Coloproctology A Practical Guide - 2nd Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/coloproctology-a-practical-guide-2nd-edition/

Click Download Now

Editors
Martyn Evans Mark Davies
Department of Colorectal Surgery Department of Colorectal Surgery
Swansea Bay University Health Board Swansea Bay University Health Board
Swansea, UK Swansea, UK

Rhiannon Harries John Beynon

Department of Colorectal Surgery Department of Colorectal Surgery
Swansea Bay University Health Board Swansea Bay University Health Board
Swansea, UK Swansea, UK

ISBN 978-3-031-59629-2 ISBN 978-3-031-59630-8 (eBook)

https://doi.org/10.1007/978-3-031-59630-8

1st edition: © Springer International Publishing AG 2017

2nd edition: © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2024

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse
of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Paper in this product is recyclable.

Contents

1 Triage Optimisation in Patients with Symptoms Suspicious

of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Ian Bissett and Kai Sheng Saw
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Symptoms Suggestive of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . 3
1.3 Current Challenges of Diagnosing Colorectal Cancer
Amongst Symptomatic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3.1 Risks of Invasive Investigations . . . . . . . . . . . . . . . . . . . . . . . 4
1.3.2 Low Patient Acceptability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.3 Excessive Investigation and Low Value Healthcare . . . . 5
1.3.4 Opportunity Costs Associated with Reliance
on Symptoms for Risk Assessment . . . . . . . . . . . . . . . . . . . . 6
1.3.5 Supply and Demand Imbalance . . . . . . . . . . . . . . . . . . . . . . . 7
1.4 The Need for Triaging and Defining Optimum . . . . . . . . . . . . . . . . . 8
1.5 An Overview of Current Approaches to Triaging . . . . . . . . . . . . . . 10
1.6 The Faecal Immunochemical Test (FIT) . . . . . . . . . . . . . . . . . . . . . . . 15
1.7 Implementing FIT—A Proposed Triaging Approach . . . . . . . . . . . 22
1.8 Further Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.9 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2 Total Neoadjuvant Therapy (TNT) in Rectal Cancer; Where
Now, Where Next? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
S. Bedrikovetski and T. Sammour
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.2 Where Are We Now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.1 Induction Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.2 Consolidation Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.2.3 Induction Versus Consolidation Chemotherapy
Sequencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.4 Total Neoadjuvant Therapy Combined
with Immunotherapy or Biologics . . . . . . . . . . . . . . . . . . . . . 46

v
vi Contents

2.3 Where Next? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.3.1 Personalized Total Neoadjuvant Therapy
Sequencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.3.2 Optimising Chemotherapy Regimen . . . . . . . . . . . . . . . . . . . 49
2.3.3 Neoadjuvant Chemotherapy or Immunotherapy
with Selective Omission of Radiotherapy . . . . . . . . . . . . . . 50
2.3.4 Pushing the Boundaries of Nonoperative
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.3.5 Quality of Life Implications . . . . . . . . . . . . . . . . . . . . . . . . . . 52
2.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3 Quality of Life and Survivorship in Extended Pelvic Resection
for Advanced and Recurrent Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Deena Harji and Claire Taylor
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.2 Quality of Life Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.2.1 Physical Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.2.2 Psychological Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.2.3 Role Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.2.4 Sexual Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.2.5 Body Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.2.6 Occupational and Financial Impact . . . . . . . . . . . . . . . . . . . . 65
3.2.7 Global QoL and General Health . . . . . . . . . . . . . . . . . . . . . . 66
3.2.8 QoL Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.3 Cancer Survivorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.4 After-Care Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.5 Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.6 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.7 Stoma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.8 Empty Pelvis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.9 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.10 Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.11 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4 Lynch Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Penelope Edwards and Kevin J. Monahan
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
4.2 History and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.2.1 History of Lynch Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
4.2.3 Gene-Specific Cancer Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.3 Diagnosis of Lynch Syndrome: MMR Testing . . . . . . . . . . . . . . . . . 89
4.4 Biology of Lynch Syndrome; Molecular Pathways . . . . . . . . . . . . . 94
Contents vii

4.5 Pathways to Carcinogenesis; Adenomatous

and Non-adenomatous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.5.1 Cancer from pMMR Adenoma . . . . . . . . . . . . . . . . . . . . . . . . 96
4.5.2 Cancer from dMMR Precursor, Adenoma . . . . . . . . . . . . . 97
4.5.3 Cancer from dMMR Precursor, ‘Non-Polypous’
Route . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.6 Role of Surveillance Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.6.1 Quality Factors in Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . 98
4.6.2 Advanced Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . 99
4.6.3 Variables in Sidedness Affecting Risk Reduction . . . . . . 100
4.6.4 Frequency of Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.6.5 Barriers to Colonoscopy Adherence . . . . . . . . . . . . . . . . . . . 101
4.7 Colorectal Surgical Management of Lynch Syndrome . . . . . . . . . . 103
4.7.1 Extensive or Segmental Resection? . . . . . . . . . . . . . . . . . . . 103
4.8 Prophylactic Surgery and Screening in Gynaecological
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
4.8.1 Gene-Specific Risk and Risk Reduction Surgery . . . . . . . 103
4.8.2 Considerations Post-surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.8.3 Pathological Features of Gynaecologic Cancers
in Lynch Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.8.4 Gynaecological Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.9 Role of Screening in Other Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.9.1 Upper Gastrointestinal (GI) Cancer Screening . . . . . . . . . 105
4.9.2 Urological Cancer Screening; Urothelial
and Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.9.3 Pancreatic Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.9.4 Diagnostic Testing Strategies Pan-Cancer
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.10 Lifestyle and Chemoprevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.10.1 Environmental/Lifestyle Modifiers in Lynch
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.10.2 Pharmacologic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
4.10.3 Endometrial Risk Reducing Agents . . . . . . . . . . . . . . . . . . . 113
4.11 Oncological Management: Radical and Advanced . . . . . . . . . . . . . . 114
4.11.1 CRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4.11.2 Immunotherapy; the Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4.11.3 Clinical Trial Data for Use of Immunotherapy
in CRC: Sporadic and Germline . . . . . . . . . . . . . . . . . . . . . . 114
4.11.4 Targeted Treatments in LS Associated
Gynaecological Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4.11.5 Toxicities Related to Immune Checkpoint
Blockade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4.11.6 Vaccine Based Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
viii Contents

4.12 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

4.13 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5 Neoadjuvant Therapy in Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Geerard L. Beets
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
5.2 Rationale for Neoadjuvant Chemotherapy . . . . . . . . . . . . . . . . . . . . . 135
5.3 Evidence on Neoadjuvant Chemotherapy . . . . . . . . . . . . . . . . . . . . . . 136
5.4 Current Status and Remaining Questions on Neoadjuvant
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
5.5 Circulating Tumour DNA and Adjuvant Therapy . . . . . . . . . . . . . . 139
5.6 Immunotherapy—Immune Checkpoint Inhibition (ICI) . . . . . . . . . 140
5.6.1 Deficient Mismatch Repair (dMMR)
and Microsatellite Instability (MSI) . . . . . . . . . . . . . . . . . . . 140
5.6.2 Neoadjuvant Immunotherapy in Colorectal Cancer . . . . 141
5.7 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
6 Appendix Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Paul A. Sutton and Sarah T. O’Dwyer
6.1 The Normal Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
6.1.1 Histopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
6.1.2 Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
6.1.3 Appearances on Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
6.2 Pathology of Appendix Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
6.2.1 Neuroendocrine Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.2 Appendiceal Mucinous Neoplasms . . . . . . . . . . . . . . . . . . . . 151
6.2.3 Appendix Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
6.2.4 Goblet Cell Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.3 Appendiceal Neuroendocrine Tumours . . . . . . . . . . . . . . . . . . . . . . . . 155
6.3.1 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.3.2 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.3.3 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.3.4 Surveillance and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.4 Appendiceal Mucinous Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.4.1 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.4.2 Pseudomyxoma Peritonei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
6.4.3 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
6.4.4 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.4.5 Multi-visceral Transplantation . . . . . . . . . . . . . . . . . . . . . . . . 163
6.4.6 Systemic Anti-cancer Therapy (SACT) . . . . . . . . . . . . . . . . 163
6.4.7 Surveillance and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.5 Appendix Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.5.1 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.5.2 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Contents ix

6.5.3 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

6.5.4 Systemic Anti-cancer Therapy . . . . . . . . . . . . . . . . . . . . . . . . 165
6.5.5 Surveillance and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
6.6 Goblet Cell Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6.6.1 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6.6.2 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6.6.3 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.6.4 Systemic Anti-Cancer Therapy (SACT) . . . . . . . . . . . . . . . 168
6.6.5 Surveillance and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
6.7 Referring to Specialist Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
6.8 Current Research and Future Directions . . . . . . . . . . . . . . . . . . . . . . . 170
6.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
7 Patient Optimisation for Colorectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . 179
Carly N. Bisset and Susan J. Moug
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
7.2 Definition of Patient Optimisation: Preassessment
and Prehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
7.2.1 Pre-assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.2.2 Prehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
7.3 The Evidence for the Effectiveness of Prehabilitation . . . . . . . . . . 187
7.3.1 Patient Safety and Feasibility . . . . . . . . . . . . . . . . . . . . . . . . . 187
7.3.2 Assessment of Prehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . 188
7.3.3 Trials, Systematic Reviews and Meta-Analyses . . . . . . . . 190
7.3.4 The Future of Prehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . 195
7.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
8 Empty Pelvis Syndrome Complication Management Following
Pelvic Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Martha Quinn and Colin W. Steele
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
8.2 Empty Pelvis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
8.3 Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
8.3.1 Negative Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
8.3.2 Myocutaneous Flap Reconstruction . . . . . . . . . . . . . . . . . . . 208
8.3.3 Mesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
8.3.4 Spacers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
8.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
8.5 Complications and Management of Empty Pelvis
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
8.5.1 Pelvic Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
8.5.2 Haemorrhagic Complications . . . . . . . . . . . . . . . . . . . . . . . . . 212
8.5.3 Wound Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
8.5.4 Enteroperineal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
x Contents

8.5.5 Perineal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

8.5.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9 Contemporary Management of the Open Abdomen . . . . . . . . . . . . . . . . 221
Dominic Alexander James Slade
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.2 Indications for an Open Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.2.1 Trauma and the Damage Control Laparotomy . . . . . . . . . 224
9.2.2 Intra-Abdominal Hypertension and Abdominal
Compartment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
9.2.3 Peritonitis and Intra-Abdominal Sepsis . . . . . . . . . . . . . . . . 229
9.2.4 Acute Mesenteric Ischaemia, Pancreatitis,
and Burns Without Abdominal Trauma . . . . . . . . . . . . . . . . 233
9.3 Management of the Open Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
9.3.1 Temporary Abdominal Closure Dressings . . . . . . . . . . . . . 234
9.3.2 Static Temporary Abdominal Closure . . . . . . . . . . . . . . . . . 235
9.3.3 Dynamic Temporary Abdominal Closure . . . . . . . . . . . . . . 237
9.3.4 Mixed Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
9.3.5 Vacuum-Assisted Wound Closure Using
Mesh-Mediated Fascial Traction . . . . . . . . . . . . . . . . . . . . . . 240
9.3.6 Immediate Management of an Enteroatmospheric
Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
9.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
10 Anastomotic Techniques for Crohn’s Surgery . . . . . . . . . . . . . . . . . . . . . . 251
Antonino Spinelli and Elisa Paoluzzi Tomada
10.1 Surgical Principles in Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . 252
10.2 Restorative Surgery Techniques After Bowel Resection . . . . . . . . 255
10.3 Anastomotic Techniques After Ileocaecal Resection . . . . . . . . . . . . 255
10.3.1 Side-to-Side Ileocolonic Anastomosis . . . . . . . . . . . . . . . . . 256
10.3.2 End-to-End Handsewn Ileocolonic Anastomosis . . . . . . . 258
10.3.3 End-to-Side and Side-to-End Ileocolonic
Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
10.3.4 Antimesenteric Hand-Sewn Functional
End-to-End Anastomosis: Kono-S Anastomosis . . . . . . . 260
10.3.5 Additional Anastomotic Techniques . . . . . . . . . . . . . . . . . . . 263
10.4 Extracorporeal and Intracorporeal Anastomoses . . . . . . . . . . . . . . . . 264
10.5 Restorative Techniques After Colectomy, Proctocolectomy
and Upper Gastrointestinal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.5.1 Ileo-Rectal Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.5.2 Ileal Pouch-Anal Anastomosis and Coloanal
Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
10.5.3 Surgical Management of the Upper
Gastrointestinal Crohn’s Disease Manifestations . . . . . . . 266
Contents xi

10.6 Bowel-Sparing Surgery: Stricturoplasties . . . . . . . . . . . . . . . . . . . . . . 267

10.6.1 Heinecke-Mikulicz-Like Stricturoplasties . . . . . . . . . . . . . . 267
10.6.2 Intermediate Stricturoplasty Procedures . . . . . . . . . . . . . . . 269
10.6.3 Enteroenterostomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
10.7 Complications in Crohn’s Disease Surgery . . . . . . . . . . . . . . . . . . . . . 271
10.8 Considerations on Disease Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . 272
10.9 Conclusions and Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . 274
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
11 The Modern Management of Haemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . 285
Steven R. Brown
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
11.2 Pathogenesis and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
11.3 Conservative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
11.3.1 Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
11.3.2 Outpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
11.3.3 ‘Walk in Walk Out’ Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 290
11.4 Surgical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
11.4.1 Haemorrhoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
11.4.2 Procedure for Prolapsed Haemorrhoids . . . . . . . . . . . . . . . . 293
11.4.3 Doppler Guided Haemorrhoidal Artery Ligation . . . . . . . 294
11.4.4 Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
11.5 Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
11.5.1 Thrombosed External Haemorrhoids . . . . . . . . . . . . . . . . . . 295
11.5.2 Perianal Haematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
11.5.3 Haemorrhoids in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
11.5.4 Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
11.5.5 Immunocompromised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
11.5.6 Haemorrhoids in Inflammatory Bowel Disease . . . . . . . . 298
11.6 Conclusion and an Evidence-Based Algorithm of Care . . . . . . . . . 298
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
12 Microbiome Manipulation in Coloproctology . . . . . . . . . . . . . . . . . . . . . . . 303
Nicholas R. Suss and Benjamin D. Shogan
12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
12.2 Brief Overview of the Role of Gut Microbiome . . . . . . . . . . . . . . . . 304
12.3 “Healthy” Microbiota Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
12.4 Manipulation of the Intestinal Microbiome and Its Role
in the Pathogenesis of Gastrointestinal Disease . . . . . . . . . . . . . . . . 307
12.4.1 Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 307
12.4.2 Development of Colorectal Cancer, Recurrence,
and Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
12.5 Clinical Manipulations of the Intestinal Microbiome
to Target Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
12.5.1 Restoring the Intestinal Microbiota Through
Faecal Microbiota Transplantation . . . . . . . . . . . . . . . . . . . . 315
xii Contents

12.5.2 Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 316

12.5.3 Bowel Preparation and Colon Cancer . . . . . . . . . . . . . . . . . 317
12.5.4 Nutritional Prehabilitation and the Intestinal
Microbiome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
12.5.5 Impact of Nutritional Prehabilitation
on the Intestinal Microbiota and Anastomotic
Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
12.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
13 Restorative Proctocolectomy–Technical Challenges of the Ileal
Pouch-Anal Procedure for Ulcerative Colitis and Familial
Adenomatous Polyposis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Peter Sagar
13.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
13.2 Principles of the Operation of IPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
13.2.1 Choice of Pouch Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
13.2.2 The Ileal Pouch Anal Anastomosis . . . . . . . . . . . . . . . . . . . . 329
13.3 Post Operative Course and Potential Problems . . . . . . . . . . . . . . . . . 332
13.3.1 Longer Term Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
13.4 Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
13.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
14 Contemporary Management of Fistula in Ano . . . . . . . . . . . . . . . . . . . . . . 337
Philip Tozer and Lillian Reza
14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
14.2 Clinical Presentation of Anal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . 339
14.3 Clinical Assessment of Anal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
14.4 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
14.5 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
14.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Triage Optimisation in Patients
with Symptoms Suspicious 1
of Colorectal Cancer
Ian Bissett and Kai Sheng Saw

Abstract
Despite the advent of screening programmes, diagnosis for the majority of
colorectal cancers (CRC) still follows a symptomatic presentation. Current
approaches to assessment of patients with symptoms suspicious of CRC rely
on subjective symptoms which are poor predictors of CRC diagnosis. Multiple
practical challenges have also arisen as a result of excessive reliance on symp-
toms for diagnosis and triage. Current approaches have also overwhelmed health
care resources without producing the expected benefits. Better ways of triaging
patients with symptoms suspicious of CRC are needed. The principles of triag-
ing are explored followed by an overview of the advantages and limitations of a
number of current triaging approaches. The faecal immunochemical test (FIT)
is a prime candidate to bring major practice change in how these patients are
triaged. FIT offers practical solutions that address many of the challenges faced
by current triaging methods. The role and evidence supporting the use of FIT in
symptomatic patients is explored in detail, with further discussion about unre-
solved considerations such as safety netting for patients with low FIT results,
equity concerns, and future directions for improving FIT implementation.

Keywords
Colorectal cancer • Faecal immunochemical test • Diagnostic triage •

Symptomatic patients

I. Bissett (B) · K. S. Saw

University of Auckland, Auckland, New Zealand
e-mail: [email protected]
I. Bissett
Department of Surgery, Auckland City Hospital, Auckland, New Zealand

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 1

M. Evans et al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_1
2 I. Bissett and K. S. Saw

Key Points

• The specificity of symptoms in predicting CRC is very low.

• Primary investigations are invasive, resource intensive and associated with
complications.
• In the majority of symptomatic patients, these investigations do not identify
significant pathology.
• A triaging system that is more sensitive and specific than symptoms alone is
needed.
• Multiple studies have demonstrated a high sensitivity and specificity for FIT
testing in symptomatic patients.
• FIT testing offers the possibility of ruling out CRC in patients with very low
FIT f-Hb levels and escalation of urgent colonoscopy in those with very high
levels.
• Unanswered questions include the best method to identify those patients
who should be referred directly for colonoscopy without FIT testing (par-
ticularly those with suspected inflammatory bowel disease) and the optimal
safety-netting process to follow up those with very low f-Hb levels.

1.1 Introduction

As the third most common malignancy with an estimated 900,000 attributable

deaths annually, colorectal cancer (CRC) is a significant public health concern
worldwide [1]. Although more common in high-income countries, the incidence
of CRC is increasing in low and middle-income countries due to increased life
expectancy and the westernisation of society [1, 2]. Notably, there has also been
a growing incidence of CRC in younger patients (<50 years) in high-income
countries [3, 4].
Historically, healthcare providers have limited tools to diagnose CRC. Struc-
tural diagnostic tests have improved significantly since the days of barium enemas
to the widely used colonoscopy and computed tomographic colonography (CTC)
today. While the diagnostic utility of colonoscopy and CTC is obvious, these are
relatively invasive diagnostic tests with limited patient acceptability and limited
accessibility due to the intensive resources required to operate and maintain a
high-quality diagnostic service. While stool based tests for diagnosis of colorectal
cancer have been in existence for decades, it was not until the early 2000s when
the faecal immunochemical test for haemoglobin (FIT) was widely adopted across
Europe for CRC screening of asymptomatic patients.
The importance of early diagnosis of CRC by stage is well established. This is
evidenced by the fact that despite high incidence rates, CRC related mortality in
many high-income countries are decreasing, largely attributable to CRC screening
programmes and to a lesser extent better treatment and surveillance [1, 4]. How-
ever, even in countries with established CRC screening programmes, the majority
of CRCs are still diagnosed when suspicious symptoms are investigated. This is
1 Triage Optimisation in Patients with Symptoms Suspicious of Colorectal … 3

crucial as the proportion of individuals with advanced stage CRC is higher in

the symptomatic cohort than in those diagnosed in screening the asymptomatic
population. Furthermore, a significant proportion of these patients are emergency
presentations (>20%) with poor prognosis [5]. Many would have experienced pro-
longed presence of symptoms and delay to diagnosis [6, 7]. Hence, the need to
optimise triage.
Diagnosis is often preceded by a complex sequence of events involving patients,
healthcare providers and the health system. It is useful to consider theoretical
models that describe the three phases of cancer in this context—the invisible
asymptomatic phase, followed by the visible asymptomatic phase and then the
symptomatic phase, generally indicative of more advanced disease stage [8]. This
chapter primarily focuses on the timeframe between when patients first present
to healthcare providers with symptoms suspicious of CRC and when a formal
diagnosis is made. The chapter provides an evidence-based discussion around the
utility and issues with using symptoms as a tool for diagnosis and various triaging
approaches for patients with symptoms suspicious of CRC.

1.2 Symptoms Suggestive of Colorectal Cancer

The symptoms and signs that are associated with presence of CRC include rec-
tal bleeding, change in bowel habit, weight loss, palpable abdominal or rectal
mass and abdominal pain. While these common symptoms are often included
in diagnostic guidelines, patients presenting with less common symptoms such
as tenesmus, unexplained anorectal pain, urgency to defaecate etc. are not infre-
quently referred for further investigation as part of a cluster of symptoms due to
concern about colorectal malignancy. Clinical symptoms of bowel obstruction or
tumour perforation are often observed in patients with CRC who first present to
emergency departments.
Despite the importance of symptoms in identifying potential cases of CRC,
there are pitfalls associated with the excessive reliance on symptoms in contempo-
rary diagnostic pathways. The following sections outline the main issues associated
with symptoms, then explore how these features interact and lead to the current
challenge of diagnosing CRC amongst symptomatic patients.
Many symptoms commonly associated with CRC such as change in bowel
habit, weight loss, and abdominal pain, are prevalent in the general adult popu-
lation. For instance, up to 10% of individuals experience a change in bowel habit,
3% experience weight loss, and 25% report abdominal pain [9]. Rectal bleeding,
the symptom most strongly associated with CRC, is estimated to occur in up to
15% of adults during their lifetime and that only half of these patients seek consul-
tation for these symptoms [9]. An increase in referrals for patients with symptoms
suspicious of CRC has also been reported in recent years [9–11].
Symptoms, by definition, are subjective with variability in definition and inter-
pretation among patients and health providers. The cited symptoms are often open
to interpretation and lack reliability, accuracy and reproducibility [12, 13]. For
4 I. Bissett and K. S. Saw

instance, the definition of “change in bowel habit” varies among different health
jurisdictions, with some considering any change including either diarrhoea or con-
stipation, while others, like the NICE guidelines, focus on looser or more frequent
stools as the defining feature. Furthermore, there is doubt over whether health
practitioners are following such definitions when using guidelines in day to day
practice [14].
As medical practice is increasingly informed by quantifiable measurements such
as biomarkers, the continued primary reliance on subjective symptoms is somewhat
incongruous. Attempts to improve the quantification of symptoms using validated
questionnaires for assessing abdominal or gastrointestinal symptoms have failed to
gain broad usage [12, 13].
Importantly, despite substantial evidence demonstrating the limited predictive
value of individual symptoms for diagnosing CRC, many clinicians and healthcare
jurisdictions still rely heavily on symptoms in contemporary diagnostic pathways.
Many of these symptoms have discriminatory abilities that are only slightly better
than chance alone at detection of CRC and are notably more effective in detecting
benign colorectal pathology [12, 13, 15]. These symptoms often concurrently lack
sufficient sensitivity and specificity for detecting CRC in the modern era. Even rec-
tal bleeding, which has demonstrated a more consistent association with CRC, only
exhibits a sensitivity ranging from 17 to 46% and a specificity range of 52–98%
in published meta-analyses [12, 13, 15]. Some symptoms such as abdominal pain
actually appear to fare worse than a coin toss at predicting CRC yet these remain
common reasons for referral [13]. Combining a number of symptoms does not nec-
essarily improve diagnostic performance significantly either but will be explored
in detail in subsequent sections [12, 13]. Diagnostic performance of symptoms
was also not significantly different regardless of whether studies were conducted
in primary or secondary care highlighting their inherent limitations regardless of
the healthcare providers experience of expertise [12, 13]. The challenges of using
symptoms may stem from the lack of a clear underlying pathophysiological link
between CRC and its presenting symptoms. The reliance on symptoms is also
hampered by the fact that these may only become evident with relatively advanced
disease.

1.3 Current Challenges of Diagnosing Colorectal Cancer

Amongst Symptomatic Patients

There are multiple practical challenges in providing diagnostic investigations for

patients with symptoms suggestive of CRC.

1.3.1 Risks of Invasive Investigations

The current approach to managing patients with concerning symptoms often leads
to investigation with an invasive procedure. Over half of these patient ultimately
1 Triage Optimisation in Patients with Symptoms Suspicious of Colorectal … 5

demonstrate no organic pathology and have no changes in the therapeutic approach

[14–20]. Invasive investigations such as colonoscopy and CTC are inevitably asso-
ciated with risks including perforation (0.005–0.091%), bleeding (0.21–1.14%),
sedation complications, fluid and electrolyte anomalies, bacteraemia and death
[21–24]. The risk of all-cause mortality within 30 days following colonoscopy
is reported at 0.007–0.07% [21–24]. Notably, major complications such as per-
foration and bleeding have been consistently shown to be more likely among
symptomatic patients undergoing diagnostic colonoscopy [22–24].
While considered less invasive than colonoscopy, CTC is not risk free. Perfo-
ration rates for CTC range from 0.035–0.04% [25, 26]. CTC complications were
also reported to be generally higher for symptomatic patients undergoing diag-
nostic CTC [25, 26]. Additionally, CTC is associated with an increased lifetime
cancer risk due to the radiation dose [27].

1.3.2 Low Patient Acceptability

The acceptability of colonoscopy to patients is not as high as most clinicians

believe. Non-attendance rates for colonoscopy can be as high as 15–48% in dif-
ferent contexts [28]. Patients consistently rank the discomfort and inconvenience
of bowel preparation as the most challenging aspect of the colonoscopy or CTC
process [28, 29]. Concerns about modesty, logistical barriers and competing health
priorities are also common reasons for not attending a colonoscopy after referral
[28, 29]. Cultural taboos also emerged as a persistent theme and may be more
important barriers to specific subgroups of the population, particularly as equity in
health outcomes in multicultural societies are increasingly discussed [28, 29].

1.3.3 Excessive Investigation and Low Value Healthcare

Over-investigation of symptoms can have unintended consequence, leading to

increased usage of healthcare resources that do not directly address the patients’
initial complaint [19, 30, 31]. Common examples include the detection of colonic
polyps unrelated to the presenting symptoms and extra colonic incidental findings
on CTC (up to 13% of cases) [13, 30, 32]. This precipitates a ‘cascade effect’ of
additional investigations and procedures that add substantial morbidity and cost
without addressing the patient’s initial symptoms [30, 32].
The concept of low value healthcare has gained increasing prominence in recent
years. Low value care can be described as the delivery of tests or interventions
where evidence suggests it confers no or very little benefit to patients; where
the risk of patient harm is in excess of potential benefit; or incurring of addi-
tional healthcare costs without proportional added benefits to patients [31, 33,
34]. Colonoscopy use for some symptomatic patients (e.g. constipation as the
sole symptom) has been highlighted as an example of low value healthcare [33].
Low value endoscopy procedures have increased in incidence over time and not
6 I. Bissett and K. S. Saw

only cause a waste of health resources but also present a significant potential for
downstream harm to patients [31, 33, 35].

1.3.4 Opportunity Costs Associated with Reliance

on Symptoms for Risk Assessment

a. Unjustified diagnostic delays

Treating large cohorts of patients with varying symptoms as if they share a

uniform risk of undiagnosed CRC inevitably results in unjustified delays for eval-
uation for some individuals with genuine underlying CRC. With rising numbers of
symptomatic patients seeking medical attention, existing symptom-based triaging
methods lead to decreasing CRC yield from colonoscopy and increased likelihood
of delayed diagnoses and associated opportunity costs for those harbouring true
undiagnosed CRC [20].

b. Enforced suboptimal rationing

A common system level response to overwhelming referrals is to ration access

based sub-optimally on blunt tools such as aggregate demographic data and unreli-
able symptoms-based referral criteria. For example, younger symptomatic patients
(<50-year-olds) harbouring true undiagnosed CRC face increased barriers to access
colonoscopy and increased risk of misdiagnosis despite emerging evidence of
increasing incidence of early onset CRC [36, 37]. This further highlights the inad-
equacy of many current triaging approaches for patients with symptoms suspicious
of CRC which inappropriately sacrifice certain groups with true pathology while
large numbers of colonoscopies with unremarkable findings are performed.

c. Wider system level trade-offs

Almost universally, a lack of adequate colonoscopy capacity has led to a bottle-

neck in population level bowel screening programmes resulting in restrictions in
screening programme parameters and prolonged rollouts [38]. Although stage shift
through CRC screening is widely recognised as the most cost-effective approach
to improving CRC related survival, screening programmes are often perceived
as an optional extra rather than essential. This is prompted by the perceived
ethical responsibility to prioritise symptomatic patients in spite of prevailing evi-
dence showing poor association between CRC and symptoms [13, 38, 39]. Each
additional healthcare professional and healthcare dollar dedicated to performing
colonoscopy on every symptomatic patients, means fewer resources for other
healthcare programs that have more robust evidence supporting their value to the
population.
1 Triage Optimisation in Patients with Symptoms Suspicious of Colorectal … 7

1.3.5 Supply and Demand Imbalance

The key health resource challenge faced as a result of current approaches to assess-
ment of patients with symptoms suspicious of CRC ultimately boils down to
imbalances in colonoscopy (or CTC) supply and demand.
The overwhelming demand for specialist consultations and structural diagnostic
tests is already well-recognised with further increases expected on the horizon [20].
The problem of increasing demand is perhaps best documented in data from the
United Kingdom and has led to an unsustainable demand for specialist services and
structural diagnostic tests [10, 14, 20]. The COVID-19 pandemic enforced down-
scaling of clinical activity further strained services despite an apparent reduction
in symptomatic referrals in the early stages of the pandemic [40]. Alarmingly, the
yield of CRC diagnosed among referred symptomatic patients has progressively
declined from 14 to 8% despite a 45% increase in referrals over the years [14, 20].
With CRC related outcomes still remaining poor, symptoms-based referral criteria
were further loosened, this increased referrals by 78–100% [20]. The result was
a reduced yield of CRC diagnosis to 3–9% without any significant improvement
in CRC related outcomes [20]. Efforts to manage the large volume of referred
patients by mandating faster treatment pathways such as the “two-week-wait path-
way”, largely based on re-categorisation of patients by age and symptoms, has been
shown to have no effect on CRC detection yield or clinically important outcomes
[10, 14]. Such efforts also fail to recognise and address the fundamental problem
of overwhelming demand due to inaccurate patient selection [14]. Straight to test
pathways were then adopted in the UK to address the pressures of meeting pol-
icy targets [41, 42]. These did not translate to demonstrable improvement in CRC
detection yield, stage shift or mortality, because these efforts only shifted the bur-
den, rather than addressing the overwhelming demand created by symptoms-based
criteria [41, 42]. All these efforts led to significant pressures within the public
health system with numerous reports attesting to the worsening of problems over
time [10, 20]. In blunt terms, policy changes based on symptoms-based criteria
resulted in increased healthcare workload and overwhelmed secondary and ter-
tiary care resources at many levels without producing the expected increases in
number of CRC diagnosed or more importantly, improvements in CRC related
survival [10, 14, 20, 42].
Many publicly funded health jurisdictions are likely to be in a similar predica-
ment. With the general trend of increasing public health messaging around CRC
and associated symptoms, most health jurisdictions are likely to see more refer-
rals as the “symptom iceberg” is progressively revealed. The United Kingdom for
example, saw an increase of referrals by 62–77% when a concerted public aware-
ness campaign about symptoms of CRC were conducted [10, 20]. There is clearly
is a need to enhance patient selection and optimise triage methods for those with
symptoms suspicious for CRC using novel approaches that address the demand for
colonoscopy (or CTC).