Search

Background:\ud Some patients with intestinal failure requiring Home Parenteral Support (HPS) may be weaned. This study considers all abdominal surgery in a cohort of HPS patients over 25 years. The aim was to identify how many patients can be weaned from HPS and by what means, and to identify what makes weaning more likely.\ud \ud Methods:\ud A prospectively collected database of HPS patients to December 2018 was analysed for outcomes of care.\ud \ud Results:\ud At five years 56% of 205 patients remained on HPS. Fifty-eight patients(28%) who had 68 operations, stopped HPS after surgery.\ud \ud Patients stopping HPS had longer median final small bowel length (155cm; range 45-350cm) and were more likely to have colon in circuit (84%) than patients who had reconstructive surgery but did not stop HPS (median small bowel length 50cm; range 15-135cm; 50% colon in circuit). The median period between HPS discharge and reconstructive surgery was 238 days. There were no deaths but 18 Clavien-Dindo Grade 3/4 complications within 30days. 90% of patients who stopped HPS survived 5 years from the start of HPS in comparison to 53% of those who remained on HPS.\ud \ud Conclusions:\ud No previous study has examined surgery in an entire cohort of HPS patients. More than one quarter of HPS patients can be weaned after reconstructive surgery. The length of bowel available for recruitment at surgery is the main determinant of ability to stop HPS. The possibility of reconstruction should be considered, since patients who stop HPS appear to have a survival advantage.

Backgrounds and Aims:\ud Long term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI). This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access.\ud \ud Methods:\ud HPN data was analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days’ distributions. Data were not normally distributed and so non-parametric tests were used. Spearman’s Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1,000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used 2 sample t-test to compare the groups.\ud \ud Results:\ud From 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n=16) was associated with total time on HPN(r2 = 0.187, P

Background and aims:\ud Home Parenteral Nutrition (HPN) is the established treatment of intestinal failure. This study considers the changes in practice in a single UK centre over the past twenty-five years.\ud \ud Methods:\ud Data was culled from a database used for clinical care and maintained prospectively.\ud \ud Results:\ud Two hundred and five patients were included from 1993 to 2018. Patient numbers increased from 22 during 1999–2003 to 158 during 2014–2018. The median age at discharge increased from 52 years during 1999–2003 to 59 years during 2014–2018. Thirty percent of patients discharged during 1999–2003 had Crohn's disease, reducing to 14% during 2014–2018. Fifteen percent of patients discharged during 1999–2003 had small bowel fistula or obstruction in comparison to 44% during 2014–2018. Only 18 patients were treated with palliative intent, the majority in recent years. An increasing number of patients required help with HPN care over the years.\ud \ud Survival in non-palliative patients was 85% at 1 year, 67% at 3 years, 53% at 5 years and 42% at 10 years. The majority of deaths were due to underlying disease and only 5 of 55 deaths were attributed to HPN alone. HPN dependence in non-palliative patients was 73% at 1 year, 59% at 3 years, 56% at 5 years and 43% at 10 years. Fifty eight patients stopped HPN after reconstructive surgery.\ud \ud Patients experienced 5.1 admissions/1000 HPN days (64.7 admission days/1000 HPN days). Admission rate did not change over the years though the percentage due to catheter problems fell from 52% to 40% while the percentage due to underlying disease or unrelated cause rose.\ud \ud Conclusions:\ud The increase in numbers, age and dependency of HPN patients requires increasing resource and consideration of new models of service. Many patients with short bowel syndrome now survive to old age and the care needs of the HPN patient who has become elderly can be complex. A significant proportion of patients are being referred for HPN as a bridge to reconstructive surgery after surgical complication and this requires close involvement of gastrointestinal surgeons in HPN teams. The need for hospital admissions remains a burden for HPN patients and there is scope for changes in service provision to try to reduce hospital days.

Aims The incidence of anal squamous cell cancer (SCCA) is rising. Although chemoradiotherapy (CRT) provides a chance of cure, a proportion of patients have an incomplete response or develop recurrence. This study assessed the value of inflammation-based prognostic indicators, including the modified Glasgow Prognostic Score (mGPS) and neutrophil:lymphocyte ratio (NLR), in patients with SCCA treated by CRT with curative intent. Material and methods Patients with histologically confirmed SCCA were identified from pathology records. Medical records were retrospectively reviewed and clinical, pathological and treatment characteristics were abstracted. The mGPS (0 = normal C-reactive protein [CRP] and albumin, 1 = CRP >10 mg/l and 2 = CRP >10 mg/l and albumin Results In total, 118 patients underwent CRT for SCCA between December 2007 and February 2018. Of these, 99 patients had appropriate pretreatment blood results available. Systemic inflammation as indicated by NLR >3 and mGPS >0 was present in 41% and 39% of patients, respectively. Most patients had T2 or larger tumours (n = 85, 86%) without nodal involvement (n = 64, 65%). An elevated mGPS was associated with more advanced T-stage (56% versus 35%, P = 0.036). NLR >5 was associated with nodal positivity (56% versus 31%, P = 0.047). On multivariate analysis, more advanced T-stage (odds ratio 7.49, 95% confidence interval 1.51–37.20, P = 0.014) and a raised mGPS (odds ratio 5.13, 95% confidence interval 1.25–21.14, P = 0.024) were independently related to incomplete CRT response. An elevated mGPS was prognostic of inferior survival (hazard ratio 3.09, 95% confidence interval 1.47–6.50, P = 0.003) and cancer-specific survival (hazard ratio 4.32, 95% confidence interval 1.54–12.15, P = 0.006), independent of TNM stage. Conclusion Systemic inflammation, as measured by the mGPS, is associated with an incomplete CRT response and is independently prognostic of inferior survival in patients with SCCA. The mGPS may offer a simple marker of inferior outcome that could be used to identify high-risk patients.

To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period. Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high. Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998–2013). Data collected included: demographics, mode of admission, pathological grouping and outcome. A total of 286 ECF were identified in 278 patients, mean age 64 years (20–96 years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p = 0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51). Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.

Background:\ud \ud Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors.\ud \ud Methods:\ud \ud Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012–2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded.\ud \ud Results:\ud \ud 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20–0.60 95% CI and 0.47; 0.25–0.88, respectively).\ud \ud Conclusion:\ud \ud Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

Introduction The importance of presence of a nutrition support team (NST) and a nutrition steering committee (NSC) were recognised in 1994 by BAPEN with the recommendation that all major UK hospitals should appoint a NSC and at least one NST. It was recognised that delivering excellent nutritional care within hospitals required the co-ordination and oversight of a NSC. The NST’s role was to bring together a multi-disciplinary team that could support hospital staff in the provision of nutritional therapy, especially enteral and parenteral nutritional support, at a ward level. A NST should contain at least a doctor, nurse, dietician and pharmacist with specialist skills in nutritional support. NICE guidelines have also made recommendations about the provision of a NSC and NST in all acute trusts. In 2010 the NCEPOD report – A Mixed bag, reported only 60.2% of hospitals in the UK as having a NST of which only 59% had a full MDT provision. We aimed to assess the current provision of NSC’s and NST’s within the UK at this present time. Methods In June 2017 BAPEN sent a freedom of information (FOI) request to all trusts in England, health boards in Scotland and Wales and social care trusts in Northern Ireland. This requested information on the size of the trust, the presence and composition of the NST and their role within the hospital along with information about the trust’s NSC. Those responses received before 18th October were collated. Hospitals with fewer than 100 beds were excluded from the analysis. Results Of the 181 FOI requests made BAPEN received responses from 122 trusts representing 154 hospitals with more than 100 beds. 91% of trusts in the UK had a NSC and only 80% of trusts reported having a NST. Of this only 25% of social care trusts in Northern Ireland and 40% of health boards in Wales reported having an NST. 48% of trusts with an NST had a nutrition nurse, a dietician, a doctor and a pharmacist. 76% of trusts with an NST had a nutrition nurse, 79% had a pharmacist, 86% had a doctor and 88% had a dietician. 57% of NSTs performed a ward round more than once a week with 10% seeing patients as required and 4% providing an advisory role only. Conclusion There has been a clear improvement in the provision of NSC’s and NST’s within the UK over time. Sadly despite this increase in NSC’s and NST’s we have not managed to fulfil the aim of having one in each trust. Furthermore the majority do not have the full multi-disciplinary team provision required to provide the highest level of care. More work needs to be done to promote the importance of the NSC and NST and provide support in developing them in trusts that currently do not have them ensure that all trusts have access to them.

Artificial nutritional support is needed when a patient is unable to absorb sufficient nutrition from normal diet. NICE guidance recommends that enteral and parenteral nutrition is supervised by a multidisciplinary nutrition team and that clear goals of nutritional support are defined and reviewed regularly. The combination of nutrition and control of the systemic inflammatory response enables the patient to become anabolic. If possible the enteral route should be used, most commonly nasogastric feeding. Recent NPSA alerts have highlighted the risks of nasogastric tube misplacement and hospitals should have clear policies about checking tube position. Percutaneous gastrostomy feeding is useful for longer term enteral feeding. In the past decade jejunal feeding has reduced the use of parenteral feeding in critical care and upper gastrointestinal disease. Feeding into the distal small bowel beyond a fistula or a proximal stoma can also avoid parenteral nutrition. Parenteral nutrition may be life saving, but may also result in serious complications such as septicaemia due to line infection. Metabolic complications have been less common since ‘standard' PN bags became widely available. Refeeding syndrome may occur in severely malnourished patients who recommence feeding. Complex electrolyte disorders, such as hypophosphataemia, hypomagnesaemia and hypokalaemia may result, owing to cellular utilization of phosphate. Feeding should be recommenced slowly with careful electrolyte monitoring.

Dipyridamole intoxication is rare and few reports exist amongst the current literature. A case of dipyridamole and paracetamol overdose is described in a previously healthy 58-year-old woman, which resulted in multi-organ failure requiring dialysis, inotropic support, ventilation and extensive surgical intervention for small bowel ischaemia. This case highlights the dangers of an unusually large overdose of a commonly prescribed drug, and reviews current knowledge of dipyridamole intoxication.

Aim It is recognised that colorectal cancer may arise from different genomic instability pathways. There is evidence to suggest that colon and rectal cancers exhibit different clinicopathological features. We examined the relationship between tumour site, clinicopathological characteristics and cancer-specific survival in patients undergoing potentially curative resection for colorectal cancer. Method Four hundred and eleven patients who underwent surgery. Clinicopathological data including components of the Peterson index, Klintrup scores, haemoglobin and the modified Glasgow Prognostic Score (mGPS) were studied. Results There were 134 (33%) right sided, 125 (30%) left sided and 152 (37%) rectal tumours. Emergency presentation (P

Summary Background & aims In Scotland, an important opportunity is provided to review long-term survival and Home Parenteral Nutrition (HPN) dependence across an entire population by the existence of the Scottish HPN Managed Clinical Network (MCN). Methods Through the existence of the MCN, we are able to report the survival rates and outcomes of HPN patients across Scotland as a whole, where treatment is delivered locally under nationally agreed guidelines: The study aims to establish whether this population of adult patients behave in a similar way to previously reported groups in terms of survival, prognostic factors and HPN dependence. All patient data has been entered prospectively since commencement of their parenteral nutrition. Results The overall survival probability after starting HPN for the 136 patients studied was 86.0% at 1 year, 78.7% at 3 years, 77.2% at 5 years and 76.5% at 6 years. In this study, dependence on HPN was 61%, 51% and 48% at 1, 3 and 5 years. No difference was found between survival in patients treated at two of Scotland’s largest HPN centres and the smaller centres treating far fewer patients. Indications for HPN are similar to those reported in UK literature. Conclusions Our outcomes are similar to those reported from large specialist centres, supporting the value of managed networks in maintaining quality of patient care across our wide geographical area and resulting diverse demographic.

Background Tumour necrosis is a marker of poor prognosis in some tumours but the mechanism is unclear. This study examined the prognostic value of tumour necrosis and host inflammatory responses in colorectal cancer. Methods This was a retrospective study of patients undergoing potentially curative resection of colorectal cancer at a single surgical institution over a 10-year period. Patients who underwent preoperative radiotherapy were excluded. The systemic and local inflammatory responses were assessed using the modified Glasgow Prognostic Score and Klintrup–Makinen criteria respectively. Original tumour sections were retrieved and necrosis graded as absent, focal, moderate or extensive. Associations between necrosis and clinicopathological variables were examined, and multivariable survival analyses carried out. Results A total of 343 patients were included between 1997 and 2007. Tumour necrosis was graded as absent in 32 (9·3 per cent), focal in 166 (48·4 per cent), moderate in 101 (29·4 per cent) and extensive in 44 (12·8 per cent). There were significant associations between tumour necrosis and anaemia (P = 0·022), white cell count (P = 0·006), systemic inflammatory response (P < 0·001), local inflammatory cell infiltrate (P = 0·004), tumour node metastasis (TNM) stage (P = 0·015) and Petersen Index (P = 0·003). On univariable survival analysis, tumour necrosis was associated with cancer-specific survival (P < 0·001). On multivariable survival analysis, age (hazard ratio (HR) 1·29, 95 per cent confidence interval 1·00 to 1·66), systemic inflammatory response (HR 1·74, 1·27 to 2·39), low-grade local inflammatory cell infiltrate (HR 2·65, 1·52 to 4·63), TNM stage (HR 1·55, 1·02 to 2·35) and high-risk Petersen Index (HR 3·50, 2·21 to 5·55) were associated with reduced cancer-specific survival. Conclusion The impact of tumour necrosis on colorectal cancer survival may be due to close associations with the host systemic and local inflammatory responses.

Objective The objective of the study was to identify determinants of disease recurrence after potentially curative resection of colorectal cancer. Summary background data The identification of patients at increased risk of disease recurrence is currently based on pathological factors. Recently, there has been considerable interest in the potential impact of perioperative factors on long-term colorectal cancer outcome. Few studies have examined pre-, intra-, and postoperative variables in a single cohort. Methods Four hundred and twenty-three patients with histologically confirmed colorectal cancer who underwent surgery with curative intent between 1997 and 2007 were included. Pre-, intra-, and postoperative variables were recorded. Logistic and Cox regression analyses were performed to identify predictors of surgical complications and disease recurrence, respectively. Results The postoperative mortality rate was 4% and the morbidity rate 34%. The most important predictors of complications were smoking (odd ratio [OR] 1.32), ASA grade (OR 1.90) and POSSUM operative score (OR 1.32). During follow up (median 80 months), 35% of patients developed disease recurrence. Predictors of recurrence, independent of tumor stage, were POSSUM physiology score (hazard ratio [HR] 1.31) and systemic inflammatory response (HR 1.31). Conclusions Preoperative risk factors, but not postoperative complications, are associated with early disease recurrence after potentially curative resection of colorectal cancer.

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer.A total of 423 patients who underwent potentially curative resection of colorectal cancer at a single institution (1997-2007) were included. Data used in the construction of the ACPGBI model was collected prospectively. The models were compared by examining observed to expected (O:E) ratios, the Hosmer-Lemeshow (H-L) goodness-of-fit test, and area under the receiver operator characteristic curve (AUC) analysis.The 30-day mortality rate was 4%. The performance of the models was as follows: revised ACPGBI model (O:E ratio = 1.05, AUC = 0.73, H-L = 11.02), original ACPGBI model (O:E ratio = 0.58, AUC = 0.76, H-L = 14.23), P-POSSUM (O:E ratio = 0.87, AUC = 0.79, H-L = 10.63), and CR-POSSUM (O:E ratio = 0.63, AUC = 0.84, H-L = 15.84). In subgroup analysis, the revised ACPGBI model performed well in both elective cases (O:E ratio = 1.06) and emergency cases (O:E ratio = 0.91).The revised ACPGBI model is simple to construct and accurately predicts operative mortality after potentially curative resection of colorectal cancer.

Undernutrition is common in hospital in-patients and should be detected by routine nutritional screening on admission. Nutritional requirements can be estimated by an expert dietitian and decisions to supplement hospital diet or to supply completely artificial nutritional support should be made based on whether intake is adequate and the gut functioning. If possible, enteral nutrition is preferred and this is most commonly supplied by oral supplements or nasogastric tube feeds. More complex enteral feeding includes nasojejunal tube-feeding, percutaneous gastrostomy feeding and percutaneous jejunostomy feeding. Parenteral nutrition is not indicated unless the gut is not functioning adequately. Venous access for feeding can now be gained by several different means but in all cases meticulous care of lines is essential. Although standard parenteral nutrition bags supplied by commercial companies may be used, vitamins and trace elements must always be added in pharmacy. A multidisciplinary team is vital for the safe delivery of artificial nutritional support.

BACKGROUND: Emergency presentation is recognized to be associated with poorer cancer-specific survival following curative resection for colorectal cancer. The present study examined the hypothesis that an enhanced systemic inflammatory response, prior to surgery, might explain the impact of emergency presentation on survival. METHODS: In all, 188 patients undergoing potentially curative resection for colorectal cancer were studied. Of these, 55 (29%) presented as emergencies. The systemic inflammatory response was assessed using the Glasgow Prognostic Score (mGPS), which is the combination of an elevated C-reactive protein (>10 mg/L) and hypoalbuminemia (

The presence of systemic inflammation before surgery, as evidenced by the glasgow prognostic score (mGPS), predicts poor long-term survival in colorectal cancer. The aim was to examine the relationship between the preoperative mGPS and the development of postoperative complications in patients undergoing potentially curative resection for colorectal cancer. Patients (n=455) who underwent potentially curative resections between 2003 and 2007 were assessed consecutively, and details were recorded in a database. The majority of patients presented for elective surgery (85%) were over the age of 65 years (70%), were male (58%), were deprived (53%), and had TNM stage I/II disease (61%), had preoperative haemoglobin (56%), white cell count (87%) and mGPS 0 (58%) in the normal range. After surgery, 86 (19%) patients developed a postoperative complication; 70 (81%) of which were infectious complications. On multivariate analysis, peritoneal soiling (P

OBJECTIVE: Ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis. Free radical activity and the status of lipid soluble antioxidant vitamins have not been previously assessed in patients with IPAA. The aim of the present study was to measure the plasma concentrations of lipophyllic antioxidants and free radical activity in IPAA patients and compare them with normal subjects. METHOD: Forty-eight IPAA patients and 50 healthy controls were studied. A dietary assessment of vitamin E (alpha-tocopherol) and carotene was undertaken and plasma antioxidant status was assessed. Plasma malondialdehyde (MDA) was measured to assess the extent of free radical damage. In IPAA patients, association between the degree of inflammation in the pouch mucosa and the plasma concentration of lipophyllic antioxidants and extent of free radical activity was investigated. RESULTS: The dietary intake of carotene was similar in both groups. Intake of vitamin E was significantly lower in patients than controls (P = 0.01). In the IPAA group plasma concentrations of alpha-carotene, beta-carotene and lycopene were significantly lower (P < 0.001) and alpha-tocopherol:cholesterol ratio significantly higher (P < 0.001). Free radical damage was significantly greater in patients than controls (P < 0.01). There were no significant correlations between the degree of inflammation in the pouch and plasma concentrations of MDA, carotenoids, alpha-tocopherol:cholesterol ratio or intake of vitamins. CONCLUSION: Compared with normal subjects, patients with IPAA have significantly lower plasma concentrations of lipophyllic antioxidants alpha-carotene, beta-carotene and lycopene and higher free radical activity suggesting increased oxidative stress. These differences do not appear to be related to diet and do not correlate with histological severity of pouch inflammation.

Participation in the Intercollegiate Surgical Curriculum Programme is mandatory for all FTSTA and ST trainees in the nine surgical specialties – General Surgery, Paediatric Surgery, Plastic Surgery, Cardiothoracic Surgery, Otorhinolaryngology, Neurosurgery, Urology, Oral and Maxillofacial Surgery and Trauma and Orthopaedics (who currently move to OCAP at ST3). All specialties have developed a syllabus which includes the progression in knowledge, clinical skills, technical skills and professional skills throughout the years of training. There is strong emphasis on educational supervision from a consultant who will formulate a specific learning agreement with the trainee early in each training placement and then review progress throughout the placement. The learning agreement is based on the syllabus and adjusted depending on previous training and assessments as well as the opportunities available locally. Throughout each placement the trainee is assessed by their seniors using workplace based assessments which include those based on the Foundation assessments (miniCEX, CBD, DOPS, miniPAT) in addition to assessments more specific to surgery (surgical DOPS, PBA, logbook). As in other specialties and based on the Gold Guide, each year the trainee’s progress is assessed by a panel of consultants during the Annual Review of Competency Progression and if progress is satisfactory, the trainee progresses to the next stage of training. The trainee’s progress is recorded in an electronic portfolio held on a secure website which also houses the syllabus and guidance about many other aspects of training.

Background: The aim of the present study was to examine the relationship between Ki-67, C-reactive protein and cancer-specific survival in patients undergoing resection for colorectal cancer. Method: One hundred and forty-seven patients undergoing potentially curative resection for colorectal cancer had preoperative C-reactive protein concentrations and tumour Ki-67 labelling index measured. Results:On univariate analysis, age (P < 0.001), Dukes stage (P < 0.001), C-reactive protein (P < 0.001) and expression of Ki-67 (< 0.01) were associated with poorer cancer-specific survival. Ki-67 labelling index and Creactive protein were correlated (rs = 0.172, P = 0.037). On multivariate analysis, age (HR 1.96, 95% CI 1.26– 3.04, P = 0.003), Dukes stage (HR 4.38, 95% CI 2.11– 9.09, P < 0.001) and C-reactive protein (HR 4.09, 95% CI 2.04–8.24, P < 0.001) retained significance. Conclusion: Increased tumour proliferation is associated with a systemic inflammatory response and poor cancerspecific survival in patients undergoing potentially curative surgery for colorectal cancer.© 2007 The Association of Coloproctology of Great Britain and Ireland

Panproctocolectomy and ileal pouch-anal anastomosis is the operation of choice for patients with ulcerative colitis and familial polyposis. The long-term nutritional consequences after pouch surgery are unknown. We have assessed the nutritional status of the essential trace elements-zinc, copper, manganese, and selenium-in patients several years (median, 10 (range, 2-15) years) after surgery.Fifty-five patients with uncomplicated ileal pouch-anal anastomosis and 46 healthy control subjects were studied. A dietary assessment of trace element intake was undertaken by using a semiquantitative food frequency questionnaire. The patients' trace elements status for zinc, copper, manganese, and selenium was assessed by measuring their concentrations in blood.The dietary intake of individual trace elements was similar in both groups (all P values0.4). There was no significant difference in the concentrations of plasma copper, zinc, and selenium between patients and healthy control subjects (all P values0.07). The concentration of whole blood manganese was significantly higher (P = 0.004) in patients (median, 178.5 nmol/l; range, 59-478 nmol/l) compared with healthy control subjects (median, 140 nmol/l; range, 53-267 nmol/l). Four (7 percent) patients had manganese concentrations more than three standard deviations of the mean of control group (255 nmol/l).This study shows that patients who have had uncomplicated pouch surgery have a normal dietary intake of trace elements and do not develop deficiencies in copper, zinc, manganese, and selenium. However, these patients may be at increased risk of manganese toxicity.

Background The aim of the present study was to evaluate the relationship between the preoperative and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for colorectal cancer. Methods One hundred and eighty patients with colorectal cancer were studied. Circulating concentrations of C-reactive protein (CRP) were measured before surgery and in the immediate postoperative period. Results The peak in CRP concentration occurred on day 2 (P < 0·001). During the course of the study 59 patients died, 30 from cancer and 29 from intercurrent disease. Day 2 CRP concentrations were dichotomized. In univariable analysis, advanced tumour node metastasis stage (P = 0·002), a raised preoperative CRP level (P < 0·001) and the presence of hypoalbuminaemia (P = 0·043) were associated with poorer cancer-specific survival. Conclusion Preoperative but not postoperative CRP concentrations are associated with poor tumour-specific survival in patients undergoing potentially curative resection for colorectal cancer.

There is increasing evidence that the presence of a systemic inflammatory response plays an important role in survival following curative resection for colorectal cancer. The present study evaluated the relationship between C-reactive protein concentrations and survival in a cohort of patients receiving adjuvant 5-fluorouracil (5-FU) chemotherapy following potentially curative resection for colorectal cancer. In all, 222 patients undergoing potentially curative resection for colorectal cancer were studied. Of these, 50 patients received adjuvant 5-FU-based chemotherapy. Circulating concentrations of C-reactive protein were measured prior to surgery. The minimum follow-up was 15 months; the median follow-up of the survivors was 38 months. During this period 61 patients died, 32 patients of their cancer and 29 of intercurrent disease. In those patients who did not receive adjuvant chemotherapy, age (P

According to the published medical literature to date, prophylactic gastrectomy undertaken in the context of carriage of a germline truncating E-cadherin mutation and an appropriate positive family history will lead to the discovery of occult foci of adenocarcinoma in all gastrectomy specimens. We describe the first published case of a patient whose prophylactic gastrectomy in this setting failed to reveal any dysplastic or malignant foci. Furthermore the patient's nephew, who was found to carry an identical E-cadherin mutation on family screening and also underwent prophylactic gastrectomy, was shown to have multi-focal diffuse adenocarcinoma after analysis of the gastrectomy specimen. Both patients were also found to have penetrant genetic haemochromatosis. Within this case, we discuss the clinical manifestations and penetrance of germline E-cadherin mutations and the difficult decisions facing both clinicians and families with this mutation. We also speculate on how these patients' undiagnosed genetic haemochromatosis may have influenced the pathology encountered.

Background Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility. Methods Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects. Results Before surgery colonic pressure was greater in patients than controls (P < 0·050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy. Conclusion Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.

Magnetic resonance (MR) imaging may contribute to staging rectal cancer and inform the decision regarding administration of pre-operative radiotherapy. The accuracy of MR has been debated. The aim of the present study was to determine the accuracy of thin section T2-weighted MR images in rectal cancer patients. MR results were compared with histological assessment of resection specimens. Over a 2-year period, 42 patients were studied. Histological staging was pT2 n = 13, pT3 n = 25 and pT4 n = 4. MR diagnostic accuracy was 74%. MR sensitivity and specificity was 62% and 79% for pT2 lesions, 84% and 59% for pT3 lesions and 50% and 76% for pT4 lesions. Estimation of tumour penetration by thin section MR imaging of rectal cancers using pelvic phased-array coil has moderate diagnostic accuracy. The limitations of MR should be acknowledged when selecting rectal cancer patients for pre-operative radiotherapy.

PURPOSE: Reports of outcome after surgery for rectal prolapse predominantly relate to single operative procedures. A single surgical operation is not appropriate for all patients with rectal prolapse. We describe a selective policy based on clinical criteria. METHODS: Patients were offered surgery according to the following broad clinical protocol. Those who were unfit for abdominal surgery had a perineal operation. The remainder had a suture abdominal rectopexy. A sigmoid resection was added for patients in whom incontinence was not a predominant symptom. RESULTS: Surgery was performed in 159 patients. Of these, 57 had a perineal operation, 65 had fixation rectopexy, and 37 had resection rectopexy. There were no in-hospital deaths, and major complications occurred in five patients (3.5 percent). Minimum follow-up was 3 years. Of the 143 patients with long-term follow-up, recurrence occurred in 7 (5 percent). Constipation increased from 41 to 43 percent (59–61/143) and incontinence decreased from 43 to 19 percent (61 to 27/143). CONCLUSIONS: A selective policy has improved outcome compared with reports of a single operation. Future studies might consider an objective method of selecting the type of operation for rectal prolapse.

The purpose of home parenteral nutrition (HPN) is to allow patients with intestinal failure a reasonable quality of life and to facilitate independence from hospital. A managed clinical network (MCN) has been established for the organisation of HPN. This multi-professional group works towards optimal patient management by adoption of nationally agreed, evidence standards and protocols, to allow equity of access to quality care. A coordinator has identified patients and practice. A MCN exists to ensure that quality care can be delivered near to the patient's home. An audit of the organisation of HPN has been completed. The aims of this study were to identify the numbers of patients receiving this treatment and to assess management practices. Data was collected from 16 centres between July 2000 and August 2001. This paper discusses the practicalities of setting up the network and presents data from the first full year of audit. This will act as the baseline for continuous audit and a basis for revision of documentation.

Background Abdominal rectopexy remains the operation of choice for patients with rectal prolapse. Recurrence rates are low but the functional results are poor. Hindgut motility was measured before abdominal rectopexy to determine whether an underlying neuropathy might explain these poor results. Methods Seven women of mean(s.d.) age 56(10) years had a multilumen catheter inserted in the colon before abdominal rectopexy. Colonic intraluminal pressure was recorded for a mean(s.d.) of 19(3) h; the number of peaks over 5 and 50 mmHg, motility and high-amplitude propagated contractions (HAPCs) were measured before and after a meal and compared with the findings in five controls. Results Patients had high numbers of contractions greater than 5 mmHg and high motility before meals. Controls responded to meals by increasing motility, unlike patients. HAPCs were seen in one patient but in all controls. Conclusion These data show that patients with rectal prolapse have a hindgut motility abnormality before abdominal rectopexy, similar to that observed in spinal cord injury. This may explain the poor functional results after surgery, offering a rationale for colonic resection.

The value of combining Dukes' stage and C-reactive protein to form a cumulative prognostic score was assessed in 147 patients undergoing potentially curative resection for colorectal cancer. The cancer-specific survival rates at 3 years for patients with a cumulative prognostic score of 0, 1 and 2 were 100, 77 and 40%, respectively (HR 4.76, 2.78–8.15, P

B vitamins have been implicated in cancer pathogenesis. It is therefore of interest that plasma B6 falls as part of the systemic inflammatory response (SIR), whereas red cell concentrations do not. The modified Glasgow Prognostic Score (mGPS) is a validated inflammation-based prognostic score that consists of a combination of albumin and C-reactive protein concentrations. The aim of this study was to examine the relationships between the concentrations of plasma and red cell vitamin B concentrations, the local and systemic inflammatory response in patients with colorectal cancer. Preoperative venous blood of 108 patients with colorectal cancer were analyzed for C-reactive protein, albumin, flavin adenine dinucleotide (FAD), and pyridoxal phosphate (PLP), and lymphocyte counts. Pathological slides were retrieved for assessment of inflammatory cell infiltration. Increasing mGPS was associated with lower plasma PLP concentrations (P < 0.01) but not plasma and red cell FAD and red cell PLP concentrations. Increasing tumor stage was associated with the presence of venous invasion (P < 0.01) and low-grade inflammatory cell infiltrate (P < 0.05) but not the SIR, FAD, or PLP concentrations. A low-grade inflammatory cell infiltrate was not significantly associated with any other parameter. The presence of a SIR was associated with lower concentrations of plasma PLP but not red cell PLP concentrations in patients with colorectal cancer. Neither FAD and PLP were associated with the tumor inflammatory cell infiltrate.

Parenteral nutrition-associated cholestasis (PNAC) is a severe complication of parenteral nutrition. Standard feed preparations contain soybean and olive oil that are rich in ω-6 polyunsaturated fats, and which studies suggest can be hepatotoxic. Preparations containing fish oil, rich in ω-3 polyunsaturated fats, may be hepatoprotective and have been used in the critical care setting as immunotherapy. A case demonstrating dramatic improvement in liver function and overall clinical condition in an adult with PNAC and intestinal failure within 8 weeks of changing to a fish oil-based parenteral feed is reported. As far as is known, this is the first report of an adult patient whose parenteral nutrition-associated liver disease resolved after a parenteral nutrition lipid emulsion was changed to the fish oil-containing emulsion, SMOFlipid.

A prospective randomised trial of "planned" chronic injection sclerotherapy (at three weekly intervals) versus "demand" injection sclerotherapy (after variceal bleeds only) was performed in 40 patients who had endoscopically proven variceal bleeding, and who were either graded as modified Child's grade C or were more than 65 years of age. 45% of patients survived for one year and 37% for two years. There was no significant difference in survival between the groups at either one or two years (p < 0.5; p < 0.1). In the "planned" sclerotherapy group 24 gastrointestinal bleeds occurred in 11 patients over the first nine months after study entry. In the "demand" group 35 bleeds occurred in 13 patients over the first 18 months after study entry. In this small group of "poor risk" patients, planned chronic injection sclerotherapy was not associated with improved survival.

Infective complications particularly in the form of surgical site infections including anastomotic leak represent a serious morbidity after colorectal cancer surgery. Systemic inflammation markers, including C-reactive protein (CRP) and white cell count, have been reported to provide early detection. However, their relative predictive value is unclear. The aim of the present study was to examine the diagnostic accuracy of serial postoperative WCC, albumin and CRP in detecting infective complications.White cell count, albumin and CRP were measured postoperatively for 7 days in 454 consecutive patients undergoing surgery for colorectal cancer. All postoperative complications were recorded. The diagnostic accuracy of the white cell count, albumin and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site infective complications as outcome measures.One hundred four patients (23 %) developed infective complications, and 26 of them developed an anastomotic leak. CRP was most sensitive to the development of an infective complication, surgical site or at a remote site. On postoperative day 3 CRP the area under the receiver operating characteristic curve was 0.80 (p0.001) and the optimal cutoff value was 170 mg/L. This threshold was also associated with an increase in the length of hospital stay (p0.001), 30 day mortality (p0.05) and 12 month mortality (p0.10).Postoperative CRP measurement on day 3 postoperatively is clinically useful in predicting surgical site infective complications, including an anastomotic leak, in patients undergoing surgery for colorectal cancer.

Despite proven benefits of adjuvant chemotherapy in colon cancer, outcomes remain heterogeneous. Several non-validated prognostic factors have been proposed. This study examines the prognostic value of tumour and patient factors currently included in the Numeracy and Adjuvant! models together with measures of the local and systemic inflammatory responses in patients receiving adjuvant chemotherapy for colon cancer. Three hundred and forty-eight patients underwent resection between 1997 and 2007. Of these, 76 received adjuvant chemotherapy. Chemotherapy was 5-FU based (single or combination). Variables from the Numeracy and Adjuvant! calculators were examined. The Petersen Index was used to assess other tumour characteristics considered high risk for recurrence (venous invasion, serosal involvement, surgical margin involvement and perforation through the tumour). Local inflammatory infiltrate was scored by the Jass and Klintrup criteria; the systemic inflammatory response by the Glasgow Prognostic Score (mGPS). Median follow-up was 78 months. Chemotherapy prescription was higher in younger patients with less comorbidity or tumours with higher nodal involvement, increasing T stage and high-risk characteristics (all P

Background: It is increasingly recognised that host-related factors may be important in determining cancer outcome. The aim was to examine the relationship between patient physiology, the systemic inflammatory response and survival after colorectal cancer resection. Methods: Patients undergoing potentially curative resection of colorectal cancer were identified from a prospectively maintained database. Patient physiology was assessed using the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) criteria. The systemic inflammatory response was assessed using the modified Glasgow Prognostic Score (mGPS). Multivariate 5-year survival analysis was carried out with calculation of hazard ratios (HR). Results: A total of 320 patients were included. During follow-up (median 74 months), there were 136 deaths: 83 colorectal cancer related and 53 non-cancer related. Independent predictors of cancer-specific survival were age (HR: 1.46, P

PURPOSE: Fecal incontinence is a distressing condition affecting up to 7% of the population. Severe urgency is a symptom associated with hypersensitivity of the rectum, a common finding in both fecal incontinence and irritable bowel syndrome. The purpose of this study was to investigate whether patients with fecal incontinence, urgency, and rectal hypersensitivity have abnormal hindgut motility, suggestive of a more generalized motility problem. METHODS: Eleven females with urgency-associated incontinence and without anal sphincter injury were compared with 5 controls. After full clinical, ultrasonographic, and physiological assessment, patients underwent prolonged colonic manometry studies. Motility patterns were recorded and, in particular, the response to a standard gastrocolic reflex was noted. RESULTS: Rectal sensation values in patients were as follows: first sensation, 22 (range, 5–58) mls; desire to defecate, 31 (range, 13–166) mls; and maximum tolerated volume, 64 (range, 21–254) mls. Compared with controls, patients had significantly higher numbers of 1) low amplitude waves (>5 mmHg) in both the sigmoid colon (101 vs 46.5; P = .028) and the descending colon (101.5 vs 41; P = .036) in the hour before the meal stimulus, and 2) high amplitude waves (>50 mmHg) in the sigmoid colon (2 vs 0; P = .006) in the fasting state. CONCLUSION: Patients with fecal incontinence associated with severe urgency may have rectal hypersensitivity and a more global colonic motility problem similar to irritable bowel syndrome.

Background Post-operative lymph leak is a potentially serious complication which may contribute to fluid and electrolyte imbalance, malnutrition and an increase risk of sepsis and mortality. We aimed to study the use of TPN in the treatment of post-operative lymph leak. Methods Retrospective review of prospectively collected clinical database comprising patients with post-operative lymph leak treated with TPN collected over 1998–2006. An analysis of morbidity and mortality was performed. Results 36 patients developed lymph leak following radical neck dissection ( n =10), Whipples procedure ( n =13), oesophagectomy ( n =10) and pulmonary/vascular/retroperitoneal ( n =3) surgery. The survival to discharge was 89%. The mortality rate in patients with chylothorax following oesophagectomy was 30% (three out of ten). The majority of patients (67%, 24 out of 36) with lymph leak settled on TPN alone. The overall re-intervention rate was 20%. Of the seven survivors after oesophagectomy, five underwent re-intervention thoracic surgery (two also had ischaemic perforation of gastric remnant needing revision surgery). Overall, the re-intervention rate in all patients undergoing oesophageal surgery is 60%. Conclusion Most patients with post-operative lymph leak receiving TPN alone survived. It is rare for re-operation to be necessary in patients who have lymph leaks in the neck or retroperitoneum. Re-operative intervention is more commonly performed in lymph leak after oesophagectomy.

Bleeding as a complication of liver disease can occur in the absence of recognised haemostatic defects. It is now possible to measure the concentration of endogenous heparinoid substances in the blood using a competitive binding assay. One such substance, heparan sulphate (normal range < 600 ng/ml) was assayed in the plasma of 49 patients admitted because of oesophageal varices. In 27 patients with recent upper gastrointestinal bleeding the median plasma heparan sulphate value was 1700 ng/ml (interquartile (IQ) range 900-3900) compared with 390 ng/ml (IQ range 256-800) in 22 patients with no recent bleed (p < 0.01). As heparan sulphate is metabolised by the same route as exogenous heparin, an attempt to establish a cause for the raised heparan concentrations was made by measuring the clearance of exogenous heparin in 10 portal hypertensive patients and 10 controls. The median half life of heparin in plasma in the portal hypertensive patients (25.5 minutes; IQ range 22-34) was significantly longer (p < 0.007) than the median half life in the controls (18.7 minutes; IQ range 17-21.5). Thus, there is evidence of raised concentrations of endogenous heparin like substances in portal hypertensive patients after gastrointestinal bleeding. These high concentrations may result from reduced hepatic clearance.

Plasma fibronectin levels were measured in 33 patients with portal hypertension and c6mpared with modified Child’s grading and a previously described prognostic index. Outcome at one year from blood sampling was recorded. Mean plasma fibronectin level was 304.1 mg/ml (sem 24.3) and significantly lower levels were found in patients who had had a variceal bleed within the previous seven days. Plasma fibronectin levels tended to be lower in patients with poor liver function as assessed by modified Child’s grading but this did not achieve statistical significance. Plasma fibronectin alone was not an accurate predictor of one year survival in these patients but only one of seven patients who had a plasma fibronectin level below 300mg/l in association with a poor prognostic index survived for one year.

Background and aims Home parenteral nutrition (HPN) has been a major advance in the management of patients with gastrointestinal failure. It demands regular monitoring to ensure optimal intake, assess treatment response, and minimize complications. The Scottish Home Parenteral Nutrition Managed Clinical Network (MCN) produced a guideline advising three-monthly monitoring of biochemistry, micronutrients, vitamins, weight, and anthropometry. This study assesses the frequency and adequacy of monitoring of these complex patients and investigates any effect of this on complication rate. Methods All patients receiving HPN funded by the National Health Service in Scotland are known to the MCN via the National Contract for provision of HPN. Data are collected in an MS Access database; 2006 data is extracted. Results There were 141 HPN clinic assessments for 53 patients. Sixteen (30%) were seen every 100 d as recommended by the guideline. Sixty percent of reviews were within 100 d of the previous appointment. Duration of HPN treatment inversely correlated with frequency of review. Bloods were checked at 93% of reviews, weight at 86%, anthropometry at 24%, and vitamins and micronutrients measurement at 62% of clinics. No difference in complication rates was found between those reviewed within the recommended time periods and those reviewed less often. Conclusions Less than one-third of patients met the current recommended review frequency. Routine bloods and weight measurements were good, micronutrients less so; anthropometry is poorly monitored. Complication rates were not increased in HPN patients reviewed less often.