The CR-POSSUM model provided an accurate predictor of operative mortality. External validation is required in hospitals different from those in which the model was developed.
Aim Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures.Method In a pragmatic, factorial (2 9 2) design trial, patients could be randomised between abdominal and perineal surgery (i), and suture vs resection rectopexy for those receiving an abdominal procedure (ii) or Altemeier's vs Delorme's for those receiving a perineal procedure (iii). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to 3 years.Results Two hundred and ninety-three patients were recruited: 49 were randomised between surgical approaches (i); 78 between abdominal procedures (ii); and 213 between perineal procedures (iii). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's vs Delorme's 24/102 (24%) and 31/99 (31%) [hazard ratio (HR) 0.81; 95% CI 0.47, 1.38; P = 0.4]; resection vs suture rectopexy 4/32 (13%) and 9/35 (26%) (HR 0.45; 95% CI 0.14, 1.46; P = 0.2); perineal vs abdominal 5/25 (20%) and 5/19 (26%) (HR 0.83; 95% CI 0.24, 2.86; P = 0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons.Conclusion No significant differences were seen in any of the randomised comparisons, although substantial improvements from baseline in quality of life were noted following all procedures.
Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.
Objective: To determine the effectiveness and efficiency of the Department of Health's new general practitioner referral guidelines for bowel cancer. Design: One year prospective audit. Setting: District general hospital serving a population of 550 000. Subjects: All patients with bowel cancer; all patients referred on the basis of the two week standard and to a routine colorectal surgical outpatient clinic. Main outcome measures: Proportion of cancers referred on the basis of the two week standard and to other colorectal clinics; the proportion with the higher risk criteria and their diagnostic yields; stage of cancers diagnosed in outpatient clinics; and time to treatment. Results: A total of 249 cancers were diagnosed in the index year. Sixty five (26.1%) were referred to two week standard clinics, 40 (16.1%) to routine colorectal surgical outpatient clinics, 54 (22%) to other clinics, and 88 (35.3%) were emergencies. Thirteen patients per week were referred to the two week standard clinics and 85% (54/65) of cancers so referred were seen within two weeks. The diagnostic yield of cancer in the two week standard clinic was 9.4% (65/695) compared with 2.2% (40/1815) in the routine colorectal surgical outpatient clinic (p,0.0001). Eighty five per cent of patients with cancer referred to outpatients matched the guidelines for the two week standard clinics. Only 46% of this group were so referred. Overall, delay to treatment and Dukes' stage were not improved in patients diagnosed in the two week standard clinics. Conclusions: Most patients with bowel cancer were not referred on the basis of the two week standard although most fulfilled the referral criteria, which had higher diagnostic yields. The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient's journey.
Bascom's operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments.
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