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Thomas GP, Wong F, Vaizey CJ, Warusavitarne JH. Laparoscopic modified mesh rectopexy: medium-term results of a novel approach for external rectal prolapse. Colorectal Dis 2023; 25:2378-2382. [PMID: 37907714 DOI: 10.1111/codi.16804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/23/2023] [Accepted: 09/17/2023] [Indexed: 11/02/2023]
Abstract
AIM Rectal prolapse is a common and significantly debilitating condition. Surgical correction is usually required. The two most common abdominal approaches are ventral mesh rectopexy and posterior suture rectopexy. Both may be complicated, respectively, by either mesh-related complications or significant postoperative constipation. We report the outcome of a novel rectopexy operation which combines aspects of both the aforementioned approaches, for the treatment of external rectal prolapse (ERP). METHOD The technique involves laparoscopic partial posterior-lateral rectal mobilization of the rectum with posterior suture fixation to the sacral promontory and placement of an absorbable mesh in the rectovaginal space. Data were collected on postoperative complications, prolapse recurrence, mesh-related complications and the assessment of quality of life. RESULTS Eighty patients underwent a modified mesh rectopexy for ERP. Seventy-seven were women. The median age was 67.5 years. Almost a third had undergone a previous rectal prolapse repair. Recurrences were seen in 11 (13.8%). No mesh-related complications were seen. Eleven patients reported postoperative constipation. CONCLUSION The laparoscopic modified mesh rectopexy may be a safe and effective operation for the treatment of ERP.
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Affiliation(s)
- G P Thomas
- Sir Alan Parks Department of Physiology, St Mark's Hospital, London, UK
| | - F Wong
- Sir Alan Parks Department of Physiology, St Mark's Hospital, London, UK
| | - C J Vaizey
- Sir Alan Parks Department of Physiology, St Mark's Hospital, London, UK
| | - J H Warusavitarne
- Sir Alan Parks Department of Physiology, St Mark's Hospital, London, UK
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Thomas GP, Saunders BP, Vaizey CJ. Is there an increased risk of missing a colon cancer after a permanent ileostomy for constipation? Colorectal Dis 2023; 25:2103-2104. [PMID: 37632132 DOI: 10.1111/codi.16723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Gregory P Thomas
- The Sir Alan Parks Department of Physiology, St Marks Hospital, London, UK
| | | | - Carolynne J Vaizey
- The Sir Alan Parks Department of Physiology, St Marks Hospital, London, UK
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Thomas GP, Dudding TC, Vaizey CJ. Are rectal prolapse repairs too diverse and complex for simple database analysis? Colorectal Dis 2023; 25:835-836. [PMID: 37254695 DOI: 10.1111/codi.16627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/25/2023] [Indexed: 06/01/2023]
Affiliation(s)
- G P Thomas
- The Sir Alan Parks Department of Physiology, St Mark's Hospital, The National Bowel Hospital, London North West University Healthcare NHS Trust, London, UK
| | - T C Dudding
- Department of Gastrointestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - C J Vaizey
- The Sir Alan Parks Department of Physiology, St Mark's Hospital, The National Bowel Hospital, London North West University Healthcare NHS Trust, London, UK
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Kurt S, Caron B, Gouynou C, Netter P, Vaizey CJ, Wexner SD, Danese S, Baumann C, Peyrin-Biroulet L. Faecal incontinence in inflammatory bowel disease: The Nancy experience. Dig Liver Dis 2022; 54:1195-1201. [PMID: 35123908 DOI: 10.1016/j.dld.2022.01.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Faecal incontinence (FI) is a disabling condition in patients with inflammatory bowel disease (IBD). The diagnosis of FI is not easy as patients are reluctant to report this embarrassing symptom. The objectives of this study were to characterize the prevalence of FI in IBD patients using available scoring systems, and to identify associated risk factors. METHODS A FI clinic was implemented in routine practice between January 2020 and April 2021. FI was defined as a Wexner score ≥5. Factors associated with FI were analyzed. RESULTS A total of 319 consecutive patients with IBD were included. The prevalence of FI was 16.4% (53/319). Age >45 years at inclusion (Odd ratio (OR)=3.33, Confidence interval (CI) 95% 1.40-7.94), diarrhea (three stools at least per day) (OR=2.94, CI 95% 1.16-7.45), stool consistency according to the Bristol stool chart (OR=2.23, CI 95% 1.00-4.99), and abdominal pain (OR=2.24, CI 95% 1.10-4.53) were independently associated with FI in a multivariate model analysis. CONCLUSIONS Approximately one fifth of IBD patients reported FI in this real-world cohort, using an available scoring system. Increased age, diarrhea, stool consistency according to the Bristol stool chart, and abdominal pain were associated with FI. A systematic screening of FI would allow a better management of this disabling condition.
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Affiliation(s)
- Simon Kurt
- Nancy University Hospital, Department of Gastroenterology, F-54000 Nancy, France
| | - Bénédicte Caron
- Nancy University Hospital, Department of Gastroenterology, F-54000 Nancy, France; Nancy University Hospital, DRCI, F-54000 Nancy, France
| | - Celia Gouynou
- Nancy University Hospital, Department of Gastroenterology, F-54000 Nancy, France
| | - Patrick Netter
- Ingénierie Moléculaire et Ingénierie Articulaire (IMoPA), UMR-7365 CNRS, Faculté de Médecine, University of Lorraine and University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Carolynne J Vaizey
- Ingénierie Moléculaire et Ingénierie Articulaire (IMoPA), UMR-7365 CNRS, Faculté de Médecine, University of Lorraine and University Hospital of Nancy, Vandoeuvre-lès-Nancy, France; Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, United States
| | - Silvio Danese
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, United States; Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele Milano Italy
| | - Cédric Baumann
- Unit of methodology, data management and statistic, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | - Laurent Peyrin-Biroulet
- Nancy University Hospital, Department of Gastroenterology, F-54000 Nancy, France; University of Lorraine, Inserm, NGERE, F-54000 Nancy, France.
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Williams KJ, Donnelly S, Gabe S, Gupta A, Holman R, Preston S, Vaizey CJ, Corr A, Mehta AM. Standardized documentation and synoptic reporting of complex intestinal anatomy in enteric fistulation and intestinal failure. Colorectal Dis 2022; 24:530-534. [PMID: 34860451 DOI: 10.1111/codi.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/06/2022]
Abstract
AIM In intestinal failure, delineation of both structure and function are key to controlling symptoms and planning further intervention. We have developed a template for developing an 'anatomy at a glance' patient-specific map to aid decision making and counselling. METHOD A core dataset was developed and used to create an editable template to demonstrate the gastrointestinal tract, its relationship to the genitourinary tract, and specific anterior abdominal wall features. This was then used to create an anatomical template, specific to each patient, and stored in the electronic patient record and imaging archive. RESULTS We have developed a technique for integration of multi-modal information into one diagram, easily referenced by the multidisciplinary team. Radiology, endoscopy and previous operation notes can be used to fill out a core dataset, which is then transposed into a standardized template. A worked example is shown. CONCLUSION The mapping template has been successfully integrated into practice and aided decision making at all stages of the patient's therapeutic journey. It has been found helpful in planning routes of nutrition, preoperative optimization, surgical planning, interpreting postoperative imaging and managing patient expectations.
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Affiliation(s)
- Katherine J Williams
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Suzanne Donnelly
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Simon Gabe
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Arun Gupta
- Department of Gastrointestinal Imaging, St Mark's Hospital, London, UK
| | - Richard Holman
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Stephen Preston
- Multimedia and Audiovisual Services, St Mark's Academic Institute, London, UK
| | - Carolynne J Vaizey
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Alison Corr
- Department of Gastrointestinal Imaging, St Mark's Hospital, London, UK
| | - Akash M Mehta
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
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Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, Carrington EV, Chiarioni G, Ebben LDA, Gladman MA, Maeda Y, Melenhorst J, Milito G, Muris JWM, Orhalmi J, Pohl D, Tillotson Y, Rydningen M, Svagzdys S, Vaizey CJ, Breukink SO. Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J 2022; 10:251-286. [PMID: 35303758 PMCID: PMC9004250 DOI: 10.1002/ueg2.12213] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI. METHODS These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus. RESULTS These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients. CONCLUSION These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.
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Affiliation(s)
- Sadé L. Assmann
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | - Foteini Anastasiou
- 4rth TOMY – Academic Primary Care Unit Clinic of Social and Family MedicineUniversity of CreteHeraklionGreece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist NurseRoyal Free HospitalLondonEnglandUK
| | | | - Emma V. Carrington
- Surgical Professorial UnitDepartment of Colorectal SurgerySt Vincent's University HospitalDublinIreland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of VeronaAOUI VeronaVeronaItaly
- Center for Functional GI and Motility DisordersUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Marc A. Gladman
- The University of AdelaideAdelaide Medical SchoolFaculty of Health & Medical SciencesAdelaideAustralia
| | - Yasuko Maeda
- Department of Surgery and Colorectal SurgeryWestern General HospitalEdinburghUK
| | - Jarno Melenhorst
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | | | - Jean W. M. Muris
- Department of General PracticeCare and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | | | - Daniel Pohl
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
- Department of Gastrointestinal SurgeryUniversity Hospital of North NorwayTromsøNorway
| | | | - Mona Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor HealthTromsøNorway
| | - Saulius Svagzdys
- Medical AcademyLithuanian University of Health SciencesClinic of Surgery Hospital of Lithuanian University of Health Sciences Kauno KlinikosKaunasLithuania
| | | | - Stephanie O. Breukink
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
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7
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Maeda Y, Espin-Basany E, Gorissen K, Kim M, Lehur PA, Lundby L, Negoi I, Norcic G, O'Connell PR, Rautio T, van Geluwe B, van Ramshorst GH, Warwick A, Vaizey CJ. European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery. Colorectal Dis 2021; 23:2228-2285. [PMID: 34060715 DOI: 10.1111/codi.15718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/31/2022]
Abstract
This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.
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Affiliation(s)
- Yasuko Maeda
- Cumberland Infirmary and University of Edinburgh, Carlisle, UK
| | | | | | - Mia Kim
- Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Lilli Lundby
- Department of Surgery Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ionut Negoi
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregor Norcic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - P Ronan O'Connell
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Tero Rautio
- Medical Research Center, University of Oulu, Oulu, Finland
| | | | | | - Andrea Warwick
- QEII Jubilee Hospital, Acacia Ridge, Queensland, Australia
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Creamer F, Orlando A, Brunner M, Buntzen S, Dennis A, Gómez-Fernández L, Handtrack C, Hanly A, Matzel KE, Duyos AM, Meurette G, O'Connell PR, Alonso CP, Ribas Y, Rydningen M, Wyart V, Vaizey CJ, Maeda Y. A European snapshot of psychosocial characteristics and patients' perspectives of faecal incontinence-do they correlate with current scoring systems? Int J Colorectal Dis 2021; 36:1175-1180. [PMID: 33438108 DOI: 10.1007/s00384-021-03836-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the current clinical scoring systems used to quantify the severity of symptoms of faecal incontinence (FI) to patients' subjective scoring of parameters of psychosocial well-being. METHODS Patients referred to six European centres for investigation or treatment of symptoms of FI between June 2017 and September 2019 completed a questionnaire that captured patient demographics, incontinence symptoms using St. Mark's Incontinence score (SMIS) and ICIQ-B, psychological well-being (HADS, Hospital Anxiety and Depression Scale), and social interaction (a three-item loneliness scale). RESULTS Three hundred eighteen patients completed questionnaires (62 men, mean age 58.7). Sixty percent of the respondents were aged under 65. Median SMIS was 15 (11-18), ICIQ-B bowel pattern was 8 (6-11) and bowel control was 17 (13-22), similar across all demographic groups; however, younger patients were more likely to experience symptoms of depression and anxiety (HADS score > 10, 65.2% of patients age < 65 vs 54.9% of those ages > = 65, p = 0.03) with lower quality of life (ICIQ-B QoL, median score 19 (14-23)) vs age > = 65 (16 (11-21) (p < 0.005)). On loneliness score 25.5% reported often feeling isolated from others. One of the most significant concerns by patients was the fear and embarrassment related to unpredictable episodes of incontinence. CONCLUSION The SMIS remains a useful tool for quantifying incontinence symptoms but may underestimate the psychosocial morbidity associated with unpredictable episodes of incontinence. Interventions aimed at decreasing anxiety and to address feelings of disgust may be helpful for a significant number of patients requiring treatment for FI.
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Affiliation(s)
- Felicity Creamer
- Department of Colorectal Surgery, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK
| | | | | | - Steen Buntzen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway
| | | | | | | | - Ann Hanly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Klaus E Matzel
- Department of Surgery, University of Erlangen, Erlangen, Germany
| | | | - Guillaume Meurette
- Department of Colorectal Surgery, Nantes University Hospital, Nantes, France
| | - P Ronan O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | | | - Yolanda Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Terrassa (Barcelona), Spain
| | - Mona Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Vincent Wyart
- Department of Colorectal Surgery, Nantes University Hospital, Nantes, France
| | | | - Yasuko Maeda
- Department of Colorectal Surgery, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
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9
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Dilke SM, Durant LR, Stentz R, Wilson A, Tozer PJ, Vaizey CJ, Hoyles L, Carding S, Knight SC, Noble A. O8: DIRECT MANIPULATION OF THE INTESTINAL MICROBIOME TO INFLUENCE POST-OPERATIVE OUTCOMES. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Distal feeding (DF) involves intubation of the distal limb of a loop ileostomy to feed with a prebiotic mix. Studies suggest that distally feeding patients following anterior resection prior to ileostomy closure may be beneficial as a form of bowel pre-habilitation. These pilot data examine the adaptive immune response to DF.
Method
Ten healthy controls with an intact GI tract were compared with 10 patients following rectal cancer resection and chemo/radiotherapy, prior to closure of ileostomy over 8 weeks of DF. We examined B and T cell memory responses from peripheral blood using cell proliferation assays. Cells were cultured with dead antigen to reflect the microbiota in the small and large bowel. Two negative and two positive controls were used to assess minimal and maximum cell proliferation.
Result
B cell responses prior to DF were increased in the defunctioned group compared to the normal controls to significance (p=0.0014). After 8 weeks of DF the groups were comparable. T cell responses to bacteria had significant differences in proliferation rate following DF commencement, CD4 week 0 vs 3 p=0.0001, week 3 vs 8 p=0.000034, CD8 week 0 vs 3 p=0.0001, week 3-8 p=0.00024). In individual patients, CD4 responses were shown to shift from responses to facultative aerobic species, to strict anaerobes.
Conclusion
These data suggest that distal feeding fundamentally resets peripheral circulating memory and it may be of use in pre-habilitating the bowel prior to restoration of continuity. Early clinical data suggests that distal feeding improves post-operative outcomes.
Take-home message
distal feeding is an easy pre-operative intervention that has a significant effect on cell proliferation and antigen response, which may contribute to improved post operative outcomes.
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Affiliation(s)
- SM Dilke
- St Mark's Hospital
- Antigen Presenting Group, Imperial College London
| | - LR Durant
- Antigen Presenting Group, Imperial College London
| | | | | | | | | | | | | | - SC Knight
- Antigen Presenting Group, Imperial College London
| | - A Noble
- Antigen Presenting Group, Imperial College London
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Leo CA, Thomas GP, Hodgkinson JD, Leeuwenburgh M, Bradshaw E, Warusavitarne J, Murphy J, Vaizey CJ. Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence. Dis Colon Rectum 2021; 64:466-474. [PMID: 33399411 DOI: 10.1097/dcr.0000000000001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed. OBJECTIVE We aimed to compare anal inserts and percutaneous tibial nerve stimulation. DESIGN This was an investigator-blinded randomized pilot study. SETTINGS The study was conducted at a large tertiary care hospital. PATIENTS Adult patients with passive or mixed fecal incontinence were recruited. INTERVENTIONS Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months. MAIN OUTCOME MEASURES The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability. RESULTS Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group. LIMITATIONS A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation. CONCLUSIONS Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460. TRIAL REGISTRATION NUMBER Clinicaltrials.gov No. NCT04273009. ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.
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Affiliation(s)
- Cosimo Alex Leo
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Surgery, The Royal London Hospital, London, United Kingdom
| | - Gregory P Thomas
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Jonathan D Hodgkinson
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Marjolein Leeuwenburgh
- Department of Surgery, The Royal London Hospital, London, United Kingdom
- Department of Surgery, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Ellie Bradshaw
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Janindra Warusavitarne
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Jamie Murphy
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Carolynne J Vaizey
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
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11
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Hodgkinson JD, Worley G, Warusavitarne J, Hanna GB, Vaizey CJ, Faiz OD. Evaluation of the Ventral Hernia Working Group classification for long-term outcome using English Hospital Episode Statistics: a population study. Hernia 2021; 25:977-984. [PMID: 33712933 PMCID: PMC8370963 DOI: 10.1007/s10029-021-02379-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/14/2021] [Indexed: 11/30/2022]
Abstract
Purpose The Ventral Hernia Working Group (VHWG) classification of ventral/incisional hernia (IH) was developed by expert consensus in 2010. Subsequently, Kanters et al. have demonstrated the validity of a modified version of the system for predicting short-term outcomes. This study aims to evaluate the modified system for predicting hernia recurrence. Methods Patients undergoing IH surgery (defined by OPCS codes) in the England Hospital Episode Statistics (HES) database, from 1997 to 2012, were identified. Baseline demographics at index hernia operation and episodes of further hernia surgery (FHS) were recorded. Risk factors for FHS were identified using cox regression and evaluated against the modified-VHWG grade using receiver-operating characteristics (ROC). Results The final analysis included 214,082 index IH operations. Of these, 52.6% were female and mean age was 56.59 (SD15.9). An admission for FHS was found in 8.3% cases (17,714 patients). Multi-variate cox regression revealed contaminated hernia (p < 0.0001), pre-existing IBD (p < 0.0001) and hernia comorbidity (p = 0.05) to be significantly related to long-term FHS. Classifying patients using these factors, according to the modified-VHWG classification, revealed that compared to Grade 1, the hazard ratio (HR) of FHS increased in Grade 2 (HR 1.19; p < 0.0001) and further increased in Grade 3 (HR 1.79; p < 0.0001). ROC analysis revealed the area under the curve to be 0.73 (95% CI 0.73–0.74). Conclusion This analysis demonstrates the broad validity of the modified-VHWG classification in discriminating risk for FHS. Inclusion of pre-existing IBD as a factor defining Grade 2 patients would be recommended. This analysis is limited by the absence of certain factors within the HES database, such as BMI.
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Affiliation(s)
- J D Hodgkinson
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Watford Road, Harrow, London, HA1 3UJ, UK. .,Department of Surgery and Cancer, Imperial College London, London, UK.
| | - G Worley
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Watford Road, Harrow, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Watford Road, Harrow, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - C J Vaizey
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Watford Road, Harrow, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - O D Faiz
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Watford Road, Harrow, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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12
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Ong K, Bordeianou L, Brunner M, Buntzen S, Collie MHS, Hanly A, Hunt CW, Matzel KE, O'Connell PR, Rydningen M, Savitt L, Totaro A, Vaizey CJ, Maeda Y. Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres. Colorectal Dis 2021; 23:710-715. [PMID: 32894636 DOI: 10.1111/codi.15349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013. METHOD This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded. RESULTS A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05). CONCLUSION The paradigm of surgical intervention for FI has changed with increasing use of SNM.
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Affiliation(s)
- K Ong
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - L Bordeianou
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brunner
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - S Buntzen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - M H S Collie
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - A Hanly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - C W Hunt
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - K E Matzel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - P R O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - M Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - L Savitt
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - A Totaro
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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13
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Zafar N, Kashora F, Qurashi K, Al-Musawi J, Watfah J, Liasis L, Sen M, Gould S, J Vaizey C, Warusavitarne J, Leo CA. Mitigating surgical emergency practice during COVID-19 pandemic? Ann Ital Chir 2021; 92:312-316. [PMID: 34193649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE To define the change in Emergency Surgical Unit (ESU) workload during the COVID-19 pandemic. METHODS Patient data for a three-week period was prospectively collected for ESU patients during lockdown period and compared to the ESU workload for the same time period prior to lockdown. RESULTS Surgical emergencies admissions reduced by 2.5 times during our study period (p value = 0.001). In this changed paradigm, the overall number of surgical emergencies were reduced. A high mortality (n = 4, 5.7%) was noted during lockdown period as compared to pre-lockdown period (n = 1, 0.58%, p value = 0.025). Almost half of surgical admissions were tested for COVID-19 based on their symptoms and more than third (n=14, 38.9%) of them were positive. Gastrointestinal symptoms were common in COVID-19 positive group (85.7%) and only a third (36%) of COVID-19 positive patients needed surgical attention. Chest x-ray findings were comparable to PCR testing in terms of sensitivity and specificity but CT chest was more sensitive. CONCLUSIONS It remains unclear how COVID-19 reduced surgical emergencies. A significant proportion of COVID-19 presented with gastrointestinal symptoms. In a new outbreak all General Surgical patients should be tested with CRP and WCC used as a triage adjunct. KEY WORDS Coronavirus, COVID-19, Emergency Surgery Pandemic, General Surgery.
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14
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Leo CA, Leeuwenburgh M, Orlando A, Corr A, Scott SM, Murphy J, Knowles CH, Vaizey CJ, Giordano P. Initial experience with SphinKeeper™ intersphincteric implants for faecal incontinence in the UK: a two-centre retrospective clinical audit. Colorectal Dis 2020; 22:2161-2169. [PMID: 32686233 DOI: 10.1111/codi.15277] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
AIM The SphinKeeper™ artificial bowel sphincter implant is a relatively new surgical technique for the treatment of refractory faecal incontinence. This study presents the first experience in two UK tertiary centres. METHOD This is a retrospective audit of prospectively collected clinical data in relation to technique, safety, feasibility and short-term effectiveness from patients undergoing surgery from January 2016 to April 2019. Baseline data, intra-operative and postoperative complications, symptoms [using St Mark's incontinence score (SMIS)] and radiological outcomes were analysed. RESULTS Twenty-seven patients [18 women, median age 57 years (range 27-87)] underwent SphinKeeper. In 30% of the patients, the firing device jammed and not all prostheses were delivered. There were no intra-operative complications and all patients were discharged the same or the following day. SMIS significantly improved from baseline [median -6 points (range -12 to +3); P < 0.00016] with 14/27 (51.9%) patients achieving a 50% reduction in the SMIS score. On postoperative imaging, a median of seven prostheses (range 0-10) were identified with a median of five (range 0-10) optimally placed. There was no relationship between number of well-sited prostheses on postoperative imaging and categorical success based on 50% reduction in SMIS (χ2 test, P = 0.79). CONCLUSION SphinKeeper appears to be a safe procedure for faecal incontinence. Overall, about 50% patients achieved a meaningful improvement in symptoms. However, clinical benefit was unrelated to the rate of misplaced/migrated implants. This has implications for confidence in proof of mechanism and also the need for technical refinement.
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Affiliation(s)
- C A Leo
- Imperial College London, London, UK.,Sir Alan Park's Physiology Unit, St Mark's Hospital Academic Institute, Harrow, UK
| | | | - A Orlando
- Imperial College London, London, UK.,Sir Alan Park's Physiology Unit, St Mark's Hospital Academic Institute, Harrow, UK
| | - A Corr
- Sir Alan Park's Physiology Unit, St Mark's Hospital Academic Institute, Harrow, UK
| | - S M Scott
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Royal London Hospital, London, UK
| | - J Murphy
- Imperial College London, London, UK
| | - C H Knowles
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Royal London Hospital, London, UK
| | - C J Vaizey
- Sir Alan Park's Physiology Unit, St Mark's Hospital Academic Institute, Harrow, UK
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15
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Leo CA, Thomas GP, Bradshaw E, Karki S, Hodgkinson JD, Murphy J, Vaizey CJ. Long-term outcome of sacral nerve stimulation for faecal incontinence. Colorectal Dis 2020; 22:2191-2198. [PMID: 32954658 DOI: 10.1111/codi.15369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/06/2020] [Indexed: 12/11/2022]
Abstract
AIM Sacral nerve stimulation (SNS) is a minimally invasive treatment for faecal incontinence (FI). We report our experience of patients who have undergone SNS for FI with a minimum of 5 years' follow-up. This is a single centre prospective observational study with the aim to assess the long-term function of SNS. METHOD All patients implanted with SNS were identified from our prospective database. The date of implantation, first and last clinic follow-up, surgical complications and St Mark's incontinence scores were abstracted and analysed. RESULTS From 1996 to 2014, 381 patients were considered for SNS. Of these, 256 patients met the study inclusion criteria. Median age at implantation was 52 years (range 18-81). The ratio of women to men was 205:51. Indications were urge FI (25%), passive FI (17.9%) and mixed FI (57%). The median of the incontinence score at baseline was 19/24 and this improved to 7/24 at the 6-month follow-up. Of the total cohort, 235 patients received a medium-term follow-up (median 110 months, range 12-270) with a median continence score of 10/24 which was also confirmed at the telephone long-term follow-up on 185 patients (132 months, range 60-276). CONCLUSION This study demonstrates that SNS is an effective treatment in the long term. SNS results in an improvement of validated scores for approximately 60% of patients; however, there is a significant reduction of efficacy over time due to underlying causes.
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Affiliation(s)
- C A Leo
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Northwest London University NHS Trust, Harrow, UK.,Imperial College London, London, UK.,Northwick Park Hospital, London North West NHS Trust, Harrow, UK
| | - G P Thomas
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Northwest London University NHS Trust, Harrow, UK
| | - E Bradshaw
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Northwest London University NHS Trust, Harrow, UK
| | - S Karki
- Northwick Park Hospital, London North West NHS Trust, Harrow, UK
| | - J D Hodgkinson
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Northwest London University NHS Trust, Harrow, UK.,Imperial College London, London, UK
| | - J Murphy
- Imperial College London, London, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Northwest London University NHS Trust, Harrow, UK.,Imperial College London, London, UK
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16
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Dilke SM, Gould L, Yao M, Souvatzi M, Stearns A, Ignjatovic-Wilson A, Tozer P, Vaizey CJ. Distal feeding-bowel stimulation to treat short-term or long-term pathology: a systematic review. Frontline Gastroenterol 2020; 12:677-682. [PMID: 34917326 PMCID: PMC8640400 DOI: 10.1136/flgastro-2019-101359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/14/2020] [Accepted: 07/19/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Distal feeding (DF) describes the insertion of a feeding tube into a fistula or stoma to administer a liquid feed into the distal bowel. It is currently used clinically in patients who are unable to absorb enough nutrition orally. This systematic review investigates DF as a therapeutic measure across a spectrum of patients with stomas and fistulae. METHODS A total of 2825 abstracts and 44 full-text articles were screened via OVID. Fifteen papers were included for analysis. Randomised controlled trials, cohort and observational studies investigating DF as a therapeutic measure were included. RESULTS Three feeds were used across the studies-reinfusion of effluent, infusion of prebiotic or a mixture. The studies varied the length of feeding between 24 hours and 61 days, and the mode of feeding, bolus or continuous varied.DF was demonstrated to effectively wean patients from parenteral nutrition in two papers. Two papers demonstrated a significant reduction in stoma output. Three papers demonstrated improved postoperative complication rates with distal feeding regimens, including ileus (2.85% vs 20% in unfed population, p=0.024). One paper demonstrated a reduction in postoperative stool frequency. CONCLUSIONS This review was limited by study heterogeneity and the lack of trial data, and in the patient groups involved, the variability in diet and length of regimen. These studies suggest that DF can significantly reduce stoma output and improve renal and liver function; however, the mechanism is not clear. Further mechanistic work on the immunological and microbiological action of DF would be important.
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Affiliation(s)
| | - Laura Gould
- Colorectal Surgery, St Mark’s Academic Institute, Harrow, UK
| | - Mark Yao
- General Surgery, Whittington Hospital, London, London, UK
| | - Maria Souvatzi
- Colorectal Surgery, St Mark’s Academic Institute, Harrow, UK
| | - Adam Stearns
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | | | - Phil Tozer
- Colorectal Surgery, St Mark's Hospital, London, UK
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D'Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Machielsen AJHM, Iqbal N, Kimman ML, Sahnan K, Adegbola SO, Kleijnen J, Vaizey CJ, Grossi U, Tozer PJ, Breukink SO. The development of a cryptoglandular Anal Fistula Core Outcome Set (AFCOS): an international Delphi study protocol. United European Gastroenterol J 2020; 8:220-226. [PMID: 32213065 DOI: 10.1177/2050640620907570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Cryptoglandular anal fistula is a disorder with an incidence of around 1 per 5,000 people per year in European countries. Many studies have been conducted to evaluate the effectiveness of interventions for anal fistula. However, there is considerable heterogeneity in the outcomes assessed and reported in these studies. This limits research quality and complicates evidence synthesis. A solution for heterogeneity in outcome reporting is the development of a Core Outcome Set (COS). This paper describes the protocol for the development of a European COS for Anal Fistula (AFCOS). METHODS The first step will be a systematic review of the literature to identify potential outcomes that may be included in the COS. Patient interviews will be conducted in The United Kingdom and The Netherlands to ensure that both clinician-important and patient-important outcomes are captured. The outcomes will be categorized using the COMET taxonomy and taken forward to a Delphi consensus exercise. In up to three web-based Delphi surveys the outcomes will be prioritized by patients, clinicians (surgeons, gastroenterologists, and radiologists), and (clinical) researchers. The responses will be summarized and reported anonymously in subsequent round(s) facilitating convergence to a consensus opinion. The final COS will be decided during a face-to-face consensus meeting with patients, clinicians, and (clinical) researchers. DISCUSSION This study protocol describes the development of a European COS for anal fistula to improve research quality, evidence synthesis, and patient care.
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Affiliation(s)
- A J H M Machielsen
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centreþ, Maastricht, The Netherlands.,Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - N Iqbal
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - M L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centreþ, Maastricht, The Netherlands
| | - K Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - S O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - J Kleijnen
- Department of Family Practice; Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - C J Vaizey
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - U Grossi
- 4th Surgery Unit, Treviso Hospital, Treviso, Italy; University of Padua, Padua, Italy
| | - P J Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - S O Breukink
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centreþ, Maastricht, The Netherlands
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Speake D, Dvorkin L, Vaizey CJ, Carlson GL. Management of colonic complications of type IV Ehlers-Danlos syndrome: a systematic review and evidence-based management strategy. Colorectal Dis 2020; 22:129-135. [PMID: 31260161 DOI: 10.1111/codi.14749] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022]
Abstract
AIM Type IV Ehlers Danlos Syndrome (EDS) is a connective tissue disorder affecting approximately 1 per 100,000-200,000 people. Life expectancy is reduced secondary to spontaneous vascular rupture or colonic perforation. Surgery carries significant morbidity and mortality. While strategies to manage colonic perforation include primary repair with or without a defunctioning stoma, Hartmann's procedure, total abdominal colectomy with end ileostomy and ileorectal anastomosis, evidence is contradictory and has not previously been evaluated in order to form a treatment strategy. We aim to review the published literature and identify outcome data relating to operative management of colonic perforation in type IV EDS. METHODS Pubmed, EM-BASE, Cochrane library and Google Scholar were searched with the following details: Ehlers Danlos Syndrome AND colonic surgery. The main outcome measure was re-perforation rates following colonic surgery on patients with type IV EDS. If the nature of surgery and follow up were reported, data were recorded in a SPSS database according to PRISMA guidelines. RESULTS One hundred and nine operations have been described in 51 patients in 44 case series. There were 26 visceral re-perforations, 2 affecting the small intestine and 24 colonic. Survival analysis favoured total abdominal colectomy compared with operations where the colon was left in situ. CONCLUSIONS Total abdominal colectomy with end ileostomy or ileorectal anastomosis are the safest strategies after colonic perforation in type IV EDS. Anastomotic leak rates are high. End colostomy is high risk for colonic re-perforation and anastomotic leak rates are extremely high. Restoration of colonic continuity should be avoided.
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Affiliation(s)
- D Speake
- Department of Colorectal Surgery, The Western General Hospital, Edinburgh, UK
| | - L Dvorkin
- North Middlesex University Hospital, London, UK
| | - C J Vaizey
- Departments of Surgery and National Intestinal Failure Centre, St Marks Hospital, Harrow, Middlesex, UK
| | - G L Carlson
- Departments of Surgery and National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, Salford, UK
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Carrington EV, Heinrich H, Knowles CH, Fox M, Rao S, Altomare DF, Bharucha AE, Burgell R, Chey WD, Chiarioni G, Dinning P, Emmanuel A, Farouk R, Felt‐Bersma RJF, Jung KW, Lembo A, Malcolm A, Mittal RK, Mion F, Myung S, O’Connell PR, Pehl C, Remes‐Troche JM, Reveille RM, Vaizey CJ, Vitton V, Whitehead WE, Wong RK, Scott SM. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil 2020; 32:e13679. [PMID: 31407463 PMCID: PMC6923590 DOI: 10.1111/nmo.13679] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. METHODS Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018. KEY RECOMMENDATIONS The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia. CONCLUSIONS AND INFERENCES This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.
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Affiliation(s)
| | | | | | - Mark Fox
- University of ZürichZürichSwitzerland
| | - Satish Rao
- Medical College of GeorgiaAugustaGeorgiaUSA
| | | | | | - Rebecca Burgell
- Monash University and Alfred HealthMelbourneVictoriaAustralia
| | | | | | | | | | - Ridzuan Farouk
- National University Hospital SingaporeSingapore CitySingapore
| | | | | | | | - Allison Malcolm
- University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | | | - Franҫois Mion
- Université de Lyon et Hospices Civils de LyonLyonFrance
| | | | | | - Christian Pehl
- Krankenhaus Vilsbiburg and Technical University MunichMunichGermany
| | | | | | | | | | | | - Reuben K. Wong
- National University Hospital SingaporeSingapore CitySingapore
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21
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Hodgkinson JD, Oke SM, Warusavitarne J, Hanna GB, Gabe SM, Vaizey CJ. Incisional hernia and enterocutaneous fistula in patients with chronic intestinal failure: prevalence and risk factors in a cohort of patients referred to a tertiary centre. Colorectal Dis 2019; 21:1288-1295. [PMID: 31218774 DOI: 10.1111/codi.14735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 04/08/2019] [Indexed: 12/14/2022]
Abstract
AIM This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development. METHOD A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression. RESULTS The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02). CONCLUSION In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.
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Affiliation(s)
- J D Hodgkinson
- St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - S M Oke
- St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - J Warusavitarne
- St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S M Gabe
- St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - C J Vaizey
- St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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22
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Leo CA, Thomas GP, Hodgkinson JD, Segal JP, Maeda Y, Murphy J, Vaizey CJ. The Renew® anal insert for passive faecal incontinence: a retrospective audit of our use of a novel device. Colorectal Dis 2019; 21:684-688. [PMID: 30770633 DOI: 10.1111/codi.14587] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/21/2019] [Indexed: 12/14/2022]
Abstract
AIM The Renew® anal insert is a recent treatment for patients who suffer from passive faecal incontinence (FI). Our aim was to assess the effectiveness of the insert and patients' satisfaction with it. METHOD A retrospective audit of patients who were treated with the Renew® anal insert was undertaken. The St Mark's Incontinence Score was used to evaluate clinical outcome. Renew® size, the number of inserts used per day and per week had also been recorded. Subjective assessment of symptoms, how beneficial Renew® was and how satisfied patients were with the device were all recorded. Major events and side effects were also noted. RESULTS Thirty patients received Renew® as a treatment for passive incontinence in 2016. The median St Mark's Incontinence Score was 15 (range 7-18) at baseline and 10 (range 2-18) at first follow-up (P < 0.0001) at a median of 11 (range 8-14) weeks. Eleven (37%) patients used the regular size and 19 (63%) the large size. Patients used an average of 1.67 inserts per day (range 1-3) on an average of 3.58 days per week (1-7). Three patients reported a deterioration in symptoms, seven (23%) had no change and 20 (67%) showed a significant improvement. Six patients (20%) did not like the device while 24 (80%) liked it. Seventeen patients (57%) wanted to continue this treatment in the long term. CONCLUSION The Renew® device seems to be an acceptable and effective therapeutic option for passive FI. Further work is needed to compare it with other treatments and establish its position in the treatment pathway.
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Affiliation(s)
- C A Leo
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK.,Imperial College London, London, UK
| | - G P Thomas
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK
| | - J D Hodgkinson
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK.,Imperial College London, London, UK
| | - J P Segal
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK.,Imperial College London, London, UK
| | - Y Maeda
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Murphy
- Imperial College London, London, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital and Academic Institute, London North West University Healthcare NHS Trust, Harrow, UK.,Imperial College London, London, UK
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23
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Yousif N, Vaizey CJ, Maeda Y. Mapping the current flow in sacral nerve stimulation using computational modelling. Healthc Technol Lett 2019; 6:8-12. [PMID: 30881693 PMCID: PMC6407445 DOI: 10.1049/htl.2018.5030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/02/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022] Open
Abstract
Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence involving the implantation of a quadripolar electrode into a sacral foramen, through which an electrical stimulus is applied. Little is known about the induced spread of electric current around the SNS electrode and its effect on adjacent tissues, which limits optimisation of this treatment. The authors constructed a 3-dimensional imaging based finite element model in order to calculate and visualise the stimulation induced current and coupled this to biophysical models of nerve fibres. They investigated the impact of tissue inhomogeneity, electrode model choice and contact configuration and found a number of effects. (i) The presence of anatomical detail changes the estimate of stimulation effects in size and shape. (ii) The difference between the two models of electrodes is minimal for electrode contacts of the same length. (iii) Surprisingly, in this arrangement of electrode and neural fibre, monopolar and bipolar stimulation induce a similar effect. (iv) Interestingly when the active contact is larger, the volume of tissue activated reduces. This work establishes a protocol to better understand both therapeutic and adverse stimulation effects and in the future will enable patient-specific adjustments of stimulation parameters.
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Affiliation(s)
- Nada Yousif
- School of Engineering and Technology, University of Hertfordshire, Hatfield, AL10 9AB, UK
| | | | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St Mark's Hospital, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
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24
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Segal JP, Leo CA, Hodgkinson JD, Cavazzoni E, Bradshaw E, Lung PFC, Ilangovan R, Vaizey CJ, Faiz OD, Hart AL, Clark SK. Acceptability, effectiveness and safety of a Renew ® anal insert in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis. Colorectal Dis 2019; 21:73-78. [PMID: 30218632 DOI: 10.1111/codi.14422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/03/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Restorative proctocolectomy has gained acceptance in the surgical management of medically refractive ulcerative colitis and cancer prevention in familial adenomatous polyposis. Incontinence following restorative proctocolectomy occurs in up to 25% of patients overnight. The Renew® insert is an inert single-use device which acts as an anal plug. The aim of this study was to assess the acceptability, effectiveness and safety of the Renew® insert in patients who have undergone restorative proctocolectomy. The device has yet to be assessed in patients who have undergone restorative proctocolectomy. METHOD This was a prospective study exploring the acceptability, effectiveness and safety of the Renew® insert in improving incontinence in patients who had undergone restorative proctocolectomy. A total of 15 patients with incontinence were asked to use the Renew® insert for 14 days following their standard care. The Incontinence Questionnaire-Bowels was used pre- and posttreatment to assess response and patients were asked to report the perceived acceptability, effectiveness and safety of the device at the end of the trial. RESULTS The device was acceptable to 8/15 (53%) of patients and was effective in 6/15 (40%). Only 2/15 (13%) of patients raised any safety concerns, and these were minor. The device was associated with a significant reduction in night seepage (P = 0.034). CONCLUSION In a small study, the Renew® insert can be both acceptable and effective and is also associated with few safety concerns. It is also associated with significant reductions in night-time seepage.
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Affiliation(s)
- J P Segal
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - C A Leo
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - J D Hodgkinson
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - E Cavazzoni
- Department of Surgery, University of Perugia, Perugia, Italy
| | | | - P F C Lung
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | | | - C J Vaizey
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - O D Faiz
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - A L Hart
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - S K Clark
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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25
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Pan YB, Maeda Y, Wilson A, Glynne-Jones R, Vaizey CJ. Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review. Acta Oncol 2018; 57:1427-1437. [PMID: 30264638 DOI: 10.1080/0284186x.2018.1503713] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy. METHOD A systematic literature review. RESULTS Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity. CONCLUSION Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.
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Affiliation(s)
- Yi Bin Pan
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Longhua Hospital, Shanghai University of TCM, Shanghai, China
| | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Imperial College London, London, UK
| | - Ana Wilson
- Imperial College London, London, UK
- Wolfson Unit of Endoscopy, St. Mark’s Hospital, Harrow, UK
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26
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Leo CA, Cavazzoni E, Thomas GP, Hodgkison J, Murphy J, Vaizey CJ. Evaluation of 153 Asymptomatic Subjects Using the Anopress Portable Anal Manometry Device. J Neurogastroenterol Motil 2018; 24:431-436. [PMID: 29879763 PMCID: PMC6034678 DOI: 10.5056/jnm17135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/05/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims The Anopress device is a new portable manometry system. The aim of this study is to formulate normative data using this new device by recording the anorectal function of asymptomatic subjects. Patient comfort was also assessed. Methods Anorectal function was assessed in asymptomatic volunteers using the Anopress. All volunteers were examined in a standardized way in accordance with the study protocol. Normative values for the Anopress were obtained from the recorded data and patient comfort was assessed using a visual analogue scale. Results We recruited 153 healthy volunteers. Eighty were female (23 parous; median age 39.5 [interquartile range {IQR}, 28.75–53.00]) and 73 were male (median age 40.5 [IQR, 29.00–52.25]). For the female cohort, the following normal range (2.5–97.5 percentile) values were recorded across the whole anal canal: resting pressure 40.0–103.0 mmHg; squeeze increment 35.0–140.6 mmHg; endurance 1.3–9.0 seconds; involuntary squeeze 41.1–120.8 mmHg; and strain pressure 22.1–77.9 mmHg. Similarly, the following male normal range (2.5–97.5 percentile) values were recorded across the whole anal canal: resting pressure 38.3–99.6 mmHg; squeeze increment 42.5–154.8 mmHg; involuntary squeeze 40.0–123.6 mmHg; endurance 2.0–10.0 seconds; and strain pressure 11.0–72.1 mmHg. The median visual analogue scale scores for discomfort during the measurement was 0.0 (IQR, 0.00–0.00). Conclusions Normative values for the Anopress device have been calculated by this study. The Anopress appears to be a safe and well tolerated way of measuring pressures from the entire anal canal. Further comparisons with other standard and commonly used manometry tests are, however, required to verify its reliability.
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Affiliation(s)
- Cosimo Alex Leo
- London North West NHS Trust - St Mark's Hospital Academic Institute, Sir Alan Park's Physiology Unit, Harrow, UK.,Imperial College of London, UK
| | - Emanuel Cavazzoni
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Gregory P Thomas
- London North West NHS Trust - St Mark's Hospital Academic Institute, Sir Alan Park's Physiology Unit, Harrow, UK
| | - Jonathan Hodgkison
- London North West NHS Trust - St Mark's Hospital Academic Institute, Sir Alan Park's Physiology Unit, Harrow, UK.,Imperial College of London, UK
| | | | - Carolynne J Vaizey
- London North West NHS Trust - St Mark's Hospital Academic Institute, Sir Alan Park's Physiology Unit, Harrow, UK.,Imperial College of London, UK
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27
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Grainger JT, Maeda Y, Donnelly SC, Vaizey CJ. Assessment and management of patients with intestinal failure: a multidisciplinary approach. Clin Exp Gastroenterol 2018; 11:233-241. [PMID: 29928141 PMCID: PMC6003282 DOI: 10.2147/ceg.s122868] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.
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Affiliation(s)
- Jennie T Grainger
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Yasuko Maeda
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Suzanne C Donnelly
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Carolynne J Vaizey
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
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28
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Leo CA, Murphy J, Hodgkinson JD, Vaizey CJ, Maeda Y. Does the Internet provide patients or clinicians with useful information regarding faecal incontinence? An observational study. G Chir 2018; 39:71-76. [PMID: 29694304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The Internet has become an important platform for information communication. This study aim to investigate the utility of social media and search engines to disseminate faecal incontinence information. METHODS We looked into Social media platforms and search engines. There was not a direct patient recruitment and any available information from patients was already on public domain at the time of search. A quantitative analysis of types and volumes of information regarding faecal incontinence was made. RESULTS Twelve valid pages were identified on Facebook: 5 (41%) pages were advertising commercial incontinence products, 4 (33%) pages were dedicated to patients support groups and 3 (25%) pages provided healthcare information. Also we found 192 Facebook posts. On Twitter, 2890 tweets were found of which 51% tweets provided healthcare information; 675 (45%) were sent by healthcare professionals to patients, 530 tweets (35.3%) were between healthcare professionals, 201 tweets (13.4%) were from medical journals or scientific books and 103 tweets (7%) were from hospitals or clinics with information about events and meetings. The second commonest type of tweets was advertising commercial incontinence products 27%. Patients tweeted to exchange information and advice between themselves (20.5%). In contrast, search engines as Google/Yahoo/Bing had a higher proportion of healthcare information (over 70%). CONCLUSION Internet appears to have potential to be a useful platform for patients to learn about faecal incontinence and share information; however, given one lack of focus of available data, patients may struggle to identify valid and useful information.
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29
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Leo CA, Maeda Y, Collins B, Thomas GP, Hodgkinson JD, Murphy J, Vaizey CJ. Current practice of continence advisors in managing faecal incontinence in the United Kingdom: results of an online survey. Colorectal Dis 2017; 19:O339-O344. [PMID: 28736932 DOI: 10.1111/codi.13823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/06/2017] [Indexed: 02/08/2023]
Abstract
AIM To investigate the current practice of continence advisors in the United Kingdom. METHOD Continence advisors were contacted by email or letter to participate in a survey. The survey contained 27 questions which addressed the practice of each continence advisor, their knowledge of continence management and the adequacy of their training. RESULTS Two hundred and twenty-six out of a total of 448 continence advisors (50.4%), responded. One hundred and seventy (76.9%) advisors treated both faecal and urinary incontinence, 51 (23.1%) treated urinary incontinence. Thirty-six advisors (16.1%) were lone workers and 130 (58.6%) had more than 10 years' experience. The majority of the advisors (75.6%) performed a digital rectal examination as part of their assessment. Regarding the management of faecal incontinence, 148 prescribed suppositories, 127 offered enemas and 147 advised on rectal irrigation. Most of the advisors taught pelvic floor exercises (n = 207) and urge resistance techniques (n = 188). One hundred and fifty-nine (87.4%) prescribed the Peristeen Coloplast® anal plug and 78 (47.6%) prescribed the Renew® anal insert. Eighty-nine advisors (42.6%) felt they had not been adequately trained to provide a bowel continence service. CONCLUSION The majority of continence advisors in the UK manage faecal incontinence. They are able to initiate a broad range of conservative treatment options; however, almost half of the advisors who answered the survey felt inadequately trained and may be better supported by further training.
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Affiliation(s)
- C A Leo
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - Y Maeda
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - B Collins
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - G P Thomas
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - J D Hodgkinson
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - J Murphy
- Imperial College London, London, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
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Abstract
This article provides an overview of the pathophysiology, causes, investigations, and management of high-output enterostomy and enterocutaneous fistula. High-output stoma and enterocutaneous fistula can result in intestinal failure and this is often fatal if not managed properly. The management involves reducing fluid losses, providing nutrients with fluids, and treating the underlying cause and sepsis. A multidisciplinary approach is required for successful management of patients with high-output enterostomy and enterocutaneous fistula.
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Affiliation(s)
- Franklin Adaba
- Intestinal Failure Unit, St Mark's Hospital, London, United Kingdom
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Rahbour G, Warusavitarne J, Hart AL, Tozer PJ, Ullah MR, Thomas GP, Gabe SM, Knight SC, Al-Hassi HO, Vaizey CJ. Pilot study of immunological factors in non-inflammatory bowel disease enterocutaneous fistulas. Int J Surg 2017; 41:127-133. [DOI: 10.1016/j.ijsu.2017.03.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
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Maeda Y, Kamm MA, Vaizey CJ, Matzel KE, Johansson C, Rosen H, Baeten CG, Laurberg S. Long-term outcome of sacral neuromodulation for chronic refractory constipation. Tech Coloproctol 2017; 21:277-286. [PMID: 28429130 PMCID: PMC5423992 DOI: 10.1007/s10151-017-1613-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/30/2017] [Indexed: 12/22/2022]
Abstract
Purpose Sacral neuromodulation has been reported as a treatment for severe idiopathic constipation. This study aimed to evaluate the long-term effects of sacral neuromodulation by following patients who participated in a prospective, open-label, multicentre study up to 5 years. Methods Patients were followed up at 1, 3, 6, 12, 24, 36, 48 and 60 months. Symptoms and quality of life were assessed using bowel diary, the Cleveland Clinic constipation score and the Short Form-36 quality-of-life scale. Results Sixty-two patients (7 male, median age 40 years) underwent test stimulation, and 45 proceeded to permanent implantation. Twenty-seven patients exited the study (7 withdrawn consent, 7 loss of efficacy, 6 site-specific reasons, 4 withdrew other reasons, 2 lost to follow-up, 1 prior to follow-up). Eighteen patients (29%) attended 60-month follow-up. In 10 patients who submitted bowel diary, their improvement of symptoms was sustained: the number of defecations per week (4.1 ± 3.7 vs 8.1 ± 3.4, mean ± standard deviation, p < 0.001, baseline vs 60 months) and sensation of incomplete emptying (0.8 ± 0.3 vs 0.2 ± 0.1, p = 0.002). In 14 patients (23%) with Cleveland Clinic constipation score, improvement was sustained at 60 months [17.9 ± 4.4 (baseline) to 10.4 ± 4.1, p < 0.001]. Some 103 device-related adverse events were reported in 27 (61%). Conclusion Benefit from sacral neuromodulation in the long-term was observed in a small minority of patients with intractable constipation. The results should be interpreted with caution given the high dropout and complication rate during the follow-up period.
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Affiliation(s)
- Yasuko Maeda
- Sir Alan Parks Physiology Unit, St. Mark's Hospital, Harrow, UK. .,Imperial College, London, UK.
| | - Michael A Kamm
- Imperial College, London, UK.,Department of Gastroenterology, St. Vincent Hospital Melbourne, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Carolynne J Vaizey
- Sir Alan Parks Physiology Unit, St. Mark's Hospital, Harrow, UK.,Imperial College, London, UK
| | - Klaus E Matzel
- Chirurgische Klinik mit Poliklinik der Friedrich Alexander, Universität Erlangen/Nürnberg, Erlangen, Germany
| | | | | | - Cornelius G Baeten
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Søren Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Hodgkinson JD, Maeda Y, Leo CA, Warusavitarne J, Vaizey CJ. Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates. Colorectal Dis 2017; 19:319-330. [PMID: 28102927 DOI: 10.1111/codi.13609] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/28/2016] [Indexed: 02/08/2023]
Abstract
AIM Minimal evidence exists to guide surgeons on the risk of complications when performing abdominal wall reconstruction (AWR) in the presence of active infection, contamination or enterocutaneous fistula. This study aims to establish the outcomes of contaminated complex AWR. METHOD Analysis was conducted according to PRISMA guidelines. Systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on single-staged repair of contaminated complex AWR were included. Pooled data were analysed to establish rates of complications. RESULTS Sixteen studies were included, consisting of 601 contaminated complex AWRs, of which 233 included concurrent enterocutaneous fistula repair. The average follow-up period was 26.7 months. There were 146 (24.3%) reported hernia recurrences. When stratified by repair method, suture repair alone had the lowest rate of recurrence (14.2%), followed by nonabsorbable synthetic mesh reinforcement (21.2%), biological mesh (25.8%) and absorbable synthetic mesh (53.1%). Hernia recurrence was higher when fascial closure was not achieved. Of the 233 enterocutaneous fistula repairs, fistula recurrence was seen in 24 patients (10.3%). Suture repair alone had the lowest rate of recurrence (1.6%), followed by nonbiological mesh (10.3%) and biological mesh reinforcement (12%). Forty-six per cent of patients were reported as having a wound-related complication and the mortality rate was 2.5%. CONCLUSION It is feasible to perform simultaneous enterocutaneous fistula repair and AWR as rates of recurrent fistula are comparable with series describing enterocutaneous fistula repair alone. Hernias recurred in nearly a quarter of cases. This analysis is limited by a lack of comparative data and variability of outcome reporting.
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Affiliation(s)
| | - Y Maeda
- St Mark's Hospital and Academic Institute, London, UK
| | - C A Leo
- St Mark's Hospital and Academic Institute, London, UK
| | | | - C J Vaizey
- St Mark's Hospital and Academic Institute, London, UK
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Stellingwerf ME, Maeda Y, Patel U, Vaizey CJ, Warusavitarne J, Bemelman WA, Clark SK. The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch-anal anastomosis. Colorectal Dis 2016; 18:O292-300. [PMID: 27338231 DOI: 10.1111/codi.13431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/28/2016] [Indexed: 02/08/2023]
Abstract
AIM Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the most frequently performed operation for intractable ulcerative colitis (UC) and for many patients with familial adenomatous polyposis (FAP). It can be complicated by a functional evacuation difficulty, which is not well understood. We aimed to evaluate the role of defaecating pouchography in an attempt to assess the mechanism of evacuation difficulty in pouch patients. METHOD All RPC patients who had had a defaecating pouchogram for evacuation difficulty at one hospital between 2006 and 2014 were retrospectively reviewed. The findings and features were correlated with the symptoms. Demographic, clinical and radiological variables were analysed. RESULTS Eighty-seven [55 (63%) female] patients aged 47.6 ± 12.5 years (mean standard ± SD) were identified. Thirty-five had a mechanical outlet obstruction and 52 had no identified mechanical cause to explain the evacuation difficulty. The mean age of these 52 [33 (63%) female] patients was 48.2 ± 13 years. Of these 52 patients, significantly more used anti-diarrhoeal medication (P = 0.029), complained of a high frequency of defaecation (P = 0.005), experienced a longer time to the initiation of defaecation (P = 0.049) and underwent pouchoscopy (P = 0.003). Biofeedback appeared to improve the symptoms in 7 of 16 patients with a nonmechanical defaecatory difficulty. The most common findings on defaecating pouchography included residual barium of more than 33% after an attempted evacuation (46%, n = 24), slow evacuation (35%, n = 18) and mucosal irregularity (33%, n = 17). Correlation between radiological features and symptoms showed a statistically significant relationship between straining, anal pain, incontinence and urgency with patterns of anismus or pelvic floor descent or weakness seen on the defaecating pouchogram. Symptoms of incomplete evacuation, difficulty in the initiation of defaecation, high defaecatory frequency and abdominal pain were not correlated with the radiological features of the pouchogram. CONCLUSION Defaecating pouchography may be useful for identifying anismus and pelvic floor disorders in pouch patients who have symptoms of straining, anal pain or incontinence. In patients with a high frequency of defaecation and abdominal pain it does not provide clinically meaningful information. Patients who complain of straining, incontinence, anal pain or urgency and have anismus or pelvic floor disorders may benefit from behavioural therapy.
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Affiliation(s)
- M E Stellingwerf
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Y Maeda
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Department of Surgery, St Mark's Hospital, Harrow, UK
| | - U Patel
- Department of Radiology, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.,Department of Surgery, St Mark's Hospital, Harrow, UK
| | | | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - S K Clark
- Department of Surgery, St Mark's Hospital, Harrow, UK
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Vaizey CJ, Maeda Y, Barbosa E, Bozzetti F, Calvo J, Irtun Ø, Jeppesen PB, Klek S, Panisic-Sekeljic M, Papaconstantinou I, Pascher A, Panis Y, Wallace WD, Carlson G, Boermeester M. European Society of Coloproctology consensus on the surgical management of intestinal failure in adults. Colorectal Dis 2016; 18:535-48. [PMID: 26946219 DOI: 10.1111/codi.13321] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/22/2016] [Indexed: 12/19/2022]
Abstract
Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.
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Affiliation(s)
| | - C J Vaizey
- The Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Northwick Park, Harrow, UK.,Imperial College London, London, UK
| | - Y Maeda
- The Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Northwick Park, Harrow, UK.,Imperial College London, London, UK
| | - E Barbosa
- Serviço de Cirurgia, Hospital Pedro Hispano, Senhora da Hora, Portugal
| | - F Bozzetti
- Faculty of Medicine, University of Milan, Milan, Italy
| | - J Calvo
- Department of General, Digestive, Hepato-Biliary-Pancreatic Surgery and Abdominal Organ Transplantation Unit, University Hospital 12 de Octubre, Madrid, Spain
| | - Ø Irtun
- Gastrosurgery Research Group, UiT the Arctic University of Norway, University Hospital North-Norway, Tromsø, Norway.,Department of Gastroenterologic Surgery, University Hospital North-Norway, Tromsø, Norway
| | - P B Jeppesen
- Department of Medical Gastroenterology CA-2121, Rigshospitalet, Copenhagen, Denmark
| | - S Klek
- General and Oncology Surgery, General and Oncology Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - M Panisic-Sekeljic
- Department for Perioperative Nutrition, Clinic for General Surgery, Military Medical Academy, Belgrade, Serbia
| | - I Papaconstantinou
- 2nd Department of Surgery, Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A Pascher
- Department of General, Visceral, Vascular, Thoracic and Transplant Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Y Panis
- Colorectal Department, Beaujon Hospital and University Paris VII, Clichy, France
| | - W D Wallace
- Northern Ireland Regional Intestinal Failure Service, Belfast City Hospital, Belfast, UK
| | - G Carlson
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, University of Manchester, Salford, Manchester, UK
| | - M Boermeester
- Department of Surgery/Intestinal Failure Team, Academic Medical Center, Amsterdam, The Netherlands
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Affiliation(s)
- F Iqbal
- The Sir Alan Parks Department of Physiology, St Marks Hospital and Academic Institute, Harrow, UK.
| | - M Samuel
- The Sir Alan Parks Department of Physiology, St Marks Hospital and Academic Institute, Harrow, UK
| | - E J K Tan
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Fulham Road, London, UK
| | - R J Nicholls
- The Sir Alan Parks Department of Physiology, St Marks Hospital and Academic Institute, Harrow, UK
| | - C J Vaizey
- The Sir Alan Parks Department of Physiology, St Marks Hospital and Academic Institute, Harrow, UK
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Affiliation(s)
| | | | - Emile Tan
- Chelsea and Westminster Hospital, London, UK
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Iqbal F, Collins B, Thomas GP, Askari A, Tan E, Nicholls RJ, Vaizey CJ. Bilateral transcutaneous tibial nerve stimulation for chronic constipation. Colorectal Dis 2016; 18:173-8. [PMID: 26333152 DOI: 10.1111/codi.13105] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/03/2015] [Indexed: 02/08/2023]
Abstract
AIM Chronic constipation is difficult to treat when symptoms are intractable. Colonic propulsion may be altered by distal neuromodulation but this is conventionally delivered percutaneously. Transcutaneous tibial nerve stimulation is noninvasive and cheap: this study aimed to assess its efficacy in chronic constipation. METHOD Eighteen patients (median age 46 years, 12 female) with chronic constipation were recruited consecutively. Conservative and behavioural therapy had failed to improve symptoms in all 18. Thirty minutes of daily bilateral transcutaneous tibial nerve stimulation was administered by each patient at home for 6 weeks. The primary outcome measure was a change in the Patient Assessment of Constipation Quality of Life (PAC-QoL) score. Change in Patient Assessment of Constipation Symptoms (PAC-SYM), weekly bowel frequency and visual analogue scale (VAS) score were also measured. RESULTS Fifteen patients (12 female) completed the trial. The PAC-QoL score improved significantly with treatment [pretreatment, median 2.95, interquartile range (IQR) 1.18; posttreatment, median 2.50, IQR 0.70; P = 0.047]. There was no change in PAC-SYM score (pretreatment, median 2.36, IQR 1.59; posttreatment, median 2.08, IQR 0.92; P = 0.53). Weekly stool frequency improved as did VAS score, but these did not reach statistical significance (P = 0.229 and 0.161). The PAC-QoL and PAC-SYM scores both improved in four (26%) patients. Two patients reported complete cure. There were no adverse events reported. CONCLUSION Bilateral transcutaneous tibial nerve stimulation appears to be effective in a quarter of patients with chronic constipation. Carefully selected patients with less severe disease may benefit more. This requires further study.
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Affiliation(s)
- F Iqbal
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - B Collins
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - G P Thomas
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - A Askari
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - E Tan
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, London, UK
| | - R J Nicholls
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - C J Vaizey
- Sir Alan Parks' Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
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Abstract
AIM Faecal incontinence may occur following rectal surgery and/or radiotherapy for rectal cancer. The aim of this paper was to review the evidence to support the use of sacral nerve stimulation (SNS) for patients with incontinence who had undergone rectal surgery or received rectal radiotherapy. METHOD A search was performed of PubMed, Medline and Embase. All studies which reported the outcome of SNS in patients who had undergone a rectal resection or radiotherapy were reviewed. RESULTS The first report of SNS following rectal surgery was in 2002. Since then seven further studies have described its effect in patients who have undergone anterior resection or pelvic radiotherapy. The total number of patients was 57. All studies were single group series, which ranged in size from one to 15 patients. The follow-up ranged from 1 to 36 months. The success of peripheral nerve evaluation ranged from 47% to 100%. Permanent SNS improved the symptoms and in some studies this was reflected in improved quality of life. The wide variation of patient factors, operations performed, the dose of radiotherapy given and time from operation makes interpretation of the results difficult. CONCLUSION Larger studies with better patient selection are needed to investigate the effect of SNS on incontinence following radiotherapy or rectal surgery.
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Affiliation(s)
- G P Thomas
- Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - E Bradshaw
- Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - C J Vaizey
- Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
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Thomas GP, Duelund-Jakobsen J, Dudding TC, Bradshaw E, Nicholls RJ, Alam A, Emmanuel A, Thin N, Knowles CH, Laurberg S, Vaizey CJ. A double-blinded randomized multicentre study to investigate the effect of changes in stimulation parameters on sacral nerve stimulation for constipation. Colorectal Dis 2015; 17:990-5. [PMID: 25916959 DOI: 10.1111/codi.12982] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/23/2015] [Indexed: 12/10/2022]
Abstract
AIM Sacral nerve stimulation (SNS) may be offered to patients with constipation who have failed to improve with conservative treatment. The response to SNS is variable, with a significant loss of efficacy in some patients. An increased frequency of stimulation may improve the efficacy of SNS for faecal incontinence. This study aimed to see if alteration of the pulse width or frequency improved the outcome for those with constipation. METHOD Eleven patients with constipation currently being treated by SNS were recruited from three centres. They were randomized to five different protocols of stimulation each applied for 5 weeks. Group 1 used standard settings (pulse width 210 μs, frequency 14 Hz); in the other four groups (Groups 2-5) the pulse width and/or frequency were halved or doubled. Patients and investigators were blinded to the group allocation. RESULTS The Cleveland Clinic constipation score varied significantly between the five groups. Group 1 achieved the lowest score mean (± SD) 13.4 (± 4.4) (P = 0.03). The number of digitations per defaecation was the lowest in Group 4, 90 μs and 14 Hz (P < 0.01). No other variable changed significantly. Standard settings were the most preferred by the recruited patients. CONCLUSION Alteration of pulse width or frequency of stimulation had no significant effect on the outcome of SNS for constipation.
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Affiliation(s)
- G P Thomas
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - J Duelund-Jakobsen
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - T C Dudding
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - E Bradshaw
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - R J Nicholls
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - A Alam
- GI Physiology Unit, University College Hospital, London, UK
| | - A Emmanuel
- GI Physiology Unit, University College Hospital, London, UK
| | - N Thin
- Barts Health NHS Trust, London, UK
| | | | - S Laurberg
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - C J Vaizey
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
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Iqbal F, Askari A, Adaba F, Choudhary A, Thomas G, Collins B, Tan E, Nicholls RJ, Vaizey CJ. Factors Associated With Efficacy of Nurse-led Bowel Training of Patients With Chronic Constipation. Clin Gastroenterol Hepatol 2015; 13:1785-92. [PMID: 26051391 DOI: 10.1016/j.cgh.2015.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 05/18/2015] [Accepted: 05/24/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether nurse-led bowel training (NBT), an individually tailored biofeedback strategy designed to improve the physiological process of defecation by operant conditioning and trial and error learning, is effective for patients with chronic constipation. We assessed the ability of NBT to reduce symptoms and increase quality of life in patients with constipation at a large tertiary medical center. METHODS We performed a retrospective analysis of data from 347 patients (median age, 50 years) who underwent a median 3 sessions of NBT for chronic constipation from January 2011 through December 2013 at St Marks Hospital in the United Kingdom. The NBT comprised a combination of sensory retraining, pelvic floor conditioning, and advice on diet and toileting behavior. Data on patient demographics (age, sex, type of constipation) were collected alongside their assessments of constipation, which were based on Patient Assessment of Constipation Quality of Life (PAC-QoL) and patient satisfaction scores. We performed binary logistic regression analysis. Each variable was tested first at the univariate level; those with significance (P < .10) were included in a multivariate model. RESULTS At the end of NBT, 62.5% of the patients (217/347) reported reduced symptoms, and 40.2% of the patients (41/102) reported a reduction of at least 1 point on the PAC-QoL score. The mean PAC-QoL scores before and after NBT were 2.42 and 1.41, respectively (P = .001). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.02-2.87; P = .042), greater number of sessions (OR, 4.14; 95% CI, 2.09-8.20; P < .001), and non-irrigation (OR, 4.39; 95% CI, 1.89-10.19; P = .001) were independent predictors of patient satisfaction. CONCLUSIONS Data collected immediately after patients with chronic constipation received NBT indicate that it is an effective treatment for most patients. Older patients with dyssynergic defecation benefit most from at least 4 sessions.
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Affiliation(s)
- Fareed Iqbal
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Alan Askari
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Franklin Adaba
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Aliya Choudhary
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Gregory Thomas
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Brigitte Collins
- Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Emile Tan
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - R John Nicholls
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Carolynne J Vaizey
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, United Kingdom.
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Adaba F, Uppara M, Iqbal F, Mallappa S, Vaizey CJ, Gabe SM, Warusavitarne J, Nightingale JMD. Chronic cholestasis in patients on parenteral nutrition: the influence of restoring bowel continuity after mesenteric infarction. Eur J Clin Nutr 2015; 70:189-93. [DOI: 10.1038/ejcn.2015.147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 07/18/2015] [Accepted: 07/25/2015] [Indexed: 01/03/2023]
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Adaba F, Askari A, Dastur J, Patel A, Gabe SM, Vaizey CJ, Faiz O, Nightingale JMD, Warusavitarne J. Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies. Colorectal Dis 2015; 17:566-77. [PMID: 25739990 DOI: 10.1111/codi.12938] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 01/19/2015] [Indexed: 12/12/2022]
Abstract
AIM The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.
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Affiliation(s)
- F Adaba
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Askari
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
| | - J Dastur
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Patel
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - S M Gabe
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - O Faiz
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
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Maeda Y, Vaizey CJ, Warusavitarne J. Response to: Consensus on ventral rectopexy: report of a panel of experts. Colorectal Dis 2014; 16:739. [PMID: 24961473 DOI: 10.1111/codi.12691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Y Maeda
- Department of Surgery and Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK.
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Affiliation(s)
- Fareed Iqbal
- Department of Physiology, St Mark's Hospital, London, UK
| | | | | | - Carolynne J Vaizey
- Sir Alan Parks Physiology Unit, Lennard Jones Intestinal Failure Unit, St Mark's Hospital London, London, UK
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Vaizey CJ, Gibson PR, Black CM, Nicholls RJ, Weston AR, Gaya DR, Sebastian S, Shaw I, Lewis S, Bloom S, Gordon JN, Beale A, Arnott I, Campbell S, Fan T. Disease status, patient quality of life and healthcare resource use for ulcerative colitis in the UK: an observational study. Frontline Gastroenterol 2014; 5:183-189. [PMID: 28839768 PMCID: PMC5369729 DOI: 10.1136/flgastro-2013-100409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/27/2013] [Accepted: 11/28/2013] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ulcerative colitis is a lifelong, chronic, relapsing-remitting disease. OBJECTIVE To assess the relationship between ulcerative colitis disease status and patient quality of life, and to determine the impact of ulcerative colitis on healthcare costs and work productivity, in the UK. METHODS Clinicians assessed 173 adult patients' current disease status at a single study visit using the partial Mayo (pMayo) instrument. Patients completed the Euro Quality of Life 5-dimension, 5-level (EQ-5D-5L) questionnaire, the Work Productivity and Activity Impairment (WPAI) questionnaire. Healthcare resource use was determined from questionnaires and from patients' medical charts. RESULTS Patients in remission had a significantly higher EQ-5D-5L scores (mean (SD) 0.86 (0.15)) than patients with active disease (0.71 (0.20); p<0.001). Patients with mild disease had significantly higher mean (SD) EQ-5D-5L scores than patients with moderate/severe disease: 0.77 (0.11) and 0.66 (0.24), respectively (p<0.001). The mean percent productivity impairment was greater for patients with active disease than for patients in remission on all items of the WPAI questionnaire: 24.6% vs 1.8% for work time missed, 34.1% vs 12.9% for impairment while working, 40.8% vs 14.4% for overall work impairment and 42.7% vs 13.0% for activity impairment (p<0.001 for all comparisons). The mean (SD) total cost of healthcare for ulcerative colitis in the prior 3 months was £1211 (1588). CONCLUSIONS When compared with patients in remission, patients with active ulcerative colitis have significantly worse quality of life and significantly more work impairment. The healthcare costs of ulcerative colitis are considerable.
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Affiliation(s)
| | - Peter R Gibson
- Alfred Hospital, Melbourne, and Monash University, Victoria, Australia
| | - Christopher M Black
- St. John's University, Queens, New York, USA,Merck & Co., Inc., Global Health Outcomes, Whitehouse Station, New Jersey, USA
| | | | | | - Daniel R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull Royal Infirmary, Hull, UK
| | - Ian Shaw
- Department of Gastroenterology, Gloucester Royal Hospital, Gloucester, UK
| | - Stephen Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College London Hospital, London, UK
| | - John N Gordon
- Department of Gastroenterology, Royal Hampshire Hospital, Winchester, UK
| | | | | | | | - Tao Fan
- Merck & Co., Inc., Global Health Outcomes, Whitehouse Station, New Jersey, USA
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Thomas GP, George AT, Dudding TC, Nicholls RJ, Vaizey CJ. A pilot study of chronic pudendal nerve stimulation for faecal incontinence for those who have failed sacral nerve stimulation. Tech Coloproctol 2014; 18:731-7. [PMID: 24952733 DOI: 10.1007/s10151-014-1174-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 01/23/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) is used as a first-line treatment for faecal incontinence when conservative measures have failed. However, one-third of patients fail to benefit from this treatment. We hypothesised that sacral afferent stimulation can be maximised using pudendal nerve stimulation (PNS) and this may be of benefit in this patient group. The aim of this study was to assess chronic PNS for those who failed to improve with SNS. METHODS Ten patients who had failed SNS were recruited. All underwent percutaneous insertion of a stimulation lead with four-electrode array adjacent to the pudendal nerve. Continuous bipolar stimulation was administered using an external pulse generator over a 3-week period. Those who experienced a ≥50% reduction in the frequency of incontinent episodes over this period proceeded to chronic stimulation with an implantable pulse generator. RESULTS Five patients experienced a ≥50% reduction of incontinent episodes during test stimulation and proceeded to chronic stimulation. In these five patients, at a median (range) follow-up of 24 (6-36) months, the median (inter quartile range) frequency of incontinent episodes reduced from 5 (18.25) to 2.5 (3) per week (p = 0.043). Three patients maintained a ≥50% improvement in soiling. There was an improvement in the St Mark's continence Score from 19 (15-24) to 16 (13-19), p = 0.042. There were no significant changes in ability to defer defecation or in quality of life scores. CONCLUSIONS Pudendal nerve stimulation failed to improve the symptoms in the majority of patient who had failed SNS. Only a third experienced any improvement.
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Affiliation(s)
- G P Thomas
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
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Thomas GP, Norton C, Nicholls RJ, Vaizey CJ. Sacral transcutaneous stimulation for faecal incontinence may have a different mechanism of action to sacral nerve stimulation. Colorectal Dis 2014; 16:68-9. [PMID: 23927727 DOI: 10.1111/codi.12376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/12/2013] [Indexed: 02/08/2023]
Affiliation(s)
- G P Thomas
- The Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, UK
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