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1.
J Hosp Infect ; 101(3): 295-299, 2019 Mar.
Article in English | MEDLINE | ID: mdl-30579970

ABSTRACT

BACKGROUND: Increasing evidence indicates that combined mechanical and oral antibiotic bowel preparation reduces the infectious complications of colorectal surgery. Anecdotal evidence suggests the combination is rarely used in the UK and Europe. AIM: To establish colorectal surgeons' current use and awareness of the benefits of such bowel preparation, and to identify decision-making influences surrounding preoperative bowel preparation. METHOD: An electronic survey was emailed to all members of the Association of Coloproctology of Great Britain and Ireland, and promoted via Twitter. FINDINGS: A total of 495 respondents completed the survey: 413 (83.2%) UK, 39 (7.9%) other European, 43 (8.7%) non-European. Respondents used oral antibiotics for 12-20% of cases. Mechanical bowel preparation (MBP), phosphate enema, and no preparation, respectively, ranged between 9 and 80%. Combined MBP and oral antibiotic bowel preparation ranged between 5.5 and 18.6%. Fifty-three percent (260/495) agreed that combined mechanical and oral antibiotic bowel preparation reduces surgical site infection; 32% (157/495) agreed that the combination reduces risk of anastomotic leak. Kappa statistics between 0.06 and 0.27 indicate considerable incongruity between surgeons' awareness of the literature, and day-to-day practice. Twenty-four percent (96/495) believed MBP to be incompatible with enhanced recovery after surgery (ERAS); 41% (204/495) believed that MBP delays return to normal intestinal function. CONCLUSIONS: Few UK and European colorectal surgeons use mechanical and oral antibiotic bowel preparation, despite evidence of its efficacy in reducing infectious complications. The influence of ERAS pathways and UK and European guidelines may explain this. In contradiction to the UK and Europe, North American guidelines recommend incorporating combined mechanical and oral antibiotic bowel preparation into ERAS programmes. This study suggests that future UK and European guidelines incorporate combined mechanical and oral antibiotic bowel preparation into the ERAS pathway.


Subject(s)
Anti-Bacterial Agents/administration & dosage , Colorectal Surgery/adverse effects , Enema/methods , Practice Patterns, Physicians' , Preoperative Care/methods , Surgical Wound Infection/prevention & control , Humans , Ireland , Surveys and Questionnaires , United Kingdom
2.
Eur J Cancer ; 104: 47-61, 2018 11.
Article in English | MEDLINE | ID: mdl-30321773

ABSTRACT

AIM: Although T3 tumour subclassifications have been linked to prognosis, its mandatory adoption in histopathological reports has not been incorporated. This article focusses on the survival outcomes in patients with T3 rectal cancer according to extramural spread beyond the muscularis propria. METHODS: A systematic review of all studies up to January 2016, without language restriction, was identified from MEDLINE, Cochrane Controlled Trials Register (1960-2016) and Embase (1991-2016). All studies reporting on survival and T3 tumours with a defined cut-off of 5 mm ± 1 mm tumour invasion beyond the muscularis propria for rectal cancers were included. Hazard ratios were extracted directly from the studies or from survival curves using the technique described by Parmar. Quality assessment was performed using the Newcastle-Ottawa scale. RESULTS: Tumours with invasion more than 5 ± 1 mm from the muscularis propria had statistically significantly worse overall survival (natural log of the hazard ratio [lnHR]: 1.40 [1.06, 2.04], p < 0.001) and there was no statistically significant heterogeneity (χ2 = 1.541, df = 3, p = 0.673, I2 = 0). There was statistically significantly worse disease-free survival in more invasive tumours (lnHR: 1.49 [1.19, 2.00], p < 0.001) and cancer specific survival (lnHR: 1.22 [0.917, 1.838], p < 0.001). Overall survival in patients who had preoperative therapy was higher in patients with less invasion beyond the muscularis propria [p < 0.01]. CONCLUSIONS: Subclassifying all T3 rectal tumours according to the depth of spread with a cut-off of 5±1 mm beyond the muscularis propria is prognostically relevant for overall survival, disease-free survival and cancer-specific survival irrespective of the nodal status; therefore, subclassifying T3 tumours should be a reporting requirement in histopathology reports.


Subject(s)
Neoplasm Staging/methods , Rectal Neoplasms/pathology , Chemoradiotherapy , Combined Modality Therapy , Disease-Free Survival , Humans , Magnetic Resonance Imaging , Neoadjuvant Therapy , Neoplasm Invasiveness , Proctectomy , Prognosis , Rectal Neoplasms/classification , Rectal Neoplasms/mortality , Rectal Neoplasms/therapy
3.
Colorectal Dis ; 20(12): 1088-1096, 2018 12.
Article in English | MEDLINE | ID: mdl-29999580

ABSTRACT

AIM: The concept of significant polyps and early colorectal cancer (SPECC) encompasses complex polyps not amenable to routine snare polypectomy or where malignancy cannot be excluded. Surgical resection (SR) offers definitive treatment, but is overtreatment for the majority which are benign and amenable to less invasive endoscopic resection (ER). The aim of this study was to investigate variations in the management and outcomes of significant colorectal polyps. METHOD: This was a retrospective observational study of significant colorectal polyps, defined as nonpedunculated lesions of ≥ 20 mm size, diagnosed across nine UK hospitals in 2014. Inclusion criteria were endoscopically or histologically benign polyps at biopsy. RESULTS: A total of 383 patients were treated by primary ER (87.2%) or SR (12.8%). Overall, 108/383 (28%) polyps were detected in the Bowel Cancer Screening Programme (BCSP). Primary SR was associated with a significantly longer length of stay and major complications (P < 0.01). Of the ER polyps, 290/334 (86.8%) patients were treated without undergoing surgery. The commonest indication for secondary surgery was unexpected polyp cancer, and of these cases 60% had no residual cancer in the specimen. Incidence of unexpected cancer was 10.7% (n = 41) and was similar between ER and SR groups (P = 0.11). On multivariate analysis, a polyp size of > 30 mm and non-BCSP status were independent risk factors for primary SR [OR 2.51 (95% CI 1.08-5.82), P = 0.03]. CONCLUSION: ER is safe and feasible for treating significant colorectal polyps. Robust accreditation within the BCSP has led to improvements in management, with lower rates of SR compared with non-BCSP patients. Standardization, training in polyp assessment and treatment within a multidisciplinary team may help to select appropriate treatment strategies and improve outcomes.


Subject(s)
Colonic Polyps/surgery , Colonoscopy/methods , Colorectal Neoplasms/prevention & control , Early Detection of Cancer/methods , Aged , Colonic Polyps/complications , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/etiology , Feasibility Studies , Female , Humans , Length of Stay , Male , Medical Overuse/prevention & control , Middle Aged , Retrospective Studies , Risk Factors , United Kingdom
4.
Colorectal Dis ; 20 Suppl 1: 100-102, 2018 05.
Article in English | MEDLINE | ID: mdl-29878682

ABSTRACT

As part of an approach to improve tumour regression and increase the proportion of patients with complete clinical and radiological response, Dr Perez reviews the methods and evidence base for augmenting therapy and thus augmenting response rates preoperatively. Much of the data reviewed were in the context of patients undergoing a watch-and-wait approach for rectal cancer after initial treatment with chemoradiotherapy.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Chemoradiotherapy/methods , Neoplasm Recurrence, Local/mortality , Rectal Neoplasms/pathology , Rectal Neoplasms/therapy , Consensus , Disease-Free Survival , Female , Humans , Male , Neoplasm Invasiveness/pathology , Neoplasm Recurrence, Local/pathology , Neoplasm Recurrence, Local/therapy , Neoplasm Staging , Prognosis , Radiotherapy Dosage , Rectal Neoplasms/mortality , Risk Assessment , Survival Analysis , Treatment Outcome
5.
Clin Radiol ; 71(9): 854-62, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27381221

ABSTRACT

AIM: To investigate whether the magnetic resonance imaging (MRI) tumour regression grading (mrTRG) scale can be taught effectively resulting in a clinically reasonable interobserver agreement (>0.4; moderate to near perfect agreement). MATERIALS AND METHODS: This study examines the interobserver agreement of mrTRG, between 35 radiologists and a central reviewer. Two workshops were organised for radiologists to assess regression of rectal cancers on MRI staging scans. A range of mrTRGs on 12 patient scans were used for assessment. RESULTS: Kappa agreement ranged from 0.14-0.82 with a median value of 0.57 (95% CI: 0.37-0.77) indicating good overall agreement. Eight (26%) radiologists had very good/near perfect agreement (κ>0.8). Six (19%) radiologists had good agreement (0.8≥κ>0.6) and a further 12 (39%) had moderate agreement (0.6≥κ>0.4). Five (16%) radiologists had a fair agreement (0.4≥κ>0.2) and two had poor agreement (0.2>κ). There was a tendency towards good agreement (skewness: 0.92). In 65.9% and 90% of cases the radiologists were able to correctly highlight good and poor responders, respectively. CONCLUSIONS: The assessment of the response of rectal cancers to chemoradiation therapy may be performed effectively using mrTRG. Radiologists can be taught the mrTRG scale. Even with minimal training, good agreement with the central reviewer along with effective differentiation between good and intermediate/poor responders can be achieved. Focus should be on facilitating the identification of good responders. It is predicted that with more intensive interactive case-based learning a κ>0.8 is likely to be achieved. Testing and retesting is recommended.


Subject(s)
Antineoplastic Agents/therapeutic use , Chemoradiotherapy, Adjuvant/methods , Image Interpretation, Computer-Assisted/methods , Magnetic Resonance Imaging/methods , Rectal Neoplasms/pathology , Rectal Neoplasms/therapy , Clinical Competence , Diagnosis, Differential , Female , Humans , Male , Neoplasm Grading , Observer Variation , Preoperative Care/methods , Rectal Neoplasms/diagnostic imaging , Reproducibility of Results , Sensitivity and Specificity , Treatment Outcome
6.
Colorectal Dis ; 17(10): 908-16, 2015 Oct.
Article in English | MEDLINE | ID: mdl-25807963

ABSTRACT

AIM: Many patients having anterior resection for rectal cancer suffer from severe long-term bowel dysfunction, known as low anterior resection syndrome (LARS). The LARS score was developed in Denmark, and Swedish, Spanish and German versions have been validated. The aim of this study was to validate the English translation of the LARS score in British rectal cancer patients. METHOD: Rectal cancer patients who underwent an anterior resection in 12 UK centres received the LARS score questionnaire, the EORTC QLQ-C30 and a single ad hoc quality of life question. A subgroup of patients received the LARS score questionnaire twice. RESULTS: The response rate was 80% and 451 patients were included in the analyses. A strong association between LARS score and quality of life (convergent validity) was found (P < 0.01), discriminative validity was good (P < 0.02) and the test-retest reliability was high (intraclass correlation coefficient 0.83). CONCLUSION: The English translation of the LARS score has shown good psychometric properties comparable with recently published results from an international multicentre study. Thus, the English translation of the LARS score can be considered a valid and reliable tool for measuring LARS.


Subject(s)
Constipation/diagnosis , Fecal Incontinence/diagnosis , Quality of Life , Rectal Neoplasms/surgery , Rectum/surgery , Translations , Aged , Aged, 80 and over , Colectomy/adverse effects , Colectomy/methods , Constipation/etiology , Cross-Sectional Studies , Denmark , Fecal Incontinence/etiology , Female , Humans , Male , Middle Aged , Postoperative Complications/diagnosis , Postoperative Complications/etiology , Rectal Neoplasms/pathology , Rectal Neoplasms/psychology , Surveys and Questionnaires , Syndrome , United Kingdom
7.
Colorectal Dis ; 16(3): 173-8, 2014 Mar.
Article in English | MEDLINE | ID: mdl-24267315

ABSTRACT

AIM: Adenocarcinoma of the lower rectum is clinically challenging because of the need to choose between a wide excision to achieve oncological clearance, on the one hand, and sphincter conservation to maintain anal function, on the other. The English National Low Rectal Cancer Development Programme (LOREC) was developed under the auspices of the Association of Coloproctology of Great Britain and Ireland and the English National Cancer Action Team to improve the outcome of low rectal cancer in England. METHOD: LOREC was initiated focusing on preoperative imaging, selective neoadjuvant therapy, optimal surgical treatment and detailed pathological assessment of the excised specimen. Its key elements were 1-day multidisciplinary team (MDT) workshops, cadaveric surgical training, surgical mentoring, pathological audit and radiological workshops. RESULTS: Overall, 147 (89.6%) of 164 MDTs from 151 National Health Service (NHS) Trusts (some with two MDTs) in England participated in 15 workshops in Basingstoke or Leeds. In addition, 112 surgeons attended a 1-day cadaveric training programme in Bristol, Newcastle or Nottingham, with the main focus on extralevator abdominoperineal excision and pelvic reconstruction, with input from anatomists and from colorectal and plastic surgeons. CONCLUSION: Optimal staging, selective preoperative chemoradiotherapy and precise surgery were considered as crucial to improve the outcome for patients with low rectal cancer.


Subject(s)
Adenocarcinoma/surgery , Anal Canal , Organ Sparing Treatments/methods , Rectal Neoplasms/surgery , Adenocarcinoma/therapy , Chemoradiotherapy/methods , Colorectal Surgery/education , Education, Medical, Continuing/methods , England , Fecal Incontinence/prevention & control , Humans , Neoadjuvant Therapy/methods , Patient Selection , Practice Guidelines as Topic , Quality Assurance, Health Care/methods , Quality of Life , Rectal Neoplasms/therapy
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