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Quyn AJ, Murthy S, Gould L, Said H, Tiernan J, Sagar P, Antoniou A, Jenkins I, Burns EM. Clinical and oncological outcomes of pelvic exenteration surgery for anal squamous cell carcinoma. Colorectal Dis 2023; 25:2131-2138. [PMID: 37753947 DOI: 10.1111/codi.16736] [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: 02/01/2023] [Revised: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 09/28/2023]
Abstract
AIM Anal cancer incidence and mortality rates are rising in the United Kingdom (UK). Surgery is an important treatment modality for persistent or recurrent disease. There is a paucity of data on outcomes for patients undergoing pelvic exenteration for anal squamous cell carcinoma (SCC) for persistent or recurrent disease. The aim of this study was to investigate the outcomes for patients who were treated with pelvic exenteration for anal SCC from two high-volume, high-complexity pelvic exenteration units in the UK. METHOD A retrospective review of prospectively maintained databases from 2011 to 2020 was undertaken. Primary endpoints included R0 resection rates, overall and disease-free survival at 2 and 5 years. RESULTS From 2011 to 2020, 35 patients with anal SCC were selected for exenteration. An R0 resection was achieved in 26 patients (77%). Of the remaining patients, seven patients had an R1 resection and one had a R2 resection. One further patient was excluded from additional analysis as the disease was inoperable at the time of laparotomy. With a median follow-up of 19.5 months (interquartile range 7.9-53.5 months), overall survival was 50% (17/34). Patients with an R1/2 resection had a significantly poorer overall survival [0.27 (0.09-0.76), p = 0.021] than those patients in whom R0 resection was achieved. Disease-free survival was 38.2% (13/34) and an R1/R2 resection was associated with a significantly reduced disease-free survival [0.12 (0.04-0.36), p < 0.001]. CONCLUSION Complete R0 resection for recurrent or persistent anal SCC is possible in the majority of patients and improves overall and disease-free survival compared with R1/R2 resection.
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Affiliation(s)
- Aaron J Quyn
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Shilpa Murthy
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Laura Gould
- Complex Cancer Clinic, St Mark's Hospital, Harrow, UK
| | - Hager Said
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Jim Tiernan
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Peter Sagar
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | | | - Ian Jenkins
- Complex Cancer Clinic, St Mark's Hospital, Harrow, UK
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Twiddy M, Birtwistle J, Edmondson A, Croft J, Gordon K, Meads D, Burke D, Griffiths B, Rose A, Sagar P, Stocken D, Brown JMB, Harji D. Recruiting to surgical trials in the emergency setting: using a mixed methods study to understand clinician and patient perspectives. BJS Open 2022; 6:zrac137. [PMID: 36417312 PMCID: PMC9683391 DOI: 10.1093/bjsopen/zrac137] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Undertaking randomized clinical trials (RCTs) in emergency surgical settings is associated with methodological and practical challenges. This study explored patients' and clinicians' perspectives associated with the conduct of an RCT comparing laparoscopic and open colorectal surgery in the acute setting. METHODS All eligible patients screened and enrolled for the 'Laparoscopic versus open colorectal surgery in the acute setting (LaCeS)' multicentre, randomized clinical feasibility trial in five UK NHS Trusts were invited to respond to a survey. Patients and healthcare professionals were also invited to take part in semi-structured interviews. Survey and interviews explored the acceptability of the feasibility trial. Interviews were audio recorded, transcribed verbatim, and analysed using thematic analysis. Survey data were analysed descriptively to assess patient views of the trial and intervention. RESULTS Out of 72 patients enrolled for the LaCeS RCT, survey data were collected from 28 patients (38.9 per cent), and interviews were conducted with 16 patients and 14 healthcare professionals. Thirteen out of 28 patients (46 per cent) had treatment preferences but these were not strong enough to deter participation. Twelve of the patients interviewed believed that their surgeon preferred laparoscopic surgery, but this did not deter them from participating in the trial. Half of the surgeons interviewed expressed the view that laparoscopic surgery was of benefit in this setting, but recognized that the need for research evidence outweighed their personal treatment preferences. Eight of the 14 recruiters reported that the emergency setting affected recruitment, especially in centres with fewer recruiting surgeons. Interviewees reported that recruitment was helped significantly by using surgical trainees to consent patients. CONCLUSION This study identified specific challenges for the LaCeS trial design to address and adds significant insights to our understanding of recruiting to emergency surgical trials more broadly.
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Affiliation(s)
- Maureen Twiddy
- Hull York Medical School, Institute of Clinical and Applied Health Research, Faculty of Health Sciences, University of Hull, Hull, UK
| | - Jacqueline Birtwistle
- Department of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Edmondson
- Department of Psychology, Nottingham Trent University,Nottingham, UK
| | - Julie Croft
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Kathryn Gordon
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - David Meads
- Department of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dermot Burke
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Azmina Rose
- Patient and Public Involvement Representative for the LaCeS Trial
| | - Peter Sagar
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deborah Stocken
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Julia M B Brown
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Deena Harji
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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Javed MA, Kohler A, Tiernan J, Quyn A, Sagar P. Evaluating potential delays and outcomes of patients undergoing surgical resection for locally advanced and recurrent colorectal cancer during a pandemic. Ann R Coll Surg Engl 2022; 104:624-631. [PMID: 35132892 PMCID: PMC9433197 DOI: 10.1308/rcsann.2021.0274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in a significant disruption of colorectal cancer (CRC) care pathways. This study evaluates the management and outcomes of patients with primary locally advanced or recurrent CRC during the pandemic in a single tertiary referral centre. METHODS Patients undergoing elective surgery for advanced or recurrent CRC with curative intent between March 2020 and March 2021 were identified. Following first multidisciplinary team discussion patients were broadly classified into two groups: straight to surgery (n=22, 45%) or neoadjuvant therapy followed by surgery (n=27, 55%). Primary outcome was COVID-19-related complication rate. RESULTS Forty-nine patients with a median age of 66 years (interquartile range: 54-73) were included. No patients developed a COVID-19 infection or related complication during hospital admission. Significant delays were identified in the treatment pathway of patients in the straight to surgery group, mostly due to delays in referral from external centres. Nine of 22 patients in the straight to surgery group had evidence of tumour progression compared with 3 of 27 in the neoadjuvant group (p=0.015839). Seven of 27 patients in the neoadjuvant group showed evidence of tumour regression. During the study, surgical waiting times were reduced, and more operations were performed during the second wave of COVID-19. CONCLUSION This study suggests that it is possible to mitigate the risks of COVID-19-related complications in patients undergoing complex surgery for locally advanced and recurrent CRC. Delay in surgical intervention is associated with tumour progression, particularly in patients who may not have neoadjuvant therapy. Efforts should be made to prioritise resources for patients requiring time-sensitive surgery for advanced and recurrent CRC.
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Sagar P, Yogesh K, Syed A, Marraiki N, Elgorban AM, Zaghloul NSS, Ashoka S. Studies on the effect of crystalline Fe2O3 on OER performance of amorphous NiOOH electrodeposited on stainless steel substrate. Chem Pap 2022. [DOI: 10.1007/s11696-022-02382-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hawthorne AB, Glatter J, Blackwell J, Ainley R, Arnott I, Barrett KJ, Bell G, Brookes MJ, Fletcher M, Muhammed R, Nevill AM, Segal J, Selinger CP, St. Clair Jones A, Younge L, Lamb CA, Arnott I, Barrett K, Bell G, Bhatnagar G, Blackwell J, Bloom S, Bramwell C, Brookes MJ, Burman A, Cairnes V, Crook KP, Dobson E, Epstein J, Faiz O, Feakins RM, Fletcher M, Garrick V, Keetarut K, Hawthorne AB, Lamb CA, Lee M, Meade U, Muhammed R, Murdock A, Pitney‐Hall N, Rochford A, Rowse G, Sagar P, Segal J, Selinger CP, Sleet S, St. Clair Jones A, Taylor SA, Wakeman R, Weaver S, Younge L. Inflammatory bowel disease patient-reported quality assessment should drive service improvement: a national survey of UK IBD units and patients. Aliment Pharmacol Ther 2022; 56:625-645. [PMID: 35770866 PMCID: PMC9541797 DOI: 10.1111/apt.17042] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/06/2022] [Accepted: 05/09/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Healthcare service provision in inflammatory bowel disease (IBD) is often designed to meet targets set by healthcare providers rather than those of patients. It is unclear whether this meets the needs of patients, as assessed by patients themselves. AIMS To assess patients' experience of IBD and the healthcare they received, aiming to identify factors in IBD healthcare provision associated with perceived high-quality care. METHODS Using the 2019 IBD standards as a framework, a national benchmarking tool for quality assessment in IBD was developed by IBD UK, comprising a patient survey and service self-assessment. RESULTS 134 IBD services and 9757 patients responded. Perceived quality of care was lowest in young adults and increased with age, was higher in males and those >2 years since diagnosis. No hospital services met all the national IBD standards for recommended workforce numbers. Key metrics associated with patient-reported high- quality care were: identification as a tertiary centre, patient information availability, shared decision- making, rapid response to contact for advice, access to urgent review, joint medical/surgical clinics, and access to research (all p < 0.001). Higher numbers of IBD nurse specialists in a service was strongly associated with patients receiving regular reviews and having confidence in self-management and reporting high- quality care. CONCLUSIONS This extensive patient and healthcare provider survey emphasises the importance of aspects of care less often measured by clinicians, such as communication, shared decision- making and provision of information. It demonstrates that IBD nurse specialists are crucial to meeting the needs of people living with IBD.
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Affiliation(s)
- A. Barney Hawthorne
- Department of GastroenterologyCardiff & Vale University Health BoardCardiffUK,Cardiff UniversityCardiffUK
| | | | | | | | - Ian Arnott
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
| | | | | | - Matthew J. Brookes
- Department of GastroenterologyRoyal Wolverhampton NHS TrustWolverhamptonUK,Research Institute in Healthcare ScienceUniversity of WolverhamptonWolverhamptonUK
| | | | - Rafeeq Muhammed
- Department of Paediatric GastroenterologyBirmingham Children's HospitalBirminghamUK
| | - Alan M. Nevill
- Faculty of Health Education and WellbeingUniversity of WolverhamptonWolverhamptonUK
| | - Jonathan Segal
- Department of GastroenterologyImperial College Healthcare NHS TrustLondonUK
| | - Christian P. Selinger
- Department of GastroenterologyLeeds Teaching Hospitals NHS TrustLeedsUK,University of LeedsLeedsUK
| | - Anja St. Clair Jones
- Department of PharmacyBrighton & Sussex University Hospitals NHS TrustBrightonUK
| | - Lisa Younge
- Department of GastroenterologySt Marks HospitalHarrowUK
| | | | - Christopher A. Lamb
- Translational & Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK,Department of GastroenterologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
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6
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Sagar P. ACPGBI Presidential report 2022. Colorectal Dis 2022; 24:695-696. [PMID: 35762415 DOI: 10.1111/codi.16197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Aim Tumours of the retrorectal space are uncommon, pathologically heterogeneous, and difficult to diagnose, with ongoing controversy over their surgical management. The aim of this study was to evaluate the surgical management of a consecutive series of patients who had undergone excision of primary retrorectal tumours (PRRTs) at a tertiary referral centre. Method Patients were identified from a prospectively maintained database between 1 March 2001 and 1 August 2021. Electronic patient records were reviewed for demographics, preoperative imaging, operative details, histology, and follow-up. A chi-squared test was used to assess the statistical significance of findings. Results A total of 144 patients were included in the study. Of these, 103 patients were female (71.5 per cent), 46 patients (31.9 per cent) presented incidentally, and 99 of the patients had tumours located below S3 (68.7 per cent). Overall, 76 patients underwent a transperineal approach (52.7 per cent) with the most common findings of a benign tailgut cyst occurring in 59 (40.9 per cent) of cases. Preoperative MRI predicted urovascular and pelvic sidewall involvement assessed intraoperatively with a sensitivity of 83.3 and 90 per cent and a specificity of 98.1 and 98 per cent respectively. Risk of malignancy in solid tumours was 31.4 versus 8.8 per cent in cystic tumours (relative risk 3.5, 95 per cent c.i. 1.6 to 7.6, P < 0.001). Major complications (Clavien–Dindo grade III and above) occurred in eight patients (5.6 per cent) and all-cause long-term mortality was 4.8 per cent (seven patients). Discussion PRRTs can be safely excised with minimal complications in specialized centres by surgical teams with the relevant expertise. This study questions the conservative management of cystic tumours and given the risk of solid tumour malignancy, supports surgical management.
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Affiliation(s)
- Joshua R. Burke
- Correspondence to: Joshua R. Burke, 7.19 Clinical Sciences Building, Leeds Teaching Hospital Trust, Beckett Street, Leeds, West Yorkshire, LS9 7TF, UK (e-mail: )
| | - Kunal Shetty
- The John Golligher Colorectal Surgery Unit, St. James’s University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James’s University Hospital, Leeds, UK
| | - Owen Thomas
- The John Golligher Colorectal Surgery Unit, St. James’s University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James’s University Hospital, Leeds, UK
| | - Mikolaj Kowal
- The John Golligher Colorectal Surgery Unit, St. James’s University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James’s University Hospital, Leeds, UK
| | - Aaron Quyn
- The John Golligher Colorectal Surgery Unit, St. James’s University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James’s University Hospital, Leeds, UK
| | - Peter Sagar
- The John Golligher Colorectal Surgery Unit, St. James’s University Hospital, Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
- Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James’s University Hospital, Leeds, UK
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8
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Glyn T, Sagar P, Frizelle F. Re: Malignant transformation of tailgut cysts is significantly higher than previously reported: Systematic review of cases in the literature. Colorectal Dis 2021; 23:3027. [PMID: 34510701 DOI: 10.1111/codi.15908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Tamara Glyn
- Christchurch Public Hospital, Christchurch, New Zealand.,University of Otago, Christchurch, New Zealand
| | | | - Frank Frizelle
- Christchurch Public Hospital, Christchurch, New Zealand.,University of Otago, Christchurch, New Zealand
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9
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Sylla P, Sagar P, Johnston SS, Dwarakanathan HR, Waggoner JR, Schwiers M, Roy S. Outcomes associated with the use of a new powered circular stapler for left-sided colorectal reconstructions: a propensity score matching-adjusted indirect comparison with manual circular staplers. Surg Endosc 2021; 36:2541-2553. [PMID: 34031743 PMCID: PMC8921098 DOI: 10.1007/s00464-021-08542-7] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/04/2021] [Indexed: 12/17/2022]
Abstract
Background This was a retrospective, matching-adjusted indirect comparison of clinical outcomes between patients from a single-arm trial of the ECHELON CIRCULAR™ Powered Stapler (ECP) and those from a historical cohort of patients who underwent left-sided colorectal resection using conventional manual circular staplers, extracted from the Premier Healthcare Database. Methods Patients in the ECP trial cohort were propensity score matched to those in the historical cohort through nearest neighbor matching. Outcomes included 30-day readmission rates; length of stay (LOS) for the index admission; rates of anastomotic leak, pelvic abscess, ileus/small bowel obstruction, infection, bleeding, and stoma creation. Results The study included 168 patients in the ECP trial cohort and 4544 patients in the historical cohort; 165 ECP trial patients were matched to 1348 historical cohort patients. After matching, conversions were more prevalent in the historical cohort than the ECP trial cohort (4.2% ECP vs. 10.2% historical, p = 0.001). Relative to the historical cohort, the ECP trial cohort had statistically significant lower rates of 30-day inpatient readmission (6.1% vs. 10.8%, p = 0.019), anastomotic leak (1.8% vs. 6.9%, p < 0.001), ileus/small bowel obstruction (4.8% vs. 14.7%, p < 0.001), infection (1.8% vs. 5.7%, p = 0.001), and bleeding (1.8% vs. 9.2%, p < 0.001) during the index admission or within 30 days thereafter. No statistically significant differences in rates of pelvic abscess, stoma creation, or LOS were found between the two cohorts. Three sensitivity analyses to address the difference in conversion rates yielded largely consistent results, with loss of statistical significance for inpatient admission in some cases. This study is limited by its potential for differences in unmeasurable factors between the ECP trial and historical cohorts. Conclusions In this study, the ECP trial cohort had lower incidence proportions of several surgical complications as compared with the historical cohort. Further controlled prospective clinical studies are needed to confirm the validity of this finding. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08542-7.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Sagar
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Stephen S Johnston
- Real-World Data Analytics and Research, Epidemiology, Medical Devices, Johnson & Johnson, 410 George Street, New Brunswick, NJ, USA.
| | | | | | | | - Sanjoy Roy
- Ethicon Endo-Surgery, Inc, Cincinnati, OH, USA
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Singh A, Sagar P, Kumar R, Kumar R. Letter to the Editor regarding "Dexamethasone eardrop with grommet placement vs intratympanic steroid injection for sudden sensorineural hearing loss: A randomized prospective clinical trial". Am J Otolaryngol 2021; 42:102785. [PMID: 33152575 DOI: 10.1016/j.amjoto.2020.102785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022]
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Akolkar D, Patil D, Fulmali P, Fulmali P, Patil R, Bendale K, Adhav A, Patel S, Khan S, Dasarathan R, Ranjan V, Chougule R, Shejwalkar P, Ainwale A, Garte M, Sonawane R, Purane M, Chaudhari Y, Sagar P, Nerkar S, Datta V, Sims C, Kumar P, Srinivasan A, Datar R. Analytical and clinical validation of the trucheckTM platform for diagnostic triaging of symptomatic cases suspected of prostate cancer. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)36226-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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12
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Sagar P, Devaraja K, Kumar R. Redefining the 'Handousa sign'. Br J Oral Maxillofac Surg 2020; 59:494-496. [PMID: 33077321 DOI: 10.1016/j.bjoms.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/04/2020] [Indexed: 11/16/2022]
Affiliation(s)
- P Sagar
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - K Devaraja
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - R Kumar
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
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13
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Burke JR, Brown P, Quyn A, Lambie H, Tolan D, Sagar P. Tumour growth rate of carcinoma of the colon and rectum: retrospective cohort study. BJS Open 2020; 4:1200-1207. [PMID: 32996713 PMCID: PMC8370463 DOI: 10.1002/bjs5.50355] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 05/29/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The growth pattern of colorectal cancer is seldom investigated. This cohort study aimed to explore tumour growth rate in colorectal cancers managed non-surgically or deemed not resectable, and to determine its implication for prognosis. METHODS Consecutive patients with colonic or rectal adenocarcinoma were identified through the colorectal multidisciplinary team database at Leeds Teaching Hospitals NHS Trust over a 2-year interval. Patients who received no treatment (surgery, stenting, colonic defunctioning procedures, chemotherapy, radiotherapy) and who underwent CT twice more than 5 weeks apart were included. Multidetector CT/three-dimensional image analysis was performed independently by three experienced radiologists. RESULTS Of 804 patients reviewed, 43 colorectal cancers were included in the final analysis. Median age at first CT was 80 (73-85) years and the median interval between scans was 150 (i.q.r. 72-471) days. An increase in T category was demonstrated in 31 of 43 tumours, with a median doubling time of 211 (112-404) days. The median percentage increase in tumour volume was 34·1 (13·3-53·9) per cent per 62 days. The all-cause 3-year mortality rate was 81 per cent (35 of 43) with a median survival time of 1·1 (0·4-2·2) years after the initial diagnostic scan. In those obstructed, the relative risk of death from subsequent perforation was 1·26 (95 per cent c.i. 1·07 to 1·49; P = 0·005). CONCLUSION This study documented a median doubling time of 211 days, with a concerning suggestion of tumour progression, which has implications for the current management standard.
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Affiliation(s)
- J. R. Burke
- John Golligher Colorectal Surgery UnitLeedsUK
- Leeds Institute of Biomedical and
Clinical SciencesSt James's University HospitalLeedsUK
| | - P. Brown
- Department of Clinical Radiology, Gastrointestinal and Abdominal Radiology,
St James's University Hospital, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - A. Quyn
- John Golligher Colorectal Surgery UnitLeedsUK
- Leeds Institute of Biomedical and
Clinical SciencesSt James's University HospitalLeedsUK
| | - H. Lambie
- Department of Clinical Radiology, Gastrointestinal and Abdominal Radiology,
St James's University Hospital, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - D. Tolan
- Department of Clinical Radiology, Gastrointestinal and Abdominal Radiology,
St James's University Hospital, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - P. Sagar
- John Golligher Colorectal Surgery UnitLeedsUK
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14
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Harji DP, Marshall H, Gordon K, Twiddy M, Pullan A, Meads D, Croft J, Burke D, Griffiths B, Verjee A, Sagar P, Stocken D, Brown J. Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial. Br J Surg 2020; 107:1595-1604. [PMID: 32573782 DOI: 10.1002/bjs.11703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology. METHODS LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery. RESULTS A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm. CONCLUSION Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).
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Affiliation(s)
- D P Harji
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - H Marshall
- Clinical Trials Research Unit, Leeds, UK
| | - K Gordon
- Clinical Trials Research Unit, Leeds, UK
| | - M Twiddy
- Institute of Clinical and Applied Health Research, University of Hull, Hull, UK
| | - A Pullan
- Clinical Trials Research Unit, Leeds, UK
| | - D Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Croft
- Clinical Trials Research Unit, Leeds, UK
| | - D Burke
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - B Griffiths
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Verjee
- Patient and Public Involvement Representative for LaCeS Trial, UK
| | - P Sagar
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - D Stocken
- Clinical Trials Research Unit, Leeds, UK
| | - J Brown
- Clinical Trials Research Unit, Leeds, UK
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15
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Jarrar A, Tiernan J, Helliwell J, Bandi B, Liska D, Seth R, Valente M, Sagar P, Steele S. Discussion on: Curative intent resection for loco-regionally recurrent colon cancer: Cleveland clinic experience. Am J Surg 2020; 219:424. [DOI: 10.1016/j.amjsurg.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Tabari A, Patino M, Westra SJ, Shailam R, Sagar P, Sahani DV, Nimkin K, Gee MS. Initial clinical experience with high-pitch dual-source CT as a rapid technique for thoraco-abdominal evaluation in awake infants and young children. Clin Radiol 2019; 74:977.e9-977.e15. [PMID: 31561835 DOI: 10.1016/j.crad.2019.08.021] [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: 02/08/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
AIM To evaluate dual-source high-pitch computed tomography (HPCT) imaging of the chest and abdomen as a rapid scanning technique to obtain diagnostic-quality imaging evaluation of infants and young children without sedation. MATERIALS AND METHODS Fifty-three paediatric patients (age 24.1±2 months) who underwent chest or abdomen HPCT (≥1.5) and standard pitch CT (SPCT, <1.5) on a dual-source 128-row multidetector CT system were included in the study. Image quality assessment was performed by two paediatric radiologists for diagnostic confidence, image artefacts, and image noise. Objective image noise was measured. RESULTS Most of the CT examinations were performed in children who were >1 year old (n=15 and n=20) followed by ≤1 year old (n=8 and n=10) in SPCT and HPCT, respectively. The mean radiation dose (SSDE) from HPCT was 1.96±1 mGy compared to 2.2±1 mGy for SPCT (p=0.3). No major artefacts were reported and overall image quality of all HPCT examinations was acceptable diagnostically. In addition, objective image noise values were not significantly different between HPCT compared with SPCT (11±3 versus 11±5, p=0.7). CONCLUSION Ultra-fast, HPCT can be performed without the need for sedation as a potential alternative to anaesthetised magnetic resonance imaging in infants and young children.
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Affiliation(s)
- A Tabari
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
| | - M Patino
- Department of Radiology, Harvard Medical School, Boston, MA, USA; Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - S J Westra
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - R Shailam
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - P Sagar
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - D V Sahani
- Department of Radiology, Harvard Medical School, Boston, MA, USA; Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - K Nimkin
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - M S Gee
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA
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17
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Brown PJ, Hyland R, Quyn AJ, West NP, Sebag-Montefiore D, Jayne D, Sagar P, Tolan DJ. Current concepts in imaging for local staging of advanced rectal cancer. Clin Radiol 2019; 74:623-636. [PMID: 31036310 DOI: 10.1016/j.crad.2019.03.023] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022]
Abstract
Imaging of rectal cancer has an increasingly pivotal role in the diagnosis, staging, and treatment stratification of patients with the disease. This is particularly true for advanced rectal cancers where magnetic resonance imaging (MRI) findings provide essential information that can change treatment. In this review we describe the rationale for the current imaging standards in advanced rectal cancer for both morphological and functional imaging on the baseline staging and reassessment studies. In addition the clinical implications and future methods by which radiologists may improve these are outlined relative to TNM8.
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Affiliation(s)
- P J Brown
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - R Hyland
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - A J Quyn
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - N P West
- Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Welcome Trust Brenner Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - D Sebag-Montefiore
- Department of Clinical Oncology, Bexley Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D Jayne
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - P Sagar
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D J Tolan
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
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TALBOT B, Sagar P, Lin R, Jun M, Sen S, Gallagher M. SUN-178 The Impact of Acute Kidney Injury Requiring Haemodialysis on Patient Survival: 10 Years of Prospective Data. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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19
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Fleming C, Pucher P, Elsey E, Glasbey J, Conneely J, Hogan A, Adair R, Lund J, Blencowe N, Smith A, Athanasiou C, Wong K, Egbuji O, Latif A, Bibi S, O'Connell E, Flanagan M, Thiyagarajan U, Kane E, Baeiv Y, Koshy R, Sudarsanam A, Gray S, Johnstone M, El Muntasar A, Adeyanzu A, Orizu M, Mallya N, Kotecha S, Daliya P, Byrne BE, Leighton P, Oliphant Z, Clement K, Scrimgeour D, Holroyd D, Doe M, Griffiths S, Chambers A, Tham J, Arunachalam P, O'Callaghan J, Bellini MI, Pereca J, Hoq O, Sagar P, Begaj A, Humm G, Williams A, Thaventhiran A, Clements JM, Ferguson H, McKay SC, Mohan H, Fleming C, Elsey E, Glasbey J, Blencowe N, Mohan H, Elsey E, Glasbey J, Mohan H, Fleming C, Kane E, Lund J, Clements J, Glasbey J, Ferguson H, McKay SC, Blencowe N, Peckham-Cooper A, Pucher P, Humm G, Mohan H. Structure and quality assurance of Fellowship Training in General Surgery: Consensus recommendations from the Association of Surgeons in Training. Int J Surg 2019; 67:101-106. [DOI: 10.1016/j.ijsu.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
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20
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Pierce TT, Shailam R, Lozano-Calderon S, Sagar P. Inter-rater Variability in the Interpretation of Pre and Post Contrast MRI for Pre-Surgical Evaluation of Osteosarcoma in Long Bones in Pediatric Patients and Young Adults. Surg Oncol 2019; 28:135-139. [PMID: 30851887 DOI: 10.1016/j.suronc.2018.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/10/2018] [Revised: 11/15/2018] [Accepted: 11/24/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES The value of gadolinium enhanced magnetic resonance imaging (MRI) sequences for extremity osteosarcoma resection planning is unverified. We evaluate the performance of intravenous gadolinium enhanced MRI for identification of neurovascular bundle involvement (NBI) and intraarticular extension (IAE) in patients with osteosarcoma. METHODS Two pediatric radiologists independently analyzed MRI examinations of patients with pathology proven extremity osteosarcoma for NBI and IAE. Initial evaluation utilized only non-contrast MRI images (PRE) and, after 2 weeks, subsequent evaluation included both the pre and post contrast images (POST). Cohen's Kappa and McNemar's test were calculated to assess agreement between PRE and POST image interpretations of NBI and IAE. RESULTS 56 patients with 90 preoperative MRI examinations were analyzed. PRE and POST interpretations were rarely discordant; 4/90 cases for NBI (Kappa 0.91) and 2/90 cases for IAE (Kappa 0.95). McNemar's test did not show a difference between PRE and POST imaging (NBI p=0.62; IAE p=0.48). CONCLUSION No significant difference between PRE and POST image interpretation was found. A high level of agreement between PRE and POST image interpretation suggests that pre-contrast MRI may be sufficient for pre-surgical planning for pediatric patients with long bone osteosarcoma.
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Affiliation(s)
- T T Pierce
- Massachusetts General Hospital, Department of Radiology, 55 Fruit Street Founders 216, Boston, MA, 02114, USA.
| | - R Shailam
- Massachusetts General Hospital, Department of Radiology, Division of Pediatric Radiology, 34 Fruit Street Ellison 237, Boston, MA, 02114, USA.
| | - S Lozano-Calderon
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street Yawkey Center for Outpatient Care, Suit 3B, Boston, MA, 02114, USA.
| | - P Sagar
- Massachusetts General Hospital, Department of Radiology, Division of Pediatric Radiology, 34 Fruit Street Ellison 237, Boston, MA, 02114, USA.
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21
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Lee M, Wu K, Yu A, Roumiantsev S, Shailam R, Nimkin K, Sagar P. Pulmonary hemorrhage in neonatal respiratory distress syndrome: Radiographic evolution, course, complications and long-term clinical outcomes. J Neonatal Perinatal Med 2019; 12:161-171. [PMID: 31256080 DOI: 10.3233/npm-1867] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Pulmonary hemorrhage (PH) is occasionally seen in premature infants after surfactant treatment for respiratory distress syndrome (RDS). These infants receive frequent chest radiographs (CXR) during and after hospitalization enabling long-term radiographic-clinical correlation. OBJECTIVE To chart the natural evolution of CXR findings of PH in RDS and correlate radiographic patterns to supplemental oxygen requirement. MATERIALS AND METHODS Retrospective review of clinical notes for gestational age (GA), birth weight (BW), intraventricular hemorrhage (IVH) and oxygen requirement were performed. CXRs were reviewed at 4 time-points; during PH, 28 days postnatal age, 36 weeks and at farthest available clinical follow-up. RESULTS 18 infants born (2003-2016), GA (24-30 weeks); BW (482-1590 grams) were included. Mean onset of PH was 1.94 (0-5) days. 9/18 (50%) had IVH. 3 died during PH; all had IVH. During PH, CXR showed whiteout 9/18 (50%); patchy opacities 5/18 (27%); diffuse haziness 1/18 (6%) and no change 3/18 (17%). At 28 days postnatal age, CXR showed fine-interstitial (FI) markings 14/15 (93%) and whiteout 1/15 (7%). At 36 weeks,12/14 (85%) had FI and 2/14 (15%) developed cystic-interstitial changes. At farthest follow-up, FI 3/13 (23%); coarse-interstitial 4/13 (30%); peri-bronchial cuffing 5/13 (38%); normal 1/13 (9%) and the majority had hyperinflation 9/13 (69%). At discharge, 9/14 (64%) required home-oxygen and 5/14 (36%) were on room-air. At farthest follow-up, 6/14 (42%) required home-oxygen and 8/14 (58%) were on room-air. CONCLUSION Premature infants that survive PH may later develop chronic lung disease of prematurity with an evolving interstitial pattern on CXR that clears overtime as they outgrow the need for supplemental oxygen.
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Affiliation(s)
- M Lee
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - K Wu
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - A Yu
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - S Roumiantsev
- Department of Pediatrics, Division of Neonatology and Newborn Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - R Shailam
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - K Nimkin
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - P Sagar
- Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA
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22
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Husain I, Sagar P, Shukla S, Babu S, Singhai A, Sankhwar SN, Husain N. The Significance of ERG and Androgen Receptor Expression in Adenocarcinoma Prostate. Kathmandu Univ Med J (KUMJ) 2018; 16:277-280. [PMID: 31729338] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Fusions of transmembrane protease, serine 2 (TMPRSS2) with erythroblast transformation specific transcription factors have been found in prostate cancer. The v-etserythroblastosis virus E26 oncogene homologue (ERG) is a proto-oncogene of the erythroblast transformation specific transcription factor family. TMPRSS2-ERG fusion is the most common molecular alteration present in about 50% of prostatic adenocarcinomas. Androgen receptor (AR) plays a key role in prostate development and is involved in the progression of prostate cancer. Objective To evaluate the significance of combined ERG and AR expression in cases of prostatic adenocarcinoma. Method The study was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. Formalin fixed-paraffin embedded archival prostatic tissue specimens were obtained. A total of 10 cases of prostatic adenocarcinoma were included in the study. Immunohistochemistry for Androgen receptor was done by the standard protocol. Multiplex immunohistochemical staining was done for ERG+CK5 using a primary antibody cocktail of mouse and rabbit antibodies. Result Specific AR immunostaining was exclusively nuclear and was present in all 10 cases in varying intensity. Specific ERG immunostaining was nuclear and was present in seven cases (70%) and absent in three cases (30%). The three cases that were negative for ERG had a Gleason score of ≤ 6 and the AR staining was strong and present in about 90% of the cells. Gleason score was directly related to the ERG staining while AR staining was inversely related to the ERG staining. Conclusion The prognostic value of combined ERG and AR over-expression, its associated genes should be further investigated as potential therapeutic targets in prostate cancer progression. Preliminary data is being presented. Larger prospective studies with survival analysis are essential for prognostic significance.
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Affiliation(s)
- I Husain
- Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh
| | | | - S Shukla
- Dr. Ram Manohar lohia, Institute of Medical Sciences, Lucknow, Uttar Pradesh
| | - S Babu
- King George's Medical University, Lucknow
| | - A Singhai
- King George's Medical University, Lucknow
| | | | - N Husain
- Dr. Ram Manohar lohia, Institute of Medical Sciences, Lucknow, Uttar Pradesh
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23
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Kumar R, Singh A, Sagar P, Behera C, Kumar R. Access to Round Window Niche via Posterior Tympanotomy and Impact of Drilling Its Overhangs: A Cadaveric Descriptive Study. Indian J Otolaryngol Head Neck Surg 2018; 70:510-514. [PMID: 30464907 DOI: 10.1007/s12070-018-1469-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/14/2018] [Indexed: 11/25/2022] Open
Abstract
We intended to study the morphological parameters of round window region and assess the gain in exposure achieved by drilling the round window niche overhang. The Exposure of the round window membrane (RWM) is of prime importance to carry out atraumatic electrode insertion for cochlear implantation. The anatomy of round window has been a subject of considerable debate in literature. Fifty-one Formalin preserved adult cadaveric temporal bones were micro-dissected to carry out an 'optimal' posterior tympanotomy to expose the round window region. The bony overhangs of round window niche (RWN) were next drilled to achieve maximal possible exposure the RWM without violating the annulus of the same. The exposure was classified as per St Thomas' Hospital classification. The round window could not be visualized in 3 bones (5.9%). The commonest morphology of RWN was dome shaped, found in 18 (37.5%) and that of the RWM was oval shaped, found in 14 (29.2%) bones. Pre drilling 41 bones had a > 50% exposure of RWM while post drilling > 50% exposure could be achieved in all the bones except the 3 bones in which RWN could not be visualized to begin with. The drilling of the RWN overhangs exposed RWM in entirety in 91.7% of bones with a visible morphology of RWN pre drilling. RWN and RWM exhibit varied morphology. Drilling of the round window niche overhangs can considerably enhance the exposure of RWM.
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Affiliation(s)
- R Kumar
- 1Department of Otolaryngology and Head and Neck Surgery, Room No.-4057, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - A Singh
- 1Department of Otolaryngology and Head and Neck Surgery, Room No.-4057, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - P Sagar
- 1Department of Otolaryngology and Head and Neck Surgery, Room No.-4057, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - C Behera
- 2Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, India
| | - R Kumar
- 1Department of Otolaryngology and Head and Neck Surgery, Room No.-4057, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, 110029 India
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24
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Harji D, Marshall H, Gordon K, Crow H, Hiley V, Burke D, Griffiths B, Moriarty C, Twiddy M, O'Dwyer JL, Verjee A, Brown J, Sagar P. Feasibility of a multicentre, randomised controlled trial of laparoscopic versus open colorectal surgery in the acute setting: the LaCeS feasibility trial protocol. BMJ Open 2018; 8:e018618. [PMID: 29472259 PMCID: PMC5879497 DOI: 10.1136/bmjopen-2017-018618] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Acute colorectal surgery forms a significant proportion of emergency admissions within the National Health Service. There is limited evidence to suggest minimally invasive surgery may be associated with improved clinical outcomes in this cohort of patients. Consequently, there is a need to assess the clinical effectiveness and cost-effectiveness of laparoscopic surgery in the acute colorectal setting. However,emergency colorectal surgical trials have previously been difficult to conduct due to issues surrounding recruitment and equipoise. The LaCeS (randomised controlled trial of Laparoscopic versus open Colorectal Surgery in the acute setting) feasibility trial will determine the feasibility of conducting a definitive, phase III trial of laparoscopic versus open acute colorectal resection. METHODS AND ANALYSIS The LaCeS feasibility trial is a prospective, multicentre, single-blinded, parallel group, pragmatic randomised controlled feasibility trial. Patients will be randomised on a 1:1 basis to receive eitherlaparoscopic or open surgery. The trial aims to recruit at least 66 patients from five acute general surgical units across the UK. Patients over the age of 18 with a diagnosis of acute colorectal pathology requiring resection on clinical and radiological/endoscopic investigations, with a National Confidential Enquiry into Patient Outcome and Death classification of urgent will be considered eligible for participation. The primary outcome is recruitment. Secondary outcomes include assessing the safety profile of laparoscopic surgery using intraoperative and postoperative complication rates, conversion rates and patient-safety indicators as surrogate markers. Clinical and patient-reported outcomes will also be reported. The trial will contain an embedded qualitative study to assess clinician and patient acceptability of trial processes. ETHICS AND DISSEMINATION The LaCeS feasibility trial is approved by the Yorkshire and The Humber, Bradford Leeds Research Ethics Committee (REC reference: 15/ YH/0542). The results from the trial will be presented at national and international colorectal conferences and will be submitted for publication to peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN15681041; Pre-results.
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Affiliation(s)
- Deena Harji
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Helen Marshall
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Katie Gordon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Hannah Crow
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Victoria Hiley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Dermot Burke
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Ben Griffiths
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Catherine Moriarty
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Azmina Verjee
- Patient and Public Representative, Association of Coloprocotology of Great Britain and Ireland, London, UK
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Peter Sagar
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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26
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. In Brief. Curr Probl Surg 2017. [DOI: 10.1067/j.cpsurg.2017.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Scheduling of elective weekend operations is entirely within our control and deaths are therefore preventable.
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Affiliation(s)
- L Hancock
- University Hospital of South Manchester
| | - P Sagar
- St James’ University Hospital, Leeds
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28
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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29
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Lee M, Heywood N, Sagar P, Brown S, Fearnhead N. Surgical management of fistulating perianal Crohn's disease – Results of a UK survey. Int J Surg 2016. [DOI: 10.1016/j.ijsu.2016.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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30
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King A, Dixon J, Harji D, Sagar P. T4 colon cancers – Elective versus emergency in the modern era. Int J Surg 2015. [DOI: 10.1016/j.ijsu.2015.07.673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Gonsalves S, Brayshaw I, Maslekar S, Hance J, Sagar P, Miskovic D. A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization. Colorectal Dis 2015; 17:O126-8. [PMID: 25754828 DOI: 10.1111/codi.12942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 07/15/2014] [Accepted: 12/23/2014] [Indexed: 02/08/2023]
Abstract
AIM This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement. METHOD A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization. RESULTS The technique was used in 12 patients. There were no adverse intra- or postoperative events. The median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9-11.25). CONCLUSION This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient's position.
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Affiliation(s)
- S Gonsalves
- The John Goligher Colorectal Unit, St James University Hospital, Leeds, UK
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Lewison R, Oro D, Godley B, Underhill L, Bearhop S, Wilson RP, Ainley D, Arcos JM, Boersma PD, Borboroglu PG, Boulinier T, Frederiksen M, Genovart M, González-Solís J, Green JA, Grémillet D, Hamer KC, Hilton GM, Hyrenbach KD, Martínez-Abraín A, Montevecchi WA, Phillips RA, Ryan PG, Sagar P, Sydeman WJ, Wanless S, Watanuki Y, Weimerskirch H, Yorio P. Research priorities for seabirds: improving conservation and management in the 21st century. ENDANGER SPECIES RES 2012. [DOI: 10.3354/esr00419] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Bansal S, Advani SH, Ambulkar IB, Sagar P, Kanekar P. Prognostic factors responsible for outcome in Hodgkin lymphoma: Analysis from a single center in India. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e18554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Retrorectal tumors are uncommon and are usually managed by open surgical excision. Recent advances in laparoscopic techniques have led to the use of laparoscopy for a variety of problems in colorectal surgery, including the excision of retrorectal tumours. This case report, which describes the laparoscopic excision of a benign schwannoma arising from the second sacral nerve root, highlights the benefits of accurate preoperative diagnosis with MR imaging and the advantages of a laparoscopic approach while pointing out principles that should be adhered to when using this approach. The tumour was successfully resected without neural compromise and with a prompt and full postoperative recovery.
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Affiliation(s)
- M Rao
- The John Goligher Colorectal Unit, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK
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Lim M, Adams JDW, Wilcox M, Finan P, Sagar P, Burke D. An assessment of bacterial dysbiosis in pouchitis using terminal restriction fragment length polymorphisms of 16S ribosomal DNA from pouch effluent microbiota. Dis Colon Rectum 2009; 52:1492-500. [PMID: 19617766 DOI: 10.1007/dcr.0b013e3181a7b77a] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [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] [Indexed: 12/17/2022]
Abstract
PURPOSE Previous studies on dysbiosis and pouchitis using conventional culture techniques have been disappointing because of inherent limitations associated with the technique. This study was designed to use terminal restriction fragment length polymorphism to evaluate patients with and without pouchitis. METHODS Bacterial microbiota in 20 pouch patients (15 healthy and 5 with inflamed) were studied. DNA was extracted from feces, and polymerase chain reaction was performed using primers (V6-V8 region) that were modified at the 5' end with cyanine dyes. Amplicons were digested with merozoite surface protein-1 enzyme. The restricted fragments were analyzed by capillary electrophoresis, and the electrophenograms were studied. Electrophenograms provide information about operational taxonomic units, which correspond to specific organisms. Principal component analysis was performed to identify dominant and important operational taxonomic units in the 20 patients. Bacterial diversity and counts of these operational taxonomic units were compared in the two groups of patients. RESULTS Total bacterial diversity in patients with pouchitis was similar to that in patients with healthy pouches (16 (11-20) vs. 12 (9-13), P = 0.279). Using principal component analysis, 29 operational taxonomic units were found to be important. Bacterial counts of seven dominant organisms (operational taxonomic unit 79 (enterococci), 85 (Pantoea), 88 (Enterobacteriaceae), 90 (eubacteria), 91 (Pseudomonas), 146 (clostridia), and 148 (bacilli)) were similar in patients with pouchitis and those with a healthy pouch (P > 0.05). Seventeen (operational taxonomic unit 73 (Leptospira), 93 (Pseudoalteromonas), 96, 100 (Desulfosporosinus), 114, 121, 134, 137, 141 (Microcystis), 159, 174 (Methylobacter), 193 (uncultured proteobacteria), 232, 376, 381, 414, and 465) of the remaining 22 nondominant organisms were seen exclusively in patients with pouchitis. The majority of these organisms were novel. CONCLUSION Terminal restriction fragment length polymorphism can be used to identify candidate organisms that may be associated with pouchitis.
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Affiliation(s)
- Michael Lim
- John Goligher Colorectal Unit, The General Infirmary at Leeds, Leeds, United Kingdom
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Jose P, Achuthan R, Sagar P. Acute abdomen due to retroperitoneal haematoma: a surgical dilemma. BMJ Case Rep 2009; 2009:bcr08.2008.0658. [PMID: 21686695 DOI: 10.1136/bcr.08.2008.0658] [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] [Indexed: 11/04/2022] Open
Abstract
A 73-year-old man presented with features of acute abdomen 2 days following evacuation of a subdural haematoma. CT scan demonstrated significant free fluid in the peritoneal cavity as well as an extensive abnormal area in the upper retroperitoneum. There was no obvious free gas or leak of contrast. As there was persistent metabolic acidosis and significant peritonism, the patient proceeded to an exploratory laparotomy. This revealed a large non-expanding retroperitoneal haematoma and free blood in the peritoneal cavity. There was no evidence of active bleeding and the bowel was found to be viable. As the patient was haemodynamically stable, a laparostomy was fashioned and the patient subsequently underwent angiography. This revealed a 1.5 cm pseudoaneurysm arising from the superior mesenteric artery which was treated with coil embolisation. The patient made an uneventful recovery and the laparostomy was closed.
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Affiliation(s)
- Paul Jose
- Leeds General Infirmary, General Surgery, D-156, Clarendon Wing, Leeds LS1 3EX, UK
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Hunt L, Morrison C, Lengyel J, Sagar P. Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option? Hernia 2008; 13:313-5. [PMID: 18956136 DOI: 10.1007/s10029-008-0438-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2008] [Accepted: 09/19/2008] [Indexed: 12/21/2022]
Abstract
An obturator hernia is a rare diagnosis that is frequently missed. Patients present with few clinical signs to identify the cause, apart from symptoms of intestinal obstruction. Therefore, obturator hernias are often diagnosed at exploratory laparotomy. The use of computed tomography (CT) has increased the chance of definitive preoperative diagnosis. However, despite these advances, patients who present acutely will frequently undergo an open procedure rather than laparoscopy. We present a case of an acute obstructed obturator hernia diagnosed in a 62-year-old female that was successfully managed laparoscopically.
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Affiliation(s)
- L Hunt
- John Goligher Colorectal Unit, Leeds General Infirmary, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
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Lim M, Gonsalves S, Thekkinkattil D, Seedat S, Finan P, Sagar P, Burke D. The assessment of a rapid noninvasive immunochromatographic assay test for fecal lactoferrin in patients with suspected inflammation of the ileal pouch. Dis Colon Rectum 2008; 51:96-9. [PMID: 18085334 DOI: 10.1007/s10350-007-9151-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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 06/11/2007] [Accepted: 08/25/2007] [Indexed: 12/14/2022]
Abstract
PURPOSE Pouchitis is a common complication after ileal pouch-anal anastomosis. Diagnosis is based on the Pouch Disease Activity Index, which comprises clinical symptoms, endoscopic appearance, and histologic confirmation. A Pouch Disease Activity Index > or = 7 confirms pouchitis. Fecal lactoferrin is a marker of intestinal inflammation, which can aid in the diagnosis of pouchitis. The IBD EZ VUE test is a simple, rapid, noninvasive test for fecal lactoferrin. Our goal was to study the sensitivity and specificity of this test in the diagnosis of pouchitis. METHODS Consecutive patients with pouch dysfunction were recruited from October 2005 to July 2006. A fecal sample was collected before calculation of the Pouch Disease Activity Index. An IBD EZ VUE test was performed on each fecal sample and the results correlated with the diagnosis of pouchitis to calculate sensitivity and specificity of the IBD EZ VUE test. RESULTS There were 32 patients (21 healthy and 11 inflamed pouches). The IBD EZ VUE test was positive in 14 patients. It had a sensitivity of 100 percent and a specificity of 86 percent in diagnosing pouchitis. The positive predictive value was 76 percent. There were three false-positive results. CONCLUSIONS The IBD EZ VUE test is a sensitive method that may remove the need for invasive pouch investigations and lead to greater confidence when antibiotic therapy is commenced. Further investigations may be reserved for those patients who have a positive lactoferrin test and fail to respond to antibiotic treatment.
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Affiliation(s)
- Michael Lim
- Department of Colorectal Surgery, Leeds General Infirmary, Leeds, United Kingdom
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Sagar P, Lalitha R, Prasad K, Ranganath K. Evolving a protocol to minimize osteoradionecrosis. Int J Oral Maxillofac Surg 2007. [DOI: 10.1016/j.ijom.2007.08.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lim M, Sagar P, Abdulgader A, Thekkinkattil D, Burke D. The impact of preoperative immunomodulation on pouch-related septic complications after ileal pouch-anal anastomosis. Dis Colon Rectum 2007; 50:943-51. [PMID: 17525860 DOI: 10.1007/s10350-007-0246-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications. METHODS A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed. RESULTS There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27-46) years. Median follow-up period was 52 (interquartile range, 26-86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02-3.45; P=0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09-0.71; P=0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08-0.76; P=0.023) remained predictive of lower rates of sepsis. CONCLUSIONS Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis.
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Affiliation(s)
- Michael Lim
- Department of Colon and Rectal Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
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Abstract
BACKGROUND The use of a loop ileostomy is an effective method in protecting pelvic anastomoses. Its use has increased recently, although there is some debate as to the routine use of a stoma. Reversal of the ileostomy is associated with a significant morbidity, which may be related to impaired function of the bypassed distal limb of the ileum. AIM To investigate the changes that might occur in the distal limb after an interval of faecal diversion. METHODS Full-thickness intestinal circular muscle (CM) strips were prepared from excised loop ileostomies taken at the time of closure. The study sample was from the distal limb and the control from the proximal limb. Contractile activity was measured using an organ bath set up to record isometric contraction after stimulation by acetylcholine (ACh). Histological sections were assessed for an index of villous atrophy, smooth muscle area, and nerve and vessel density. Analysis was with the Wilcoxon signed ranks test for paired data and the Mann-Whitney U test for unpaired data. RESULTS Samples were acquired prospectively from 35 consecutive patients. The median time between formation and closure of ileostomy was 34 weeks. Significant reduction was observed in the strength of CM contraction, smooth muscle area and median villous index of the distal limb compared with the proximal limb. CONCLUSION Impaired intestinal function has been proposed as a contributory factor in the morbidity that may follow closure of loop ileostomy. Significant loss of contractility and smooth muscle strength and villous atrophy occur in the distal ileal limb after faecal diversion. Methods of preventing these changes should be considered.
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Affiliation(s)
- Leith Williams
- Department of Colorectal Surgery, Clarendon Wing, Leeds General Infirmary, Leeds LS1 3EX, UK
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Abstract
BACKGROUND AND METHODS The exact aetiology of pouchitis is unknown, but an association with dysbiosis has been suggested. This is a retrospective review of 17 studies published between 1985 and 2005, identified by a search of the Medline, Pubmed and Embase databases. RESULTS The methodology of the studies varied widely. Many were performed at a time when the distinction between a healthy and an inflamed pouch was vague; misclassification of patients makes the analysis of data difficult and conclusions uncertain. CONCLUSION The evidence that dysbiosis is a cause of pouchitis is poor. Nevertheless, available data allow the construction of an algorithm to aid management and suggest a structured approach for future research.
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Affiliation(s)
- M Lim
- Department of Colorectal Surgery, Leeds General Infirmary, Leeds, UK.
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Lim M, Akhtar S, Sasapu K, Harris K, Burke D, Sagar P, Finan P. Clinical and subclinical leaks after low colorectal anastomosis: a clinical and radiologic study. Dis Colon Rectum 2006; 49:1611-9. [PMID: 16990979 DOI: 10.1007/s10350-006-0663-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to examine the natural history of subclinical leaks and their effect on bowel function and quality of life and to evaluate water-soluble contrast enema features that predict anastomotic healing after leaks. METHODS Consecutive patients who underwent low rectal anastomosis were followed up postoperatively for leaks. All leaks were confirmed radiologically with CT scanning and water-soluble contrast enema imaging. Water-soluble contrast enemas were serially repeated to identify healing. Characteristics on initial water-soluble contrast enema were correlated with observed healing. Postoperatively, patients were required to fill in a quality of life and a bowel function questionnaire. RESULTS A total of 138 patients underwent low rectal anastomosis procedures with a median follow-up period of 26 (interquartile range, 19-37) months. There were 23 documented leaks of which 13 (9 percent) presented clinically and 10 (8 percent) presented subclinically. Ileostomy closure was possible in 4 of 13 (30 percent) patients with a clinical leak and all 10 (100 percent) patients with a subclinical leak. Median quality of life scores were lower for patients with clinical leaks and no ileostomy closure (P = 0.03). Bowel function for subclinical leak patients and clinical leak patients with ileostomy closure were similarly impaired. The presence of a cavity (P = 0.01) and a stricture (P = 0.01) at the anastomotic site were unfavorable radiologic features associated with nonhealing. CONCLUSIONS Subclinical leaks are more benign in their natural history compared with clinical leaks. Quality of life and bowel function is no better in patients with a subclinical leak compared with patients with a clinical leak who have ileostomy closure. Anastomotic leaks may resolve if favorable radiologic features are present.
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Affiliation(s)
- Michael Lim
- Department of Colorectal Surgery, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
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Pring C, Hornung B, Burke D, Sagar P. Letter 1: randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery (Br J Surg 2006; 93: 427-433). Br J Surg 2006; 93:1147; author reply 1147-8. [PMID: 16915583 DOI: 10.1002/bjs.5588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
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Messiou C, Chalmers A, Boyle K, Sagar P. Surgery for recurrent rectal carcinoma: The role of preoperative magnetic resonance imaging. Clin Radiol 2006; 61:250-8. [PMID: 16488206 DOI: 10.1016/j.crad.2005.11.008] [Citation(s) in RCA: 21] [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] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 10/24/2005] [Accepted: 11/01/2005] [Indexed: 12/13/2022]
Abstract
Despite apparent curative resection of rectal carcinoma, local recurrence rates of between 3 and 32% have been reported. For those patients, radical surgical resection offers the only hope of cure. We present a review of the magnetic resonance imaging (MRI) findings and contraindications to curative surgery demonstrated using imaging.
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Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 2005; 242:74-82. [PMID: 15973104 PMCID: PMC1357707 DOI: 10.1097/01.sla.0000167926.60908.15] [Citation(s) in RCA: 309] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Examine the cause of local recurrence (LR) and patient survival (S) following abdominoperineal resection (APR) and anterior resection (AR) for rectal carcinoma and the effect of introduction of total mesorectal excision (TME) on APR. METHODS A total of 608 patients underwent surgery for rectal cancer in Leeds from 1986 to 1997. CRM status and follow-up data of local recurrence and patient survival were available for 561 patients, of whom 190 underwent APR (32.4%) and 371 AR (63.3%). Also, a retrospective study of pathologic images of 93 specimens of rectal carcinoma. RESULTS Patients undergoing APR had a higher LR and lower survival (LR, 22.3% versus 13.5%, P = 0.002; S, 52.3% versus 65.8%, P = 0.003) than AR. LR free rates were lower in the APR group and cancer specific survival was lowered (LR, 66% versus 77%, log rank P = 0.03; S, 48% versus 59%, log rank P = 0.02). Morphometry: total area of surgically removed tissue outside the muscularis propria was smaller in APR specimens (n = 27) than AR specimens (n = 66) (P < 0.0001). Linear dimensions of transverse slices of tissue containing tumor, median posterior, and lateral measurements were smaller (P < 0.05) in the APR than the AR group. APR specimens with histologically positive CRM (n = 11) had a smaller area of tissue outside the muscularis propria (P = 0.04) compared with the CRM-negative APR specimens (n = 16). Incidence of CRM involvement in the APR group (41%) was higher than in the AR group (12%) (P = 0.006) in the 1997 to 2000 cohort. Similar results (36% and 22%) were found in the 1986 to 1997 cohort (P = 0.002). CONCLUSIONS Patients treated by APR have a higher rate of CRM involvement, a higher LR, and poorer prognosis than AR. The frequency of CRM involvement for APR has not diminished with TME. CRM involvement in the APR specimens is related to the removal of less tissue at the level of the tumor in an APR. Where possible, a more radical operation should be considered for all low rectal cancer tumors.
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Affiliation(s)
- Roger Marr
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, UK
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Abstract
The aim of this study is to determine the usefulness of different patterns of gallbladder mucosal enhancement on contrast-enhanced computed tomography (CT) for differentiating between gangrenous and uncomplicated acute cholecystitis. This retrospective evaluation involved 56 patients with histopathologically proved acute cholecystitis (32 with gangrenous and 24 with uncomplicated acute cholecystitis) who had preoperative contrast-enhanced CT imaging. CT in 38 patients showed a gallbladder mucosal enhancement pattern that could be categorized into continuous, discontinuous, and/or irregular categories. In the other 18 patients, the mucosal enhancement pattern could not be classified due to lack of mucosal enhancement or inadequate mucosal enhancement. On contrast-enhanced CT evaluation, continuous and discontinuous and/or irregular mucosal enhancement patterns were seen in 20 and 18 patients, respectively. Among the 20 patients with continuous mucosal enhancement, 17 had uncomplicated acute cholecystitis. Seventeen of the 18 patients with discontinuous and/or irregular mucosal enhancement had gangrenous cholecystitis. The sensitivity and positive predictive value (PPV) of discontinuous and/or irregular mucosal enhancement in the diagnosis of gangrenous cholecystitis were 30.3% and 94.4% (17 of 18), respectively. The sensitivity and PPV of continuous mucosal enhancement in the diagnosis of uncomplicated acute cholecystitis were 30.3% and 85.5% (17 of 20), respectively. There was a statistically significant difference (p=0.0005) between the PPV of discontinuous and/or irregular (94.4%) and that of continuous (15%) mucosal enhancement for predicting gangrenous cholecystitis. The pattern of gallbladder mucosal enhancement on CT can be used as a reliable criterion for distinguishing acute, uncomplicated cholecystitis from gangrenous cholecystitis.
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Affiliation(s)
- A K Singh
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, White 270, 55 Fruit Street, Boston, MA 02114, USA.
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49
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Abstract
We report computed tomographic findings of two unusual cases of sudden cardiac arrest. The imaging features documented include reflux of contrast into the abdomen as indicated by opacification of renal veins, hepatic veins, inferior vena cava, and hepatic and renal parenchyma. The reflux of contrast into the portal vein in one patient has not been described in the literature. The thoracic findings were reflux of contrast into the coronary sinus, nonopacificaton of the left ventricle with intravenous contrast, and lack of cardiac motion artifact.
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Affiliation(s)
- A K Singh
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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50
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Abidov A, Hachamovitch R, Friedman JD, Hayes SW, Kang X, Cohen I, Germano G, Berman DS, Kjaer A, Cortsen A, Federspiel M, Hesse B, Holm S, O’Connor M, Dhalla AK, Wong MY, Wang WQ, Belardinelli L, Therapeutics CV, Epps A, Dave S, Brewer K, Chiaramida S, Gordon L, Hendrix GH, Feng B, Pretorius PH, Bruyant PP, Boening G, Beach RD, Gifford HC, King MA, Fessler JA, Hsu BL, Case JA, Gegen LL, Hertenstein GK, Cullom SJ, Bateman TM, Akincioglu C, Abidov A, Nishina H, Kavanagh P, Kang X, Aboul-Enein F, Yang L, Hayes S, Friedman J, Berman D, Germano G, Santana CA, Rivero A, Folks RD, Grossman GB, Cooke CD, Hunsche A, Faber TL, Halkar R, Garcia EV, Hansen CL, Silver S, Kaplan A, Rasalingam R, Awar M, Shirato S, Reist K, Htay T, Mehta D, Cho JH, Heo J, Dubovsky E, Calnon DA, Grewal KS, George PB, Richards DR, Hsi DH, Singh N, Meszaros Z, Thomas JL, Reyes E, Loong CY, Latus K, Anagnostopoulos C, Underwood SR, Kostacos EJ, Araujo LI, Kostacos EJ, Araujo LI, Lewin HC, Hyun MC, DePuey EG, Tanaka H, Chikamori T, Igarashi Y, Harafuji K, Usui Y, Yanagisawa H, Hida S, Yamashina A, Nasr HA, Mahmoud SA, Dalipaj MM, Golanowski LN, Kemp RAD, Chow BJ, Beanlands RS, Ruddy TD, Michelena HI, Mikolich BM, McNelis P, Decker WAV, Stathopoulos I, Duncan SA, Isasi C, Travin MI, Kritzman JN, Ficaro EP, Corbett JR, Allison JS, Weinsaft JW, Wong FJ, Szulc M, Okin PM, Kligfield P, Harafuji K, Chikamori T, Igarashi Y, Tanaka H, Usui Y, Yanagisawa H, Hida S, Ishimaru S, Yamashima A, Giedd KN, Bergmann SR, Shah S, Emmett L, Allman KC, Magee M, Van Gaal W, Kritharides L, Freedman B, Abidov A, Gerlach J, Akincioglu C, Friedman J, Kavanagh P, Miranda R, Germano G, Berman DS, Hayes SW, Damera N, Lone B, Singh R, Shah A, Yeturi S, Prasad Y, Blum S, Heller EN, Bhalodkar NC, Koutelou M, Kollaros N, Theodorakos A, Manginas A, Leontiadis E, Kouzoumi A, Cokkinos D, Mazzanti M, Marini M, Cianci G, Perna GP, Pai M, Greenberg MD, Liu F, Frankenberger O, Kokkinos P, Hanumara D, Goheen E, Wu C, Panagiotakos D, 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Abstracts of original contributions ASNC 2004 9th annual scientific session September 3-–October 3, 2004 New York, New York. J Nucl Cardiol 2004. [DOI: 10.1007/bf02974964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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