Shankar P J, Achuthan R, Haray P N
Department of General Surgery, Prince Charles Hospital, North Glamorgan NHS Trust and School of Care Sciences, University of Glamorgan, Pontypridd, UK.
Colorectal Dis. 2001 Nov;3(6):396-401. doi: 10.1046/j.1463-1318.2001.00279.x.
To audit all aspects of the diagnosis and management of colorectal cancers by a specialist unit within a District General Hospital (DGH). To compare the clinical effectiveness of the specialist service with the service prior to specialization and attempt to assess the feasibility of setting up such a service within the constraints imposed by a DGH.
Data for this study was collected prospectively over a 3-year period from July 1997 to June 2000 since the establishment of a specialist colorectal service. The results so obtained have been compared with the Trent and Wales audit of 1993 as well as with the guidelines issued by the Royal College of Surgeons of England and the Association of Colo-proctologists of Great Britain and Ireland. We have attempted to evaluate whether specialization has altered the outcome for patients with colorectal cancer.
A total of 2181 patients were seen at the specialist colorectal clinic and 42% underwent immediate flexible sigmoidoscopy. A total of 241 colorectal cancers were diagnosed during this period by the specialist unit, of which the rapid access clinic had picked up 191 (a pick-up rate of 8.75%). The mean age of patients with colorectal cancer was 69.23 years and the median waiting time from referral to clinic and from referral to treatment was 9 days and 24 days, respectively. These compare favourably with the waiting times prior to specialization. 117 rectal cancers were diagnosed of whom 32 (32%) underwent APER. A selective approach to short course preoperative radiotherapy resulted in 24% of rectal cancer patients receiving this treatment. The CRM was positive in 14% of resected rectal cancers, all of whom had received preoperative radiotherapy. The percentage of patients with Dukes' stage A disease has risen from 11% in 1993 to 23% and the percentage of patients undergoing emergency surgery have fallen from 29% in 1993 to 8.2%. The rate of permanent stoma formation has also decreased from 52% to 32%. This audit has also confirmed that the guidelines for the management of colorectal cancers were all being met or exceeded.
The study demonstrates that, even within the constraints of a DGH, a specialist service can result in earlier diagnosis, shorter waiting periods and judicious use of adjuvant treatment leading to improved clinical effectiveness. It is possible to deliver a high quality service, which meets, and in some areas, surpasses the minimum guidelines, provided there is an integrated multidisciplinary approach.
对一家地区综合医院（DGH）内的专科单位对结直肠癌诊断和管理的各个方面进行审核。将专科服务的临床效果与专科化之前的服务进行比较，并尝试评估在DGH所施加的限制条件下设立此类服务的可行性。
本研究的数据自1997年7月至2000年6月的3年期间前瞻性收集，自专科结直肠服务建立以来。将如此获得的结果与1993年特伦特和威尔士的审核以及英国皇家外科医师学院和大不列颠及爱尔兰结直肠病学家协会发布的指南进行了比较。我们试图评估专科化是否改变了结直肠癌患者的治疗结果。
专科结直肠诊所共诊治了2181例患者，42%的患者立即接受了乙状结肠镜检查。在此期间，专科单位共诊断出241例结直肠癌，其中快速通道诊所发现了191例（检出率为8.75%）。结直肠癌患者的平均年龄为69.23岁，从转诊到诊所以及从转诊到治疗的中位等待时间分别为9天和24天。这些与专科化之前的等待时间相比具有优势。共诊断出117例直肠癌，其中32例（32%）接受了腹会阴联合切除术。对短程术前放疗采用选择性方法，导致24%的直肠癌患者接受了这种治疗。在切除的直肠癌中，14%的患者环周切缘阳性，所有这些患者均接受了术前放疗。Dukes A期疾病患者的百分比从1993年的11%上升至23%，急诊手术患者的百分比从1993年的29%降至8.2%。永久性造口形成率也从52%降至32%。此次审核还证实，结直肠癌管理指南均得到满足或超越。
该研究表明，即使在DGH的限制条件下，专科服务也可导致更早的诊断、更短的等待时间以及合理使用辅助治疗，从而提高临床效果。只要采取综合的多学科方法，就有可能提供高质量的服务，该服务符合并在某些领域超越最低指南。
