Empowering patients and educating staff - An online solution for the COVID era and beyond!

BACKGROUND: Bowel disease is a significant cause of significant morbidity and mortality around the world. Though colorectal cancer is a major cause for concern, there are a variety of other conditions which are chronic, debilitating and/or socially embarrassing. While the internet provides excellent resources, there is often conflicting and confusing material of doubtful veracity. There is pressing need for trainees and patients/carers to be able to access reliable resources whenever and wherever they are. AIM: To create an integrated, interactive platform providing reliable information on aspects of bowel disease for patients while addressing educational needs of surgical trainees and other healthcare professionals. APPROACH: Since 2006, we have progressed from leaflets, diagrammatic booklets to DVDs and then downloadable applications all of which, though very successful, had significant limitations.Trainees struggle with balancing their educational needs with their service commitments. This online resource, www.colorectaleducation.com provides an opportunity to view detailed operative training videos on the go. The website also hosts detailed chapterised information videos for patients, care pathway videos and patient experiences. The modular design of the website allows for ease of updating and sequential expansion. The initial emphasis has been on colorectal cancer and the site is being gradually expanded to include a variety of other conditions. RESULTS: The website gained widespread popularity with Google Analytics revealing steadily rising global hit rate with very low bounce rate for both sections. Structured feedback showed 96% satisfaction on both patient and professional sections. CONCLUSION: On-demand information became the norm with the use of smartphones/tablets. This website provides patients, surgical trainees and healthcare professionals access to information and education in clear reliable format, anywhere in the world. This is particularly relevant now as pandemic reduced opportunities for face to face patients consultations as well as for learners with educators.

Radiological Surveillance Post-Curative Colorectal Cancer Resection: Is There a Need for a Targeted Protocol?

Background The frequency of radiological surveillance after curative colorectal cancer resection has long been a controversial issue with the need to balance potential harm from ionizing radiation and the financial burden of intense surveillance against advantages of early detection of recurrent disease. NICE guidelines issued in 2018 suggested having two surveillance computed tomography (CT) scans within three years of surgery without specifying the timing or the interval. Aim To examine whether an evidence-based flexible approach based on individual patients' risk factors can add value to surveillance protocols. Reaching a targeted protocol that can maximize early detection of metastasis without consumption of resources and most important without compromising patient safety. Methodology A retrospective study involving five years of data of patients who underwent curative colorectal cancer resections. Data extracted after patients completed their three-year surveillance CT scans, CT reports retrieved together with post-operative histology reports, and a detailed database was constructed. Results Of 179 patients included, 66 developed recurrence (7 local and 59 distant). Recurrence increased from 23.5% in T1 to 66% in T4 (P=0.0001). The median time to recurrence 23 months in T4 disease compared to 36, 42 and 43 months for stages T1, T2 and T3, respectively (P=0.0001). A similar incremental increase in recurrence noted from 22% in the N0 stage to 73.5% in the N2 stage (P=0.0001); the median time to recurrence of 14 months in N2 patients compared to 45 and 33 months for stages N0 and N1, respectively (P=0.0001). Recurrence correlated well with positive extramural vascular invasion (EMVI) status, (71.7% versus 19.3% P=0.0001) being detected significantly earlier in EMVI positive group at 17 versus 45 months (P=0.0001). Conclusion Flexible protocol for radiological surveillance after curative resection of colorectal cancer, based on known pathological prognostic factors, is likely to be more effective in maximizing resource utilization as well as improving patient outcomes.

An innovative solution to raise public awareness using a mobile colorectal clinic - The 'bowel bus'.

INTRODUCTION: Colorectal cancer is the fourth most common cancer in the United Kingdom; however, figures show that the uptake for bowel cancer screening lags behind other cancer screening programmes. METHODS: This is a report of a multi-staged development of an outreach colorectal clinical community service provided through a Mobile Unit (a Bowel Bus). The unit delivers a one-stop colorectal clinic that provides a rapid access pathway to members of the public who have concerns about, or symptoms of, bowel cancer. The aims of the project were to increase public awareness about colorectal cancer and to provide an outreach clinic as a supplement to the hospital based colorectal clinic. This service is a result of collaborative efforts between Tenovus Cancer Care (TCC) and the colorectal surgery department of the local NHS Hospital. RESULTS: During one year, the Bowel Bus has provided services to 772 members of the local community. 244 patients were examined by the colorectal nurse specialist including 66 drop-in patients and 135 patients referred by the GPs. The service led to decrease in the waiting list for routine referrals to be seen in the colorectal clinic at the hospital from a mean of 10.5 weeks-5.9 weeks. A feedback questionnaire from 180 patients, used to audit the quality of the service, has confirmed an overwhelming satisfaction with the service. CONCLUSION: The Mobile Unit is a novel solution to addressing the ever increasing demand for specialist outpatient services without compromising the quality of care whilst enhancing the patient experience.

Does an enhanced recovery programme add value to laparoscopic colorectal resections?

PURPOSE: Enhanced recovery programmes (ERP) are now becoming integral to the management of patients undergoing colorectal resection. The benefits of ERP in patients undergoing open colorectal resections have been well recognized; however, the value of ERP in patients undergoing laparoscopic resections is still uncertain. This study was undertaken to assess the impact of ERP in our unit where nearly 90 % of elective colorectal resections are performed laparoscopically. METHODS: A prospectively maintained database of all patients undergoing colorectal resections between Jan 2008 to December 2012 was analysed. The ERP programme was introduced in Aug 2010. The primary outcome measure was post-operative length of stay. Secondary outcome measures were post-operative morbidity and mortality. RESULTS: A total of 506 patients underwent major colorectal resections in the study period (282 patients since introduction of ERP). There were no demographic differences between the pre-ERP and post-ERP groups of patients. The median length of stay prior to the introduction of ERP was 6 days (right-sided resections = 6, left-sided resections = 7.5 and rectal resections = 5.5). For post-ERP, the median length of stay was 5 days (right = 5.5, left = 5 and rectal = 4). Patients who had their laparoscopic procedure converted to open had a course similar to open resections. The morbidity and mortality was lesser in the ERP group but did not reach statistical significance. CONCLUSION: The introduction of an ERP adds additional value in laparoscopic colorectal resections, with further reductions in morbidity and length of stay.

Long-term outcome of prucalopride for chronic constipation: a single-centre study.

AIM: Newer 5-hydroxytryptamine agonists, such as prucalopride, have been demonstrated to be effective in the short term for treatment of chronic constipation. To date, few studies have investigated their medium- and long-term effectiveness. METHOD: An analysis was carried out of a prospectively maintained database of all patients started on prucalopride for chronic constipation between April 2011 and April 2014. Cleveland Clinic Constipation Score (CCCS) questionnaires were administered before starting treatment with prucalopride and at the first follow-up visit to assess change in CCCS scores in 50 randomly selected patients. RESULTS: A total of 155 patients (median age: 47 years; seven men) were started on prucalopride in this period. Of these, 16 (10%) had slow-transit constipation, 31 (20%) had obstructive defaecation syndrome and 30 (19%) had a combination of both. Of these 155 patients, 78% patients were on three or more laxatives at the time of starting prucalopride. Patients were started on 1 mg or 2 mg according to their age. The median follow-up period was 24 (range: 4-40) months. At the first follow-up visit, 106 (68%) patients reported good symptomatic improvement, whereas the remainder had no response. Third of initial responders showed decreased efficacy after a median duration of 6 months and needed regular laxatives/irrigation. Of the 50 patients who filled in the CCCS questionnaires (15 patients were nonresponders), 32 (64%) reported improved scores with a median improvement of two points per criterion. CONCLUSION: This study provides evidence that prolonged use of prucalopride is effective in achieving a sustained benefit in the majority of patients.

Multimedia educational tools for cognitive surgical skill acquisition in open and laparoscopic colorectal surgery: a randomized controlled trial.

AIM: Conventional teaching in surgical training programmes is constrained by time and cost, and has room for improvement. This study aimed to determine the effectiveness of a multimedia educational tool developed for an index colorectal surgical procedure (anterior resection) in teaching and assessment of cognitive skills and to evaluate its acceptability amongst general surgical trainees. METHOD: Multimedia educational tools in open and laparoscopic anterior resection were developed by filming multiple operations which were edited into procedural steps and substeps and then integrated onto interactive navigational platforms using Adobe® Flash® Professional CS5 10.1. A randomized controlled trial was conducted on general surgical trainees to evaluate the effectiveness of online multimedia in comparison with conventional 'study day' teaching for the acquisition of cognitive skills. All trainees were assessed before and after the study period. Trainees in the multimedia group evaluated the tools by completing a survey. RESULTS: Fifty-nine trainees were randomized but 27% dropped out, leaving 43 trainees randomized to the multimedia group (n = 25) and study day group (n = 18) who were available for analysis. Posttest scores improved significantly in both groups (P < 0.01). The change in scores (mean ± SD) in the multimedia group was not significantly different from the study day group (6.02 ± 5.12 and 5.31 ± 3.42, respectively; P = 0.61). Twenty-five trainees completed the evaluation survey and experienced an improvement in their decision making (67%) and in factual and anatomical knowledge (88%); 96% agreed that the multimedia tool was a useful additional educational resource. CONCLUSION: Multimedia tools are effective for the acquisition of cognitive skills in colorectal surgery and are well accepted as an educational resource.

Rectal irrigation: a useful tool in the armamentarium for functional bowel disorders.

AIM: The efficacy of rectal irrigation (RI) was assessed in patients with various functional bowel disorders. METHOD: A prospective analysis was carried out of patients presenting to our functional bowel clinic from 2005 to 2009. The Cleveland Clinic Constipation and Incontinence Scores were used to assess outcomes following rectal irrigation. Patients were asked if they were satisfied with RI and would recommend it to a friend. RESULTS: Ninety-one patients (80 female, median age 51 (17-78) years had undergone rectal irrigation for the following indications: chronic constipation (n = 32), slow transit constipation (n = 18), obstructed defaecation (n = 10), and faecal incontinence (n = 31). Of the 60 patients with constipation, 50 (83%) were available for follow up. Mean constipation scores improved from 18.72 to 11.45 following rectal irrigation (P = 0.001). Twenty-five patients experienced failure of RI to control symptoms, 10 of whom were offered surgery. Of the patients with incontinence, 20 (67%) were available for follow up. Mean incontinence scores improved from 16.2 to 10.8 with rectal irrigation (P = 0.005). Twelve patients discontinued RI, the commonest reason being lack of improvement in symptoms. Seven of these patients were offered surgery. The only complication was in one patient with constipation who had minor rectal bleeding following irrigation, which was stopped. CONCLUSION: Rectal irrigation can be a useful tool in the management of functional bowel disorders and should be tried prior to the consideration of any surgery. However, further work is needed to define the precise indications and patient selection criteria.

A tool-kit for the quantitative assessment of proficiency in laparoscopic colorectal surgery.

AIM: Laparoscopic colorectal surgery includes operative procedures of varying complexity, and traditional assessment tools may not be enough to assess competence. This study defines quantitative tools for assessing proficiency in laparoscopic colorectal surgery. METHOD: A single surgeon's 11-year experience was subdivided into five phases with equal numbers of patients. A tool-kit, with specific tools defined as the complexity score, the conversion score, the technical score, the training score and the proficiency score, has been developed and used to evaluate each phase of the experience. RESULTS: There were 400 patients, with 80 in each of the five phases. The complexity score increased from 23.75 to 63.75 over the five phases. Similar increases were also demonstrable in the conversion score (from 0.45 to 15.45), the technical score (from 30 to 96.5), the training score (from 5.8 to 34.8) and the overall proficiency score (from 15 to 52.63). CONCLUSION: The results show that it is possible to quantify the workload in laparoscopic colorectal surgery and to assess increasing proficiency using a simple, reproducible and reliable tool-kit.

A unique approach to quantifying the changing workload and case mix in laparoscopic colorectal surgery.

AIM: Laparoscopic colorectal surgery includes a range of operations with differing technical difficulty, and traditional parameters, such as conversion and complication rates, may not be sensitive enough to assess the complexity of these procedures. This study aims to define a reproducible and reliable tool for quantifying the total workload and the complexity of the case mix. METHOD: This is a review of a single surgeon's 10-year experience. The intermediate equivalent value scoring system was used to code complexity of cases. To assess changes in the workload and case mix, the period has been divided into five phases. RESULTS: Three hundred and forty-nine laparoscopic operations were performed, of which there were 264 (75.6%) resections. The overall conversion rate was 17.8%, with progressive improvement over the phases. Complex major operation (CMO), as defined in the British United Provident Association (BUPA) schedule of procedures, accounted for 35% of the workload. In spite of similar numbers of cases in each phase, there was a steady increase in the workload score, correlating with the increasing complexity of the case mix. There was no significant difference in the conversion and complications rates between CMO and non-CMO. The paradoxical increase in the mean operating time with increasing experience corresponded to the progressive increase in the workload score, reflecting the increasing complexity of the case mix. CONCLUSION: This article establishes a reliable and reproducible tool for quantifying the total laparoscopic colorectal workload of an individual surgeon or of an entire department, while at the same time providing a measure of the complexity of the case mix.

Use of uterine manipulator in laparoscopic colorectal surgery.

Laparoscopic colorectal surgery has become more common with the increase in the number of trained surgeons. We have used a disposable uterine manipulator to retract the uterus. This technique has been found to be very useful for laparoscopic low anterior resection and abdomino-perineal resection in females.

Implications of sub-specialisation on the waiting times of general surgical clinics.

INTRODUCTION: Controversy around sub-specialisation in a district general hospital (DGH) has been ongoing for years. AIM: To study the effect of colorectal sub-specialisation on general surgical cases. METHODS: A retrospective audit between October 2002 and September 2003, including all referrals to the outpatient clinics of a single consultant surgeon in a DGH. RESULTS: 1,055 patients were seen in outpatient clinics, of which 53% (563) were seen in rapid access colorectal clinics. Overall, 87% (914) of patients were diagnosed to have colorectal pathology. The majority of the colorectal cases were referred using the designated referral forms. There were 427 urgent, 162 soon and 325 routine referrals with colorectal pathology, and 35 urgent, 22 soon and 84 routine referrals with non-colorectal pathology. Median waiting times for urgent, soon and routine referrals were 12, 61 and 91 days, respectively, for patients with colorectal pathology, in comparison with 44, 75 and 397 days for non-colorectal pathology. CONCLUSION: This audit confirms that colorectal sub-specialisation has resulted in a significant delay in the management of patients with non-colorectal diseases. This has major implications within a DGH setting.

Laparoscopic colorectal surgery: learning curve and training implications.

AIMS: This paper is a review of experience of laparoscopic colorectal surgery at a district general hospital with particular emphasis on the learning curve and training implications. METHODS: All patients undergoing colorectal surgery where laparoscopy was attempted between March 1998 and October 2003 were included in this study. RESULTS: There were 80 patients of which 49 had malignancy. Twenty eight stomas and 52 bowel resections were performed laparoscopically. The conversion rate for bowel resection was 32% (decreasing from 38% to 44% to 22%). This was significant (p = 0.001) when compared with stoma formation (7%). The firm has support from a specialist registrar and staff grade surgeon. In 22% of cases, one of the middle grades was the principal operating surgeon, mainly laparoscopic mobilisation and stoma formation. Only 6% of resections were performed by the middle grades. Conversely, a middle grade was the main operating surgeon in 66% of open resections and 61% of stoma formations during the same period. There were in all two deaths and 14 postoperative complications. All patients who had laparoscopic resections for malignancy had clear resection margins. CONCLUSION: This audit highlights that there is a long learning curve in laparoscopic colorectal surgery with decrease in conversion rates with increasing experience. There is also a reduction in training opportunities in open surgery during the learning phase of the consultant, although this may be counterbalanced by the exposure to laparoscopic techniques. Laparoscopic colonic mobilisation, as a part of stoma formation, is a good starting point for specialist registrar training.

Splenic rupture following colonoscopy: rare in the UK?

Splenic injury following colonoscopy is rare, with only 28 cases reported so far in the English language literature. Direct trauma during colonoscopy or traction on the spleno-colic ligament is the proposed mechanism of injury. Computed tomography (CT) of the abdomen is usually considered to be the most sensitive and specific modality for diagnosis. We report a case of a 56-year-old female, who was diagnosed having a splenic rupture following a routine colonoscopy for investigation of anaemia. She underwent an emergency laparotomy with splenectomy and made a satisfactory recovery post-operatively. We wish to highlight that there should be a high index of suspicion of splenic rupture in patients presenting with abdominal pain and demonstrating a positive Kehr's sign following colonoscopy. Only two case reports from the United Kingdom have been published, raising the possibility of under-reporting of such cases.

Laparoscopic colorectal surgery in Great Britain and Ireland--where are we now?

OBJECTIVE: We aimed to gather information from the members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to assess trends in the current practice of laparoscopic colorectal surgery. METHODS: A postal questionnaire survey of the members of ACPGBI. RESULTS: The response rate was 37% (200/540). Only 45 surgeons currently perform laparoscopic colorectal work in Great Britain and Ireland mainly right hemicolectomy and laparoscopic stoma formation, of these about one third practiced laparoscopy for benign colorectal conditions only. The majority (68%) of surgeons had enough resources at their place of work, but further training seemed to be a major issue. Nearly 22% of surgeons had not had any formal training. Only 50% of surgeons trained their specialist registrars. The incidence of conversion rate was not different for benign or malignant conditions and also did not appear to be related to the duration of experience. Only four surgeons had noted port a site recurrence during the past 10 years. Seventy-five percent (150/200) felt that laparoscopic colorectal work could be carried out safely in a District General Hospital. CONCLUSION: Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.