of RCAVFs.

Initiation of adjuvant chemotherapy within 8 weeks of elective colorectal resection improves overall survival regardless of reoperation.

AIM: Reoperation after elective colorectal resection may delay the start of adjuvant chemotherapy (AC). The study investigated the dual impact of a reoperation and AC delay on overall survival (OS). METHOD: The Hospital Episode Statistics database was analysed between 1997 and 2012. Patients were divided into colon and rectal cancer cohorts and data were analysed based on whether there was delay in receiving AC beyond 8 weeks and whether a patient suffered reoperation within 30 days. Multivariate regression analysis was undertaken to investigate the relationship between delay in giving AC and reoperation and their combined effect on OS. RESULTS: Logistic regression showed reoperation, amongst other things, to be an independent predictor of AC delay, in both colon and rectal cancer (colon, odds ratio 2.31, P < 0.001; rectal, odds ratio 2.19, P < 0.001). There was no significant difference in OS between patients who had no AC delay but suffered a reoperation and patients who had no AC delay and no reoperation. Patients who had AC delay but no reoperation, however, had significantly worse OS compared to those who had no AC delay and no reoperation [colon, hazard ratio (HR) 1.16, P < 0.001; rectal, HR 1.17, P < 0.001]. Individuals who had both AC delay and a reoperation also had worse OS compared with patients who had neither (colon, HR 1.33, P = 0.037; rectal, HR 1.38, P < 0.001). CONCLUSION: Delayed receipt of AC beyond 8 weeks after surgery is associated with significantly reduced OS regardless of reoperation status in both colon and rectal cancer patients.