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Ni M, Adam ME, Akbar F, Huddy JR, Borsci S, Buckle P, Rubulotta F, Carr R, Fotheringham I, Wilson C, Tsang M, Harding S, White N, Hanna GB. Development and validation of ester impregnated pH strips for locating nasogastric feeding tubes in the stomach-a multicentre prospective diagnostic performance study. Diagn Progn Res 2021; 5:22. [PMID: 34903303 PMCID: PMC8670038 DOI: 10.1186/s41512-021-00111-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND NG (nasogastric) tubes are used worldwide as a means to provide enteral nutrition. Testing the pH of tube aspirates prior to feeding is commonly used to verify tube location before feeding or medication. A pH at or lower than 5.5 was taken as evidence for stomach intubation. However, the existing standard pH strips lack sensitivity, especially in patients receiving feeding and antacids medication. We developed and validated a first-generation ester-impregnated pH strip test to improve the accuracy towards gastric placements in adult population receiving routine NG-tube feeding. The sensitivity was improved by its augmentation with the action of human gastric lipase (HGL), an enzyme specific to the stomach. METHODS We carried out a multi-centred, prospective, two-gate diagnostic accuracy study on patients who require routine NG-tube feeding in 10 NHS hospitals comparing the sensitivity of the novel pH strip to the standard pH test, using either chest X-rays or, in its absence, clinical observation of the absence of adverse events as the reference standard. We also tested the novel pH strips in lung aspirates from patients undergoing oesophageal cancer surgeries using visual inspection as the reference standard. We simulated health economics using a decision analytic model and carried out adoption studies to understand its route to commercialisation. The primary end point is the sensitivity of novel and standard pH tests at the recommended pH cut-off of 5.5. RESULTS A total of 6400 ester-impregnated pH strips were prepared based on an ISO13485 quality management system. A total of 376 gastric samples were collected from adult patients in 10 NHS hospitals who were receiving routine NG-tube feeding. The sensitivities of the standard and novel pH tests were respectively 49.2% (95% CI 44.1‑54.3%) and 70.2% (95% CI 65.6‑74.8%) under pH cut-off of 5.5 and the novel test has a lung specificity of 89.5% (95% CI 79.6%, 99.4%). Our simulation showed that using the novel test can potentially save 132 unnecessary chest X-rays per check per every 1000 eligible patients, or direct savings of £4034 to the NHS. CONCLUSIONS The novel pH test correctly identified significantly more patients with tubes located inside the stomach compared to the standard pH test used widely by the NHS. TRIAL REGISTRATION http://www.isrctn.com/ISRCTN11170249 , Registered 21 June 2017-retrospectively registered.
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Affiliation(s)
- Melody Ni
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
| | - Mina E. Adam
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
| | - Fatima Akbar
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
| | - Jeremy R. Huddy
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
| | - Simone Borsci
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
- grid.6214.10000 0004 0399 8953Cognitive Psychology and Ergonomics, University of Twente, Enschede, The Netherlands
| | - Peter Buckle
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
| | - Francesca Rubulotta
- grid.417895.60000 0001 0693 2181Imperial College Healthcare NHS Trust, London, UK
| | - Reuben Carr
- grid.421032.60000 0004 4648 5306Ingenza Ltd., Roslin, UK
| | | | - Claire Wilson
- grid.421032.60000 0004 4648 5306Ingenza Ltd., Roslin, UK
| | - Matthew Tsang
- grid.421032.60000 0004 4648 5306Ingenza Ltd., Roslin, UK
| | - Susan Harding
- grid.430342.20000 0001 0507 9019The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Nichola White
- grid.451052.70000 0004 0581 2008Medway Maritime NHS Foundation Trust, Gillingham, UK
| | - George B. Hanna
- grid.7445.20000 0001 2113 8111Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St. Mary’s Hospital, London, W2 1NY UK
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Tilney HS, Huddy JR, Nizar AS, Smith R, Gudgeon AM. Minimal access rectal cancer surgery: an observational study of patient outcomes from a district general hospital with over a decade of experience with robotic rectal cancer surgery. Colorectal Dis 2021; 23:1961-1970. [PMID: 34157214 DOI: 10.1111/codi.15776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
AIM Robotic surgery for colorectal cancer has become established more slowly than in other specialities. The aim of this study was to assess the risks and benefits of the use of robotic rectal cancer surgery in comparison with laparoscopic surgery within the confines of a subspecialist rectal cancer service in a district general hospital. METHOD Outcomes from consecutive patients undergoing minimal access rectal cancer surgery between July 2008 and January 2020 were analysed. Comparisons were made between short-term outcomes including conversion rates, anastomotic leakage and pathological outcomes as well as long-term survival and cancer recurrence. RESULTS A total of 337 patients were included in the analysis, 204 (60.5%) of whom underwent robotic surgery. Demographic characteristics and use of neoadjuvant chemoradiotherapy were similar between groups. However, patients having robotic surgery had significantly lower tumours than in the laparoscopic group (7.6 cm vs. 9.8 cm, p = 0.003). Conversion to open surgery in the robotic group was significantly less likely (9.8% vs. 22.6%, p = 0.001). Operative mortality, clinical leakage and major complications were similar between groups. While asymptomatic 'radiological' leaks were significantly more common following robotic surgery (13.7% vs. 5.3%, p = 0.017) this did not affect the long-term stoma closure rate. Pathological outcomes were similar with the exception of shorter mean distal resection margins (25.9 mm vs. 32.8 mm, p = 0.001) for the robotic group of patients. There was no statistical difference in 5-year survival between groups (78.7% robotic vs. 85.4% laparoscopic, p = 0.263) nor local recurrence (2.0% robotic vs. 3.8% laparoscopic, p = 0.253). CONCLUSIONS These results illustrate how the selective use of robotic surgery by a dedicated rectal cancer team can achieve low rates of cancer recurrence and low permanent stoma rates.
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Affiliation(s)
- Henry S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Jeremy R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Shiyam Nizar
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Ralph Smith
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Mark Gudgeon
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
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Huddy JR, Freeman Z, Vaughan S, Tilney HS. Challenge of maintaining the initial benefits of a 'cold' elective surgical unit established during the first COVID-19 peak. Br J Surg 2021; 108:e194-e195. [PMID: 33619551 PMCID: PMC7989569 DOI: 10.1093/bjs/znab052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 11/17/2022]
Affiliation(s)
- J R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK
| | - Z Freeman
- Department of General Surgery, Frimley Park Hospital, Camberley, UK
| | - S Vaughan
- Department of General Surgery, Frimley Park Hospital, Camberley, UK
| | - H S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK
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Huddy JR, Ni MZ, Barlow J, Hanna GB. Qualitative analysis of stakeholder interviews to identify the barriers and facilitators to the adoption of point-of-care diagnostic tests in the UK. BMJ Open 2021; 11:e042944. [PMID: 33849848 PMCID: PMC8051412 DOI: 10.1136/bmjopen-2020-042944] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/21/2021] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study investigated the barriers and facilitators to the adoption of point-of-care tests (POCTs). DESIGN Qualitative study incorporating a constant comparative analysis of stakeholder responses to a series of interviews undertaken to design the Point-of-Care Key Evidence Tool. SETTING The study was conducted in relation to POCTs used in all aspects of healthcare. PARTICIPANTS Forty-three stakeholders were interviewed including clinicians (incorporating laboratory staff and members of trust POCT committees), commissioners, industry, regulators and patients. RESULTS Thematic analysis highlighted 32 barriers in six themes and 28 facilitators in eight themes to the adoption of POCTs. Six themes were common to both barriers and facilitators (clinical, cultural, evidence, design and quality assurance, financial and organisational) and two themes contained facilitators alone (patient factors and other (non-financial) resource use). CONCLUSIONS Findings from this study demonstrate the complex motivations of stakeholders in the adoption of POCT. Most themes were common to both barriers and facilitators suggesting that good device design, stakeholder engagement and appropriate evidence provision can increase the likelihood of a POCT device adoption. However, it is important to realise that while the majority of identified barriers may be perceived or mitigated some may be absolute and if identified early in device development further investment should be carefully considered.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Melody Zhifang Ni
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - James Barlow
- Imperial College Business School, Imperial College London, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
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Huddy JR, Crockett M, Nizar AS, Smith R, Malki M, Barber N, Tilney HS. Experiences of a "COVID protected" robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic. J Robot Surg 2021; 16:59-64. [PMID: 33570736 PMCID: PMC7877309 DOI: 10.1007/s11701-021-01199-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/17/2021] [Indexed: 12/13/2022]
Abstract
The recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a "COVID protected" robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. "COVID protected" robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in "COVID protected" units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.
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Affiliation(s)
- Jeremy R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Matthew Crockett
- Frimley Renal Cancer Centre, Frimley Park Hospital, Camberley, UK
| | - A Shiyam Nizar
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK
| | - Ralph Smith
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK
| | - Manar Malki
- Frimley Renal Cancer Centre, Frimley Park Hospital, Camberley, UK
| | - Neil Barber
- Frimley Renal Cancer Centre, Frimley Park Hospital, Camberley, UK
| | - Henry S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, UK.
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Affiliation(s)
- J R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Portsmouth Road, Surrey, Camberley, GU16 7UJ, UK
| | - S Rasheed
- Department of Surgery, The Royal Marsden Hospital, London, UK
- Inspiral Health, St Luke's House, London, UK
| | - H S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Portsmouth Road, Surrey, Camberley, GU16 7UJ, UK.
- Inspiral Health, St Luke's House, London, UK.
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Huddy JR, Freeman Z, Crockett M, Hadjievangelou N, Barber N, Gerrard D, Tilney HS. Establishing a "cold" elective unit for robotic colorectal and urological cancer surgery and regional vascular surgery following the initial COVID-19 surge. Br J Surg 2020; 107:e466-e467. [PMID: 32790172 PMCID: PMC7436658 DOI: 10.1002/bjs.11922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | - Zoe Freeman
- Department of General Surgery, Frimley Park Hospital
| | | | | | - Neil Barber
- Frimley Renal Cancer Centre, Frimley Park Hospital
| | - David Gerrard
- Department of Vascular Surgery, Frimley Park Hospital
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Stefanova I, Huddy JR, Richardson J. A rare case of acute congestive ischaemic colitis related to combined superior and inferior mesenteric arteriovenous malformations. J Surg Case Rep 2020; 2020:rjaa083. [PMID: 32377333 PMCID: PMC7193457 DOI: 10.1093/jscr/rjaa083] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/15/2022] Open
Abstract
Visceral arteriovenous malformations (AVMs) are extremely rare with only a few cases described within the literature. To date, no cases of ischaemic colitis related to arteriovenous malformations affecting both superior and inferior mesenteric arteries have been reported. We report the first case of acute ischaemic colitis caused by venous congestion and reduced arterial flow due to combined AVMs in the territory of superior and inferior mesenteric arteries in a 51-year-old patient. After a multidisciplinary meeting, interventional radiology embolization was considered to be of unlikely benefit due to extensive varicosities; therefore, surgical treatment in the form of open subtotal colectomy and end ileostomy was performed. This case report demonstrates the severity and the complexity in the management of AVM-related ischaemic colitis, together with a review of the literature.
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Affiliation(s)
- Irena Stefanova
- Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, UK
- Correspondence address. Department of Colorectal Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK. Tel: +44-7449745876; E-mail:
| | - Jeremy R Huddy
- Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, UK
| | - John Richardson
- Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, UK
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Huddy JR, Ni M, Misra S, Mavroveli S, Barlow J, Hanna GB. Development of the Point-of-Care Key Evidence Tool (POCKET): a checklist for multi-dimensional evidence generation in point-of-care tests. ACTA ACUST UNITED AC 2018; 57:845-855. [DOI: 10.1515/cclm-2018-1089] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/10/2018] [Indexed: 01/05/2023]
Abstract
Abstract
Background
This study aimed to develop the Point-of-Care Key Evidence Tool (POCKET); a multi-dimensional checklist to guide the evaluation of point-of-care tests (POCTs) incorporating validity, utility, usability, cost-effectiveness and patient experience. The motivation for this was to improve the efficiency of evidence generation in POCTs and reduce the lead-time for the adoption of novel POCTs.
Methods
A mixed qualitative and quantitative approach was applied. Following a literature search, a three round Delphi process was undertaken incorporating a semi-structured interview study and two questionnaire rounds. Participants included clinicians, laboratory personnel, commissioners, regulators (including members of National Institute for Health and Care Excellence [NICE] committees), patients, industry representatives and methodologists. Qualitative data were analysed based on grounded theory. The final tool was revised at an expert stakeholder workshop.
Results
Forty-three participants were interviewed within the semi-structured interview study, 32 participated in the questionnaire rounds and nine stakeholders attended the expert workshop. The final version of the POCKET checklist contains 65 different evidence requirements grouped into seven themes. Face validity, content validity and usability has been demonstrated. There exists a shortfall in the evidence that industry and research methodologists believe should be generated regarding POCTs and what is actually required by policy and decision makers to promote implementation into current healthcare pathways.
Conclusions
This study has led to the development of POCKET, a checklist for evidence generation and synthesis in POCTs. This aims to guide industry and researchers to the evidence that is required by decision makers to facilitate POCT adoption so that the benefits they can bring to patients can be effectively realised.
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Affiliation(s)
- Jeremy R. Huddy
- Department of Surgery and Cancer , Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary’s Hospital , London , UK
| | - Melody Ni
- Department of Surgery and Cancer , Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary’s Hospital , London , UK
| | - Shivani Misra
- Diabetes, Endocrinology and Metabolism , St Mary’s Hospital, Imperial College London , London , UK
| | - Stella Mavroveli
- Department of Surgery and Cancer , Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary’s Hospital , London , UK
| | - James Barlow
- Imperial College Business School , South Kensington Campus , London , UK
| | - George B. Hanna
- Department of Surgery and Cancer , Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary’s Hospital , London , UK
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Huddy JR, Sodergren MH, Deguara J, Thway K, Jones RL, Mudan SS. Pancreaticoduodenectomy for the Management of Pancreatic or Duodenal Metastases from Primary Sarcoma. Anticancer Res 2018; 38:4041-4046. [PMID: 29970529 DOI: 10.21873/anticanres.12693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 03/05/2018] [Revised: 04/05/2018] [Accepted: 05/05/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIM Sarcomas are rare and heterogeneous solid tumours of mesenchymal origin and frequently have an aggressive course. The mainstay of management for localized disease is surgical excision. Following excision there is approximately 30-50% risk of developing distant metastases. The role of pancreatic resection for metastatic sarcoma is unclear. Therefore, the aim of this study was to asses the outcome of patients with pancreatic metastases of sarcoma treated with surgical resection. PATIENTS AND METHODS A retrospective analysis of a prospectively maintained single-surgeon, single-centre database was undertaken. Seven patients were identified who underwent pancreaticoduodenectomy for the management of metastatic disease from sarcoma between 2006-2016. RESULTS The median age was 59 (range=19-73) years, and there were six females and one male. The primary sites included the uterus, broad ligament, femur and inferior vena cava. One patient died in the early postoperative period. The remaining six patients developed further recurrent disease, with a median disease-free interval of 11 (range=4-27) months and median overall survival of 21 months (range=4 days to 86 months). CONCLUSION To our knowledge, this is the largest series of patients with pancreatic metastases of sarcoma treated with surgical resection. Despite optimal resection with R0 margins, in the absence of effective adjuvant systemic therapies, the benefit of such an approach in metastatic disease remains unclear.
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Affiliation(s)
- Jeremy R Huddy
- Department of Academic Surgery, The Royal Marsden Hospital, London, U.K
| | | | - Jean Deguara
- Department of Academic Surgery, The Royal Marsden Hospital, London, U.K
| | - Khin Thway
- Sarcoma Unit, The Royal Marsden Hospital, London, U.K
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden Hospital, London, U.K
| | - Satvinder S Mudan
- Department of Academic Surgery, The Royal Marsden Hospital, London, U.K. .,Sarcoma Unit, The Royal Marsden Hospital, London, U.K
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Huddy JR, Huddy FMS, Markar SR, Tucker O. Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer-a narrative review. Dis Esophagus 2018; 31:1-11. [PMID: 29024949 DOI: 10.1093/dote/dox110] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 05/01/2017] [Accepted: 08/21/2017] [Indexed: 12/11/2022]
Abstract
This narrative review aims to evaluate the evidence for the different nutritional approaches employed during neoadjuvant therapy in patients with locoregional esophageal cancer. Patients with esophageal cancer are often malnourished and difficult to optimize nutritionally. While evidence suggests that neoadjuvant therapy can offer a survival advantage, associated toxicity can exacerbate poor nutritional status. There is currently no accepted standard of care regarding optimal nutritional approach. A systematic literature search was undertaken. Studies describing the utilization of an additional nutritional intervention in patients with esophageal cancer receiving neoadjuvant therapy prior to esophagectomy were included. Primary outcome measure was 30-day postoperative mortality after esophagectomy. Secondary outcome measures were loss of weight during neoadjuvant therapy, completion rate of intended neoadjuvant therapy, complications from nutritional intervention, 30-day postoperative morbidity after esophagectomy and quality of life during neoadjuvant treatment. Given the heterogeneity of retrieved articles results was presented as a narrative review. Twenty-five studies were included of which 16 evaluated esophageal stenting, four feeding jejunostomy, three gastrostomy, one nasogastric feeding, and one comparative study of esophageal stenting to feeding jejunostomy. 30-day postoperative mortality was only reported in two of the 26 included studies limiting comparison between nutritional strategies. All studies of esophageal stents reported improvements in dysphagia with reported weight change ranging from -5.4 to +6 kg and one study reported 30-day postoperative mortality after esophagectomy (10%). In patients undergoing esophageal stenting for their neoadjuvant treatment overall migration rate was 29.9%. Studies of laparoscopically inserted jejunostomy were all retrospective reviews that demonstrated an increase in weight ranging from 0.4 to 11.8 kg and similarly no study reported 30-day postoperative mortality. Only one comparative study was included that compared esophageal stents to jejunostomy. This study reported no significant difference between the two groups in respect to complication rates (stents 22% vs. jejunostomy 4%, P = 0.11) or increase in weight (stents 4.4 kg vs. jejunostomy 4.2 kg, P = 0.59). Quality of life was also poorly reported. This review demonstrates the uncertainty on the optimal nutritional approach for patients with resectable esophageal cancer undergoing neoadjuvant treatment prior to esophagectomy. A prospective, multicenter, observational cohort study is needed to determine current practice and inform a prospective clinical trial.
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Affiliation(s)
- J R Huddy
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - F M S Huddy
- Department of Oesophago-Gastric Surgery, Royal Surrey County Hospital, Guildford, UK
| | - S R Markar
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - O Tucker
- Department of Oesophago-Gastric Surgery, Heart of England NHS Foundation Trust and University of Birmingham, UK
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Markar SR, Mackenzie H, Ni M, Huddy JR, Askari A, Faiz O, Griffin SM, Lovat L, Hanna GB. The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection. Gut 2018; 67:79-85. [PMID: 27797934 PMCID: PMC5754854 DOI: 10.1136/gutjnl-2015-311237] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 08/19/2016] [Accepted: 08/28/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper GI disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality. DESIGN Patients undergoing upper GI EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer re-intervention. Risk-adjusted cumulative sum (RA-CUSUM) analysis was used to assess patient mortality risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in the RA-CUSUM curve. RESULTS 11 051 patients underwent upper GI EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight per cent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30-day and 90-day mortality rate for patients with cancer, 6.1% vs 0.4% (p<0.001) and 12% vs 2.1% (p<0.001), respectively. The requirement for emergency intervention after EMR for cancer was also greater with low volume endoscopists (1.8% vs 0.1%, p=0.002). In patients with cancer, the RA-CUSUM curve change points for 30-day mortality and elective re-intervention were 4 cases and 43 cases, respectively. CONCLUSIONS EMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
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Affiliation(s)
- Sheraz R Markar
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Hugh Mackenzie
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Melody Ni
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Jeremy R Huddy
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Alan Askari
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Omar Faiz
- Department of Surgery & Cancer, Imperial College London, London, UK,St Mark's Hospital and Academic Institute, Harrow, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laurence Lovat
- Division of Surgery & Interventional Science, University College London, London, UK
| | - George B Hanna
- Department of Surgery & Cancer, Imperial College London, London, UK
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Ni MZ, Huddy JR, Priest OH, Olsen S, Phillips LD, Bossuyt PMM, Hanna GB. Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach. BMJ Open 2017; 7:e018128. [PMID: 29102995 PMCID: PMC5695306 DOI: 10.1136/bmjopen-2017-018128] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The existing British National Patient Safety Agency (NPSA) safety guideline recommends testing the pH of nasogastric (NG) tube aspirates. Feeding is considered safe if a pH of 5.5 or lower has been observed; otherwise chest X-rays are recommended. Our previous research found that at 5.5, the pH test lacks sensitivity towards oesophageal placements, a major risk identified by feeding experts. The aim of this research is to use a decision analytic modelling approach to systematically assess the safety of the pH test under cut-offs 1-9. MATERIALS AND METHODS We mapped out the care pathway according to the existing safety guideline where the pH test is used as a first-line test, followed by chest x-rays. Decision outcomes were scored on a 0-100 scale in terms of safety. Sensitivities and specificities of the pH test at each cut-off were extracted from our previous research. Aggregating outcome scores and probabilities resulted in weighted scores which enabled an analysis of the relative safety of the checking procedure under various pH cut-offs. RESULTS The pH test was the safest under cut-off 5 when there was ≥30% of NG tube misplacements. Under cut-off 5, respiratory feeding was excluded; oesophageal feeding was kept to a minimum to balance the need of chest X-rays for patients with a pH higher than 5. Routine chest X-rays were less safe than the pH test while to feed all without safety checks was the most risky. DISCUSSION The safety of the current checking procedure is sensitive to the choice of pH cut-offs, the impact of feeding delays, the accuracy of the pH in the oesophagus, as well as the extent of tube misplacements. CONCLUSIONS The pH test with 5 as the cut-off was the safest overall. It is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximise safety and to minimise the use of chest X-rays. TRIAL REGISTRATION NUMBER ISRCTN11170249; Pre-results.
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Affiliation(s)
- Melody Zhifang Ni
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Jeremy R Huddy
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Oliver H Priest
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - Sisse Olsen
- Specialist Surgery, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Lawrence D Phillips
- Department of Management, London School of Economics and Political Sciences, London, UK
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics (KEBB), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - George B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
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El-Osta A, Woringer M, Pizzo E, Verhoef T, Dickie C, Ni MZ, Huddy JR, Soljak M, Hanna GB, Majeed A. Does use of point-of-care testing improve cost-effectiveness of the NHS Health Check programme in the primary care setting? A cost-minimisation analysis. BMJ Open 2017; 7:e015494. [PMID: 28814583 PMCID: PMC5724165 DOI: 10.1136/bmjopen-2016-015494] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To determine if use of point of care testing (POCT) is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check (NHSHC) programme in the primary care setting. DESIGN Observational study and theoretical mathematical model with microcosting approach. SETTING We collected data on NHSHC delivered at nine general practices (seven using POCT; two not using POCT). PARTICIPANTS We recruited nine general practices offering NHSHC and a pathology services laboratory in the same area. METHODS We conducted mathematical modelling with permutations in the following fields: provider type (healthcare assistant or nurse), type of test performed (total cholesterol with either lab fasting glucose or HbA1c), cost of consumables and variable uptake rates, including rate of non-response to invite letter and rate of missed [did not attend (DNA)] appointments. We calculated total expected cost (TEC) per 100 invites, number of NHSHC conducted per 100 invites and costs for completed NHSHC for laboratory and POCT-based pathways. A univariate and probabilistic sensitivity analysis was conducted to account for uncertainty in the input parameters. MAIN OUTCOME MEASURES We collected data on cost, volume and type of pathology services performed at seven general practices using POCT and a pathology services laboratory. We collected data on response to the NHSHC invitation letter and DNA rates from two general practices. RESULTS TEC of using POCT to deliver a routine NHSHC is lower than the laboratory-led pathway with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of POCT can deliver NHSHC in one sitting, whereas the laboratory pathway offers patients several opportunities to DNA appointment. CONCLUSIONS TEC of using POCT to deliver an NHSHC in the primary care setting is lower than the laboratory-led pathway. Using POCT minimises DNA rates associated with laboratory testing and enables completion of NHSHC in one sitting.
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Affiliation(s)
- Austen El-Osta
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Maria Woringer
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Talitha Verhoef
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Claire Dickie
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Melody Z Ni
- Department of Surgery and Cancer, NIHR DEC London, Imperial College London, London W2 JNY, UK
| | - Jeremy R Huddy
- Department of Surgery and Cancer, NIHR DEC London, Imperial College London, London W2 JNY, UK
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - George B Hanna
- Department of Surgery and Cancer, NIHR DEC London, Imperial College London, London W2 JNY, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Affiliation(s)
- Piers R Boshier
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Jeremy R Huddy
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
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Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GB. The psychological impact of symptoms related to esophagogastric cancer resection presenting in primary care: A national linked database study. Eur J Surg Oncol 2016; 43:454-460. [PMID: 27919514 DOI: 10.1016/j.ejso.2016.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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] [Received: 06/22/2016] [Revised: 10/01/2016] [Accepted: 10/13/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The objective was to evaluate incidence, risk factors and impact of postoperative symptoms following esophagogastric cancer resection in primary care. METHODS Patients undergoing esophagogastrectomy for cancer from 1998 to 2010 with linked records in Clinical Practice Research Datalink, Hospital Episodes Statistics and Office of National Statistics databases were studied. The recording of codes for reflux, dysphagia, dyspepsia, nausea, vomiting, dumping, diarrhea, steatorrhea, appetite loss, weight loss, pain and fatigue were identified up to 12 months postoperatively. Psychiatric morbidity was also examined and its risk evaluated by logistic regression analysis. RESULTS Overall, 58.6% (1029/1755) of patients were alive 2 years after surgery. Of these, 41.1% had recorded postoperative symptoms. Reflux, dysphagia, dyspepsia and pain were more frequent following esophagectomy compared with gastrectomy (p < 0.05). Complications (OR = 1.40 95%CI 1.00-1.95) and surgical procedure predicted postoperative symptoms (p < 0.05). When compared with partial gastrectomy, esophagectomy (OR = 2.03 95%CI 1.26-3.27), total gastrectomy (OR = 2.44 95%CI 1.57-3.79) and esophagogastrectomy (OR = 2.66 95%CI 1.85-2.86) were associated with postoperative symptoms (p < 0.05). The majority of patients with postoperative psychiatric morbidity had depression or anxiety (98%). Predictors of postoperative depression/anxiety included younger age (OR = 0.97 95%CI 0.96-0.99), complications (OR = 2.40 95%CI 1.51-3.83), psychiatric history (OR = 6.73 95%CI 4.25-10.64) and postoperative symptoms (OR = 1.78 95%CI 1.17-2.71). CONCLUSIONS Over 40% of patients had symptoms related to esophagogastric cancer resection recorded in primary care, and were associated with an increase in postoperative depression and anxiety.
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Affiliation(s)
- G Bouras
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - S R Markar
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - E M Burns
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - J R Huddy
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - A Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College, London, United Kingdom
| | - T Athanasiou
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - A Darzi
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - G B Hanna
- Department of Surgery & Cancer, Imperial College London, United Kingdom.
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Huddy JR, Weldon SM, Ralhan S, Painter T, Hanna GB, Kneebone R, Bello F. Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics. BMJ Open 2016; 6:e011043. [PMID: 27625053 PMCID: PMC5030544 DOI: 10.1136/bmjopen-2016-011043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Public and patient engagement (PPE) is fundamental to healthcare research. To facilitate effective engagement in novel point-of-care tests (POCTs), the test and downstream consequences of the result need to be considered. Sequential simulation (SqS) is a tool to represent patient journeys and the effects of intervention at each and subsequent stages. This case study presents a process evaluation of SqS as a tool for PPE in the development of a volatile organic compound-based breath test POCT for the diagnosis of oesophagogastric (OG) cancer. SETTING Three 3-hour workshops in central London. PARTICIPANTS 38 members of public attended a workshop, 26 (68%) had no prior experience of the OG cancer diagnostic pathway. INTERVENTIONS Clinical pathway SqS was developed from a storyboard of a patient, played by an actor, noticing symptoms of oesophageal cancer and following a typical diagnostic pathway. The proposed breath testing strategy was then introduced and incorporated into a second SqS to demonstrate pathway impact. Facilitated group discussions followed each SqS. PRIMARY AND SECONDARY OUTCOME MEASURES Evaluation was conducted through pre-event and postevent questionnaires, field notes and analysis of audiovisual recordings. RESULTS 38 participants attended a workshop. All participants agreed they were able to contribute to discussions and like the idea of an OG cancer breath test. Five themes emerged related to the proposed new breath test including awareness of OG cancer, barriers to testing and diagnosis, design of new test device, new clinical pathway and placement of test device. 3 themes emerged related to the use of SqS: participatory engagement, simulation and empathetic engagement, and why participants attended. CONCLUSIONS SqS facilitated a shared immersive experience for participants and researchers that led to the coconstruction of knowledge that will guide future research activities and be of value to stakeholders concerned with the invention and adoption of POCT.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College, London, UK
| | | | - Shvaita Ralhan
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Tim Painter
- Patient Representative, London Cancer Alliance, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Roger Kneebone
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Fernando Bello
- Department of Surgery and Cancer, Imperial College, London, UK
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Huddy JR, Markar SR, Ni MZ, Morino M, Targarona EM, Zaninotto G, Hanna GB. Laparoscopic repair of hiatus hernia: Does mesh type influence outcome? A meta-analysis and European survey study. Surg Endosc 2016; 30:5209-5221. [PMID: 27129568 DOI: 10.1007/s00464-016-4900-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [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: 01/18/2016] [Accepted: 04/01/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice. METHODS An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery. RESULTS Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17-0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12-0.73); P = 0.008 vs. 0.69 (95 % CI 0.26-1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career. CONCLUSIONS Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair of hiatal hernia.
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Affiliation(s)
- Jeremy R Huddy
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK
| | - Sheraz R Markar
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK
| | - Melody Z Ni
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Edoardo M Targarona
- Department of General Surgery and Cancer, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Giovanni Zaninotto
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK
| | - George B Hanna
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
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Huddy JR, Ni MZ, Barlow J, Majeed A, Hanna GB. Point-of-care C reactive protein for the diagnosis of lower respiratory tract infection in NHS primary care: a qualitative study of barriers and facilitators to adoption. BMJ Open 2016; 6:e009959. [PMID: 26940107 PMCID: PMC4785316 DOI: 10.1136/bmjopen-2015-009959] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Point-of-care (POC) C reactive protein (CRP) is incorporated in National Institute of Health and Care Excellence (NICE) guidelines for the diagnosis of pneumonia, reduces antibiotic prescribing and is cost effective. AIM To determine the barriers and facilitators to adoption of POC CRP testing in National Health Service (NHS) primary care for the diagnosis of lower respiratory tract infection. DESIGN The study followed a qualitative methodology based on grounded theory. The study was undertaken in 2 stages. Stage 1 consisted of semistructured interviews with 8 clinicians from Europe and the UK who use the test in routine practice, and focused on their subjective experience in the challenges of implementing POC CRP testing. Stage 2 was a multidisciplinary-facilitated workshop with NHS stakeholders to discuss barriers to adoption, impact of adoption and potential adoption scenarios. Emergent theme analysis was undertaken. PARTICIPANTS Participants included general practitioners (including those with commissioning experience), biochemists, pharmacists, clinical laboratory scientists and industry representatives from the UK and abroad. RESULTS Barriers to the implementation of POC CRP exist, but successful adoption has been demonstrated abroad. Analysis highlighted 7 themes: reimbursement and incentivisation, quality control and training, laboratory services, practitioner attitudes and experiences, effects on clinic flow and workload, use in pharmacy and gaps in evidence. CONCLUSIONS Successful adoption models from the UK and abroad demonstrate a distinctive pattern and involve collaboration with central laboratory services. Incorporating antimicrobial stewardship into quality improvement frameworks may incentivise adoption. Further research is needed to develop scaling-up strategies to address the resourcing, clinical governance and economic impact of widespread NHS implementation.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Melody Z Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | - James Barlow
- Imperial College Business School, South Kensington Campus, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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Huddy JR, Ni M, Mavroveli S, Barlow J, Williams DA, Hanna GB. A research protocol for developing a Point-Of-Care Key Evidence Tool 'POCKET': a checklist for multidimensional evidence reporting on point-of-care in vitro diagnostics. BMJ Open 2015; 5:e007840. [PMID: 26163033 PMCID: PMC4499707 DOI: 10.1136/bmjopen-2015-007840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Point-of-care in vitro diagnostics (POC-IVD) are increasingly becoming widespread as an acceptable means of providing rapid diagnostic results to facilitate decision-making in many clinical pathways. Evidence in utility, usability and cost-effectiveness is currently provided in a fragmented and detached manner that is fraught with methodological challenges given the disruptive nature these tests have on the clinical pathway. The Point-of-care Key Evidence Tool (POCKET) checklist aims to provide an integrated evidence-based framework that incorporates all required evidence to guide the evaluation of POC-IVD to meet the needs of policy and decisionmakers in the National Health Service (NHS). METHODS AND ANALYSIS A multimethod approach will be applied in order to develop the POCKET. A thorough literature review has formed the basis of a robust Delphi process and validation study. Semistructured interviews are being undertaken with POC-IVD stakeholders, including industry, regulators, commissioners, clinicians and patients to understand what evidence is required to facilitate decision-making. Emergent themes will be translated into a series of statements to form a survey questionnaire that aims to reach a consensus in each stakeholder group to what needs to be included in the tool. Results will be presented to a workshop to discuss the statements brought forward and the optimal format for the tool. Once assembled, the tool will be field-tested through case studies to ensure validity and usability and inform refinement, if required. The final version will be published online with a call for comments. Limitations include unpredictable sample representation, development of compromise position rather than consensus, and absence of blinding in validation exercise. ETHICS AND DISSEMINATION The Imperial College Joint Research Compliance Office and the Imperial College Hospitals NHS Trust R&D department have approved the protocol. The checklist tool will be disseminated through a PhD thesis, a website, peer-reviewed publication, academic conferences and formal presentations.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Melody Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | | | - James Barlow
- Imperial College Business School, South Kensington Campus, London, UK
| | | | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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Abstract
Esophageal cancer recurrence rates after esophagectomy are high, and locally recurrent or distant metastatic disease has poor prognosis. Management is limited to palliative chemotherapy and symptomatic interventions. We report our experience of four patients who have undergone successful liver resection for metastases from esophageal cancer. All underwent esophagectomy and were referred to our unit with metastatic recurrent liver disease, two with solitary metastases and two with multi-focal disease. The patients underwent multidisciplinary assessment and proceeded to a course of neoadjuvant chemotherapy followed by open or laparoscopic liver resection. Three patients were male, and the mean age was 57.5 (range 44-71) years. Response to chemotherapy ranged from partial to complete response. Following liver resection, two patients developed recurrent disease at 5 and 15 months, and both had disease-specific mortality at 10 and 21 months, respectively. The other two patients remain disease free at 22 and 92 months. Recurrent metastatic esophageal cancer continues to have a poor prognosis, and the majority of patients with liver involvement will not be candidates for hepatic resection. However, this series suggests that in selected patients, liver resection of metastases from esophageal cancer combined with neoadjuvant and adjuvant chemotherapy is feasible, but further research is required to determine whether this can offer a survival advantage.
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Affiliation(s)
- J R Huddy
- Department of Hepatopancreaticobiliary Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - R L Thomas
- Department of Hepatopancreaticobiliary Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - T R Worthington
- Department of Hepatopancreaticobiliary Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - N D Karanjia
- Department of Hepatopancreaticobiliary Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK
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Huddy JR, Ni MZ, Markar SR, Hanna GB. Point-of-care testing in the diagnosis of gastrointestinal cancers: Current technology and future directions. World J Gastroenterol 2015; 21:4111-4120. [PMID: 25892860 PMCID: PMC4394071 DOI: 10.3748/wjg.v21.i14.4111] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/20/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
Point-of-care (POC) tests enable rapid results and are well established in medical practice. Recent advances in analytical techniques have led to a new generation of POC devices that will alter gastrointestinal diagnostic pathways. This review aims to identify current and new technologies for the POC diagnosis of gastrointestinal cancer. A structured search of the Embase and Medline databases was performed. Papers reporting diagnostic tests for gastrointestinal cancer available as a POC device or containing a description of feasibility for POC application were included. Studies recovered were heterogeneous and therefore results are presented as a narrative review. Six diagnostic methods were identified (fecal occult blood, fecal proteins, volatile organic compounds, pyruvate kinase isoenzyme type M2, tumour markers and DNA analysis). Fecal occult blood testing has a reported sensitivity of 66%-85% and specificity greater than 95%. The others are at a range of development and clinical application. POC devices have a proven role in the diagnosis of gastrointestinal cancer. Barriers to their implementation exist and the transition from experimental to clinical medicine is currently slow. New technologies demonstrate potential to provide accurate POC tests and an ability to diagnose gastrointestinal cancer at an early stage with improved clinical outcome and survival.
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Abstract
Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase-1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase-1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow-up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase-1 measured. PERT was then offered to patients with fecal elastase-1 less than 200 μg/g (EPI) as well as those in the 200-500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase-1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1-42) following surgery. Ten patients had fecal elastase-1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty-nine patients had a fecal elastase-1 in the 200-500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase-1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed.
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Affiliation(s)
- J R Huddy
- Regional Oesophagogastric Unit, Royal Surrey County Hospital, Guildford, Surrey, UK
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Abstract
Introduction: Experience has allowed increasingly complex procedures to be undertaken by single port surgery. We describe a technique for single port Billroth I gastrectomy with a hand-sewn intracorporeal anastomosis in the resection of a benign tumour diagnosed incidentally on a background of cholelithiasis. Materials and Methods: Single port Billroth I gastrectomy and cholecystectomy was performed using a transumbilical quadport. Flexible tipped camera and straight conventional instruments were used throughout the procedure. The stomach was mobilised including a limited lymph node dissection and resection margins in the proximal antrum and duodenum were divided with a flexible tipped laparoscopic stapler. The lesser curve was reconstructed and an intracorporal hand sewn two layer end-to-end anastomosis was performed using unidirectional barbed sutures. Intraoperative endoscopy confirmed the anastomosis to be patent without leak. Results: Enteral feed was started on the day of surgery, increasing to a full diet by day 6. Analgesic requirements were a patient-controlled analgesia morphine pump for 4 postoperative days and paracetamol for 6 days. There were no postoperative complications and the patient was discharged on the eighth day. Histology confirmed gastric submucosal lipoma. Discussion: As technology improves more complex procedures are possible by single port laparoscopic surgery. In this case, flexible tipped cameras and unidirectional barbed sutures have facilitated an intracorporal hand-sewn two layer end-to-end anastomosis. Experience will allow such techniques to become mainstream.
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Affiliation(s)
- Jeremy R Huddy
- Regional Oesophago-gastric Unit, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, United Kingdom
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Qureshi YA, Huddy JR, Miller JD, Strauss DC, Thomas JM, Hayes AJ. Unplanned excision of soft tissue sarcoma results in increased rates of local recurrence despite full further oncological treatment. Ann Surg Oncol 2011; 19:871-7. [PMID: 21792512 DOI: 10.1245/s10434-011-1876-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Unplanned excision of soft tissue sarcoma (STS) accounts for up to 40% of all initial operations for STS and is undertaken when the mass is presumed to be benign. The effect this has on outcome has never been fully established. METHODS Patients with extremity or trunk STS between 2001 and 2005 who were treated by an initial inadvertent operation and then referred immediately to our unit were identified. Outcomes were compared with a control group of patients with STS who were stage-matched and had been treated conventionally by core biopsy and definitive surgery. Endpoints were local recurrence, distant metastases and sarcoma-specific survival. RESULTS 134 patients who had undergone unplanned excision of STS were identified. One hundred twenty-one underwent further re-excision, and 51 (48%) of these patients had residual tumour identified after surgical re-excision. Two hundred nine stage-matched controls were identified who were treated conventionally. Median follow-up was 51.6 months. Local recurrence rates were considerably higher in the study group (23.8 vs. 11%, p = 0.0016), despite the control group having more stage 3 tumours. When the tumours were matched by stage, an increase in local recurrence was seen across all stages but was most pronounced for stage 3 tumours (37.5 vs. 14.2%, p = 0.005). Metastasis-free and sarcoma-specific survival were also significantly increased for stage 3 tumours. CONCLUSION Unplanned initial excision of extremity soft tissue sarcoma may compromise long-term local control of extremity STS despite full further oncological management.
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Affiliation(s)
- Y A Qureshi
- Soft Tissue Sarcoma and Melanoma Unit, Department of Academic Surgery, The Royal Marsden Hospital, London, UK
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