Introduction

Diabetes mellitus affects 6-7% of the population in the United Kingdom (UK), with a consistently increasing prevalence over the last 15 years.^​ The impact of diabetes on outcomes after resectional colorectal surgery have yet to be fully quantified. We aimed to investigate the effect of diabetes mellitus on perioperative outcomes following resectional colorectal surgery using a national cohort.

Aims & Methods

All adult patients undergoing colorectal resections in England registered in the Clinical Practice Research Database (CPRD) with linked Hospital Episode Statistics (HES) data between 2010 and 2020 were included. Data relating to diabetes status and insulin use were extracted using CPRD read codes. Gestational diabetes and type 3c diabetes subtypes were excluded. The primary outcome was all-cause 90-day mortality, whilst secondary outcomes included hospital length of stay and unplanned hospital readmission within 90 days of discharge. Adjusted hazard ratios (HR) were calculated using Cox proportional hazard models for 90-day mortality and 90-day readmission. Length of stay was analysed using an accelerate failure time model, with results presented in the form of adjusted time ratios (TR). The hazard and time ratios resulting from these multivariate models were adjusted for patient age, sex, deprivation, comorbidity burden (excluding diabetes), operative urgency (elective versus emergency), operative indication (benign versus malignant disease) and surgical access (open versus minimally-invasive). P values of <0.05 were considered statistically significant. All data were analysed using STATA v17.

Results

106139 (50% male) patients with a median age of 66 years (Interquartile Range (IQR) 52 to 76) were included. The prevalence of diabetes in this cohort was 10% (n = 10931), including 653 (6%) patients with Type 1 and 10278 (94%) with Type 2 diabetes. 20% of all patients with diabetes had a record of insulin use. The overall unadjusted 90-day mortality risk was 5.7%, with an increased hazard rate for patients with diabetes compared with those without diabetes (adjusted HR 1.28, 95% CI 1.18 to 1.40, p < 0.001). This risk was higher in patients with diabetes with associated insulin use (adjusted HR 1.49, 95% CI 1.23 to 1.78, p < 0.001), and without insulin use (adjusted HR 1.24, 95% CI 1.23 to 1.36, p < 0.001), compared to patients without diabetes. The median length of stay was 8 days (IQR 5 to 15) for the overall cohort. Patients with diabetes experienced a 10% longer hospital length of stay (adjusted TR 1.10, 95% CI 1.08 to 1.11, p < 0.001) compared with those without diabetes. Emergency readmission within 90 days occurred in 23% of those operated for benign disease, versus 18% of patients operated for malignant disease. Patients with diabetes were more likely to experience 90-day readmission (adjusted HR 1.22, 95% CI 1.16 to 1.28, p < 0.001) compared with those without diabetes.

Conclusion

Patients with diabetes undergoing resectional colorectal surgery are at a higher risk of 90-day mortality, prolonged length of stay and 90-day readmissions. Awareness of these increased risks should be considered during perioperative optimisation of the patient, as well as in consent discussions and the patient selection processes.

Introduction

In colorectal cancer (CRC) the pathway to diagnosis has rapidly evolved over the past 5 years incorporating Faecal Immunochemical Testing (FIT) as the chosen biomarker in the field. A FIT cut off of ≥10 µg Hb/g faeces is recommended by NICE for investigation of colorectal cancer (CRC) on an urgent pathway based on an expected CRC risk threshold of 3% in England. It is crucial to balance the risk of CRC against the ability of the health service to investigate and diagnose cancer in an appropriate and timely manner.

Aims & Methods

Our aim was to determine the empirical thresholds of CRC risk in a representative population at different FIT cut offs to assess optimal use of FIT in patients with symptoms of CRC. Cohort study of a symptomatic CRC pathway from primary care with a FIT test in Nottingham, UK (November 2017-2021) with 1-year follow-up. Heat maps showed the cumulative 1-year CRC risk using Kaplan-Meier estimates stratified by FIT (fHb <4 µg Hb/g faeces, 4-9.9 µg Hb/g faeces, 10-19.9 µg Hb/g faeces, 20 – 39.9 µg Hb/g faeces, 40- 99.9 µg Hb/g faeces and ≥100 µg Hb/g faeces), age, anaemia (≤130g/l in men; ≤120g/l in women), and thrombocytosis (≥400 x10⁹/l). We estimated the number of investigations that could potentially be re-purposed if a threshold of ≥3% 1-year risk of CRC was instigated.

Results

In total 514 (1.5%) CRC’s were diagnosed following 33694 index FIT tests. Individuals with a FIT ≥10 µg Hb/g faeces had a greater than 3% risk of CRC, except patients under the age of 40 years (CRC risk 1.45% (95% CI 0.03-2.86%)). Non-anaemic patients with a FIT <100 µg Hb/g faeces had a CRC risk of less than 3%, except those between the age of 70-85 years (CRC risk 5.26% 95% CI 2.72-7.73%). Non-anaemic patients do not meet the 3% threshold set by NICE for investigation until they have a FIT ≥40 µg Hb/g faeces. In contrast, those patients with anaemia meet the 3% threshold at a FIT of ≥20 µg Hb/g faeces. Using a ≥3% CRC threshold in patients < 55 years calculated using FIT, age and anaemia would allow 160-220 colonoscopies per 10000 FIT tests to be re-purposed, at a cost of missing 1-2 CRCs.

Conclusion

CRC risk varies by FIT, age and anaemia when fHb levels are below 100 µg Hb/g faeces. Tailored FIT cut offs for investigation on a CRC pathway could reduce the number of investigations needed at a 3% CRC risk threshold rather than a single cut off of ≥10 µg Hb/g faeces.

Disclosure

none to declare

Introduction

Diabetes mellitus (DM) is an independent risk factor for colorectal cancer (CRC). Glycemic control and variability are the main components of glycemic homeostasis. We aim to identify the association of glycemic control and variability with CRC development in individuals with DM.

Aims & Methods

Patients with DM diagnosed between 2005 and 2013 were followed up till 2020 (CRC or death occurrence) via a territory-wide electronic healthcare registry from Asia. We excluded age <18 years, those with human immunodeficiency virus, inflammatory bowel disease, insufficient HbA1c measurements, and prior diagnosed CRC. We identified DM following the American Diabetes Association criteria with at least two abnormal tests of hemoglobin A1c (HbA1c) ≥6.5% or fasting plasma glucose ≥7 mmol/L; antidiabetic medication use; or International Classification of Diseases Ninth Revision (ICD-9). An initial three-year lead-in period from the DM diagnosis date was applied to evaluate glycemic control and variability: optimal glycemic control was regarded as mean HbA1c <7% from at least two measurements; lower glycemic variability was regarded as measurements of <25% quantile, including standard deviation (SD), coefficient of variation, and average successive variability. Cox regression models with inverse probability of treatment weighting (IPTW) of study characteristics were used to calculate hazard ratios (HRs) of CRC with optimal glycemic control.

Results

During a median follow-up of 6.7 (interquartile: 5.3-8.7) years, 2,231 (1.3%) of 171,270 patients with DM (mean [SD] age: 61.7 [11.7] years; male: 90,441 [52.8%]) developed CRC. Patient characteristics were well balanced after IPTW (all standardized mean differences <0.01). The 12-year cumulative incidence of CRC was 2.2% (95%CI 2.0%-2.4%) and 2.7% (95%CI 2.5%-3.0%) in optimal and suboptimal glycemic control respectively with an HR of 0.83 (95%CI 0.76-0.90). The association was validated in sensitivity analyses (HRs: 0.79-0.88) and consistent across subgroups regardless of at-risk age (40-75 years), obesity, smoking status, aspirin use, and diabetes-related comorbidity (HRs: 0.73-0.86). CRC risk increased incrementally with HbA1c increases beyond ≥7% in the multivariate Cox regression model, from an adjusted HR of 1.31 (95%CI 1.17-1.48) for HbA1c 7.0%-7.5%, to 1.36 (95%CI, 1.16-1.59) for HbA1c 7.5%-<8.0%, to 1.47 (95%CI, 1.20-1.80) for HbA1c 8.0%-<8.5%. The beneficial effects of glycemic control were limited to the left colon (HR 0.82, 95%CI 0.71-0.94) and rectum (HR 0.81, 95%CI 0.68-0.96) but not to the right colon (HR 0.92, 95%CI 0.75-1.11). Among those who had colonoscopy during the study period (n=14,399), optimal glycemic control was associated with lower CRC risk in patients with (HR 0.78, 95%CI 0.67-0.92) and without (HR 0.85, 95%CI 0.73-0.98) adenomas. Lower vs. higher glycemic variability yielded consistent associations for CRC risk (HRs: 0.81-0.85; All P <0.001). Optimal glycemic control had no association with adenoma (HR 1.01, 95%CI, 0.96-1.07) and advanced adenoma (HR 0.98, 95%CI 0.87-1.10) development.

Conclusion

Optimal glycemic control was independently associated with reduced CRC development in patients with DM, while the worsening of glycemic control was associated with an incrementally increased cancer risk. Our study findings can aid CRC risk stratification of among patients with DM.

Introduction

Colorectal cancer (CRC) and other bowel diseases is a significant health concern globally. In several countries, the fecal immunochemical test (FIT) is a cornerstone in CRC screening for early detection of cancer in asymptomatic individuals. Moreover, the utility of FIT extends beyond this, as it is increasingly recommended for evaluating symptomatic patients as part of the clinical pathway to render possible or rule out serious bowel pathology. Therefore, we aimed to quantify the findings of serious bowel conditions following a non-screening FIT test in the Danish population.

Aims & Methods

This study investigated use of FIT beyond the national CRC screening program in Denmark. We aimed (1) to assess utilization patterns of FIT in contexts other than screening and (2) to examine ensuing diagnoses. Our goal was to quantify the findings of CRC and other bowel diseases in symptomatic patients, thereby assessing its broader potential.
This cohort study was conducted within the Danish universal public healthcare system, delivered by five administrative regions. National CRC screening using FIT was initiated in 2014, but utilization of FIT for symptomatic patients varies between regions. The cut-off for a positive test is ≥10 µg haemoglobin/g faeces for symptomatic populations.
The study used data from the Danish Civil Registration System, the Danish National Patient Registry covering all Danish hospitals, and the Clinical Laboratory Information Register. The cohort included all patients who underwent FIT between 2014 and 2021 outside the Danish CRC screening program.
We employed descriptive statistics to examine FIT administration and demographic distributions across the Danish regions, as well as fecal haemoglobin levels among tested individuals. In addition, we estimated the cumulative incidence of CRC and inflammatory bowel disease (IBD) diagnoses following FIT, considering death as a competing risk and evaluated the proportion of diagnoses for CRC and IBD during the year following FIT.

Results

We identified 19,787 individuals who underwent FIT outside the national CRC screening program in 2014 to 2021. Of these, 4,283 (22%) individuals had a positive FIT result. Among tested individuals, 10,807 (55%) were female. Median age at testing was 64 years. Use of FIT varied across the regions, with 36% of the study cohort being from the Central Denmark Region, and 1.6% being from the Region of Southern Denmark.
Positive FIT cases had a shorter median time to CRC diagnosis (28 days) and any diagnosis (36 days) compared to negative FIT cases (711 and 58 days, respectively). Within one year of the FIT, 370 (1.9%) individuals were diagnosed with CRC, with higher occurrence for FIT positive individuals (7.9%) than for FIT negative individuals (0.2%) (risk difference: 7.7 percentage points [95% CI: -3.2, 11.1]).
Among individuals with a positive FIT result, 83 (1.9%) were diagnosed with IBD within one year, compared to 51 (0.3%) individuals with a negative FIT (risk difference: 1.6 percentage points [95% CI: -5.8, 7.3]).

Conclusion

We found that FIT used outside the national CRC screening program had over 20% positivity. A positive test indicated higher risk of CRC and IBD. Differences in diagnoses are expected due to varied follow-up procedures after positive and negative FIT results. A negative test, while not definitive, suggests a potential to rule out disease and could reduce unnecessary investigations when assessing symptomatic patients.

Introduction

Leaks and strictures on the anastomotic site of the lower gastrointestinal tract increase morbidity and mortality of colorectal surgery. Multiple endoscopic methods have been described to treat anastomotic leaks, namely, endoscopic vacuum-assisted therapy, over-the-scope clips and sealants (fibrin glue and cyanoacrylate). As for anastomotic strictures, lumen apposing metal stents, self-expandable metal stents, balloon dilatation, intralesional steroid injection and endoscopic stricturotomy have all been proposed.

Aims & Methods

We aimed to report the indications and the overall clinical efficacy of endoscopic therapies applied for anastomotic leaks and/or strictures following colorectal surgery. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines were followed and a literature search was performed by two independent reviewers using relevant search terms in the databases PubMed and Scopus. A total of 14 studies were found and 21 additional reports were obtained from their references, overall, containing 992 patients.

Results

The overall clinical success rate of all endoscopic methods to treat leaks and strictures was 78.3%. For the treatment of leaks in 572 patients 83.4% long-term success was achieved. In 68 patients over-the-scope clips reached 67.2% symptom relief, in 473 patients the endoscopic vacuum therapy had 86.3% success rate and in 31 individuals sealants reached 79.8% efficacy. A sum of 420 cases with strictures were identified. Clinical success was reported at 72.3% for this group. A total of 101 cases with strictures were managed with self-expanding metal stents and 54.7% experienced clinical improvement. The introduction of lumen apposing metal stents for the treatment of strictures in 19 patients produced 92.4% clinical efficacy. Migration rate for fully covered stents was 46.1% and for lumen apposing metal stents 9.1%. Balloon dilatation was applied in 182 patients reporting clinical improvement in 94% of cases and in 71 cases the strictures were treated with endoscopic stricturotomy, leading to symptom relief in 41% of patients. Forty-four patients had anastomotic strictures with concomitant leaks and were managed with self-expanding metal stents reaching clinical success in 82.1% of cases. Major complications, namely bleeding or perforation, were recorded in 2.4% and the highest rate (7.2%) was reported for stricturotomy.

Conclusion

Patients with anastomotic colorectal strictures should be treated with balloon dilation initially. Self-expandable metal stent deployment, either fully-covered or uncovered or lumen-apposing metal stents, can be used in refractory cases, with the latest expressing lower rates of migration. Colorectal anastomotic leaks with concomitant cavity can be treated with endoscopic vacuum therapy and avoid re-surgery. In the case of no cavity, sealants represent an appropriate alternative method. Strictures with leaks should be considered for treatment with fully-covered metal stent deployment. Stricturotomy is associated with high rates of complications and it is not recommended unless the technique is modified appropriately to guarantee safety.

References

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