One of the highlights of day one of ESCP 2017 was the International Trials Forum. During the session the audience heard about ground breaking trials from the UK, The Netherlands and France as well as results from the 2017 ESCP Cohort Study which involved 335 centres in 49 countries.
Jim Hill from the UK presented the findings from the CREST trial which found that stenting as a bridge to surgery in cases of obstructing colorectal cancer has 80% clinical success rate and in particular can be a reasonable alternative to emergency surgery, especially when no expert surgeon is available. Stenting compared to emergency surgery does not impact mortality rates and stoma rates are significantly reduced.
The Liric trial was presented by Willem Bemelman. This study compared a laparascopic ileocecal resection with infliximab treatment for patients with active Crohn’s Disease not responding to conventional treatment. For the primary outcome the study found that the surgical intervention was at least as effective as the medical intervention in improving quality of life, but as many patients on infliximab needed surgery within a year the surgical intervention was found to be less costly and more effective overall. This raises the question of whether more patients should be referred to surgery earlier.
From France, Jeremie Lefevre, presented the results of the GRECCAR6 study on the impact of lengthening the interval between neoadjuvant radiochemotherapy and surgery for rectal cancer patients. The study found that lengthening the interval to 11 weeks rather 7 weeks had no impact on tumoral characteristics or overall survival. However, those patients who waited only 7 weeks had lower rates of local recurrence compared to patients who waited 11 weeks.
Yves Panis also presented the fascinating results of REHAB which compared outcomes after laparoscopic colorectal cancer surgery for patients on a full multimodal fast track management with a limited fast track care programme. Perhaps surprisingly, the trial found that the full multimodal programme made no difference to postoperative morbidity rates or length of stay in hospital except for patients with no complications. Prof Panis said the takeaway message from this trial is that laparoscopic surgery followed by no tube and early feeding are the most important factors for reducing length of stay.
The FIAT trial presented by David Jayne proved very popular with the audience – who were very surprised by some of the surgeons’ choices of methodology for treating anal fistula. FIAT compared the results of using a fistula plug with four other options which were used at the surgeon’s discretion. These were advanced flap, cutting seton, fistolotomy and LIFT procedure. The study found that there was no difference to incontinence rates between the fistula plug and the other methods at 12 months but there was significantly more early pain for patients with the fistula plug. Overall the study found that as only half of fistulas healed irrespective of treatment we have still yet to find the best method for treating this challenging condition. Prof Jayne added there will further the health economics analysis done on these results.
Finally the audience was presented with early results from ESCP’s 2017 Cohort Study into left colon, sigmoid and rectal resections. Alaa El-Hussuna explained that this is the largest international collaborative study of its kind, with 5641 patients entered across 335 centres in 49 countries. The early analysis has shown that the majority of operations 56.5% across the centres were done with a laparoscopic approach. A further 39.5% of the operations entered used more traditional open surgery but transanal (14.3%) and robotic (4%) approaches are gaining ground. This study will provide a huge amount of data for further study and is a compelling demonstration of what can be achieved when surgeons work together.
