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Bunce JA, Wall JJS, Lund JN, Tierney GM. A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease. Colorectal Dis 2023; 25:2317-2324. [PMID: 37872854 DOI: 10.1111/codi.16783] [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: 05/28/2023] [Revised: 08/07/2023] [Accepted: 09/17/2023] [Indexed: 10/25/2023]
Abstract
AIM The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD. METHODS A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries. RESULTS It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission. CONCLUSION To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.
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Affiliation(s)
- J A Bunce
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - J J S Wall
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
- Department of General Surgery, Royal Derby Hospital, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - G M Tierney
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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2
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Paul M, Smart TF, Doleman B, Toft S, Williams JP, Lund JN, Phillips BE. A systematic review of the impact of postoperative aerobic exercise training in patients undergoing surgery for intra-abdominal cancers. Tech Coloproctol 2023; 27:1169-1181. [PMID: 37548782 PMCID: PMC10638144 DOI: 10.1007/s10151-023-02844-9] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/01/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) programmes which advocate early mobility after surgery have improved immediate clinical outcomes for patients undergoing abdominal cancer resections with curative intent. However, the impact of continued physical activity on patient-related outcomes and functional recovery is not well defined. The aim of this review was to assess the impact of postoperative aerobic exercise training, either alone or in conjunction with another exercise modality, on patients who have had surgery for intra-abdominal cancer. METHODS A literature search was performed of electronic journal databases. Eligible papers needed to report an outcome of aerobic capacity in patients older than 18 years of age, who underwent cancer surgery with curative intent and participated in an exercise programme (not solely ERAS) that included an aerobic exercise component starting at any point in the postoperative pathway up to 12 weeks. RESULTS Eleven studies were deemed eligible for inclusion consisting of two inpatient, one mixed inpatient/outpatient and eight outpatient studies. Meta-analysis of four outpatient studies, each reporting change in 6-min walk test (6MWT), showed a significant improvement in 6MWT with exercise (MD 74.92 m, 95% CI 48.52-101.31 m). The impact on health-related quality of life was variable across studies. CONCLUSION Postoperative exercise confers benefits in improving aerobic function post surgery and can be safely delivered in various formats (home-based or group/supervised).
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Affiliation(s)
- M Paul
- Centre of Metabolism, Ageing and Physiology (COMAP), School of Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Academic Unit of Injury, Rehabilitation, and Inflammation Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
- Department of Surgery and Anaesthetics, Royal Derby Hospital, Derby, UK
| | - T F Smart
- Centre of Metabolism, Ageing and Physiology (COMAP), School of Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Academic Unit of Injury, Rehabilitation, and Inflammation Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
- Department of Surgery and Anaesthetics, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Department of Surgery and Anaesthetics, Royal Derby Hospital, Derby, UK
| | - S Toft
- Library and Knowledge Service, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - J P Williams
- Centre of Metabolism, Ageing and Physiology (COMAP), School of Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Academic Unit of Injury, Rehabilitation, and Inflammation Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
- Department of Surgery and Anaesthetics, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Centre of Metabolism, Ageing and Physiology (COMAP), School of Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Academic Unit of Injury, Rehabilitation, and Inflammation Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
- Department of Surgery and Anaesthetics, Royal Derby Hospital, Derby, UK
| | - B E Phillips
- Centre of Metabolism, Ageing and Physiology (COMAP), School of Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Academic Unit of Injury, Rehabilitation, and Inflammation Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK.
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3
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Javanmard-Emamghissi H, Doleman B, Lund JN, Lockwood S, Hare S, Pearce L, Moug S, Tierney GM. Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit. Anaesthesia 2023; 78:1376-1385. [PMID: 37772642 DOI: 10.1111/anae.16130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, William Harvey Hospital, East Kent University Hospitals, Ashford, UK
| | - L Pearce
- Department of Colorectal Surgery, Salford Royal Hospital, Salford, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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Blackwell JEM, Herrod PJJ, Doleman B, Boyd-Carson H, Dolan D, Wheldon L, Brown SR, Banerjea A, Moug S, Lund JN. CT-derived measures of muscle quantity and quality predict poorer outcomes from elective colorectal surgery: a UK multicentre retrospective cohort study. Tech Coloproctol 2023; 27:1091-1098. [PMID: 37133735 PMCID: PMC10562328 DOI: 10.1007/s10151-023-02769-3] [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: 10/25/2022] [Accepted: 02/04/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE To assess whether preoperative radiologically defined lean muscle measures are associated with adverse clinical outcomes in patients undergoing elective surgery for colorectal cancer. METHODS This retrospective UK-based multicentre data collection study identified patients having had colorectal cancer resection with curative intent between January 2013 to December 2016. Preoperative computed-tomography (CT) scans were used to measure psoas muscle characteristics. Clinical records provided postoperative morbidity and mortality data. RESULTS This study included 1122 patients. The cohort was separated into a combined group (patients with both sarcopenia and myosteatosis) and others group (either sarcopenia or myosteatosis, or neither). For the combined group, anastomotic leak was predicted on univariate (OR 4.1, 95% CI 1.43-11.79; p = 0.009) and multivariate analysis (OR 4.37, 95% CI 1.41-13.53; p = 0.01). Also for the combined group, mortality (up to 5 years postoperatively) was predicted on univariate (HR 2.41, 95% CI 1.64-3.52; p < 0.001) and multivariate analysis (HR 1.93, 95% CI 1.28-2.89; p = 0.002). A strong correlation exists between freehand-drawn region of interest-derived psoas density measurement and using the ellipse tool (R2 = 81%; p < 0.001). CONCLUSION Measures of lean muscle quality and quantity, which predict important clinical outcomes, can be quickly and easily taken from routine preoperative imaging in patients being considered for colorectal cancer surgery. As poor muscle mass and quality are again shown to predict poorer clinical outcomes, these should be proactively targeted within prehabilitation, perioperative and rehabilitation phases to minimise negative impact of these pathological states.
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Affiliation(s)
- J E M Blackwell
- Royal Derby Hospital, Derby, England, UK.
- Queens Medical Centre, Nottingham, England, UK.
| | - P J J Herrod
- Royal Derby Hospital, Derby, England, UK
- University of Nottingham, Nottingham, England, UK
| | - B Doleman
- Royal Derby Hospital, Derby, England, UK
- University of Nottingham, Nottingham, England, UK
| | | | - D Dolan
- Royal Alexandra Hospital, Paisley, Scotland, UK
- University of Glasgow, Glasgow, Scotland, UK
| | - L Wheldon
- The Northern General Hospital, Sheffield, England, UK
- University of Sheffield, Sheffield, England, UK
| | - S R Brown
- The Northern General Hospital, Sheffield, England, UK
- University of Sheffield, Sheffield, England, UK
| | - A Banerjea
- Queens Medical Centre, Nottingham, England, UK
- University of Nottingham, Nottingham, England, UK
| | - S Moug
- Royal Alexandra Hospital, Paisley, Scotland, UK
- University of Glasgow, Glasgow, Scotland, UK
| | - J N Lund
- Royal Derby Hospital, Derby, England, UK
- University of Nottingham, Nottingham, England, UK
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5
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Javanmard-Emamghissi H, Doleman B, Lund JN, Frisby J, Lockwood S, Hare S, Moug S, Tierney G. Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit. Tech Coloproctol 2023; 27:729-738. [PMID: 36609892 PMCID: PMC10404199 DOI: 10.1007/s10151-022-02747-1] [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: 10/04/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. METHODS A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. RESULTS Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85). CONCLUSIONS Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J Frisby
- Department of Palliative Care Medicine, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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6
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Bunce JA, Doleman B, Lund JN, Tierney GM. The Impact of Surgeon Speciality Interest on Outcomes of Emergency Laparotomy in IBD. World J Surg 2023; 47:2287-2295. [PMID: 37222782 PMCID: PMC10387454 DOI: 10.1007/s00268-023-07051-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Emergency laparotomy may be required in patients with inflammatory bowel disease (IBD). NELA is the largest prospectively maintained database of adult emergency laparotomies in England and Wales and includes clinical urgency of the cases. The impact of surgeon subspeciality on outcomes after emergency laparotomy for IBD is unclear. We have investigated this association, according to the degree of urgency in IBD emergency laparotomy, including the effect of minimally invasive surgery (MIS). METHODS Adults with IBD in the NELA database between 2013 and 2016 were included. Surgeon subspeciality was colorectal or non-colorectal. Urgencies are 'Immediate', '2-6 h', '6-18 h' and '18-24 h'. Logistic regression was used to investigate in-patient mortality and post-operative length of stay (LOS). RESULTS There was significantly reduced mortality and LOS in IBD patients who were operated on by a colorectal surgeon in the least urgent category of emergency laparotomies; Mortality adjusted OR 2.99 (CI 1.2-7.8) P = 0.025, LOS IRR 1.18 (CI 1.02-1.4) P = 0.025. This association was not seen in more urgent categories. Colorectal surgeons were more likely to use MIS, P < 0.001, and MIS was associated with decreased LOS in the least urgent cohort, P < 0.001, but not in the other urgencies. CONCLUSIONS We found improved outcomes in the least urgent cohort of IBD emergency laparotomies when operated on by a colorectal surgeon in comparison to a non-colorectal general surgeon. In the most urgent cases, there was no benefit in the operation being performed by a colorectal surgeon. Further work on characterising IBD emergencies by urgency would be of value.
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Affiliation(s)
- J A Bunce
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK.
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - G M Tierney
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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7
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Hardy EJ, Deane CS, Lund JN, Phillips BE. Loss of muscle mass in the immediate post-operative period is associated with inadequate dietary protein and energy intake. Eur J Clin Nutr 2023; 77:503-505. [PMID: 36702923 PMCID: PMC10115623 DOI: 10.1038/s41430-023-01264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/27/2023]
Abstract
Despite the implementation of 'Enhanced Recovery After Surgery' (ERAS) protocols, major abdominal surgery is still associated with significant and detrimental losses of muscle mass and function in the post-operative period. Although ERAS protocols advocate both early mobility and dietary intake, dietary composition in the immediate post-operative period is poorly characterised, despite muscle losses being greatest in this period. Herein, we show in 15 patients (66 ± 6 y, 12:3 M:F) who lost ~10% m. vastus lateralis muscle mass in the 5 days after open colorectal resective surgery, mean energy intake was only ~25% of the minimum ESPEN recommendation of 25 kcal/kg/d and daily dietary protein intake was only ~12% of the ESPEN recommended guidelines of 1.5 g/kg/d. Given the known importance of nutrition for muscle mass maintenance, innovative dietary interventions are needed in the immediate post-operative period, accounting for specific patient dietary preference to maximise compliance (e.g., soft-textured foods).
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Affiliation(s)
- E J Hardy
- Department of General Surgery, Royal Derby Hospital, Derby, UK.,Centre Of Metabolism, Ageing and Physiology, University of Nottingham, Royal Derby Hospital Centre, Derby, UK.,Nottingham NIHR Biomedical Research Centre and MRC/Versus Arthritis Centre for Musculoskeletal Ageing Research, Nottingham, UK
| | - C S Deane
- Department of Sport and Health Sciences, College of Life and Environmental Sciences and Living Systems Institute, University of Exeter, Exeter, UK.,Human Development & Health, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - J N Lund
- Department of General Surgery, Royal Derby Hospital, Derby, UK.,Centre Of Metabolism, Ageing and Physiology, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - B E Phillips
- Centre Of Metabolism, Ageing and Physiology, University of Nottingham, Royal Derby Hospital Centre, Derby, UK. .,Nottingham NIHR Biomedical Research Centre and MRC/Versus Arthritis Centre for Musculoskeletal Ageing Research, Nottingham, UK.
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8
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Javanmard-Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN, Moler-Zapata S, Grieve R, Moug SJ, Tierney GM. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg 2021; 108:1351-1359. [PMID: 34476484 PMCID: PMC8499866 DOI: 10.1093/bjs/znab287] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.
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Affiliation(s)
- H Javanmard-Emamghissi
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - M Hollyman
- Upper Gastrointestinal Surgery Department, Musgrove Park Hospital, Taunton, UK
| | - H Boyd-Carson
- Colorectal Department, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - A Adiamah
- Department of Gastrointestinal Surgery, NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J N Lund
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Moler-Zapata
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - R Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S J Moug
- Colorectal Department, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Colorectal Department, Royal Derby Hospital, Derby, UK
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9
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Clements JM, Burke JR, Hope C, Nally DM, Doleman B, Giwa L, Griffiths G, Lund JN. The quantitative impact of COVID-19 on surgical training in the United Kingdom. BJS Open 2021; 5:6309263. [PMID: 34169311 PMCID: PMC8226285 DOI: 10.1093/bjsopen/zrab051] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/05/2021] [Indexed: 12/20/2022] Open
Abstract
Background COVID-19 has had a global impact on all aspects of healthcare including surgical training. This study aimed to quantify the impact of COVID-19 on operative case numbers recorded by surgeons in training, and annual review of competency progression (ARCP) outcomes in the UK. Methods Anonymized operative logbook numbers were collated from electronic logbook and ARCP outcome data from the Intercollegiate Surgical Curriculum Programme database for trainees in the 10 surgical specialty training specialties. Operative logbook numbers and awarded ARCP outcomes were compared between predefined dates. Effect sizes are reported as incident rate ratios (IRR) with 95 per cent confidence intervals. Results Some 5599 surgical trainees in 2019, and 5310 in surgical specialty training in 2020 were included. The IRR was reduced across all specialties as a result of the COVID-19 pandemic (0.62; 95 per cent c.i. 0.60 to 0.64). Elective surgery (0.53; 95 per cent c.i. 0.50 to 0.56) was affected more than emergency surgery (0.85; 95 per cent c.i. 0.84 to 0.87). Regional variation indicating reduced operative activity was demonstrated across all specialties. More than 1 in 8 trainees in the final year of training have had their training extended and more than a quarter of trainees entering their final year of training are behind their expected training trajectory. Conclusion The COVID-19 pandemic has had a major effect on surgical training in the UK. Urgent, coordinated action is required to minimize the impacts from the reduction in training in 2020.
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Affiliation(s)
- J M Clements
- The Association of Surgeons in Training, London, UK
| | - J R Burke
- The Association of Surgeons in Training, London, UK
| | - C Hope
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, Derby, UK
| | - D M Nally
- The Association of Surgeons in Training, London, UK
| | - B Doleman
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, Derby, UK
| | - L Giwa
- The Association of Surgeons in Training, London, UK
| | - G Griffiths
- Joint Committee on Surgical Training, London, UK
| | - J N Lund
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, Derby, UK.,Joint Committee on Surgical Training, London, UK
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10
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Ahmed S, Bonnett L, Melhuish A, Adil MT, Aggarwal I, Ali W, Bennett J, Boldock E, Burns FA, Czarniak E, Dennis R, Flower B, Fok R, Goodman AL, Halai S, Hanna T, Hashem M, Hodgson SH, Hughes G, Hurndall KH, Hyland R, Iqbal MR, Jarchow-MacDonald A, Kailavasan M, Klimovskij M, Laliotis A, Lambourne J, Lawday S, Lee F, Lindsey B, Lund JN, Mabayoje DA, Malik KI, Muir A, Narula HS, Ofor U, Parsons H, Pavelle T, Prescott K, Rajgopal A, Roy I, Sagar J, Scarborough C, Shaikh S, Smart CJ, Snape S, Tabaqchali MA, Tennakoon A, Tilley R, Vink E, White L, Burke D, Kirby A. Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection. Br J Surg 2021; 108:441-447. [PMID: 33615351 DOI: 10.1093/bjs/znaa117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse. METHODS A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further. RESULTS Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively. CONCLUSION Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.
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Affiliation(s)
- S Ahmed
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - L Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - A Melhuish
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M T Adil
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - I Aggarwal
- Infection Unit, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - W Ali
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - J Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - E Boldock
- Department of Microbiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - F A Burns
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Czarniak
- Department of Microbiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - R Dennis
- Colorectal Surgery Department, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - B Flower
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - R Fok
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - A L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - S Halai
- Department of Surgery, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - T Hanna
- Department of Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - M Hashem
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - S H Hodgson
- Department of Infection, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - G Hughes
- Infectious Diseases and Microbiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - K-H Hurndall
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - R Hyland
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M R Iqbal
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | | | - M Kailavasan
- Department of Urology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Klimovskij
- Department of Surgery, Conquest Hospital, East Sussex NHS Healthcare Trust, East Sussex, UK
| | - A Laliotis
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - J Lambourne
- Division of Infection, Barts Health NHS Trust, London, UK
| | - S Lawday
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - F Lee
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - B Lindsey
- Department of Microbiology, The Whittington Hospital, Whittington Health NHS Trust, London, UK
| | - J N Lund
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK
| | - D A Mabayoje
- Division of Infection, Barts Health NHS Trust, London, UK
| | - K I Malik
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Muir
- Department of Microbiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - H S Narula
- Department of Surgery, Chesterfield Royal Hospital NHS Trust Hospital, Chesterfield, UK
| | - U Ofor
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - H Parsons
- Department of Microbiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - T Pavelle
- Shrewsbury and Telford NHS Trust, Shrewsbury, UK
| | - K Prescott
- Microbiology and Infectious Diseases, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rajgopal
- Department of Microbiology, Calderdale and Huddersfield NHS Trust, Huddersfield, UK
| | - I Roy
- Colorectal Surgery Department, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - J Sagar
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - C Scarborough
- Department of Infection, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - S Shaikh
- Department of Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - C J Smart
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Cheshire, UK
| | - S Snape
- Microbiology and Infectious Diseases, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M A Tabaqchali
- Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
| | - A Tennakoon
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - R Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - E Vink
- Department of Microbiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - L White
- Department of Microbiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - D Burke
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
| | - A Kirby
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
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Boyd-Carson H, Doleman B, Cromwell D, Lockwood S, Williams JP, Tierney GM, Lund JN, Anderson ID. Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study. World J Surg 2020; 44:869-875. [PMID: 31664496 DOI: 10.1007/s00268-019-05254-x] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Delay to theatre for patients with intra-abdominal sepsis is cited as a particular risk factor for death. Our aim was to evaluate the potential relationship between hourly delay from admission to surgery and post-operative mortality in patients with perforated peptic ulcer (PPU). METHODS All patients entered in the National Emergency Laparotomy Audit who had an emergency laparotomy for PPU within 24 h of admission from December 2013 to November 2017 were included. Time to theatre from admission was modelled as a continuous variable in hours. Outcome was 90-day mortality. Logistic regression adjusting for confounding factors was performed. RESULTS 3809 patients were included, and 90-day mortality rate was 10.61%. Median time to theatre was 7.5 h (IQR 5-11.6 h). The odds of death increased with time to operation once adjustment for confounding variables was performed (per hour after admission adjusted OR 1.04 95% CI 1.02-1.07). In patients who were physiologically shocked (N = 334), there was an increase of 6% in risk-adjusted odds of mortality for every hour Em Lap was delayed after admission (OR 1.06 95% CI 1.01-1.11). CONCLUSION Hourly delay to theatre in patients with PPU is independently associated with risk of death by 90 days. Therefore, we suggest that surgical source control should occur as soon as possible after admission regardless of time of day.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK. .,National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK. .,Division of Medical Sciences and Graduate Entry Medicine, Department of Surgery, University of Nottingham, Nottingham, UK.
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, Department of Surgery, University of Nottingham, Nottingham, UK
| | - D Cromwell
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - S Lockwood
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, Department of Surgery, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK.,National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK.,Division of Medical Sciences and Graduate Entry Medicine, Department of Surgery, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, Department of Surgery, University of Nottingham, Nottingham, UK
| | - I D Anderson
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK.,University of Manchester Academic Health Sciences Centre, Manchester, UK
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12
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Boyd-Carson H, Doleman B, Lockwood S, Williams JP, Tierney GM, Lund JN. Trainee-led emergency laparotomy operating. Br J Surg 2020; 107:1289-1298. [DOI: 10.1002/bjs.11611] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/21/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
Abstract
Background
To achieve completion of training in general surgery, trainees are required to demonstrate competency in common procedures performed at emergency laparotomy. The aim of this study was to describe the patterns of trainee-led emergency laparotomy operating and the association between postoperative outcomes.
Methods
Data on all patients who had an emergency laparotomy between December 2013 and November 2017 were extracted from the National Emergency Laparotomy Audit database. Patients were grouped by grade of operating surgeon: trainee (specialty registrar) or consultant (including post-Certificate of Completion of Training fellows). Trends in trainee operating by deanery, hospital size and time of day of surgery were investigated. Univariable and adjusted regression analyses were performed for the outcomes 90-day mortality and return to theatre, with analysis of patients in operative subgroups segmental colectomy, Hartmann's procedure, adhesiolysis and repair of perforated peptic ulcer disease.
Results
The study cohort included 87 367 patients. The 90-day mortality rate was 15·1 per cent in the consultant group compared with 11·0 per cent in the trainee group. There were no increased odds of death by 90 days or of return to theatre across any of the operative groups when the operation was performed with a trainee listed as the most senior surgeon in theatre. Trainees were more likely to operate independently in high-volume centres (highest- versus lowest-volume centres: odds ratio (OR) 2·11, 95 per cent c.i. 1·91 to 2·33) and at night (00.00 to 07.59 versus 08.00 to 11.59 hours; OR 3·20, 2·95 to 3·48).
Conclusion
There is significant variation in trainee-led operating in emergency laparotomy by geographical area, hospital size and by time of day. However, this does not appear to influence mortality or return to theatre.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - S Lockwood
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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13
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Affiliation(s)
- S R Brown
- University of Sheffield, Sheffield, UK.
| | - J N Lund
- University of Nottingham, Nottingham, UK
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14
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Thomas PW, Blackwell JEM, Herrod PJJ, Peacock O, Singh R, Williams JP, Hurst NG, Speake WJ, Bhalla A, Lund JN. Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients. Tech Coloproctol 2019; 23:761-767. [PMID: 31392530 PMCID: PMC6736926 DOI: 10.1007/s10151-019-02056-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 03/29/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
Background Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER. Methods A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view). Results One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%. Conclusions This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.
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Affiliation(s)
- P W Thomas
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J E M Blackwell
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - P J J Herrod
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK. .,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK.
| | - O Peacock
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - R Singh
- Department of Radiology, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J P Williams
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK.,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK
| | - N G Hurst
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - W J Speake
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - A Bhalla
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J N Lund
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK.,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK
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15
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Hardy E, Herrod P, Sian T, Boyd-Carson H, Blackwell J, Lund JN, Quarmby JW. Fibrin glue obliteration is safe, effective and minimally invasive as first line treatment for pilonidal sinus disease in children. J Pediatr Surg 2019; 54:1668-1670. [PMID: 30268489 DOI: 10.1016/j.jpedsurg.2018.07.024] [Citation(s) in RCA: 7] [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: 05/30/2018] [Accepted: 07/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND / PURPOSE Sacrococcygeal pilonidal sinus disease (PSD) has an incidence of 1.2-2.5/1000 in children. Onset is around puberty. Symptoms of recurrent abscess and chronic suppuration may interfere with education and social integration. Treatments should cause minimal disruption while having good cure and recurrence rates. Curettage and Fibrin glue obliteration (FGO) show promising results in adults. We present our experience of its use in children. METHODS Review of all pediatric patients receiving FGO of pilonidal sinus performed by a single surgeon from September 2014 to February 2018. RESULTS Eighteen patients were identified. Median age was 16 (range 15-17), 55.6% were male. All procedures were completed as day cases. Median operative duration was 14 .1 (6-29) min. Twelve patients required only 1 procedure, 4 required 2 procedures, 1 required 5 procedures and 1 elected for formal excision after 2 FGO treatments. Median return to normal activities was 3 days, with 1 day school absence. Two patients developed minor surgical site infections. Median follow-up was 52 weeks (17-102), during which time there was 1 recurrence (5.6%). CONCLUSION This study demonstrates FGO is a safe, effective procedure for pediatric PNS, with results comparable to off-midline flap techniques and without the need for extensive tissue excision and the associated morbidity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ejo Hardy
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT.
| | - Pjj Herrod
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - T Sian
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - H Boyd-Carson
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - Jem Blackwell
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - J N Lund
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - J W Quarmby
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2
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16
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Boyd-Carson H, Doleman B, Herrod PJJ, Anderson ID, Williams JP, Lund JN, Tierney GM, Murray D, Hare S, Lockwood S, Oliver CM, Spurling LJ, Poulton T, Johnston C, Cromwell D, Kuryba A, Martin P, Lourtie J, Goodwin J, Mooesinghe R, Eugene N, Catrin-Cook S, Anderson I. Association between surgeon special interest and mortality after emergency laparotomy. Br J Surg 2019; 106:940-948. [DOI: 10.1002/bjs.11146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/07/2019] [Accepted: 01/31/2019] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy.
Methods
Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes.
Results
A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12).
Conclusion
Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - P J J Herrod
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - I D Anderson
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
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17
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Herrod P, Boyd-Carson H, Doleman B, Blackwell J, Hardy E, Harper F, Lund JN. Safe investigation of isolated change in bowel habit with a flexible sigmoidoscopy? A systematic review and meta-analysis. Ann R Coll Surg Engl 2019; 101:379-386. [PMID: 30855983 DOI: 10.1308/rcsann.2019.0012] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Public awareness campaigns have led to increasing referrals of patients to colorectal surgery for possible cancer. Change in bowel habit, is traditionally described as a symptom of a left sided bowel cancer. If this is the case in practice, it raises the potentially attractive option of investigating such patients with flexible sigmoidoscopy only. This study sought to systematically review the literature describing tumour location of patients with bowel cancer presenting with left-sided symptoms to establish the safety of potential investigation of these patients with flexible sigmoidoscopy alone. METHODS A systematic review of studies reporting both the presenting symptoms of patients with bowel cancer and the location of their cancer in the bowel was prospectively registered (CRD42017072492). MEDLINE, EMBASE and CENTRAL were searched with no date or language restriction. RESULTS Seven studies were included. Isolated change in bowel habit (with or without rectal bleeding) was a presenting symptom of 73% (95% CI 41-96%, I2 = 99%) of left-sided cancers but also in 13% (95% CI 2-30%, I2 = 96%) of right-sided cancers. In all patients with cancer who presented with isolated change in bowel habit (with or without rectal bleeding), the cancer was right sided in 8% (95% CI 4-12%, I2 = 69%). CONCLUSIONS There is a higher than expected risk that if a cancer is diagnosed in a patient presenting with either an isolated change in bowel habit or a combination of change in bowel habit with rectal bleeding, the cancer may be right sided.
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Affiliation(s)
| | | | | | | | | | - F Harper
- Royal Derby Hospital , Derby , UK
| | - J N Lund
- Royal Derby Hospital , Derby , UK
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18
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Sian TS, Herrod PJJ, Blackwell JEM, Hardy EJO, Lund JN. Fibrin glue is a quick and effective treatment for primary and recurrent pilonidal sinus disease. Tech Coloproctol 2018; 22:779-784. [DOI: 10.1007/s10151-018-1864-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/30/2018] [Indexed: 10/27/2022]
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Herrod PJJ, Cox M, Keevil H, Smith KJE, Lund JN. NICE guidance on sepsis is of limited value in postoperative colorectal patients: the scores that cry 'wolf!'. Ann R Coll Surg Engl 2018; 100:275-278. [PMID: 29364019 PMCID: PMC5958846 DOI: 10.1308/rcsann.2017.0227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/19/2022] Open
Abstract
Background and aims Late recognition of sepsis and consequent death remains a problem. To address this, the National Institute for Health and Care Excellence has published updated guidance recommending the use of the Quick Sequential Organ Failure Assessment (Q-SOFA) score when assessing patients at risk of sepsis following the publication of the Third International Consensus Definitions for Sepsis and Septic Shock. The trauma from major surgery produces a systemic inflammatory response syndrome (SIRS) postoperatively as part of its natural history, which may falsely trigger scoring systems. We aimed to assess the accuracy of Q-SOFA and SIRS criteria as recommended scores for early detection of sepsis and septic complications in the first 48hrs after colorectal cancer surgery. Methods We reviewed all elective major colorectal operations in a single centre during a 12-month period from prospectively maintained electronic records. Results One hundred and thirty nine patients were included in this study. In all, 29 patients developed postoperative infective complications in hospital. Nineteen patients triggered on SIRS without developing infective complications, while 42 patients triggered on Q-SOFA with no infective complications. The area under the ROC curve was 0.52 for Q-SOFA and 0.67 for SIRS. Discussion Q-SOFA appears to perform little better than a coin toss at identifying postoperative sepsis after colorectal cancer resection and is inferior to the SIRS criteria. More work is required to assess whether a combination of scoring criteria, biochemical markers and automated tools could increase accurate detection of postoperative infection and trigger early intervention.
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Affiliation(s)
- PJJ Herrod
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - M Cox
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - H Keevil
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - KJE Smith
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - JN Lund
- Department of General Surgery, Royal Derby Hospital, Derby, UK
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20
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Sian TS, Tierney GM, Park H, Lund JN, Speake WJ, Hurst NG, Al Chalabi H, Smith KJ, Tou S. Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential. J Robot Surg 2017; 12:271-275. [PMID: 28721636 DOI: 10.1007/s11701-017-0728-7] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/04/2017] [Indexed: 01/21/2023]
Abstract
A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5 years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.
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Affiliation(s)
- Tanvir Singh Sian
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - G M Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - H Park
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - J N Lund
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK.,Division of Health Sciences, University of Nottingham, School of Medicine, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - W J Speake
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - N G Hurst
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - H Al Chalabi
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - K J Smith
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - S Tou
- Department of Colorectal Surgery, Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE, UK
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21
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Baker BG, Bhalla A, Doleman B, Yarnold E, Simons S, Lund JN, Williams JP. Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment. Med Teach 2017; 39:53-57. [PMID: 27631579 DOI: 10.1080/0142159x.2016.1230188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Simulation-based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. We aimed to compare objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment. METHODS HRV recordings were obtained from eight anesthetic trainees performing an uncomplicated rapid sequence induction at pre-determined procedural steps using a wireless Polar RS800CX monitor © in an emergency theatre setting. This was repeated in the simulated environment. Participants completed an STAI before and after the procedure. RESULTS Eight trainees completed the study. The theatre environment caused an increase in objective stress vs baseline (p = .004). There was no significant difference between average objective stress levels across all time points (p = .20) between environments. However, there was a significant interaction between the variables of objective stress and environment (p = .045). There was no significant difference in subjective stress (p = .27) between environments. DISCUSSION Simulation was unable to accurately replicate the stress of the technical procedure. This is the first study that compares the stress during SBT with the theatre environment and has implications for the assessment of simulated environments for use in examinations, rating of technical and non-technical skills, and stress management training.
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Affiliation(s)
- B G Baker
- a Division of Surgery, Royal Derby Hospital , Derby , UK
| | - A Bhalla
- a Division of Surgery, Royal Derby Hospital , Derby , UK
| | - B Doleman
- b Division of Medical Sciences and Graduate Entry Medicine , University of Nottingham , Derby , UK
| | - E Yarnold
- b Division of Medical Sciences and Graduate Entry Medicine , University of Nottingham , Derby , UK
| | - S Simons
- b Division of Medical Sciences and Graduate Entry Medicine , University of Nottingham , Derby , UK
| | - J N Lund
- a Division of Surgery, Royal Derby Hospital , Derby , UK
- b Division of Medical Sciences and Graduate Entry Medicine , University of Nottingham , Derby , UK
| | - J P Williams
- a Division of Surgery, Royal Derby Hospital , Derby , UK
- b Division of Medical Sciences and Graduate Entry Medicine , University of Nottingham , Derby , UK
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22
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Doleman B, Blackwell J, Karangizi A, Butt W, Bhalla A, Lund JN, Williams JP. Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation. Acta Anaesthesiol Scand 2016; 60:910-6. [PMID: 26940201 DOI: 10.1111/aas.12716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/29/2016] [Accepted: 02/07/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aims of this study were to determine if patient ASA grade was associated with increased stress in anaesthetists with a subsequent effect on non-technical skills. METHODS Stress was measured using a validated objective (heart rate variability or heart rate) and subjective tool. We studied eight consultant anaesthetists at baseline (rest) and during 16 episodes of intubation with an ASA 1 or 2 patient vs. an ASA 3 or 4 patient. The primary outcome for the study was objective and subjective stress between both patient groups. Secondary outcomes were non-technical skill ratings and the association between stress measurements. RESULTS ASA 3 or 4 patients were associated with increases in objective stress when compared to baseline (mean 4.6 vs. 6.7; P = 0.004). However, ASA 1 or 2 patients were not associated with increases in stress when compared to baseline (mean 4.6 vs. 4.7; P = 1). There was no significant difference in subjective stress between the groups (P = 0.18). Objective stress negatively affected situational awareness (P = 0.03) and decision-making (P = 0.03); however, these did not decline to a clinically significant threshold. Heart rate variability (r = 0.60; P = 0.002) better correlated with subjective stress when compared to heart rate (r = 0.30; P = 0.15). Agreement between raters for Anaesthetic Non-Technical Skills (ANTS) scores was acceptable (ICC = 0.51; P = 0.003). CONCLUSION This study suggests that higher patient ASA grade can increase stress in anaesthetists, which may impair non-technical skills.
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Affiliation(s)
- B. Doleman
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - J. Blackwell
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - A. Karangizi
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - W. Butt
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - A. Bhalla
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - J. N. Lund
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
| | - J. P. Williams
- Division of Medical Sciences and Graduate Entry Medicine; Royal Derby Hospital; University of Nottingham; Derby UK
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23
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Boereboom CL, Phillips BE, Williams JP, Lund JN. A 31-day time to surgery compliant exercise training programme improves aerobic health in the elderly. Tech Coloproctol 2016; 20:375-382. [PMID: 27015678 DOI: 10.1007/s10151-016-1455-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 08/28/2015] [Accepted: 02/26/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Over 41,000 people were diagnosed with colorectal cancer (CRC) in the UK in 2011. The incidence of CRC increases with age. Many elderly patients undergo surgery for CRC, the only curative treatment. Such patients are exposed to risks, which increase with age and reduced physical fitness. Endurance-based exercise training programmes can improve physical fitness, but such programmes do not comply with the UK, National Cancer Action Team 31-day time-to-treatment target. High-intensity interval training (HIT) can improve physical performance within 2-4 weeks, but few studies have shown HIT to be effective in elderly individuals, and those who do employ programmes longer than 31 days. Therefore, we investigated whether HIT could improve cardiorespiratory fitness in elderly volunteers, age-matched to a CRC population, within 31 days. METHODS This observational cohort study recruited 21 healthy elderly participants (8 male and 13 female; age 67 years (range 62-73 years)) who undertook cardiopulmonary exercise testing before and after completing 12 sessions of HIT within a 31-day period. RESULTS Peak oxygen consumption (VO2 peak) (23.9 ± 4.7 vs. 26.2 ± 5.4 ml/kg/min, p = 0.0014) and oxygen consumption at anaerobic threshold (17.86 ± 4.45 vs. 20.21 ± 4.11 ml/kg/min, p = 0.008) increased after HIT. CONCLUSIONS It is possible to improve cardiorespiratory fitness in 31 days in individuals of comparable age to those presenting for CRC surgery.
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Affiliation(s)
- C L Boereboom
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
- Surgical Department, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - B E Phillips
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK.
| | - J P Williams
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
| | - J N Lund
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
- Surgical Department, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
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25
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Hall SJ, Peacock JDH, Cochrane LA, Peacock O, Tierney GM, Tou SIH, Lund JN. The bowel cancer awareness campaign 'Be Clear on Cancer': sustained increased pressure on resources and over-accessed by higher social grades with no increase in cancer detected. Colorectal Dis 2016; 18:195-9. [PMID: 26333198 DOI: 10.1111/codi.13107] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/31/2015] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the impact of the national 'Be Clear on Cancer' bowel cancer reminder campaign on service and diagnosis at a single UK institution. Secondly, to evaluate the socio-economic background of patients referred before and after the reminder campaign compared with the regional demographic. METHOD Suspected cancer 2-week wait patients in the 3 months precampaign, postcampaign and after the reminder campaign were included. Demographics, investigations and diagnosis were recorded. The postcode was used to allocate a National Readership Survey social grade. RESULTS Three hundred and eighty-three referrals were received in the 3 months precampaign, 550 postcampaign and 470 postreminder campaign. There were significant increases in the monthly referral rates following the campaign (P < 0.001 in both the post- and postreminder periods). Significantly more patients from social grades AB and C1C2 than expected from regional demographics were referred precampaign and after the reminder campaign (P < 0.001 in each case). There were no significant differences between the proportions of patients diagnosed with colorectal cancer in the three study periods (P = 0.710). CONCLUSION The 'Be Clear on Cancer' bowel cancer campaign has had a significant sustained impact on resources. It has failed to increase referrals among lower socio-economic grades, leading to an increase in 'worried well' referrals and no change in numbers, or the stage, of colorectal cancers diagnosed.
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Affiliation(s)
- S J Hall
- Division of Urology, Royal Derby Hospital, Derby, UK
| | - J D H Peacock
- Division of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | | | - O Peacock
- Division of Surgery, School of Graduate Entry Medicine and Health, Royal Derby Hospital, University of Nottingham, Derby, UK
| | - G M Tierney
- Division of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - S I H Tou
- Division of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Division of Surgery, School of Graduate Entry Medicine and Health, Royal Derby Hospital, University of Nottingham, Derby, UK
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26
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Boereboom C, Doleman B, Lund JN, Williams JP. Systematic review of pre-operative exercise in colorectal cancer patients. Tech Coloproctol 2015; 20:81-9. [PMID: 26614304 DOI: 10.1007/s10151-015-1407-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [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: 08/24/2015] [Accepted: 11/14/2015] [Indexed: 12/13/2022]
Abstract
The aim of this systematic review was to evaluate the evidence for exercise interventions prior to surgery for colorectal cancer resection. The evidence for use of exercise to improve physical fitness and surgical outcomes is as yet unknown. A systematic search was performed of MEDLINE, EMBASE, CINAHL, AMED and BNI databases for studies involving pre-operative exercise in colorectal cancer patients. Eight studies were included in the review. There is evidence that pre-operative exercise improves functional fitness, and to a lesser extent objectively measurable cardio-respiratory fitness prior to colorectal cancer resection. There is no clear evidence at present that this improvement in fitness translates into reduced peri-operative risk or improved post-operative outcomes. Current studies are limited by risk of bias. This review highlights the common difficulty in transferring promising results in a research setting, into significant improvements in the clinical arena. Future research should focus on which type of exercise is most likely to maximise patient adherence and improvements in cardio-respiratory fitness. Ultimately, adequately powered, randomised controlled trials are needed to investigate whether pre-operative exercise improves post-operative morbidity and mortality.
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Affiliation(s)
- C Boereboom
- University of Nottingham, Royal Derby Hospital, Derby, UK
| | - B Doleman
- University of Nottingham, Royal Derby Hospital, Derby, UK.
| | - J N Lund
- University of Nottingham, Royal Derby Hospital, Derby, UK
| | - J P Williams
- University of Nottingham, Royal Derby Hospital, Derby, UK
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27
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Affiliation(s)
- A Bhalla
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - O Peacock
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Uttoxeter Road, Derby, DE22 3NE, UK
| | - J N Lund
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Uttoxeter Road, Derby, DE22 3NE, UK
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28
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Bhalla A, Peacock O, Tierney GM, Tou S, Hurst NG, Speake WJ, Williams JP, Lund JN. Day-case closure of ileostomy: feasible, safe and efficient. Colorectal Dis 2015; 17:820-3. [PMID: 25808587 DOI: 10.1111/codi.12961] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [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: 01/02/2015] [Accepted: 02/19/2015] [Indexed: 02/08/2023]
Abstract
AIM Over 5000 loop ileostomy closures were performed in the UK in 2013 with a median inpatient stay of 5 days. Previously we have successfully implemented a 23-h protocol for loop ileostomy closure which was modified for same-day discharge. We present our early experience of day-case loop ileostomy closure. METHOD A specific patient pathway for day-case discharge following loop ileostomy closure was implemented with inclusion criteria to conform with British Association of Day Surgery guidelines. Exclusion criteria included postoperative chemoradiotherapy, multiple comorbidities and social care needs. Follow-up consisted of telephone contact (24 and 72 h after discharge) and a routine outpatient appointment. Patients were provided with a 24-h contact point in case of emergency. RESULTS Fifteen (12 male) patients were enrolled of median age 67 (39-80) years. The median operating time was 41 (23-80) min. The indication for ileostomy formation was to cover a low anterior resection for adenocarcinoma (13), reversal of Hartmann's procedure (1) and functional bowel disorder (1). The median interval from the primary procedure to day-case loop ileostomy closure was 8 (3-14) months. Every patient was discharged on the day of surgery. There were no complications related to the surgery and there was one readmission due to a urinary tract infection. The median length of follow-up was 4 (2-16) months. CONCLUSION Our early experience shows that day-case loop ileostomy closure is feasible, safe and efficient. This protocol will become standard within our institution for suitable patients, saving on average five inpatient bed days per patient.
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Affiliation(s)
- A Bhalla
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK.,School of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, UK
| | - O Peacock
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK
| | - G M Tierney
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK
| | - S Tou
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK
| | - N G Hurst
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK
| | - W J Speake
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK
| | - J P Williams
- School of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, UK.,Department of Anaesthesia, Royal Derby Hospital NHS Trust, Derby, UK
| | - J N Lund
- Department of Colorectal Surgery, Royal Derby Hospital NHS Trust, Derby, UK.,School of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, UK
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Doleman B, Heinink TP, Read DJ, Faleiro RJ, Lund JN, Williams JP. A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain. Anaesthesia 2015; 70:1186-204. [DOI: 10.1111/anae.13179] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | | | - J. N. Lund
- Department of Surgery; University of Nottingham; Derby UK
| | - J. P. Williams
- Department of Anaesthesia; University of Nottingham; Derby UK
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30
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Jones KI, Amawi F, Bhalla A, Peacock O, Williams JP, Lund JN. Assessing surgeon stress when operating using heart rate variability and the State Trait Anxiety Inventory: will surgery be the death of us? Colorectal Dis 2015; 17:335-41. [PMID: 25406932 DOI: 10.1111/codi.12844] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [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: 03/24/2014] [Accepted: 08/13/2014] [Indexed: 12/13/2022]
Abstract
AIM Performance in the operating room is affected by a combination of individual, patient and environmental factors amongst others. Stress has a potential negative impact on performance with the quality of surgical practice and patient safety being affected as a result. In order to appreciate the level of stress encountered during surgical procedures both objective and subjective methods can be used. This study reports the use of a combined objective (physiological) and subjective (psychological) method for evaluating stress experienced by the operating surgeon. METHOD Six consultant colorectal surgeons were evaluated performing eighteen anterior resections. Heart rate was recorded using a wireless chest strap at eight pre-determined operative steps. Heart Rate Variability indices were calculated offline using computerized software. Surgeon reported stress was collected using the State Trait Anxiety Inventory, a validated clinical stress scale. RESULTS A significant increase in stress was demonstrated in all surgeons whilst operating as indicated by sympathetic tone (control: 4.02 ± 2.28 vs operative: 11.42 ± 4.63; P < 0.0001). Peaks in stress according to operative step were comparable across procedures and surgeons. There was a significant positive correlation with subjective reporting of stress across procedures (r = 0.766; P = 0.0005). CONCLUSION This study demonstrates a significant increase in sympathetic tone in consultant surgeons measured using heart rate variability during elective colorectal resections. A significant correlation can be demonstrated between HRV measurements and perceived stress using the State Trait Anxiety Inventory. A combined approach to assessing operative stress is required to evaluate any effect on performance and outcomes.
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Affiliation(s)
- K I Jones
- Oxford University Hospitals, Oxford, UK
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31
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Jones KI, Doleman B, Scott S, Lund JN, Williams JP. Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications. Colorectal Dis 2015; 17:O20-6. [PMID: 25328119 DOI: 10.1111/codi.12805] [Citation(s) in RCA: 247] [Impact Index Per Article: 27.4] [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: 05/28/2014] [Accepted: 09/06/2014] [Indexed: 12/12/2022]
Abstract
AIM Radiologically assessed muscle mass has been suggested as a surrogate marker of functional status and frailty and may predict patients at risk of postoperative complications. We hypothesize that sarcopenia negatively impacts on postoperative recovery and is predictive of complications. METHOD One hundred patients undergoing elective resection for colorectal carcinoma were included in this study. Lean muscle mass was estimated by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra identified on a preoperative CT scan, normalizing for patient height. Perioperative morbidity was scored according to the Clavien-Dindo classification. All statistical data analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 20.0. RESULTS Fifteen per cent of patients were identified as sarcopenic. There were no deaths in the study group. Sarcopenia was associated with a significantly increased risk of developing major complications (Grade 3 or greater, OR = 5.41, 95% CI: 1.45-20.15, P = 0.01). Sarcopenia did not predict length of stay, critical care dependency or time to mobilization. CONCLUSION Sarcopenia, as a marker of frailty, is an important risk factor in surgical patients but difficult to estimate using bedside testing. CT scans, performed for preoperative staging, provide an opportunity to quantify lean muscle mass without additional cost or exposure to radiation and eliminate the inconvenience of further investigations.
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Affiliation(s)
- K I Jones
- Department of Surgery, Oxford University Hospitals, Oxford, UK
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32
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Tierney GM, Tou S, Hender J, Lund JN. Pilot study of a new paradigm in the management of surgical emergencies using emergency surgery ambulatory care. ACTA ACUST UNITED AC 2014. [DOI: 10.1308/rcsbull.2014.96.6.198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The number of emergency admissions to hospital in the UK has been increasing for many years. The cause is multifactorial and relates to increasing population age and associated comorbidity, changes in community medical emergency cover, patient expectations and decreased clinical experience of junior medical staff. Beds occupied by emergency patients within a constrained total lead inevitably to cancellation of procedures for elective patients.
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Peacock O, Simpson JA, Tou SI, Hurst NG, Speake WJ, Tierney GM, Lund JN. Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER). Tech Coloproctol 2014; 18:571-7. [PMID: 24435472 DOI: 10.1007/s10151-013-1107-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [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: 10/24/2013] [Accepted: 12/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Extra-levator abdominoperineal excision of the rectum (ELAPER) for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. This wider excision creates a large defect requiring pelvic floor reconstruction, and there is still controversy regarding the best method of closure. The aim of this study is to present outcomes of biological mesh pelvic floor reconstruction following ELAPER. METHODS Prospective data on consecutive patients having ELAPER for low rectal cancer at a single UK institution between October 2008 and March 2013 were collected. The perineum was reconstructed using a biological mesh and the short-term outcomes were evaluated, focusing particularly on perineal wound complications and perineal hernias. RESULTS Thirty-four patients were included [median age 62 years, range 40-72 years, 27 males (79 %)]. The median operative time was 248 min (range 120-340 min). The median length of hospital stay was 9 days (range 4-20 days). There were three perineal complications (9 %) requiring surgical intervention, but no meshes were removed. There were no perineal hernias. The median length of follow-up was 21 months (range 1-54 months). The overall mortality was 9 % from distant metastases. CONCLUSIONS Our series adds to the increasing evidence that good outcomes can be achieved for pelvic floor reconstruction with biological mesh following ELAPER without the additional use of myocutaneous flaps. The low serious complication rate, good outcomes in perineal wound healing and the absence of perineal hernias demonstrates that this is a safe and feasible procedure.
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Affiliation(s)
- O Peacock
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK,
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Williams JP, Nyasavajjala SM, Phillips BE, Chakrabarty M, Lund JN. Surgical resection of primary tumour improves aerobic performance in colorectal cancer. Eur J Surg Oncol 2013; 40:220-6. [PMID: 24332580 DOI: 10.1016/j.ejso.2013.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 10/09/2013] [Accepted: 11/04/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Colorectal cancer is the third most common cancer in the UK, with patients suffering declines in muscle mass and aerobic function. We hypothesised that tumour removal in non-metastatic colorectal cancer would lead to a restoration of lean muscle mass and increases in objective and subjective measures of aerobic performance. METHODS We recruited two groups: patients with colorectal cancer (n = 30, 65.3 (51-77) y, body mass index 27.67 (4.83) kg m(-2)) and matched controls (n = 30, 64.6 (42-77) y, BMI 27.14 (3.51) kg m(-2)). Controls underwent a single study while colorectal cancer patients were studied before and 10 months after tumour resection. Aerobic performance was assessed via cardiopulmonary exercise testing and activity questionnaires. Lean muscle mass was measured via dual-energy X-ray absorptiometry. RESULTS Lean muscle mass was not different between groups (control: 47.82 (8.23); pre-resection: 52.41 (10.59); post-resection: 52.38 (10.52), kg). Anaerobic threshold was lower in pre-operative patients compared to controls (14.40 (3.23) vs. 19.67 (5.81) ml kg(-1) min(-1), p < 0.0001), increasing significantly post-resection (17.00 (3.56) ml kg(-1) min(-1)p < 0.0001). Self reported maximal physical activity was lower after resection compared to preoperatively (pre-resection 6.0 (6.5-5 IQR), post-resection 3.75 (4-3 IQR), p < 0.0001). CONCLUSION In colorectal cancer, anaerobic threshold is reached more rapidly than in matched controls, returning toward normal with tumour resection. Self-reported measures of activity do not mirror this objective change, cardiopulmonary exercise testing may therefore allow for a more accurate evaluation of pre and postoperative performance capability. The variance between objective and subjective measures of exercise capacity may be important in determining return to normal activities.
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Affiliation(s)
- J P Williams
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Derby DE22 3DT, UK; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, NG7 2UH, UK
| | - S M Nyasavajjala
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Derby DE22 3DT, UK.
| | - B E Phillips
- School of Biomedical Sciences, Queens Medical Centre, Nottingham NG7 2UH, UK; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, NG7 2UH, UK
| | - M Chakrabarty
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Derby DE22 3DT, UK
| | - J N Lund
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Derby DE22 3DT, UK; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, NG7 2UH, UK
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Peacock O, Clayton S, Atkinson F, Tierney GM, Lund JN. 'Be Clear on Cancer': the impact of the UK National Bowel Cancer Awareness Campaign. Colorectal Dis 2013; 15:963-7. [PMID: 23656572 DOI: 10.1111/codi.12220] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [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: 09/03/2012] [Accepted: 12/15/2012] [Indexed: 01/30/2023]
Abstract
AIM The National Bowel Cancer Awareness Campaign ('Be Clear on Cancer') was launched by the UK government in January 2012, encouraging people with bowel symptoms to present to primary care. Our aim was to evaluate the impact of the campaign on colorectal services in secondary care. METHOD Suspected cancer 2-week-wait (2WW) patients 3 months before and 3 months after the launch of the campaign were included. Demographics, reason for referral, investigations performed, cost analysis and eventual diagnoses were collected. RESULTS Three hundred and forty-three patients [median age 70 (36-100) years, 194 (57%) women] were seen and investigated in the 3 months prior to the launch of the campaign at an average cost of £575 per patient. Twenty-seven (8%) were diagnosed with lower gastrointestinal cancer and 29 (8%) with polyps. In the 3 months following the launch, 544 patients [median age 68 (30-92) years, 290 (53%) women] were reviewed (59% increase; P = 0.004). The 'did not attend' rate fell from 10% to 1%. Thirty-two (6%) patients were diagnosed with a lower gastrointestinal cancer and 20 (4%) with colorectal polyps. The cost per colorectal cancer detected rose from £7585.58 before the campaign to £9662.72 after launch (P = 0.04). CONCLUSION The 'Be Clear on Cancer' campaign has substantially increased the number of referrals under the 2WW rule, but mainly in the worried well. This has increased demands on both resources (59% more tests) and finance. Cost per cancer detected rose by 27% with no increase in funding to support the increased activity.
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Affiliation(s)
- O Peacock
- School of Graduate Entry Medicine and Health, University of Nottingham, UK.
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Mitchell WK, Lund JN, Williams JP. The role of carbohydrate drinks in preoperative nutrition. Comment 2. Ann R Coll Surg Engl 2013; 95:82-3. [PMID: 23317746 PMCID: PMC3964658 DOI: 10.1308/003588413x13511609956499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - JN Lund
- University of Nottingham, Derby,UK
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Elsey E, Lund JN. Fibrin glue in the treatment for pilonidal sinus: high patient satisfaction and rapid return to normal activities. Tech Coloproctol 2012; 17:101-4. [PMID: 23224857 DOI: 10.1007/s10151-012-0956-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [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] [Received: 08/24/2012] [Accepted: 11/21/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pilonidal sinus is a common condition often managed with invasive surgery associated with a significant morbidity and often a prolonged recovery time. Fibrin glue has been used in our institution as an alternative to conventional surgery. The purpose of this study was to perform a service evaluation of patient satisfaction and recovery following fibrin glue treatment for pilonidal sinus. METHODS All pilonidal glue procedures for a single surgeon were identified from theatre and consultant diary records from March 2007 to September 2011. A questionnaire was sent by post to all patients. Patient satisfaction, time to return to normal activities, the need for further procedures and whether they would recommend a glue procedure to a friend were evaluated. RESULTS Ninety-three patients were identified, accounting for a total of 119 glue procedures and 57/93 responses were received (61 %). The median age of respondents was 26 (17-70) years. Seventy-nine per cent (n = 45) were satisfied, pleased or very pleased with the result of their procedure. Fifty-four per cent (n = 31) were back to normal activities within a week with a further 17 % (n = 10) back to normal activities within 2 weeks. Seventy-four per cent (n = 42) required no further treatment. Of the 15 patients requiring a further procedure, 3 went on to have a repeat glue treatment which resulted in complete healing. Eighty-two per cent (n = 47) would recommend a glue procedure to a friend. CONCLUSIONS Fibrin gluing for pilonidal sinus should be considered as first-line treatment for most pilonidal sinuses. It has a high level of patient satisfaction and allows a rapid return to normal activities in this group of patients of working age.
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Affiliation(s)
- E Elsey
- Department of Surgery, Royal Derby Hospital, Derby, UK.
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Peacock O, Bhalla A, Simpson JA, Gold S, Hurst NG, Speake WJ, Tierney GM, Lund JN. Twenty-three-hour stay loop ileostomy closures: a pilot study. Tech Coloproctol 2012; 17:45-9. [DOI: 10.1007/s10151-012-0880-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/10/2012] [Indexed: 12/29/2022]
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Hotouras A, Collins P, Speake W, Tierney G, Lund JN, Thaha MA. Diagnostic yield and economic implications of endoscopic colonic biopsies in patients with chronic diarrhoea. Colorectal Dis 2012; 14:985-8. [PMID: 21973327 DOI: 10.1111/j.1463-1318.2011.02847.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [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] [Indexed: 02/08/2023]
Abstract
AIMS Random colonic biopsies are recommended to exclude microscopic colitis in patients with chronic diarrhoea especially when mucosa is macroscopically normal at endoscopy. This study aimed to assess the clinical outcome and economic impact of such a policy in an unselected group of patients with macroscopically normal mucosa. METHODS All new patients undergoing colonoscopy for investigation of chronic diarrhoea between April and December 2009 were included. Patients were divided into two groups: macroscopically normal mucosa and macroscopically inflamed mucosa. Endoscopic findings were correlated with histology of random biopsies and haematological parameters. Symptom status and any treatment were established from follow-up. The breakdown and overall cost of random biopsies for each patient with a macroscopically normal mucosa were determined, and cost incurred per diagnosis of microscopic colitis was established. RESULTS Altogether 137 (90.1%) of 152 patients with chronic diarrhoea had macroscopically normal mucosa at colonoscopy. Overall incidence of microscopic colitis in the study was 1.3% (2/152); both patients belonged to the macroscopically normal mucosa group. At follow-up, both these patients had spontaneous symptom resolution without any specific treatment. The policy of undertaking random biopsies in patients with macroscopically normal mucosa incurred an extra cost of £22,057 to diagnose two cases of microscopic colitis but did not alter medical treatment. CONCLUSIONS In unselected patients with chronic diarrhoea and macroscopically normal mucosa, random colonic biopsies have a low diagnostic yield and incur a high cost. Continued research for predictive markers to improve patient selection for targeted biopsies is needed to develop a cost-effective investigative algorithm in chronic diarrhoea.
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Affiliation(s)
- A Hotouras
- Centre for Digestive Diseases, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Coughlin TA, Jones KI, Lund JN, Clement RGE, Longman CL, Jones K. The uptake of podcasting and portable media players amongst UK medical students. Med Teach 2011; 33:85. [PMID: 21182391 DOI: 10.3109/0142159x.2011.549789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
OBJECTIVE It has recently been reported that up to one-third of patients with nonmetastatic distal rectal cancer managed with neoadjuvant chemoradiation therapy (CRT) had a complete clinical response (cCR) to treatment. In the selected cases, this has been used as the sole treatment. The aim of this study was to determine the frequency of complete pathological response for patients receiving CRT in one centre in the UK. METHOD Patients receiving 6 weeks of neoadjuvant CRT were identified using the two cancer audit databases in two different tertiary hospitals from January 2002 to November 2007. Pathology was reviewed and the histopathological response of the resected specimen to CRT was evaluated using the Mandard classification (1 = complete response, 5 = no response) RESULTS One hundred and thirty-two consecutive patients [median age 61 (range 44-86) years, 90 men] with nonmetastatic locally advanced rectal cancer received neoadjuvant chemo radiotherapy between 2002 and 2007 followed by resection of the tumour. Data were available from 129 patients. CONCLUSION Only 13 out of 132 (10%) of patients had a complete pathological response. This is one-third of the cCR previously reported. Nonsurgical therapy for rectal cancer using the Habr-Gama treatment algorithm may only be effective in a very small proportion of patients with rectal cancer in the UK and nonoperative treatment would not be recommended.
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Affiliation(s)
- S M Nyasavajjala
- Derby School of Graduate Entry Medicine and Health, University of Nottingham, Derby DE22 3DT, UK.
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Abstract
AIM To find the proportion of patients with a faecal occult blood (FOB) performed as part of the referral for the lower gastrointestinal two week wait (2WW) referral system, and whether this correlates with the cancer status. METHOD All patients referred to the colorectal cancer service using the 2WW referral criteria, between August 2005 and August 2007, were identified using the hospital's cancer audit database. Faecal occult bloods and cancer status were recorded for each patient. RESULTS Two thousand one hundred and fifty-nine patients (1177 female: 903 male; median age 58; age range 18-98) were referred by general practitioners. The FOBT was only performed on three samples in all cases. In total, 172 of 2159 patients (7.9%) had an FOB performed prior to their referral, with 55 of 172 patients (31.9%) as part of the referral for 2WW. Sixteen of 172 patients (9.3%) had an FOB performed in the presence of overt rectal bleeding. In only 2 of 172 patients (1.1%) the FOB correlated with a colorectal cancer. Unnecessary testing for FOB costs has cost pound4072.96 in total. DISCUSSION A significant number of faecal occult bloods are being performed and the detection rate, even in this symptomatic group of patients, is very low. It is evident that the test is being performed in the community on three samples and not six. This, combined with the high false positive rate, leads to patients not only undergoing unnecessary psycho-social consequences but could potentially lead to significant risks from unnecessary invasive investigation as well as the added financial burden of test itself.
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Affiliation(s)
- A G Shaw
- School of Graduate Entry Medicine and Health, University of Nottingham, Nottingham, UK.
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Shaw A, Collins EE, Fakis A, Patel P, Semeraro D, Lund JN. Colorectal surgeons and biomedical scientists improve lymph node harvest in colorectal cancer. Tech Coloproctol 2008; 12:295-8. [PMID: 19018472 DOI: 10.1007/s10151-008-0438-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [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] [Received: 05/09/2008] [Accepted: 09/08/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to review lymph node retrieval from colorectal cancer resections. METHODS We examined consecutive, single colorectal cancers excised between September 1999 and February 2007. Data gathered included patient age and gender, cancer location, total number of lymph nodes and involved lymph nodes identified. The speciality of the operating surgeon was recorded. Whether a pathologist or biomedical scientist was responsible for harvesting lymph nodes from the resected specimen was also noted. RESULTS A total of 1,194 patients were identified. Increased numbers of lymph nodes identified was associated with increased lymph node positivity (p<0.001, r=0.121). Biomedical scientists identified more lymph nodes (median 15, range 12-20) within specimens than consultant pathologists (median 10, range 7-13; p<0.001). Colorectal surgeons removed more lymph nodes (median 11, range 7-15) than non-colorectal surgeons (median 9, range 7-14; p=0.002). CONCLUSIONS There was a significant increase in lymph node harvesting over time and this correlated with lymph node positivity. Lymph node harvest was significantly higher when the resection was performed by a colorectal surgeon and when the specimen was examined by a biomedical scientist. For accurate staging and consequent correct planning of adjuvant treatment and prognosis, resections should be performed by a colorectal surgeon and the lymph nodes harvested by a biomedical scientist.
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Affiliation(s)
- A Shaw
- School of Graduate Entry Medicine and Health, University of Nottingham, Derby, DE22 3DT, UK.
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Abdelrazeq AS, Kandiyil N, Botterill ID, Lund JN, Reynolds JR, Holdsworth PJ, Leveson SH. Predictors for acute and chronic pouchitis following restorative proctocolectomy for ulcerative colitis. Colorectal Dis 2008; 10:805-13. [PMID: 18005192 DOI: 10.1111/j.1463-1318.2007.01413.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [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] [Indexed: 01/20/2023]
Abstract
OBJECTIVE This study was undertaken to evaluate the cumulative incidence, onset and risk predicting factors for acute and chronic pouchitis. METHOD A consecutive series of patients (n = 210), who underwent restorative proctocolectomy (RPC) and had a minimum follow-up of 12 months was reviewed. The cumulative incidence and onset of pouchitis was determined. Univariate analysis, followed by logistic regression analysis was used to evaluate the association of various demographic, clinical and histopathologic variables with the subsequent development of acute and chronic pouchitis. RESULTS A total of 198 patients were included. The mean follow-up was 64 months (range, 12-180). Sixty-four patients (32%) developed pouchitis, 35 acute and 29 chronic. The first episode of pouchitis occurred within the first year in 70% of cases. The presence of backwash ileitis (OR, 2.6; P = 0.015), primary sclerosing cholangitis (PSC; OR, 2; P = 0.018) and the duration of follow-up (OR, 1.1; P = 0.043) were associated with a higher incidence of pouchitis. The duration of follow-up was the only variable associated with acute pouchitis (P = 0.007). The presence of backwash ileitis and PSC were independent risk factors for chronic pouchitis (OR, 5.9; P < 0.001; OR, 2.8; P = 0.001 respectively). CONCLUSION Pouchitis is a heterogeneous disease which tends to occur early after restoration of gastrointestinal continuity. Patients with backwash ileitis and/or PSC are at considerable risk of developing chronic pouchitis. The strong association between backwash ileitis, PSC and chronic pouchitis suggests a common link in their pathogenesis.
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Shaw A, Lund JN, Semeraro D, Cartmill M, Reynolds JR, Tierney GM. Large bowel obstruction and perforation secondary to endometriosis complicated by a ventriculoperitoneal shunt. Colorectal Dis 2008; 10:520-1. [PMID: 18355375 DOI: 10.1111/j.1463-1318.2008.01505.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [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] [Indexed: 02/08/2023]
Abstract
A 36-year-old lady, with a past medical history of hydrocephalus requiring a ventriculoperitoneal (VP) shunt, was admitted with symptoms and signs of large bowel obstruction. Her condition worsened and she underwent laparotomy, where she had faecal peritonitis secondary to a perforated sigmoid colon. The shunt was contaminated with faeces leading to postoperative shunt infection and meningitis. Histology of the resected sigmoid colon revealed endometriosis at the site of perforation. Endometriosis is a rare cause of large bowel obstruction and literature review has found only two other cases of perforation because of endometriosis not associated with pregnancy. No case has been reported involving the concurrent surgical management of a contaminated VP shunt. We discuss the rarity of large bowel perforation and obstruction because of endometriosis, and the complications and management of VP shunts.
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Affiliation(s)
- A Shaw
- Department of Gastrointestinal Surgery, University of Nottingham, Derby, UK.
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Affiliation(s)
- A Shaw
- Department of Colorectal Surgery, Derby City General Hospital, Derby DE22 3NE, UK.
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Abstract
OBJECTIVE One of the 2-week wait (2WW) criteria for suspected lower gastrointestinal cancer states that patients should be referred who have iron deficiency anaemia (IDA) without obvious cause [Haemoglobin (Hb) <11 g/dl men, <10 g/dl postmenopausal women]. AIM Our aim was to find the proportion of patients referred as a 2WW not meeting the criteria, and the cost accrued by unnecessary referral. METHOD Patients referred over 1 year were identified using the hospitals cancer database. Haematology, haematinics, coeliac serology and cancer status were recorded for each patient. RESULTS A total of 204 patients were referred. In total, only 22/204 patients (10.8%) met all the necessary criteria for diagnosis and investigation of IDA prior to referral. As only 43/204 (21.1%) had been assessed for coeliac serology, this accounted for the majority of incomplete referrals. Excluding coeliac serology, only 127 (62.3%) met 2WW criteria for IDA. Of the remaining 77 patients, 57 (74%) patients did not meet the 2WW criteria on Hb alone and 35/77 were referred with no evidence of IDA. 12/127 (9.4%) patients were diagnosed with colorectal cancer. No cancers were detected in patients without BSG evidence of IDA, although one patient did not meet the criteria on Hb level alone. CONCLUSION Although iron deficiency is a good marker for gastrointestinal cancer, it is evident that 2WW referral guidelines are not being followed. 89.2% of referrals are inappropriate according to guidelines. This not only has considerable workload and financial implications but could be potentially detrimental to patient health.
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Affiliation(s)
- A G Shaw
- Department of Colorectal Surgery, Derby City General Hospital, Derby, UK.
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Abstract
Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.
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Affiliation(s)
- E E Collins
- Department of Surgery, University of Nottingham Medical School, Derby, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Lund JN, Nyström PO, Coremans G, Herold A, Karaitianos I, Spyrou M, Schouten WR, Sebastian AA, Pescatori M. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol 2006; 10:177-80. [PMID: 16969620 DOI: 10.1007/s10151-006-0276-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Accepted: 06/02/2006] [Indexed: 11/24/2022]
Abstract
Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.
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Affiliation(s)
- J N Lund
- Wolfson Digestive Diseases Centre, Clinical Sciences Wing The Medical School Derby City Hospital, Derby, UK.
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