A Biffin’s research while affiliated with Newport Hospital and other places

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Publications (11)


One-year survey of carcinoma of the oesophagus and stomach in Wales
  • Article

February 2001

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18 Reads

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74 Citations

BJS (British Journal of Surgery)

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J Charles

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A Biffin

The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales. Patients were identified from hospital records. Details were recorded in structured format for analysis. Analysable data were obtained for 910 of 916 patients. The overall incidence was 31.4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0.001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. 'Open and close' operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0.05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0.01) irrespective of case volume. Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.



Percentage of all gastric resection reports containing statements on individual data items audited (all Wales)
Percentage of all oesophageal resection reports containing statements on individual data items audited (all Wales)
Percentage of reports fulfilling standards
Oesophageal and gastric cancer pathology reporting: A regional audit
  • Article
  • Full-text available

July 1999

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81 Reads

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14 Citations

Journal of Clinical Pathology

To audit the information content of pathology reports of oesophageal and gastric cancer resection specimens in Wales. All such reports from the 16 NHS histopathology laboratories in Wales in a one year period were evaluated for their information content. Two standards were used: (1) best practice reporting, and (2) a minimum dataset required for informed patient management that included clear statements on histological tumour type, depth of tumour invasion, lymph node involvement, and completeness of excision. 282 reports were audited. Minimum standards were achieved in 77% of gastric resections (156/203) and 53% of oesophageal resections (42/79). All laboratories achieved minimum standards in some gastric cancer reports (range 50-100%); three laboratories did not achieve minimum standards in any oesophageal cancer reports (range 0-100%). Best practice reporting was achieved in only 20% of gastric and 18% of oesophageal cancer reports. Failure to include an explicit statement on completeness of excision or involvement of the oesophageal circumferential resection margin were the most frequent causes of inadequate reporting. Most other data items were generally well reported, but apparent inadvertent omission of just one item was noted in many of the substandard reports. This audit shows the need to improve the information content of pathology reports in gastric and oesophageal cancer. The widespread implementation of template proforma reporting is proposed as the most effective way of achieving this. Multidisciplinary meetings of clinicians involved in cancer management should provide a forum for greater communication between pathologists and surgeons, and help to maintain standards of pathological practice.

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Mortality from ruptured aortic aneurysm in Wales

June 1999

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26 Reads

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129 Citations

BJS (British Journal of Surgery)

The aim of this study was to identify the incidence of, and mortality in, patients with a ruptured abdominal aortic aneurysm (AAA) reaching hospital alive in Wales. Patients who presented with a ruptured AAA between September 1996 and August 1997 were analysed. Data were collected prospectively by an independent body, observing strict confidentiality. Some 233 patients with a confirmed ruptured AAA were identified, giving an incidence of eight per 100 000 total population. Some 133 patients (57 per cent) underwent attempted operative repair; 85 (64 per cent) of these died within 30 days. Of the 233 patients, 92 were admitted under the care of a vascular surgeon and 141 under a non-vascular surgeon. Vascular surgeons operated on 82 patients (89 per cent), of whom 50 (61 per cent) died, whereas non-vascular surgeons operated on 51 patients (36 per cent), of whom 35 (69 per cent) died. This study is unique as it is an independent prospective study of mortality in patients with a ruptured AAA who reached hospital alive. Mortality was independent of the operating surgeon, but vascular surgeons turned down significantly fewer patients than non-vascular surgeons (11 versus 64 per cent, P < 0.001).


Deaths from ruptured abdominal aortic aneurysm in Wales

May 1999

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13 Reads

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52 Citations

BJS (British Journal of Surgery)

The aim was to determine the true incidence and operative mortality rate of patients with ruptured abdominal aortic aneurysm (AAA) who reach hospital alive in Wales. Patients presenting with a ruptured AAA between September 1996 and August 1997 were analysed. The data were collected prospectively by an independent body, observing strict confidentiality. Two hundred and thirty-three patients with confirmed ruptured AAA were identified. One hundred and thirty-three patients (57 per cent) underwent attempted operative repair. Eighty-five (64 per cent) died within 30 days. All 100 patients who received no operation died. Of the 233 patients, 92 were admitted under vascular surgeons (VSs) and 141 under non-vascular surgeons (NVSs). VSs operated on 82 patients (89 per cent) of whom 50 (61 per cent) died; NVSs operated on 51 (36 per cent) of whom 35 (69 per cent) died. This study is the only independent prospective study of death among patients with ruptured AAA who reached hospital alive. Some 57 per cent of the patients with a ruptured AAA were operated on. The operative mortality rate was 64 per cent and the overall mortality rate was 79 per cent. VSs were significantly more aggressive (89 per cent) in the management of ruptured AAA (i.e. more likely to operate) than NVSs (36 per cent) (P < 0·0001). Despite this, the operative mortality rate for VSs was 61 per cent, whereas for NVSs it was 69 per cent (P = 0·372). The overall mortality rate (including operated and non-operated patients) for NVSs (89 per cent) was significantly higher than that for VSs (65 per cent) (P < 0·0001). In Conclusion, ruptured AAA is common in Wales and associated with a high mortality rate even when managed by VSs. © 1999 British Journal of Surgery Society Ltd


Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit

January 1998

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13 Reads

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219 Citations

BJS (British Journal of Surgery)

To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales. Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period. Of 3520 patients, 3221 (91.5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17.1 per cent). Resection of the primary disease was achieved in 2859 (81.2 per cent) and this was deemed curative in 2070 (58.8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7.6 per cent (21.7 per cent for emergency/urgent and 5.5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4.9 per cent); this was 3.9 per cent after colonic resections and 7.9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent). This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.


Population-based audit of colorectal cancer management in two UK health regions

December 1997

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176 Reads

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208 Citations

BJS (British Journal of Surgery)

Background To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales.Methods Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period.Results Of 3520 patients, 3221 (91·5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17·1 per cent). Resection of the primary disease was achieved in 2859 (81·2 per cent) and this was deemed curative in 2070 (58·8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7·6 per cent (21·7 per cent for emergency/urgent and 5·5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4·9 per cent); this was 3·9 per cent after colonic resections and 7·9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent).Conclusion This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.


Table 1 . Duration and frequency of outpatient follow-up after surgery 
Surgeons' follow-up practice after resection of colorectal cancer

May 1997

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62 Reads

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37 Citations

Annals of The Royal College of Surgeons of England

Consultant surgeons in two United Kingdom Health Regions were invited to complete a questionnaire on details of their personal management of patients with colon and rectal cancer, with particular emphasis on follow-up. Replies from 140 (94%) were analysed by the surgeon's subspecialty of colorectal and gastrointestinal surgery (group 1) and all others (group 2). There was a wide variation in the duration of followup, but no difference between the two groups. More group 1 surgeons carried out investigations as a routine after colonic (P < 0.01) and rectal (P < 0.01) resection. Colonoscopy was used more frequently by group 1 (P < 0.0001) and barium enema by group 2 surgeons (P < 0.05). Investigations to detect asymptomatic metastases were used as a routine by 33.3% of surgeons, in whom there was no concordance over the choice or combination of tests and no difference between the two groups of surgeons. There is no consensus among surgeons as to the ideal duration, intensity and method of follow-up after resection for colorectal cancer and little difference between the practice of colorectal and gastrointestinal surgeons and that of other specialists, except in the use of colonoscopy and barium enema. These results reflect the continuing lack of evidence on which to base the follow-up of patients after surgery for colorectal cancer.


Table 2 Minimum criteria for an adequate report 
Table 3 shows the percentage of reports con- 
Colorectal cancer pathology reporting: A regional audit

March 1997

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178 Reads

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109 Citations

Journal of Clinical Pathology

To audit the information content of pathology reports of colorectal cancer specimens in one National Health Service region. All reports of colorectal cancer resection specimens from the 17 NHS histopathology laboratories in Wales during 1993 were evaluated against: (a) standards previously agreed as desirable by pathologists in Wales; and (b) standards considered to be the minimum required for informed patient management. 1242 reports were audited. There was notable variation in the performance of different laboratories and in the completeness of reporting of individual items of information. While many items were generally well reported, only 51.5% (640/ 1242) of rectal cancer reports contained a statement on the completeness of excision at the circumferential resection margin and only 30% (373/1242) of all reports stated the number of involved lymph nodes. All of the previously agreed items were contained in only 11.3% (140/1242) of reports on colonic tumours and 4.0% (40/1242) of reports on rectal tumours. Seventy eight per cent (969/1242) of colonic carcinoma reports and 46.6% (579/ 1242) of rectal carcinoma reports met the minimum standards. The informational content of many routine pathology reports on colorectal cancer resection specimens is inadequate for quality patient management, for ensuring a clinically effective cancer service through audit, and for cancer registration. Template proforma reporting using nationally agreed standards is recommended as a remedy for this, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management teams.


Citations (10)


... It can be classified anatomically as supra-renal, juxta-renal or infrarenal in relation to the renal arteries, with infra-renal AAA being the most common. Rupture of a AAA is associated with a mortality rate of between 65% and 85% resulting in up to 8,000 deaths annually in the UK with approximately half of the deaths attributed to rupture occurring before the patient reaches hospital (Basnyat et al., 1999;Ashton et al., 2002). ...

Reference:

Cardiorespiratory fitness is impaired and predicts mid-term postoperative survival in patients with abdominal aortic aneurysm disease
Deaths from ruptured abdominal aortic aneurysm in Wales (vol 86, pg 693, 1999)
  • Citing Article
  • July 1999

BJS (British Journal of Surgery)

... Synchronous liver metastases (LM) occur in approximately 20% of patients, while nearly 50% will develop them during the course of their illness. 2 Surgical resection is considered the most effective treatment option for LM, but only a subset of patients are candidates for resection, depending on factors such as tumor size, number, location, and liver function. Neoadjuvant chemotherapy (CT) significantly improves the prognosis of resectable cases and can make initially unresectable lesions amenable to surgery. 3 The pathological response of LM to neoadjuvant therapy is a crucial prognostic factor for recurrence and survival. ...

Population-based audit of colorectal cancer management in two UK health regions
  • Citing Article
  • December 1997

BJS (British Journal of Surgery)

... During early 2000s, the underestimation of incidence rates of pathology-based cancer registration led to the the completeness of pathology reports. Ambiguity and incomplete reporting of pathology findings may adversely affect the clinical outcomes (12). ...

Colorectal cancer pathology reporting: A regional audit

Journal of Clinical Pathology

... However, there is still an ongoing debate on the appropriate management of recurrent CRC patients. Although there is an opinion supporting aggressive management of these patients to improve the outcome, another strategy is the intensive follow-up of the patients [3,8]. Thus, establishing the role of FDG PET-CT in predicting survival outcomes of recurrent CRC patients can help to clarify the most efficient management protocol. ...

Surgeons' follow-up practice after resection of colorectal cancer

Annals of The Royal College of Surgeons of England

... Almost all of the emergency admissions for CRC patients during the observation periods were due to a bowel obstruction which required decompression procedures. The reported incidence of obstructive CRCs requiring decompression procedures is 10%-20% [19,20], which is compatible with the incidence of CRCs with complete obstruction before the state of emergency in our present investigation. However, we observed that the incidence of obstructive CRCs requiring decompression significantly increased to 39% during the COVID-19 pandemic. ...

Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit
  • Citing Article
  • January 1998

BJS (British Journal of Surgery)

... Fixed risk factors include advancing age, with risk increasing by 40% every 5 years after the age of 65 years, being male (male to female ratio, 6:1) and having a positive family history, notably first degree male family members. Modifiable risk factors include smoking, hypertension and hypercholesterolaemia (Basnyat et al. 1999). Approximately 2–20% of AAAs are classified as juxtarenal (JR) if their proximal extent is close to the origin of the renal arteries but does not involve them (Crawford et al. 1986). ...

Deaths from ruptured abdominal aortic aneurysm in Wales
  • Citing Article
  • May 1999

BJS (British Journal of Surgery)

... Despite being typically asymptomatic, AAA is prone to rupture, 1 leading to devastating consequences with a mortality rate of nearly 80%. 2,3 The risk of AAA is associated with hypertension, atherosclerosis, smoking, and family history. [4][5][6] Given the stealthy nature of AAA symptoms and the lifethreatening complications associated with it, there is an urgent need for early prevention strategies focusing on modifiable risk factors. ...

Mortality from ruptured aortic aneurysm in Wales
  • Citing Article
  • June 1999

BJS (British Journal of Surgery)

... In addition to oncologists, other clinical staff such as surgeons and general physicians may need to interpret cancer pathology reports; these reports should therefore be readily comprehensible. 7 According to the 7 th edition of the TNM Staging Classification for carcinoma of the stomach, at least 15 LNs must be surgically resected and evaluated by a pathologist. Unfortunately only two reports (3.5%) in our study had sufficient LNs. ...

Oesophageal and gastric cancer pathology reporting: A regional audit

Journal of Clinical Pathology

... Therefore, it may indeed be reasonable to assign greater priority to the anonymity of ratings, as is currently the case in the " Connect " community. The fact that certain individuals did not hesitate to exert pressures on editors to disclose the identity of raters who negatively rated their contributions [41] lends additional support to the stated conclusion. ...

CORRESPONDENCE: Authors' reply
  • Citing Article
  • August 2000

BJS (British Journal of Surgery)