Nurse specialist led flexible sigmoidoscopy in an outpatient setting

Objective There has been an increasing demand for diagnostic flexible sigmoidoscopy. In order to improve our diagnostic services, we established a nurse specialist led flexible sigmoidoscopy clinic in 1999. The aim of this study was to review the outcomes of this service between 1999 and 2004. Method The following information was collected prospectively: source of referral, presenting symptoms, the result of the flexible sigmoidoscopy, depth of insertion, the follow‐up plan and complications. Results A total of 3956 patients had a flexible sigmoidoscopy performed between 1999 and 2004. The presenting symptoms were as follows: rectal bleeding (RB) in 1915 patients, change of bowel habit (CBH) in 421 patients, RB+CBH in 814 patients. The depth of insertion of the sigmoidoscope was as follows: rectum in 85 patients, sigmoid colon in 595 patients, descending colon in 1969 patients, splenic flexure in 958 patients and transverse colon in 311 patients. The findings at sigmoidoscopy were as follows: normal in 1560 patients, cancer in 132 patients, inflammatory bowel disease in 276 patients, polyps in 415 patients, diverticular disease in 584 patients and haemorrhoids in 926 patients. Two patients sustained an iatrogenic rectal perforation. Conclusion The nurse specialist led flexible sigmoidoscopy clinic offers an efficient and safe diagnostic service for patients presenting with colorectal symptoms.     

Nurse endoscopy in a district general hospital

INTRODUCTION: This study describes the first full year of independent practice by a newly appointed nurse endoscopist in a district general hospital. PATIENTS AND METHODS: Patients underwent either 'one stop' flexible sigmoidoscopy and barium enema or flexible sigmoidoscopy alone. Barium enema results, video photography, clinical follow-up, and histology were used to validate the results of the flexible sigmoidoscopy. One stop clinic: 161 endoscopies were performed, with 104 female patients (65%), and a mean age of 64 years. There was one failed endoscopy due to poor bowel preparation. Abnormalities were identified in 84% of endoscopies. Flexible sigmoidoscopy detected abnormalities not seen on the barium enema in 28 cases, all of which were polyps (18%). Barium enema identified one abnormality within reach of the flexible sigmoidoscope not identified at endoscopy (small polyp in sigmoid; 1%). Elective flexible sigmoidoscopy list: 121 endoscopies were performed, with 65 female patients (54%), and a mean age of 59 years. There were two failed endoscopy procedures, both attributed to poor bowel preparation. Two-thirds of patients had an abnormality on investigation. There were no complications in either group of patients. CONCLUSIONS: The nurse-led endoscopy service has been successfully initiated with a high completion rate for flexible sigmoidoscopies. All significant conditions were identified with 99% sensitivity. Nurse endoscopy is a safe, useful and practical procedure in the setting of this district general hospital.     

How has the ‘two‐week wait’ rule affected the presentation of colorectal cancer?

OBJECTIVE: To assess the impact of the 'two-week wait' rule on the presentation of colorectal cancer. METHODS: A retrospective study of all patients referred to a fast-track clinic in a colorectal cancer centre over an 18-month period, documenting outcome, especially colorectal cancer diagnosis. Comparison was made with patients diagnosed with colorectal cancer presenting via other routes in the same time period. RESULTS: Over an 18-month period, 462 patients were seen in the fast-track clinic and 64 (13.8%) were diagnosed with colorectal cancer. A further 131 patients with colorectal cancer presented to the department in the same time period through other means; 66 via standard out-patient letters, 26 from other departments and 39 (20%) as emergency admissions. Median (range) time to first clinic was 12 (2-28) days for fast-track and 24 (1-118) days for standard referrals (P < 0.0001); median time to first treatment was a further 36 (9-134) and 36.5 (1-226) days, respectively. The fast-track cohort had more advanced staging than those referred by standard letter. There were 19 Dukes' B, 22 Dukes' C and 14 Dukes' D cancers in the fast-track group compared with 28 Dukes' B, 25 Dukes' C and 6 Dukes' D in the standard referral group. After patient interview, only 337 (73%) of 462 fast-track patients appeared to fulfil the referral criteria but of the 64 diagnosed with cancer, 59 (92%) satisfied the criteria. Of the 66 patients with cancer referred by standard letter, 61 (92%) fulfilled the criteria. CONCLUSION: Patients referred to the fast-track clinic were seen quicker than those referred by standard letter, but they tended to have more advanced disease. The fast-track referral criteria were fulfilled by most patients with cancer (whether or not they were referred to the fast track clinic), confirming their validity. After detailed interview in the clinic, a quarter of fast-track referrals were found not to satisfy referral criteria, suggesting that prioritization in primary care could be improved.     

The impact of open access flexible sigmoidoscopy: a comparison of two services

BACKGROUND: Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of barium enema and tumour-stage migration. METHODS: This was a non-randomised comparison (over two one-year periods, four years apart) of two unselected groups of patients, with different inclusion criteria, in adjacent similarly populated health districts. One offered a nurse practitioner endoscopy service while the other had a doctor-led colorectal clinic. RESULTS: The doctor-led service with its broad inclusion criteria detected more colorectal cancers [13.2% versus 0.7%; OR = 16.05; 2.16-119.2]. Neither nurse practitioner (130 cases) nor doctor-led (262 cases) flexible sigmoidoscopy reduced the total number of barium enemas [Odds Ratio (OR) = 1.16 (95% CI 1.03-1.3)]. However, the doctor-led service did reduce the number of barium enemas requested by general practitioners (from 249 to 152). The total number of colorectal cancers (detected by all available methods) were similar [OR = 0.82 (0.53-1.25)] and both services resulted in a similar tumour-stage migration [OR = 1.39 (0.31-6.23)]. CONCLUSION: Open access flexible sigmoidoscopy services have minimal impact on the utilisation of radiology services. Broader inclusion criteria of doctor-led services produce a higher cancer-yield. Tumour-stage migration may be related to greater awareness of colorectal cancer symptoms rather than to the type of OAFS.     

Comparison of rigid vs flexible sigmoidoscopy in detection of significant anorectal lesions

OBJECTIVE: Sigmoidoscopy is an essential tool in colorectal clinics in the detection of anorectal lesions including rectosigmoid adenomas and carcinomas. However, rigid sigmoidoscope (RS) is still more widely used than flexible sigmoidoscope (FS) as the primary investigation, despite the fact that the latter is more comfortable to the patient and has greater diagnostic yield. Hence we wanted to compare the two modalities in terms of diagnostic use for picking up significant anorectal lesions. METHODS: A retrospective review of all patients referred to the colorectal clinic who had undergone both rigid and flexible sigmoidoscopy for investigation of colorectal symptoms in 2001 was done. Findings recorded during rigid and flexible sigmoidoscopy including depth of insertion, site of lesion and complications were analysed. RESULTS: 152 patients underwent both rigid and flexible sigmoidoscopy as part of investigation of colorectal symptoms. Of the 115 (75.6%) declared normal by RS, 39 (33.9%) had significant lesions including 7 polyps and 4 malignant lesions within 20 cm of the anal verge during FS. Of the 31 patients (20.4%) in whom RS was not helpful due to faecal loading, 15 (48.4%) had significant lesions including 4 malignancies and 1 polyp --all within 20 cm of the anal verge during FS. Only 2 polyps and 1 malignant lesion were picked up by both flexible and rigid sigmoidoscopy. There were no complications in both procedures. CONCLUSION: Since flexible sigmoidoscopy is superior to rigid sigmoidoscopy in terms of patient comfort, diagnostic value and ease of doing procedures like biopsy and polypectomy; it can be used as a front line investigation to exclude colorectal pathology in out patient clinics. The utility of rigid sigmoidoscope is in question and in view of obvious shortcomings, may be replaced by flexible sigmoidoscopy, though obvious resource constraints need to be considered.     

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND: Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector. METHODS: A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time. RESULTS: Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action. CONCLUSIONS: Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.     

One stop rectal bleeding clinic: the coventry experience

Among most patients attending a rectal clinic, rectal bleeding is a common presenting feature. In most patients, the cause is attributed to a benign lesion. In a small percentage, the cause is neoplastic, and for this reason, rectal bleeding merits further study. Left-sided tumors account for the majority of these tumors and are within the reach of a flexible sigmoidoscopy. This study aimed at examining the diagnostic performance of the one stop rectal clinic in Coventry. Between November 2001 and May 2002, 250 consecutive patients were seen in the one stop rectal bleeding clinic of a tertiary referral hospital. Patients were asked of the nature of rectal bleed and altered bowel habits and were examined by digital rectal examination, with a proctoscopy and rigid sigmoidoscopy before either a full colonoscopic examination or flexible sigmoidoscopy with a completion Barium enema. During the study period, colorectal cancer was detected in 4 patients (1.6%), adenomatous polyps in 36 patients (14.4%), and ulcerative colitis in 8 patients (3.2%). In 98 patients (39.2%), no abnormality was present, and in the remaining patients, diverticulosis (n = 60; 24%) and hemorrhoids were present (n = 44; 17.6%).     

The Effectiveness of a Rapid-Access Flexible Sigmoidoscopy Clinic in a District Hospital

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics'' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35–86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.Key words: Rapid access, Department of health, Colorectal cancer, Screening, Flexible sigmoidoscopyEfforts to improve diagnostic and treatment services for colorectal cancer (CRC) have been implemented in the National Health Service (NHS) since the early 1990s. The NHS Bowel Cancer Screening Programme focusing on occult fecal tests has been piloted, assessed, and rolled out on a national level.^1,2Recommendations from the Department of Health of a maximum 2-week wait for initial specialist assessment of all urgent general practitioner (GP) referrals with suspected cancer led to the restructuring of colorectal services and the widespread establishment of dedicated rapid-access flexible sigmoidoscopy clinics in hospitals across the United Kingdom.^3,4 Evidence-based reviews for stratifying CRC risk have further contributed to the outline of current referral protocols for patients with high-risk symptoms.⁵Over the past decade, the service has significantly evolved, as a result of considerable work examining its effectiveness and efficiency. Various authors have commented positively on the suitability and safety of the use of flexible sigmoidoscopy in establishing a diagnosis of distal colonic pathologies and excluding carcinoma,^6,7 while others have highlighted the need for flexible sigmoidoscopy in order for a one-stop service to be effective and safe.^8,9Queen Mary''s Hospital (QMH) is a District General Hospital (DGH) situated in Kent and serving a population of approximately 300,000. Since its establishment, the rapid-access flexible sigmoidoscopy clinic averages 250 patients per year. There is a consultant-led dedicated endoscopy session each week. The majority of referrals come through primary care physicians, with some cases directly referred from the Trust''s Emergency Department.This study aimed to determine the efficacy of the rapid-access flexible sigmoidoscopy clinic in meeting the 2-week target from referral to preliminary assessment, including an assessment of the pathologies found, and the adherence to the Department of Health''s referral guidelines for bowel cancer by GPs.     

Outcomes in 2748 patients referred to a colorectal two-week rule clinic

OBJECTIVE: To assess the 3-year outcomes of a nurse-led, one-stop, 2-week rule (TWR) clinic for suspected colorectal cancer (CRC) in a large teaching hospital. METHOD: Data were collected prospectively from January 2002 to December 2004. In total, 2748 patients were seen over the 3-year period. The ratio of male:female subjects was 1190:1558 (43%:57%). Median age at presentation was 66 years (range 17-96). RESULTS: A total of 1363 (49.6%) nonconforming referrals were made; 1300 patients (47.3%) underwent flexible sigmoidoscopy during their initial assessment in clinic; 1439 patients (52.4%) underwent a barium enema during the course of their investigation; 2503 patients (91.1%) were seen within 14 working days. The median overall wait for the initial clinic appointment was 10 days. The annual number of patients seen was similar over the 3-year period. A total of 174 cancers (6.3%) were identified which accounted for 36.4% of all CRCs diagnosed during the study period. Nineteen cancers presented in the nonconforming group (1.6% of all non-conforming patients). Rectal tumours accounted for 59.8% (n = 104) of all cancers diagnosed while right-sided tumours accounted for only 10.9% (n = 19). Advanced tumours accounted for 73.0% (n = 127) of the total; 133 (76.4%) cancer patients underwent some form of surgical intervention. CONCLUSION: A specialist nurse-led, one-stop TWR clinic for suspected colorectal cancer is sustainable and can be run successfully with over 90% of referrals seen within the targeted time period. The proportion of non-conforming referrals was high and a large number of advanced and unstaged tumours was observed. Low numbers of proximal tumours were detected.     

Investigating chronic, bright red, rectal bleeding

Background: Chronic, bright red, rectal bleeding is a common symptom in our community and the aetiology is frequently benign anal disease. The aim of the present study was to determine the efficacy of performing a flexible sigmoidoscopy on patients with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who, on rigid sigmoidoscopy, are found to have an identifiable anal cause (e.g. haemorrhoids, fissure) for their bleeding. Methods: A prospective study was conducted on patients presenting with chronic, bright red, rectal bleeding. Patients were considered at low risk for colorectal neoplasia if they fulfilled the following criteria: (i) less than 55 years of age; (ii) no past or family history of colorectal neoplasia or inflammatory bowel disease; (iii) no symptoms of altered bowel habit or abdominal pain; and (iv) a source of bleeding identified (e.g. haemorrhoids, fissure) on rigid sigmoidoscopy. All patients underwent a flexible sigmoidoscopy. Results: Eighty‐two patients were entered into the trial, mean age 39 ± 9 years (range: 22–55 years), and the ratio of men:women was 1.8:1. The anal cause of bleeding was haemorrhoids in 96%, and anal fissure in 4%. At flexible sigmoidoscopy, five patients were found to have adenomatous polyps. Rigid sigmoidoscopy missed diminutive neoplastic lesions in 6% of patients. Conclusions: Flexible sigmoidoscopy results in a low yield of colorectal neoplasia in patients presenting with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who have an identifiable anal cause for their bleeding.     

Evolution of the two-week rule pathway – direct access colonoscopy vs outpatient appointments: one year''s experience and patient satisfaction survey

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.     

Experience with a one-stop colorectal clinic

BACKGROUND AND OBJECTIVE: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. PATIENTS AND METHODS: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. RESULTS: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n = 104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. CONCLUSION: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.     

Variations in the evaluation of colorectal cancer risk

OBJECTIVES: To test the variability in estimating cancer risk and demonstrate the consequences that subjectivity has on patient care. SUBJECTS AND METHODS: Forty-three clinicians were each asked to assess 40 symptomatic colorectal referrals. Each clinician was provided with a comprehensive history on the 40 patients. The clinicians graded the referral according to a malignancy risk score, decided on the required first line investigation and the priority of that investigation. The main outcome measures used was accuracy in cancer detection and appropriateness of investigations selected. RESULTS: There was a wide degree of variation among all clinicians grading both benign and malignant disease with the overall correct classification of 54% (P-value of <0.001). On average, the clinicians correctly diagnosed 71.3% of the cancer patients as compared to 44% of the benign patients. Of the cancer patients, 47% were correctly classified as an urgent referral whilst 52% of the benign patients were over classified and graded as an urgent referral. The mean number chosen by clinicians to have a flexible sigmoidoscopy as the appropriate first investigation was 13 (of 40 patients); this was despite the diagnosis being possible in all cases with a flexible sigmoidoscopy. The choice to use full colonic investigation was seen throughout all disciplines. Junior doctors demonstrated the highest tendency choosing full colonic investigation in 92.3%. Consultants and senior grades showed the least tendency to choose full colonic imaging although even here colonoscopy or barium enema represented 48.5%. CONCLUSION: Subjective assessment of cancer referrals is a significant problem that needs to be confronted. Improvements are needed to resolve the inherent problems of subjectivity and operator bias if uniform quality of patient care and best use of resources is to be achieved.     

The South Tyneside FASTRAK service: evaluation of a new model for day surgery

Objective: To evaluate a service (FASTRAK) offering general practitioners direct access to day surgery operative waiting lists, based on explicit guidelines regarding patient suitability for surgery and anaesthesia. Design: Notes abstraction for a cohort of patients referred via FASTRAK and a cohort referred via conventional day surgery routes; postal questionnaire survey of patient satisfaction amongst FASTRAK patients and matched controls referred via conventional routes; postal survey of professional satisfaction. Setting: One district general hospital in the north east of England, and all general practices in that district. Subjects: 1278 patients (1100 conventional day case patients; 178 FASTRAK patients) for notes abstraction; 70 patients for patient satisfaction survey 83 general practitioners for professional satisfaction survey. Main outcome measures: interval from referral to operation, and appropriateness of referral; patient experience and satisfaction with hospital and post-discharge care, especially with respect to information provision, for patient survey; overall rating of service, perceived benefits and disadvantages and future intentions for professional satisfaction survey. Results: The interval from referral to operation was significantly shorter for FASTRAK patients by a median of 91 days. Out of a total of 178 FASTRAK referrals, only seven (4%) were inappropriate whilst diagnosis was wrong in three (2%) cases. Patients referred via FASTRAK were much more likely to have received written information prior to admission (83 vs. 37%: χ²=12.25. P=0.0019). General practitioners (GPs) had positive views of the service; 94% rated it as ‘fair' to ‘very good'. GPs, 90%, perceived the main benefit to patients to be a shorter waiting time for operation; 40% felt that the availability of clear information for patients benefited doctors. Increased general practitioner workload was recognised as a disadvantage (61%) and the main barrier to use of the service was lack of eligible patients under the current guidelines (69%). Conclusions: When diagnosis, indication for surgery and fitness for anaesthesia are not in doubt, general practitioners, given appropriate guidance, are able to provide all the necessary pre-operative services that are usually provided in the general surgical outpatient clinic, without prejudicing the quality of care or decreasing patient satisfaction.     

Six-year prospective analysis of the rectal bleeding clinic at the Queen Elizabeth Hospital, Adelaide, South Australia

BACKGROUND: One-stop rectal bleeding clinics (RBC) are designed to diagnose and treat colorectal diseases that present with rectal bleeding. The Queen Elizabeth Hospital RBC is an open access clinic and is unique in South Australia. It offers flexible sigmoidoscopy and facilities for treating common anorectal conditions. METHODS: Data of all patients presenting to the RBC were prospectively recorded into a database. Data were collected on the patient details, presentation, medical history, physical examination, treatment and intended follow-up. RESULTS: A total of 1539 cases was seen in the clinic between March 2000 and February 2006. Flexible sigmoidoscopy was carried out in 1145 cases (75.03%). Banding or injection of haemorrhoids was carried out in 383 cases. A total of 590 patients was referred for colonoscopy and of these, 27 were diagnosed with colorectal adenocarcinoma or squamous cell cancer of the anus. Most of these patients were more than 50 years old (26 of 27; 96.30%) and had associated symptoms, such as weight loss or altered bowel habit with their rectal bleeding (23 of 27; 85.19%). CONCLUSION: Rectal bleeding clinics can facilitate early diagnosis of colorectal malignancy and can also provide a 'one-stop shop' for treating benign anorectal conditions.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

Three-year evaluation of a rapid-access coloproctology clinic

BACKGROUND/AIMS: Evolving surgical practice has placed increasing pressures on surgical outpatient clinics. This article provides a prospective evaluation of a rapid-access coloproctology clinic over a 3-year period. METHODS: Primary care physicians (PCP) were circulated details of the clinic, and invited to refer any patient presenting with colorectal or anorectal symptoms, or with a family history of bowel cancer wishing advice about screening. Data were collected prospectively and patients and the referring PCPs were invited to complete a self-administered structured questionnaire. RESULTS: In all, 3,119 patients were referred, the main indications being rectal bleeding (67%), abdominal pain (16%) and change in bowel habit (15%). The average time interval between PCP visit and specialist consultation was 2 days and neoplastic disease was detected in 7.1% of patients. 70% of patients with haemorrhoids and 39% of those with other minor diseases were discharged back to their PCPs after definitive treatment at the time of their visit to the clinic. The majority of PCPs and patients expressed satisfaction with the service as evidenced by the returned questionnaires. CONCLUSION: These data show that a more universal implementation of such clinics may result in improved care of colorectal disease and considerable savings of outpatient time and resources.     

An evaluation of a direct access flexible fibreoptic sigmoidoscopy service

During a 3 year period 146 general practitioners referred 630 patients to a direct access flexible sigmoidoscopy clinic. The yield was 53.3% with significant colonic or rectal pathology in 30%. Twenty six cancers, 4 Dukes' A, and 38 patients with symptomatic adenomatous polyps were detected. Five further cancers were detected by subsequent barium enemas. The service reduced delay in diagnosing colorectal pathology but did not reduce the number of barium enemas requested by general practitioners. It is suggested that where facilities are already available, such a service to investigate rectal bleeding in patients over 40 years is of benefit both to patients and general practitioners.     

Referral Letters for 2-Week Wait Suspected Colorectal Cancer do not Allow a ‘Straight-to-Test’ Pathway

INTRODUCTION

Some clinicians have argued that 2-week wait suspected colorectal cancer patients can go ‘straight-to-test’ to facilitate time to diagnosis and treatment. The aim of this study was to evaluate whether the currently used referral letters are reliable enough to allow that pathway.

PATIENTS AND METHODS

General practitioner (GP) letters referring patients under the Two Week-Wait Rule for suspected colorectal cancer were prospectively reviewed over a 6-month period. Three examining consultants were asked to outline the tests they would perform having only read the letter, and then again after a clinical consultation with the patient. The outcome of these tests was tracked.

RESULTS

A total of 217 referral letters of patients referred under Two Week Wait Rule for suspected colorectal cancer were studied. Having just read the referral letter, the most frequently requested test was colonoscopy (148), then CT scan (48), barium enema (44), followed by gastroscopy (23) and flexible sigmoidoscopy in 15 patients (some patients would have had more than one test requested). After consultation with the patients, tests requested as guided by the GP letter were changed in 67 patients (31%), where 142 colonoscopies, 61 CT scans, 37 barium enemas, 23 flexible sigmoidoscopies and 19 gastroscopies were organised. The referral indication which had tests changed most often was definite palpable rectal mass (67%), while patients referred with definite palpable right-sided abdominal mass had their tests least often changed (9%). A total of 22 patients were found to have colorectal cancers (10%) and 30 patients were diagnosed with polyps (14%). Out of 142 colonoscopies performed, 19 (13%) showed some pathology beyond the sigmoid colon and of the 23 patients who had flexible sigmoidoscopy initially, only three went on to have colonoscopy subsequently. During the 6-month period of the study, only five breaches of the waiting time targets were recorded (1 to the 31-day target and 4 to the 62-day target).

CONCLUSIONS

A significant number of patients would have had tests changed after a clinical consultation. However, only a small number required further investigations having had a consultation prior to their initial investigations. We conclude that 2-week wait suspected colorectal cancer patients should be seen in the clinic first and should not proceed ‘straight-to-test’.     

An approach to haemorrhoids

OBJECTIVE: Many patients with haemorrhoids are investigated because of the fear of missing colorectal cancer (CRC). The aim of this study was to determine whether a primarily clinical approach regarding the need for investigation was safe and did not miss patients with CRC. PATIENTS AND METHODS: Data was collected prospectively on 589 consecutive patients with the principle diagnosis of haemorrhoids at first clinic visit. All had clinical assessment including rigid sigmoidoscopy and were treated by phenol injection or banding. They were categorized for (1) no review unless symptoms persisted -'One Stop SOS' (2) outpatient review or (3) investigation. To check for the development of CRC they were contacted by postal questionnaire or telephone interview with a minimum of one year from diagnosis and treatment. All 589 patients were cross-referenced with the Pathology database and the Hospital Information Services System. RESULTS: Four hundred and sixty-nine (80%) answered the questionnaire; 352 patients (60% of the total group) fell in the 'one stop SOS' outpatient category; 95 (16%) patients were followed up to review response to treatment for large haemorrhoids; 105 (18%) were investigated with barium enema (12%), flexible sigmoidoscopy (4%), colonoscopy (1%) and miscellaneous (1%); 37 (6%) patients were either given a haemorrhoidectomy date or referred on with a different diagnosis. No patients selected for 'one-stop' treatment developed CRC. Five (0.8%) patients were diagnosed with CRC after appropriate investigation was instituted for suspicious symptoms. One patient with distal transverse colon cancer had a delayed diagnosis as she was investigated initially by flexible sigmoidoscopy. CONCLUSION: Most patients with the primary diagnosis of symptomatic haemorrhoids do not need investigation.