Background: Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists. Methods: A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes. Results: Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience. Conclusion: In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.

Objectives To determine whether preoperative dexamethasone reduces postoperative vomiting in patients undergoing elective bowel surgery and whether it is associated with other measurable benefits during recovery from surgery, including quicker return to oral diet and reduced length of stay. Design Pragmatic two arm parallel group randomised trial with blinded postoperative care and outcome assessment. Setting 45 UK hospitals. Participants 1350 patients aged 18 or over undergoing elective open or laparoscopic bowel surgery for malignant or benign pathology. Interventions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia compared with standard care. Main outcome measures Primary outcome: reported vomiting within 24 hours reported by patient or clinician. Secondary outcomes: vomiting with 72 and 120 hours reported by patient or clinician; use of antiemetics and postoperative nausea and vomiting at 24, 72, and 120 hours rated by patient; fatigue and quality of life at 120 hours or discharge and at 30 days; time to return to fluid and food intake; length of hospital stay; adverse events. Results 1350 participants were recruited and randomly allocated to additional dexamethasone (n=674) or standard care (n=676) at induction of anaesthesia. Vomiting within 24 hours of surgery occurred in 172 (25.5%) participants in the dexamethasone arm and 223 (33.0%) allocated standard care (number needed to treat (NNT) 13, 95% confidence interval 5 to 22; P=0.003). Additional postoperative antiemetics were given (on demand) to 265 (39.3%) participants allocated dexamethasone and 351 (51.9%) allocated standard care (NNT 8, 5 to 11; P<0.001). Reduction in on demand antiemetics remained up to 72 hours. There was no increase in complications. Conclusions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia significantly reduces both the incidence of postoperative nausea and vomiting at 24 hours and the need for rescue antiemetics for up to 72 hours in patients undergoing large and small bowel surgery, with no increase in adverse events. Trial registration EudraCT (2010-022894-32) and ISRCTN (ISRCTN21973627).

Introduction Average monthly referrals to our institution fast track LGI clinics have almost doubled between 2010 and 2014. Patients are being repeatedly referred, increasing the workload and cost of this service. We examined the outcomes of those re-referrals. Method A retrospective review of a prospectively maintained database and notes review was performed. Results Over the three-year study period, 3696 were referred to the fast track clinic. Eighty (2.2%) were referred twice or more. 19/80 (24%) were re-referred having missed their first appointment. 29/80 (36%) had repeated investigations that were normal with 24/80 (30%) confirming the presence of diverticular disease. Seven patients had colorectal cancer (CRC) diagnosed following the second referral and one after the third. Five of these newly diagnosed individuals had failed to attend or declined investigation initially. Conclusion Discussion Re-referral of patients to fast track LGI clinics has significant cost implications. The implication of patients attending such a clinic needs to be emphasised in the primary care setting to minimise non-attendance. 66% of those re-referred had diverticular disease or normal bowel diagnosed on repeat investigation, suggesting that second referral or repeat investigation was unnecessary. Further education/guidelines for both patient and health care professional would help minimise this repetition. CRC detection miss rates are a known phenomenon and need to be audited and highlighted to the LGI MDT to improve service provision and excellence. Disclosure of interest None Declared.

Introduction Total parenteral nutrition (TPN) is an invasive feeding method, with stringent indications due to higher associated cost and morbidity. The National Confidentiality Enquiry into Patient Outcome and Death (NCEPOD) review – A Mixed Bag,1identified good clinical practice in only 19% of patients receiving TPN as recently as 2010. We present improvements in standards of care for patients receiving TPN, which were found on completion of an audit cycle at our institution. Method Retrospective data collection was undertaken on all patients receiving TPN from December 2013–January 2014 at The Countess of Chester Hospital (Audit 2). This was compared to the same dataset extracted from November 2010–February 2011 (Audit 1). NCEPOD1and NICE2guidance recommendations were used as gold standards. Results Over the 13 month period, 64 patients received TPN. The median age was 68 (range 23–89); male:female ratio 1.5:1. Median duration of TPN was 8 days (range 1–144 days). TPN was commenced in level 1 care in 59.4% of cases; level 2/3 40.6%. 36 patients (56%) received TPN via a dedicated PICC line and 28 (44%) through a central line. Data comparison between audit 1 and 2 is tabulated below. Conclusion Early involvement and supervision by the nutrition support team remained at a high standard. Following earlier recommendation, major improvements were seen in the monitoring of daily bloods, obtaining central venous access, and documentation of weekly weight measurements. A multi-disciplinary electronic referral and assessment proforma is now being developed to enable NCEPOD targets to continue to be met. Disclosure of interest None Declared.

PURPOSE:Timely administration of adjuvant chemotherapy following colorectal resection is associated with improved outcome. We aim to assess the factors which are associated with delay to adjuvant chemotherapy in patients who underwent colorectal resection as part of an enhanced recovery protocol.METHOD:A univariate and multivariate analysis of patient data collected as part of a prospectively maintained database of colorectal cancer patients between 2007 and 2012.RESULTS:166 patients underwent colorectal resection followed by adjuvant chemotherapy. Median postoperative hospital stay was 6 days, and time to commencement of adjuvant chemotherapy was 50 days. Longer inpatient stay correlated with increased time to adjuvant chemotherapy (P = 0.05). Factors found to be independently associated with duration of hospital stay and time to commencement of adjuvant chemotherapy included stoma formation (P = 0.032), anastaomotic leak (P = 0.027), and preoperative albumin (P = 0.027). The use of laparoscopic surgery was associated with shorter time to adjuvant chemotherapy but did not reach significance (P = 0.143).CONCLUSION:A number of independent variables associated with delay to adjuvant therapy previously not described have been identified. Further work may be required to elucidate the effect that these variables have on long-term outcome.

The Opportunities in Surgery committee of the RCS provides advice and guidance to surgeons and aspiring surgeons. For the 2012 annual medical student prize, entrants were required to submit a 500-word abstract in response to the question 'Who is in charge in the operating theatre?' A wide range of suggestions, parallels, anecdotes and, clearly, some traumatic memories were recollected. But are we any closer to answering the question?

BACKGROUND & AIMS Screening of high-risk groups for pancreatic cancer has not been adopted because of concerns regarding specificity and sensitivity. Suitability of a combination of 3 novel molecular screening techniques was investigated. METHODS Pancreatic juice was extracted from 146 patients with pancreatic ductal adenocarcinoma, chronic pancreatitis, or biliary tract stones. p53 mutations were analyzed by using a modified yeast functional assay, K-ras status was analyzed using mutation-specific real-time PCR and the proportion of p16(INK4a) promoter methylation was estimated using comparative methylation-specific real-time PCR. RESULTS p53 mutations were detected in 20 of 48 (42%) cancer cases, none of 49 controls, and 2 of 49 (4%) patients with pancreatitis. K-ras mutations were detected in 31 of 57 (54%) cancer patients, 13 of 61 (21%) controls, and 23 of 67 (34%) patients with pancreatitis. Twenty-six of 42 (62%) cancer patients had promoter methylation levels > 12%, compared with 3 of 24 (13%) controls, and 2 of 26 (8%) with pancreatitis. Mutations in p53 or high-level p16(INK4a) promoter methylation occurred in 29 of 36 (80%) patients with cancer, 3 of 24 (13%) controls, and 3 of 22 (13%) with pancreatitis. Three patients (8%) of 36 with cancer; 14 of 24 (58%) controls, and 13 of 22 (59%) patients with pancreatitis had no marker. The gallstone disease patients had a high rate of positive K-ras mutations, possibly reflecting the fact that they were not disease free. CONCLUSIONS Combination molecular analysis increased the discrimination between patients with malignant and benign disease. This level of discrimination would allow patients in high-risk groups to be stratified from negligible risk to over 50% probability of an early cancer.

Familial pancreatic cancer (FPC) (approximately 3% of all cases) has not been linked to defects in any specific gene. Germline inactivation of the gene LKB1/STK11 have been shown to cause Peutz-Jeghers syndrome (PJS) associated with a ∼100-fold higher risk for the development of pancreatic cancer. We have analysed 39 index patients from European FPC families for mutations of LKB1/STK11 by sequencing of their DNA. No germline mutation was found within the complete coding region. Therefore, our results indicate that LKB1/STK11 is not altered in the germline of patients with hereditary pancreatic cancer.