INTRODUCTION Squamous cell carcinoma is the most common variant of anal malignancy. Certain disease-related factors have been established in determining survival. These include tumour size, differentiation and nodal involvement. Other factors such as HIV status, human papillomavirus infection, smoking and socioeconomic disparity may have important roles, however few data are available on the UK population. We aim to correlate social deprivation and survival of anal cancer patients at a tertiary centre. MATERIALS AND METHODS All consecutive cases diagnosed with anal squamous cell carcinoma and treated as per local protocol between July 2010 and April 2017 were included. The pathological and demographical details were collected from a prospectively maintained database. Socioeconomic deprivation was defined for each postcode using the Index of Multiple Deprivation decile compiled by local governments in England. Survival was estimated using Kaplan-Meier analysis and Cox regression was used to investigate the effect of different factors on overall survival. RESULTS A total of 129 patients with anal squamous cell carcinoma over a median follow-up of 43 months were included. Overall survival for the entire patient cohort was 87.7% (95% confidence interval, CI, 82.0-93.7%), 75.5% (95% CI 67.5-84.5%) and 68.9% (95% CI 59.7-79.6%) at one year, three years and five years, respectively. On multivariate analysis, Index of Multiple Deprivation and income do not significantly influence overall survival (p = 0.79, hazard ratio, HR, 1.07; 95% CI 0.61-1.63), (p = 0.99, HR=1.00; 95% CI 0.61-1.63), respectively. Increased risk of death was observed for male sex (p = 0.02, HR=2.80; 95% CI 1.02-5.50) and larger tumour size (p = 0.01, HR=1.64; 95% CI 1.12-2.41). CONCLUSION In contrast to US studies, there is little difference in survival between the least deprived and most deprived groups. We attribute this to equal access to intensity-modulated radiation therapy-based chemoradiotherapy. Thus, a highly effective treatment made available to all mitigates any survival difference between socioeconomic groups.

Introduction: Post-operative pulmonary complications in perioperative SARS-CoV- 2 infection are associated with significant morbidity and mortality. To maintain a safe cancer service, the Countess of Chester Hospital adopted “Cold-site” operating and maintained ERAS principles for patients undergoing elective colorectal cancer surgery during the pandemic. A comparative assessment of service was undertaken for benchmarking purposes. Methods: A comparative retrospective audit was undertaken of consecutive patients undergoing elective colorectal cancer surgery from May to December 2019 and compared to May to December 2020. The Somerset Cancer Registry and electronic medical case records were used to obtain the data set. Outcomes measured were;approach to surgery;stoma rate;length of stay;level of care required;post-operative complications (>Clavien-Dindo 2) and survival at 30 days. Mann-Whitney U test and Chi-squared were used for analysis. Results: There were 44 and 50 elective colorectal cancer operations in 2019 and 2020 respectively. There was a significant difference in the median age (66:70;P = 0.03) but not in ASA grade (P = 0.14). The median length of stay was 5 and 4 days respectively (P = 0.06). There was a 17% reduction in laparoscopic approach to surgery in 2020 (57% vs 40%;P = 0.10). There was no difference in the stoma rate (P = 0.7), post-operative complication rate (P = 0.6), ITU admission rate (P = 0.14), length of ITU stay (P = 0.2) and 30-day mortality rates. Conclusion: “Cold-site” operating allows robust ERAS care to be adopted to ensure comparative outcomes for patients undergoing colorectal cancer surgery and was associated with a non-significant trend to shorter hospital stay during the COVID-19 pandemic.

Abstract Aim Since December 2019, SARS-CoV-2 has dramatically impacted the global landscape. One of the biggest challenges has been the additional strain put on healthcare systems. Although there are numerous studies on the effects of COVID-19 on intensive care beds and ventilator availability, there has been little exploration into the wider impacts of COVID-19 on the provision of other services. This study was designed to explore how COVID-19 has impacted surgical service provision at a large NHS hospital. Methods We compared the number and types of general surgical procedures carried out in a tertiary centre in the six months prior to the UK COVID-19 outbreak (September 2019-February 2020) and the six months after (March 2020-August 2020). Results We found that since March 2020 there has been a 70% decrease in the amount of operations taking place, with numbers dropping from a pre-COVID total of 1761 to a post-COVID total of 529. This mainly affected elective procedures with emergency surgeries remaining relatively constant (48 pre-COVID vs 44 post-COVID). Conclusion COVID-19 has caused a significant decrease in the number of surgeries being undertaken. This is due to a combination of factors including staffing issues, reduced investigative capacity, and national mandates on the cessation of non-urgent procedures. Although this mainly affected elective operations, it will have wider implications on future NHS workload and training. The knock on effects will inevitably result in a rise in delayed and emergency presentations with worse patient outcomes.

Abstract Aims COVID19 has placed unprecedented constraints on healthcare services. Colorectal cancer (CRC) care was one of the many areas predicted to suffer due to these additional pressures. We believe that despite the challenges posed by COVID19, we have continued to deliver a standard of care for elective and emergency CRC resection that compares favorably with the national average. Method We conducted an analysis of the elective and emergency CRC resections carried out at a tertiary center over a 10-month period (Feb-Dec 2020). Data was collated from patient, operative, and theatre records and compared to the national average as defined by the 2020 National Bowel Cancer Audit (NBOCA). Results A total of 227 patients underwent surgery (189 elective and 38 emergencies), with a median age of 69. Of these, 153 were laparoscopic (67%), 57 open (27%), and 17 robotic (7%). The median length of stay was less than the national average; 5 days for elective surgery (NBOCA: 6) and 8 days for emergencies (NBOCA: 10). Within 30 days, overall unplanned readmissions rate was 6.5% (NBOCA: 11.6%) and return to theatre was 3.2% (NBOCA: 8.4%). Elective surgery had a 90-day mortality of 1% (NBOCA: 3%) compared to 7.8% for emergencies (NBOCA: 10.5%). Conclusion Despite the added constraints of the COVID19 pandemic, CRC resection in our unit remains safe with better outcomes than the national standard. We have demonstrated that with adequate precaution and a concerted team effort, delivery of safe care with reasonable outcome is achievable.

Abstract Aim This paper gives an account of our institutional experience with safe adoption of robotic surgery in colorectal service. Method Analysis of our prospectively maintained database of all patients who underwent robotic colorectal surgery in our institute between February 2015 and February 2020. Overall surgical and oncological outcomes were interrogated. Results A total of 255 patients underwent robotic surgery between 2015 and 2020. 148 were males, and 107 were females. Median age was 68 years (range: 35–89). 198 patients had bowel cancer and 57 had benign conditions. Operative procedures performed were anterior resection (n = 125), right colectomy (n = 77), abdominoperineal resection (n = 40), subtotal colectomy (n = 5), completion proctocolectomy (n = 2) and reversal of Hartmann’s procedure (n = 6). Mean operative time was 164 (SD ± 47.5) for right colectomy and 267 (SD ± 77.8) for anterior resection. Median length of hospital stay was 6 days (IQR: 4 – 9). There was no 30 days mortality or intraoperative complications. Conversion to open or laparoscopy surgery rate was 5.1% (n = 13). Anastomotic leakage occurred in 3 patients (1.2%). Median lymph nodes harvested were 21 (range 4 – 79) and the R0 resection rate was 96.5%. Conclusions Our results demonstrate that colorectal robotic surgery is feasible and can be adopted safely for both benign and neoplastic conditions without undermining clinical or oncological outcomes.

Abstract Aims Transanal-endoscopic microsurgery (TEMS) for early rectal cancer is an attractive alternative to radical surgery. With proper patient selection, it is possible to achieve acceptable oncological outcomes with fewer complications. We aim to study the outcomes following TEMS for suspicious or proven rectal cancers performed in our unit. Method We performed a retrospective analysis of prospectively collected data between May-17 and Oct-20. The patients’ details, tumour specific data, short term outcomes, and recurrences were recorded. Results A total of 45 patients with early rectal cancer (M = 29, F = 15) were included in this study. With1 exclusion due to intraoperative rectal perforation, 44 were available for further analysis. Eleven had a diagnosis of cancer at the time of surgery, an additional 11 patients were confirmed on final histology, and 22 were benign. Final histology showed: T1=14, T2=4, T3=3 &Tx=1. The majority (68%) had clear resection margins (R1=3, R2=1, Rx = 3). Twelve patients went on to have further treatment. Seven had resectional surgery (AR = 5, APR=2) for unfavorable histology (2), residual disease (3), or recurrence (2). The other 5(23%) received chemotherapy+/-radiotherapy (unfit/patients’ choice) for unfavorable. Histology (3) or residual disease (2). Conclusion With judicious patient selection, it is possible to offer a less invasive option with acceptable oncological and patient related outcomes for suspicious and proven malignant rectal lesions. The majority of patients (84%) were able to avoid radical surgery or stoma, thereby reducing the associated morbidity. Whilst this is a single institution study, we believe with available expertise this could be widely replicated.

Abstract Background Factors related to CRC survival include age, tumour site and stage. Other factors that may play a role on survival include race and socioeconomic status(SES).We aim to investigate the impact of SES on CRC survival. Method All patients diagnosed with CRC between January 2006-January 2019 were included. Demographics were collected from a prospective database. SES was defined using the Index of Multiple Deprivation(IMD).Cox-regression was used to investigate the effect of factors on survival and Kaplan-Meier to estimate survival. Results A total of 5,073 patients diagnosed with CRC with a median follow up of 65 months were include. Overall survival was 72.2% (76.0%0-78.4%), 59.6%(58.2%-61.0%) and 50.3% (48.8%-51.8%) at 1 year, 3 years and 5 years, respectively. Colon cancer was associated with worse survival(p = 0.00256,HR = 1.163). On multivariate analysis, socioeconomic deprivation was associated with poorer survival (HR = 1.02,p=0.00302).Male and female sex were associated with similar survival outcomes(HR = 0.9831 and 0.9341,respectively; p = 0.986 and 0.946 respectively). Conclusions SES impact on CRC survival seems to be inconsistent across the literature potentially due to lack of uniformity of indices used to assess SES and the heterogeneity of access to healthcare. This could ultimately impact comparability across different studies investigating the impact SES on CRC survival.

INTRODUCTION The definitive treatment of anal cancer with chemoradiotherapy spares abdominoperineal resection for salvage treatment but carries a high burden of toxicity. Intensity-modulated radiation therapy has been implemented to reduce toxicity, reduce treatment breaks and improve survival. However, large and long-term studies are lacking. We aimed to investigate the toxicities and long-term survival of anal cancer patients treated with intensity-modulated radiation therapy at James Cook University Hospital, Middlesbrough. MATERIALS AND METHODS We conducted a retrospective analysis of all patients with squamous cell anal cancer treated at James Cook University Hospital between July 2010 and April 2017. All patients were uniformly treated with intensity-modulated radiation therapy-based chemoradiation with curative intent. A subset of these patients was followed-up prospectively by an oncologist for acute and late toxicity. We calculated Kaplan-Meier estimates of survival statistics and compared our results with those of previous trials which used conventional radiotherapy. RESULTS We studied 132 patients, including a toxicity subset of 64, for a median follow-up time of 43 months (range 3-84 months). Eleven patients (8.3%) underwent salvage abdominoperineal resection. Grade 3+ acute non-haematological, gastrointestinal, genitourinary and dermatological toxicity were found in 56.2%, 12.3%, 0% and 50.7% of the toxicity subset (n = 64). Median treatment duration was 37 days. Overall and colostomy-free survival at five years were 68.3% and 85.3%, respectively. Tumour size (P= 0.006) and age (P= 0.002) predicted shorter overall survival. CONCLUSIONS Intensity-modulated radiation therapy probably reduces acute gastrointestinal and genitourinary toxicity compared with conventional radiotherapy, while resulting in similar overall and colostomy-free survival. We suggest that further dose escalation may improve survival in patients with T3/T4 tumours.

To compare patient quality of life (QoL) and short-term surgical outcomes between robotic anterior resection (r-AR) and laparoscopic (l-AR) approach.

Introduction Some studies advocate a laparoscopic extralevator abdominoperineal excision (l-ELAPE) approach for low rectal cancer. The da Vinci™ robot (r-ELAPE) technique has potential to overcome some limitations of l-ELAPE, such as reduction of the learning curve and more precise tissue handling. It is unknown whether this approach results in improved surgical or quality of life outcomes compared with l-ELAPE. This study aimed to address this issue. Methods Consecutive patients having undergone either robotic or laparoscopic ELAPE for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by postoperative histology and short-term complications. Quality of life was prospectively assessed using the European Organisation for Research and Treatment of Cancer QLC-CR30 and QLC-CR29 questionnaires. Results A total of 22 patients (11 r-ELAPE) with a median follow-up of 13 months (8 months robotic; 22 months laparoscopic) were studied. The groups were similarly matched for age, gender, American Society of Anesthesiologists status, preoperative chemoradiotherapy and tumour height. All had R0 resection. There was no significant difference in short-term surgical outcomes between groups. There was no significant difference in mean global health scores between the two groups (74 ± 14 r-ELAPE vs. 73 ± 10 l-ELAPE). The r-ELAPE group had a lower mean impotence score compared with the I-ELAPE group (55.5 ± 40 vs. 72.2 ± 44), although this was not statistically significant. Conclusions The newly introduced r-ELAPE was non-inferior to l-ELAPE in either patient quality of life or surgical outcomes. Robotic surgery could be particularly beneficial in the technically challenging area of low rectal cancer surgery with a shorter learning curve than laparoscopy.

Introduction As the principal site of distant spread, the detection and management of liver metastasis is crucial in patients with colorectal cancer. Untreated, the median survival is around 6–12 months. The aim of this study was to assess the way in which colorectal liver secondaries are detected and to assess the outcomes associated with their management. Method We set up and prospectively maintained a database detailing the clinical and radiological features of all patients with liver metastasis secondary to colorectal cancer in a high-volume unit. For the period 2008–2012, we reviewed the events leading to a diagnosis of liver metastasis, the initial treatment intent and median survival rates. Results During the study period, 1292 new cases of colorectal cancer were discussed in our multidisciplinary team meeting and of these, 216 had liver metastasis confirmed by computed tomography (CT) scanning. Liver metastasis was noted at the time of the initial diagnosis in 160 patients and metachronous lesions were detected in 56 patients. Metachronous metastases were detected after a median of 12 months (range 3–53). The length of the interval had no bearing on survival. The majority of metachronous liver metastases were detected with scheduled monitoring (41% by carcino-embryonic antigen and 39% on surveillance CT scan) but 16% presented symptomatically. From the time of initial diagnosis, the median survival for the synchronous and metachronous cases was 53 months and 57 months, respectively. 20% of the synchronous and 88% of the metachronous cases were treated with curative intent after the initial diagnosis of colorectal cancer. Of the 216 patients diagnosed with liver metastasis, 50 (23%) were referred to the local hepatobiliary unit for consideration of metastectomy. 11 patients were deemed unresectable and a further eight patients were either unfit or declined resection. Liver resection was undertaken in 9% of the synchronous and 30% of the metachronous cases. From the time of their initial diagnosis, the median survival for the 31 patients who underwent hepatic metastectomy was 53 months; survival was 59 months in the synchronous and 47 months in the metachronous groups. Conclusion Scheduled colorectal cancer surveillance serves to identify the majority of liver metastases, but history-taking and examination lead on to detection in a significant minority. With appropriate patient selection, resection of both synchronous and metachronous liver secondaries offers a significant survival benefit. Disclosure of interest None Declared.