Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) – Surgical Management

摘要

The Department of Health published national referral guidelines in 2000 for suspected cancers, based on high-risk symptoms and signs, the so called ‘2 week rule’. The recommendation was that units should see in excess of 95% of referrals within 2 weeks. This recommendation has successfully improved service delivery and patient processing within the NHS, although evidence of improved outcomes is unproven (Hitchins et al., 2014; Patel et al., 2014; Schneider et al., 2013). In 2005, the NHS National Cancer Plan produced treatment targets for colorectal cancer, consisting of 62 days from ‘2 week’ referral and 31 days from the ‘decision to treat date’ (Department of Health, 2006). However, the health service's primary emphasis should be on quality and outcomes, rather than on time to treatment (Murchie et al., 2014). Treatment should begin within 31 days of the decision to treat. Recommendation grade D A colorectal cancer MDT serving a population of 200 000 is expected to manage around 120 new patients per year. Quality cancer treatment depends on coordination between multiple treatments and treatment providers, the exchange of technical information, and effective communication between clinical, nursing and other disciplines involved in the patients’ management. Multidisciplinary teams (MDTs) should improve coordination, communication, and decision making between health-care team members and patients, and produce better outcomes. This can be achieved by reflective practice, audit, patient surveys, MDT ‘away days’ to develop the service delivered. Feedback should be systematically evaluated and any changes made to the care for both the general patient population and for individual patients, should be subsequently reviewed and evaluated by the team to see if improvement has been achieved. Despite the standardization of delivery of cancer services via this method, research showing the effectiveness of MDT working is scarce (Fennell et al., 2014; Fleissig et al., 2006). The ACPGBI ‘Resources for Coloproctology 2015’ document (Association of Coloproctology of Great Britain and Ireland, 2015) informs clinicians, managers, medical directors, chief executives and politicians, to address any existing inequalities in care for patients and achieve uniform standards nationally. The core colorectal MDT should include; The extended MDT members should include; The management plans for all colorectal cancer patients should be reviewed by a Colorectal MDT. Recommendation grade C There have been a number of reports assessing effects of surgical specialization and patient throughput (both the number of cases treated per surgeon and per hospital) on outcomes in colorectal cancer (Etzioni et al., 2014). The NICE colorectal cancer guidance (2004) identified 6 systematic reviews and 28 other studies in this field. The evidence indicates that better surgical specialization and training is associated with improved outcomes, particularly in rectal cancer (Archampong et al., 2012; Etzioni et al., 2014). These benefits of surgical specialization appear more pronounced for rectal cancer than for colon cancer. In rectal cancer, 11 of 13 studies reported that more specialized surgeons achieved better outcomes. Six out of eight good quality studies showed significant effects on one or more of the following measures; survival rates (up to 5 years), quality of surgery (assessed by complication rates or tumour-free excision margins) and local recurrence rates (Archampong et al., 2012). Greater specialization is also associated with shorter in-patient stay and less frequent use of stomas (National Institute for Health and Clinical Excellence, 2004). It is advised that each surgeon in the MDT should ideally carry out a minimum of 20 radical colorectal cancer resections per annum (The Association of Coloproctology of Great Britain and Ireland, 2012). Surgery for colorectal cancer should be performed by surgeons with appropriate training and experience, working within a