A service evaluation of FIT and anaemia for risk stratification in the two week wait pathway for colorectal cancer

Introduction: New national guidance on urgent referral for investigation for Colorectal Cancer (CRC) included faecal occult blood testing in 2015. We evaluated faecal immunochemical testing (FIT) and anaemia as risk stratification tools in symptomatic patients suspected of having CRC.Methods: Postal FIT was incorporated into the CRC two week wait (2WW) pathway for all patients without rectal bleeding in 2016. Patients were investigated in the 2WW pathway as normal and outcomes of investigations were prospectively recorded. Anaemia was defined as haemoglobin less than 120g/L in women and less than 130g/L in men.Results: FIT kits were sent to 1106 patients with an 80.9% return rate; 810 patients completed investigation with 40 CRCs diagnosed (4.9%). Median FIT results were significantly higher in patients who were anaemic (median 4.8 iqr 0.8-34.1 versus 1.2 iqr 0-6.4, Mann-Whitney p less than 0.001).Some 538 (60.4%) had a result of less than 4 µgHb/gFaeces (limit of detectability) and 621 (69.7%) a result less than 10 µgHb/gFaeces. Sixty per cent of CRCs had a FIT reading of >150 µgHb/gFaeces. Five CRCs diagnosed in patients with a FIT4 µgHb/gFaeces had 97.5% sensitivity and 64.5% specificity for CRC diagnosis. A FIT result of >4 µgHb/gFaeces and/or anaemia had a 100% sensitivity and 45.3% specificity for CRC diagnosis.Conclusion: FIT is most useful at the extremes of detectability; strongly positive readings predict high rates of CRC and other significant pathology, whilst very low readings in the absence of anaemia or palpable rectal mass identify a group with very low risk. High return rates for FIT within this 2WW pathway indicate its acceptability

Duration and Magnitude of Postoperative Risk of Venous Thromboembolism after Cholecystectomy: A Population-Based Cohort Study

Background: This study aimed to identify burden and risk of VTE associated with cholecystectomy in England. Methods: An historical cohort study of cholecystectomy patients from 2001-2011 was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Crude rates and adjusted hazard ratios (HRs) were calculated for risk of VTE following cholecystectomy using Cox regression.Results: 24 677 patients were identified with a rate of VTE in the first year following cholecystectomy of 2.80 per 1000 person years (95% CI 2.18-3.59). Patients aged >/=70 vs aged 30 vs BMI less than 0 had 2.4-fold increase in risk (HR 2.42, 95% CI 1.40–4.18); open vs. laparoscopic operation had 3-fold increase in risk (HR 2.94, 95% CI 1.55–5.55). Compared to general population, VTE risk was the highest in the first 30 days post-operatively with 9.9-fold risk following emergency cholecystectomy and 4.5-fold risk after inpatient cholecystectomy (HR 9.90, 95% CI 4.42–22.21; HR 4.54, 95% CI 2.85–7.21). Conclusions: Cholecystectomy is associated with a low absolute risk of VTE and we have identified high risk groups including the elderly, obese and those having open surgery

GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

ObjectiveService evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for “rule out”, “rule in” and “first test selection”.DesignRetrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience.ResultsBetween November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were [less than]4.0 μg Hb/g faeces, 579 (10.1%) were 4.0–9.9 μg Hb/g faeces, 836 (14.6%) were 10.0–149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of “rule out” results [less than]4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p [less than] 0.0001) and the proportion of “rule in” results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P [less than] 0.0001).There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT[less than]4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT.ConclusionsFIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a “stage migration” effect which may ultimately improve CRC outcomes

Meta-analysis of operative experiences of general surgery trainees during training

BACKGROUND: General surgical training curricula around the world set defined operative numbers to be achieved before completion of training. However, there are few studies reporting total operative experience in training. This systematic review aimed to quantify the published global operative experience at completion of training in general surgery. METHODS: Electronic databases were searched systematically for articles in any language relating to operative experience in trainees completing postgraduate general surgical training. Two reviewers independently assessed citations for inclusion using agreed criteria. Studies were assessed for quantitative data in addition to study design and purpose. A meta-analysis was performed using a random-effects model of studies with appropriate data. RESULTS: The search resulted in 1979 titles for review. Of these, 24 studies were eligible for inclusion in the review and data from five studies were used in the meta-analysis. Studies with published data of operative experience at completion of surgical training originated from the USA (19), UK (2), the Netherlands (1), Spain (1) and Thailand (1). Mean total operative experience in training varied from 783 procedures in Thailand to 1915 in the UK. Meta-analysis produced a mean pooled estimate of 1366 (95 per cent c.i. 1026 to 1707) procedures per trainee at completion of training. There was marked heterogeneity between studies (I2 = 99.6 per cent). CONCLUSION: There is a lack of robust data describing the operative experiences of general surgical trainees outside the USA. The number of surgical procedures performed by general surgeons in training varies considerably across the world

O087 Predictors of persistent opioid use after discharge following colectomy: a population-based cohort study from England

Introduction Little is known regarding whether opioid prescriptions following colectomy lead to persistent use. We aimed to determine the prevalence of persistent post-discharge opioid use following colectomy, stratified by preadmission opioid exposure, and identify associated predictors of prolonged use. Methods This cohort study on adults undergoing colectomy between 2010 and 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data. Patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and prior exposed (prescription 6-12 months before admission). Persistent use was defined as needing an opioid prescription within 90 days of hospital discharge, along with another opioid prescription 91 to 180 days after discharge. Multivariable logistic regression analyses were performed to identify predictors of persistent use. Results Of the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 45.0% were opioid-naïve, 49.9% currently exposed, and 5.0% prior exposed. From the whole cohort, 7540 (8.1%) developed persistent opioid use. Patients with preoperative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group and 305 (9.8%) from the prior exposed group, with only 2.5% from the opioid-naïve group. Predictors of persistent use included prior opioid exposure, high deprivation index, multiple comorbidities, White ethnicity, and open surgery. Conclusion After colectomy, more than 1:12 patients continued to receive opioids three months beyond discharge. Minimally invasive surgery was associated with lower risk of persistent opioid use and may represent a modifiable risk factor

O128 Time trends in opioid prescribing after discharge following colectomy in England: a cross-sectional study

Introduction Opioid prescribing patterns after discharge following colectomy within a population from England are not well characterised. This study aimed to report changes in opioid prescribing prevalence, formulation choices and opioid analgesics over time. Methods This cross-sectional analysis included people undergoing colectomy between 2010 and 2019 using primary (Clinical Practice Research Datalink) and linked secondary care (Hospital Episode Statistics) data. The prevalence of initial opioid prescription within 90 days of surgical discharge was calculated, and prescription characteristics in terms of analgesics and formulation were described. Trend analysis was performed using the Cochran Armitage test, and percentage change between 2010 and 2019 was tested using univariate logistic regression. Results Of the 95,155 individuals undergoing colectomy within the study period, 15,503 (16.3%) received opioid prescriptions. There was a decreasing trend in the prevalence of post-discharge opioids for opioid naïve people (P<0.001), with a decrease from 11.4% in 2010 to 6.7% in 2019 (-41.3%, p<0.001). Whereas the prevalence remained stable for patients prescribed opioids prior to surgery (p=0.637). The prescribing of immediate release formulations decreased from 86% in 2010 to 82% in 2019 (-4.65%). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Moreover, morphine and oxycodone prescriptions rose significantly by 76.6% and 131%, respectively, while tramadol prescribing dropped by 48%. Conclusion This study identified a changing pattern of opioid prescribing following colectomy, with prescribing prevalence decreasing for opioid naïve people. Trends suggested decreased tramadol prescribing, but a shift toward increasing codeine, oxycodone and morphine prescriptions

Variation in the risk of venous thromboembolism following colectomy

Background: Guidelines recommend extended thromboprophylaxis following colectomy for malignant disease, but not for non-malignant disease. The aim of this study was to determine absolute and relative rates of venous thromboembolism (VTE) following colectomy by indication, admission type and time after surgery. Methods: A cohort study of patients undergoing colectomy in England was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data (2001–2011). Crude rates and adjusted hazard ratios (HRs) were calculated for the risk of first VTE following colectomy using Cox regression analysis. Results: Some 12 388 patients were identified; 312 (2·5 per cent) developed VTE after surgery, giving a rate of 29·59 (95 per cent c.i. 26·48 to 33·06) per 1000 person-years in the first year after surgery. Overall rates were 2·2-fold higher (adjusted HR 2·23, 95 per cent c.i. 1·76 to 2·50) for emergency compared with elective admissions (39·44 versus 25·78 per 1000 person-years respectively). Rates of VTE were 2·8-fold higher in patients with malignant disease versus those with non-malignant disease (adjusted HR 2·84, 2·04 to 3·94). The rate of VTE was highest in the first month after emergency surgery, and declined from 121·68 per 1000 person-years in the first month to 25·65 per 1000 person-years during the rest of the follow-up interval. Crude rates of VTE were similar for malignant and non-malignant disease (114·76 versus 120·98 per 1000 person-years respectively) during the first month after emergency surgery. Conclusion: Patients undergoing emergency colectomy for non-malignant disease have a similar risk of VTE as patients with malignant disease in the first month after surgery