The most frequent cause of 90-day unplanned hospital readmission following colorectal cancer resection is chemotherapy complications.

AIM: NHS England deems 90-day readmission rates as a marker of quality of care. The causes of readmission have not been previously reported in the UK. The aim of this study was to examine the factors associated with 90-day readmission following colorectal cancer surgery at a hospital trust with a catchment population 1.2 million. METHOD: A retrospective review was performed of all patients undergoing resection for colorectal cancer between January 2012 and December 2013. Unplanned readmission was defined as an emergency admission to the trust for any cause within 90 days of surgery. Readmission analyses were restricted to patients discharged from hospital within 28 days of resection. RESULTS: A total of 570 patients underwent surgery, of whom 522 were discharged within 28 days and are included for readmission analysis. The readmission rate was 24.3% (127 patients with a total of 163 episodes of hospital readmissions) within 90 days following surgery. The most frequent cause for readmission was complications related to adjuvant chemotherapy (18.4%) followed by wound-related complications (14.1%). Most patients presenting with wound-related complications were admitted within 60 days and patients with chemotherapy-related complications after 61 days; 13/127 (10.2%) patients who were readmitted underwent emergency surgery, and one patient died following readmission. Multivariate analysis demonstrated that comorbidity was the only independent risk factor. CONCLUSION: Ninety-day readmissions include a high number of readmissions secondary to chemotherapy-related complications, whereas most surgical-related readmission present within 60 days.

The 2-week wait referral system does not improve 5-year colorectal cancer survival.

AIM: The aim of this study was to compare 5-year survival rates in colorectal cancer (CRC) patients who underwent potentially curative surgery before and after the introduction of the 2-week wait (2WW) referral system. METHOD: Data were collected retrospectively from a prospectively maintained cancer database for CRC patients who underwent surgery in 1999 (pre-2WW group, n = 150) and 2002 (post-2WW group, n = 126). Patients who presented as an emergency, those who died within 30 days of surgery and those who presented with incurable CRC were excluded. We used the Kaplan-Meier method to plot survival curves and the log rank test to compare survival rates between the two groups. RESULTS: The 5-year survival rates in the pre-2WW and post-2WW groups did not differ significantly (71%vs 72%, respectively; P = 0.880). The number of CRC patients who presented via urgent pathways was higher in the post-2WW group than in the pre-2WW group (77%vs 38%, P < 0.001). Further, owing to this change in the referral pattern, the overall delay between referral and treatment was significantly lower in the post-2WW group than in the pre-2WW group (median 76 days vs 115, P = 0.009). CONCLUSION: The 2WW referral system for patients with symptoms of CRC does not translate into improved survival. However, more patients with symptomatic CRC are being referred via urgent pathways.

Is whole colonic imaging necessary for symptoms of change in bowel habit and/or rectal bleeding?

AIM: Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging patients with change in bowel habit (CIBH) and/or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfactory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice. METHOD: This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malignancy over a 4-year period. Two-week-wait referral proforma and case notes were analysed for mode of presentation. RESULTS: Of 206 elective right hemicolectomies performed, 20/206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. Twelve patients had polyposis identified in the left colon and eight patients had no left-sided colonic pathology. One patient had a strong family history of colon cancer (two first-degree relatives) in the group absent of left-sided pathology. CONCLUSION: Twelve patients who had left-sided polyposis and one patient with a strong family history would have undergone whole colonic imaging based on current colorectal cancer management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and/or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer.

A meta-analysis of the association of physical activity with reduced risk of colorectal cancer.

BACKGROUND: Physical activity may be associated with reduced risk of colorectal cancer. The main aim of this paper is to review the available evidence for a link between exercise and large bowel cancer. METHODS: A Cochrane-type methodology was performed. Data extracted included, type of study, type of physical activity measured and the numerical results. The risk ratios (RR) of the studies have been pooled according to the type of study, type of exercise, type of cancer and sex. Pooling was undertaken using fixed effect meta-analysis. A random effect meta-analysis was used where substantial heterogeneity existed. RESULT: Data from 19 cohort studies showed a statistically significant reduction in the risk of colon cancer in physically active males, RR being 0.79 (95% CI 0.72-0.87) and 0.78 (95% CI 0.68-0.91) for occupational and recreational activities, respectively. In women only recreational activities are protective against colon cancer (RR = 0.71, 95%CI 0.57-0.88). Case-control studies showed significantly reduced risks of colon cancer in both sexes irrespective of the type of activity. No protection against rectal cancer is seen in either sex. CONCLUSION: There is considerable evidence that physical activity is associated with reduced risk of colon cancer in both males and females.

Sulphide-induced energy deficiency in colonic cells is prevented by glucose but not by butyrate.

BACKGROUND: In ulcerative colitis, hydrogen sulphide is postulated to impair colonocyte butyrate metabolism, leading to cellular energy deficiency and dysfunction. AIMS: To determine the effects of sulphide exposure on butyrate metabolism and adenosine triphosphate levels of HT29 colonic epithelial cancer cells, and to establish whether energy deficiency can be prevented by increased butyrate concentrations or the presence of glucose. METHODS: HT29 cells were maintained in medium containing 3 mM butyrate, 5 mM glucose, or both substrates. Oxidation rates were measured by 14CO2 release from 14C-labelled substrates. Cellular adenosine triphosphate was assayed using the luciferin/luciferase chemiluminescent method. The effects of sulphide (0-5 mM) on substrate oxidation and adenosine triphosphate levels and of increasing butyrate concentration (0-30 mM) with sulphide were observed. RESULTS: HT29 cells showed similar energy substrate usage to primary colonocyte cultures. Sulphide exposure inhibited butyrate oxidation and led to a reduction in cellular adenosine triphosphate. This fall was prevented by co-incubation with glucose, but not by increasing concentrations of butyrate. CONCLUSIONS: HT29 cells utilize butyrate as an energy substrate and represent a useful in vitro model of the effects of sulphide on colonocytes. Sulphide inhibits butyrate oxidation and leads to demonstrable energy deficiency, prevented by the presence of glucose but not by increased butyrate concentrations.