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Adiamah A, Rashid A, Crooks CJ, Hammond J, Jepsen P, West J, Humes DJ. The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England. Hernia 2024; 28:109-117. [PMID: 38017324 PMCID: PMC10891219 DOI: 10.1007/s10029-023-02898-6] [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] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis. METHODS Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression. RESULTS In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively. CONCLUSION Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - A Rashid
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK
| | - P Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
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Bailey JA, Morton AJ, Jones J, Chapman CJ, Oliver S, Morling JR, Patel H, Humes DJ, Banerjea A. 'Low' faecal immunochemical test (FIT) colorectal cancer: a 4-year comparison of the Nottingham '4F' protocol with FIT10 in symptomatic patients. Colorectal Dis 2024; 26:309-316. [PMID: 38173125 DOI: 10.1111/codi.16848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 01/05/2024]
Abstract
AIM The aim of this work was to evaluate colorectal cancer (CRC) outcomes after 'low' (sub-threshold) faecal immunochemical test (FIT) results in symptomatic patients tested in primary care. METHOD This work comprised a retrospective audit of 35 289 patients with FIT results who had consulted their general practitioner with lower gastrointestinal symptoms and had subsequent CRC diagnoses. The Rapid Colorectal Cancer Diagnosis pathway was introduced in November 2017 to allow incorporation of FIT into clinical practice. The local '4F' protocol combined FIT results with blood tests and digital rectal examination (DRE): FIT, full blood count, ferritin and finger [DRE]. The outcome used was detection rates of CRC, missed CRC and time to diagnosis in local 4F protocols for patients with a subthreshold faecal haemoglobin (fHb) result compared with thresholds of 10 and 20 μg Hb/g faeces. RESULTS A single threshold of 10 μg Hb/g faeces identifies a population in whom the risk of CRC is 0.2%, but this would have missed 63 (10.5%) of 599 CRCs in this population. The Nottingham 4F protocol would have missed fewer CRCs [42 of 599 (7%)] despite using a threshold of 20 μg Hb/g faeces for patients with normal blood tests. Subthreshold FIT results in patients subsequently diagnosed with a palpable rectal tumour yielded the longest delays in diagnosis. CONCLUSION A combination of FIT with blood results and DRE (the 4F protocol) reduced the risk of missed or delayed diagnosis. Further studies on the impact of such protocols on the diagnostic accuracy of FIT are expected. The value of adding blood tests to FIT may be restricted to specific parts of the fHb results spectrum.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Queens Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - A J Morton
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Queens Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - J Jones
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Oliver
- NHS Nottingham and Nottinghamshire Integrated Care Board, Nottingham, UK
| | - J R Morling
- NHS Nottingham and Nottinghamshire Integrated Care Board, Nottingham, UK
- Lifespan and Population Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
| | - H Patel
- NHS Nottingham and Nottinghamshire Integrated Care Board, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Morton AJ, Simpson A, Humes DJ. Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England. Tech Coloproctol 2023; 28:9. [PMID: 38078978 PMCID: PMC10713759 DOI: 10.1007/s10151-023-02874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/18/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity. METHODS Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis. RESULTS A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS. CONCLUSIONS MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.
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Affiliation(s)
- A J Morton
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- NIHR Nottingham BRC, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - A Simpson
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham BRC, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
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Baamer RM, Humes DJ, Toh LS, Knaggs RD, Lobo DN. Predictors of persistent postoperative opioid use following colectomy: a population-based cohort study from England. Anaesthesia 2023; 78:1081-1092. [PMID: 37265223 PMCID: PMC10953341 DOI: 10.1111/anae.16055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/03/2023]
Abstract
This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.
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Affiliation(s)
- R. M. Baamer
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Department of Pharmacy Practice, Faculty of PharmacyKing Abdulaziz UniversityJeddahSaudi Arabia
| | - D. J. Humes
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
| | - L. S. Toh
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
| | - R. D. Knaggs
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Pain Centre Versus ArthritisUniversity of NottinghamNottinghamUK
| | - D. N. Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing ResearchSchool of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
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Leow TW, Rashid A, Lewis-Lloyd CA, Crooks CJ, Humes DJ. O042 Risk of postoperative venous thromboembolism following benign colorectal surgery: systematic review and meta-analysis. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.042] [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: 11/05/2022]
Abstract
Abstract
Introduction
Venous thromboembolism (VTE) is a well-established complication after colectomy. VTE prophylaxis guidelines for benign colorectal disease is scarce, partly due to the paucity of studies reporting post-operative VTE rates of benign disease. This meta-analysis aimed to quantify the VTE risk after benign colorectal resection and determine its variability.
Methods
Embase, Medline, and 4 other registered medical databases were searched from database inception to 21 June 2021. Inclusion criteria: RCTs and large population-based database cohort studies reporting 30-day and 90-day VTE rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: Patients undergoing colorectal cancer surgery. Studies were grouped for meta-analysis according to post-operative follow-up duration, admission type and indication for surgery.
Results
17 studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day VTE incidence rates after benign colorectal resection were 284 (95%CI, 224–360) and 84 (95%CI, 33–218) per 1,000 person-years. Stratified by admission type, 30-day VTE incidence rates per 1,000 person-years were 532 (95% CI, 447–664) for emergency and 213 (95% CI, 100–453) for elective colorectal resections. 30-day VTE incidence rates per 1,000 person-years postcolectomy were 485 (95%CI, 411–573) for ulcerative colitis, 228 (95%CI, 181–288) for Crohn's disease and 208 (95%CI, 152–288) for diverticulitis patients.
Conclusion
VTE rates remain high up to 90-days after colectomy. Emergency compared to elective benign resections have higher rates of post-operative VTE. Further studies reporting VTE rates by type of benign disease need to stratify rates by admission type to more accurately define postcolectomy VTE risk.
Take-home message
VTE risk following benign colorectal surgery is high, especially among those who underwent emergency surgery. Extended venous thromboprophylaxis should be considered for these group of patients.
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Affiliation(s)
- TW Leow
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre , Nottingham
| | - A Rashid
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre , Nottingham
| | - CA Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre , Nottingham
| | - CJ Crooks
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre , Nottingham
| | - DJ Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre , Nottingham
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Adiamah A, Ban L, Otete H, Crooks CJ, West J, Humes DJ. O23 Outcomes after non-operative management of perforated diverticular disease: a population based cohort study. Br J Surg 2021. [DOI: 10.1093/bjs/znab282.028] [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: 11/13/2022]
Abstract
Abstract
Introduction
The management of perforated diverticular disease has changed in the last 10 years with a move towards less surgical intervention. This population based cohort study aimed to define the risk of mortality and readmission following non-operative management of perforated diverticular disease (DD).
Method
Patients diagnosed with perforated DD and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case-fatality, re-admissions and surgery at re-admission.
Result
In total, 880 patients with perforated DD were managed without surgery, comprising of 523 females (59.4%). One year case-fatality was 33.2% (293/880). The majority of deaths occurred in the first 90 days following the index admission with a 90 day case-fatality of 28.8%. 90 day survival varied by age with 97.2% survival at 90 days in those under 65 years compared to 85.0% in those between 65–74 years and 51.5% in those over 75 years.
Of 767 patients discharged from hospital, 250 (32.6%, 250/767) were re-admitted (47 elective(6.1%) and 203 emergency(26.5%)) during a median of 1.6 years of follow-up (iqr 0.1–3.9 years) with similar proportions in each age category. In the first year of follow-up only 5.1% of patients required surgery of whom 16/767 (2.1%) required elective and 23/767 (3.0%) emergency surgery.
Conclusion
Conservative management of perforated diverticulitis in those under 65 years is feasible and safe. A third of patients are readmitted during follow-up, however, re-intervention rates following conservative management were low across all age categories.
Take-home Message
In younger patients (<65yrs) conservative management of perforated diverticulitis is feasible and safe. A third of conservatively managed patients are readmitted during follow-up, however, need for surgery on readmission is rare.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK, NG7 2UH
| | - L Ban
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK, NG7 2UH
| | - H Otete
- School of Medicine, Harrington building, University of Central Lancashire, Preston, UK, PR1 2HE
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK, NG7 2UH
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City, Hospital, Nottingham, UK, NG5 1PB
| | - J West
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK, NG7 2UH
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City, Hospital, Nottingham, UK, NG5 1PB
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK, NG7 2UH
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City, Hospital, Nottingham, UK, NG5 1PB
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Adiamah A, Crooks CJ, Hammond JS, Jepsen P, West J, Humes DJ. O2 Mortality following elective and emergency colorectal surgery in patients with cirrhosis: a population-based cohort study. Br J Surg 2021. [DOI: 10.1093/bjs/znab282.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
This population based cohort study, aimed to quantify the risk of mortality following colectomy in patients with cirrhosis by urgency of surgery and stage of cirrhosis.
Method
Linked primary and secondary-care electronic healthcare data from England was used to identify all patients undergoing colectomy from January 2001 to December 2017. Patients were classified into three cohorts, non-cirrhotics, compensated cirrhotics and decompensated cirrhosis and followed up for 90-days from the date of surgery. Cox proportional hazards models were used to estimate the hazard ratio (HR) of postoperative mortality.
Result
A total of 36380 eligible patients were included. Of these, 248(0.7%) had liver cirrhosis and 70% had compensated disease. The proportion undergoing a colectomy who had a diagnosis of cirrhosis increased from 0.40% in 2001 to 1.07% in 2017 (χ2(16, N = 36380)=50.53, P < 0.0001).
Following elective colectomy, 90-day case fatality was 4% in non-cirrhotics , 7% in compensated cirrhotics and 10% in decompensated cirrhotics. Following emergency colectomy 90-day case fatality was higher, it was 16% in non-cirrhotics, 35% in compensated cirrhotics and 41% in decompensated cirrhotics. This corresponded to an adjusted 2-fold (HR 2.57(95% CI 1.75–3.76)) and 3-fold (3.43(95% CI 2.02–5.83)) increased mortality rate in compensated and decompensated cirrhotics respectively compared to non-cirrhotics following emergency colectomy.
Conclusion
Over the study period, the proportion of patients undergoing colectomy who had liver cirrhosis increased to 1 in every 100 colectomies. The 90-day case fatality rates were high in all patients with cirrhosis in both emergency and elective settings but the greatest mortality risk was seen in those with decompensation following emergency surgery.
Take-home Message
1 in 100 colectomy procedures are in patients with cirrhosis. These cirrhotic patients have a very high risk of postoperative mortality, especially, emergency colectomy in patients with decompensated cirrhosis.
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Affiliation(s)
- A Adiamah
- Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - C J Crooks
- Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - J S Hammond
- Department of Hepatobiliary and Transplantation Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - P Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City, Hospital, Nottingham NG5 1PB, UK
| | - D J Humes
- Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City, Hospital, Nottingham NG5 1PB, UK
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Catton J, Banerjea A, Gregory S, Hall C, Crooks CJ, Lewis-Lloyd CA, Marshall A, Humes DJ. Planned surgery in the COVID-19 pandemic: a prospective cohort study from Nottingham. Langenbecks Arch Surg 2021; 406:2469-2477. [PMID: 34129109 PMCID: PMC8204733 DOI: 10.1007/s00423-021-02207-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/16/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Globally planned surgical procedures have been deferred during the current COVID-19 pandemic. The study aimed to report the outcomes of planned urgent and cancer cases during the current pandemic using a multi-disciplinary prioritisation group. METHODS A prospective cohort study of patients having urgent or cancer surgery at a NHS Trust from 1st March to 30th April 2020 who had been prioritised by a multi-disciplinary COVID Surgery group. Rates of post-operative PCR positive and suspected COVID-19 infections within 30 days, 30-day mortality and any death related to COVID-19 are reported. RESULTS Overall 597 patients underwent surgery with a median age of 65 years (interquartile range (IQR) 54-74 years). Of these, 86.1% (514/597) had a current cancer diagnosis. During the period, 60.8% (363/597) of patients had surgery at the NHS Trust whilst 39.2% (234/597) had surgery at Independent Sector hospitals. The incidence of COVID-19 in the East Midlands was 193.7 per 100,000 population during the study period. In the 30 days following surgery, 1.3% (8/597) of patients tested positive for COVID-19 with all cases at the NHS site. Overall 30-day mortality was 0.7% (4/597). Following a PCR positive COVID-19 diagnosis, mortality was 25.0% (2/8). Including both PCR positive and suspected cases, 3.0% (18/597) developed COVID-19 infection with 1.3% at the independent site compared to 4.1% at the NHS Trust (p=0.047). CONCLUSIONS Rates of COVID-19 infection in the post-operative period were low especially in the Independent Sector site. Mortality following a post-operative diagnosis of COVID-19 was high.
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Affiliation(s)
- J Catton
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - A Banerjea
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - S Gregory
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C Hall
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C J Crooks
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, E Floor West Block, Queen's Medical Centre Campus, Nottingham, NG7 2UH, UK
| | - C A Lewis-Lloyd
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK. .,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, E Floor West Block, Queen's Medical Centre Campus, Nottingham, NG7 2UH, UK.
| | - A Marshall
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - D J Humes
- Division of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, E Floor West Block, Queen's Medical Centre Campus, Nottingham, NG7 2UH, UK
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9
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Adiamah A, Ban L, Otete H, Crooks CJ, West J, Humes DJ. Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study. BJS Open 2021; 5:6246781. [PMID: 33889950 PMCID: PMC8062256 DOI: 10.1093/bjsopen/zraa073] [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] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background The management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease. Methods Patients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission. Results In total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation. Conclusion Non-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - L Ban
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - H Otete
- School of Medicine, Harrington building, University of Central Lancashire, Preston, UK
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
| | - J West
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
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10
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Bailey JA, Khawaja A, Andrews H, Weller J, Chapman C, Morling JR, Oliver S, Castle S, Simpson JA, Humes DJ, Banerjea A. GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham. Surgeon 2021; 19:93-102. [PMID: 32327303 DOI: 10.1016/j.surge.2020.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/13/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection". DESIGN Retrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience. RESULTS Between November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were <4.0 μg Hb/g faeces, 579 (10.1%) were 4.0-9.9 μg Hb/g faeces, 836 (14.6%) were 10.0-149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of "rule out" results <4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p < 0.0001) and the proportion of "rule in" results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P < 0.0001). There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT<4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT. CONCLUSIONS FIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a "stage migration" effect which may ultimately improve CRC outcomes.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - A Khawaja
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - H Andrews
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J Weller
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C Chapman
- Eastern Hub, Bowel Cancer Screening Programme, A Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J R Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, NG5 1PB, UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group, Nottingham, UK
| | - S Castle
- Nottingham City Clinical Commissioning Group, Nottingham, UK
| | - J A Simpson
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - D J Humes
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, NG5 1PB, UK
| | - A Banerjea
- Nottingham Colorectal Service, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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11
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Bailey JA, Weller J, Chapman CJ, Ford A, Hardy K, Oliver S, Morling JR, Simpson JA, Humes DJ, Banerjea A. Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation. BJS Open 2021; 5:6162967. [PMID: 33693553 PMCID: PMC7947575 DOI: 10.1093/bjsopen/zraa056] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation. METHODS The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses. RESULTS In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4-9.9 µg Hb/g in 1583 (11.8 per cent), 10-99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4-9.9 µg Hb/g faeces, 3.3 per cent for fHb 10-99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10-19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent. CONCLUSION Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Weller
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Ford
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Hardy
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group, Nottingham,UK
| | - J R Morling
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J A Simpson
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK,National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK,Correspondence to: Nottingham Colorectal Service, E Floor West Block, Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK (e-mail: )
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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12
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Bailey JA, Ibrahim H, Bunce J, Chapman CJ, Morling JR, Simpson JA, Humes DJ, Banerjea A. Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population. Tech Coloproctol 2021; 25:1151-1154. [PMID: 34263362 PMCID: PMC8279105 DOI: 10.1007/s10151-021-02466-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines for urgent investigation of colorectal cancer (CRC) are based on age and symptom-based criteria. This study aims to compare the diagnostic value of clinical features and faecal immunochemical test (FIT) results to identify those at a higher risk of CRC, thereby facilitating effective triage of patients. METHODS We undertook a review of all patients referred for investigation of CRC at our centre between September 2016 and June 2018. Patients were identified using a prospectively recorded local database. We performed a logistic regression analysis of factors associated with a diagnosis of CRC. RESULTS One-thousand-and-seven-hundred-eighty-four patients with FIT results were included in the study. Change in bowel habit (CIBH) was the most common referring clinical feature (38.3%). Patients diagnosed with CRC were significantly older than those without malignancy (74.0 years vs 68.9 years, p = 0.0007). Male patients were more likely to be diagnosed with CRC than females (6.5% vs 2.5%, Chi-squared 16.93, p < 0.0001). CRC was diagnosed in 3.5% (24/684) with CIBH compared to 8.1% (6/74) with both CIBH and iron deficiency anaemia. No individual or combination of referring clinical features was associated with an increased diagnosis of CRC (Chi-squared, 8.03, p = 0.155). Three patients with negative FIT results (< 4 µg Hb/g faeces) were diagnosed with CRC (3/1027, 0.3%). The highest proportion of cancers detected was in the ≥ 100 µg Hb/g faeces group (55/181, 30.4%). CONCLUSION In a multivariate model, FIT outperforms age, sex and all symptoms prompting referral. FIT has greater stratification value than any referral symptoms. FIT does have value in patients with iron deficiency anaemia.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - H Ibrahim
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Bunce
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of NottinghamCity Hospital, Nottingham, UK
| | - J A Simpson
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of NottinghamCity Hospital, Nottingham, UK
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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13
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Bailey JA, Hanbali N, Premji K, Bunce J, Mashlab S, Simpson JA, Humes DJ, Banerjea A. Thrombocytosis helps to stratify risk of colorectal cancer in patients referred on a 2-week-wait pathway. Int J Colorectal Dis 2020; 35:1347-1350. [PMID: 32358719 PMCID: PMC7320058 DOI: 10.1007/s00384-020-03597-9] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Primary care studies suggest that thrombocytosis (platelet counts > 400 × 109/L) is associated with an increased risk of colorectal cancer (CRC). We aimed to establish whether this marker has significant stratification value in patients seen in secondary care. METHODS A retrospective review of 2991 patients referred to our colorectal 2-week-wait (2WW) pathway between August 2014 and August 2017. Patient demographics were recorded prospectively, and local electronic records systems were used to retrieve full blood counts (FBC) and cancer diagnoses. Patients with no recent platelet count at the time of referral or incomplete records were excluded. RESULTS 2236 patients were included in this evaluation. There was no significant difference in the age distribution of those with thrombocytosis and those without. There were significantly more females in the thrombocytosis group (72.1% vs 53.9%, chi-squared 24.63, p < 0.0001). 130 CRCs were detected (5.8%) and patients with thrombocytosis were more likely to have CRC (OR 2.62, 95% CI 1.60-4.30). The CRC diagnosis rate was significantly higher in females with thrombocytosis (10.3% vs 2.9%, chi-squared 19.41, p < 0.0001) and males with thrombocytosis (16.1% vs 7.9%, chi-squared 4.62, p = 0.032). CONCLUSION Thrombocytosis appears to have stratification value in the 2WW population. Further evaluation of its value alone or in combination with other stratification tests is required.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK.
| | - N Hanbali
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - K Premji
- Department of Clinical Chemistry, City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - J Bunce
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - S Mashlab
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - J A Simpson
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
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14
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Chapman C, Thomas C, Morling J, Tangri A, Oliver S, Simpson JA, Humes DJ, Banerjea A. Early clinical outcomes of a rapid colorectal cancer diagnosis pathway using faecal immunochemical testing in Nottingham. Colorectal Dis 2020; 22:679-688. [PMID: 31876975 DOI: 10.1111/codi.14944] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/29/2019] [Indexed: 12/29/2022]
Abstract
AIM We introduced primary care access to faecal immunochemical testing (FIT) as a stratification tool for symptomatic patients considered to be at risk of colorectal cancer (CRC) prior to urgent referral. We aimed to evaluate clinical and pathway outcomes during the first 6 months of this novel approach. METHOD FIT was recommended for all patients who consulted their general practitioner with lower gastrointestinal symptoms other than rectal bleeding and rectal mass. We undertook a retrospective audit of the results of FIT, related clinical outcomes and resource utilization on prospectively logged cases between November 2017 and May 2018. RESULTS Of the 1862 FIT kits dispatched by post 91.4% were returned, with a median return time of 7 days (range 2-110 days); however, 1.3% of returned kits could not be analysed. FIT results ≥ 150.0 μg haemoglobin (Hb)/g faeces identified patients with a significantly higher risk of CRC (30.9% vs 1.4%, chi-square 167.1, P < 0.0001). FIT results ≥ 10.0 μg Hb/g faeces identified patients with significantly higher risk of significant noncancer bowel pathology (24.1% vs 4.9%, chi-square 73.6, P < 0.0001) and FIT results < 4.0 μg Hb/g faeces identified a group more likely to have non-CRC pathology (5.1% vs 2.4%, chi-square 3.9, P < 0.05). The CRC detection rate in 531 patients investigated after a FIT result of < 4.0 μg Hb/g faeces was 0.2%. In 899 investigated patients, a FIT result with a threshold of 4.0 μg Hb/g faeces had sensitivity 97.2% (85.5-99.9% CI), specificity 61.4% (58.1-64.7% CI), negative predictive value 99.8% (98.7-100.0% CI) and positive predictive value 9.5% (8.7-10.4% CI). CONCLUSION A symptomatic pathway incorporating FIT is feasible and appears more clinically effective than pathways based on age and symptoms alone.
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Affiliation(s)
- C Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Thomas
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Morling
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - A Tangri
- Riverlyn Medical Centre, Nottingham, UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group, Nottingham, UK
| | - J A Simpson
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - A Banerjea
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
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15
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Chapman C, Bunce J, Oliver S, Ng O, Tangri A, Rogers R, Logan RF, Humes DJ, Banerjea A. Service evaluation of faecal immunochemical testing and anaemia for risk stratification in the 2-week-wait pathway for colorectal cancer. BJS Open 2019; 3:395-402. [PMID: 31183456 PMCID: PMC6551399 DOI: 10.1002/bjs5.50131] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Background New national guidance on urgent referral for investigation of colorectal cancer included faecal occult blood testing in 2015. A service evaluation of faecal immunochemical testing (FIT) and anaemia as risk stratification tools in symptomatic patients suspected of having CRC was undertaken. Methods Postal FIT was incorporated into the colorectal cancer 2-week wait (2WW) pathway for all patients without rectal bleeding in 2016. Patients were investigated in the 2WW pathway as normal, and outcomes of investigations were recorded prospectively. Anaemia was defined as a haemoglobin level below 120 g/l in women and 130 g/l in men. Results FIT kits were sent to 1106 patients, with an 80·9 per cent return rate; 810 patients completed investigations and 40 colorectal cancers were diagnosed (4·9 per cent). FIT results were significantly higher in patients with anaemia (median (i.q.r.) 4·8 (0·8-34·1) versus 1·2 (0-6·4) μg Hb/g faeces in those without anaemia; P < 0·001). Some 60·4 per cent of patients (538 of 891) had a result lower than 4 μg haemoglobin (Hb) per g faeces (limit of detectability), and 69·7 per cent (621 of 891) had less than 10 μg Hb/g faeces. Some 60 per cent of patients with colorectal cancer had a FIT reading of 150 μg Hb/g faeces or more. For five colorectal cancers diagnosed in patients with a FIT value below 10 μg Hb/g faeces, there was either a palpable rectal mass or the patient was anaemic. A FIT result of more than 4 μg Hb/g faeces had 97·5 per cent sensitivity and 64·5 per cent specificity for a diagnosis of colorectal cancer. A FIT result above 4 μg Hb/g faeces and/or anaemia had a 100 per cent sensitivity and 45·3 per cent specificity for colorectal cancer diagnosis. Conclusion FIT is most useful at the extremes of detectability; strongly positive readings predict high rates of colorectal cancer and other significant pathology, whereas very low readings in the absence of anaemia or a palpable rectal mass identify a group with very low risk. High return rates for FIT within this 2WW pathway indicate its acceptability.
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Affiliation(s)
- C Chapman
- Eastern Hub, Bowel Cancer Screening Programme Nottingham University Hospitals NHS Trust Nottingham UK
| | - J Bunce
- Nottingham Colorectal Service Nottingham University Hospitals NHS Trust Nottingham UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group University of Nottingham Nottingham UK
| | - O Ng
- Nottingham Colorectal Service Nottingham University Hospitals NHS Trust Nottingham UK
| | - A Tangri
- Nottingham City Clinical Commissioning Group University of Nottingham Nottingham UK
| | - R Rogers
- Nottingham City Clinical Commissioning Group University of Nottingham Nottingham UK
| | - R F Logan
- Eastern Hub, Bowel Cancer Screening Programme Nottingham University Hospitals NHS Trust Nottingham UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham Nottingham UK
| | - D J Humes
- Nottingham Colorectal Service Nottingham University Hospitals NHS Trust Nottingham UK.,National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust Nottingham UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham Nottingham UK
| | - A Banerjea
- Nottingham Colorectal Service Nottingham University Hospitals NHS Trust Nottingham UK
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16
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Pitiot A, Smith JK, Humes DJ, Garratt J, Francis ST, Gowland PA, Spiller RC, Marciani L. Cortical differences in diverticular disease and correlation with symptom reports. Neurogastroenterol Motil 2018; 30:e13303. [PMID: 29392838 DOI: 10.1111/nmo.13303] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/07/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies have shown that the brain of patients with gastrointestinal disease differ both structurally and functionally from that of controls. Highly somatizing diverticular disease (HSDD) patients were also shown to differ from low somatizing (LSDD) patients functionally. This study aimed to investigate how they differed structurally. METHODS Four diseases subgroups were studied in a cross-sectional design: 20 patients with asymptomatic diverticular disease (ADD), 18 LSDD, 16 HSDD, and 18 with irritable bowel syndrome. We divided DD patients into LSDD and HSDD using a cutoff of 6 on the Patient Health Questionnaire 12 Somatic Symptom (PHQ12-SS) scale. All patients underwent a 1-mm isotropic structural brain MRI scan and were assessed for somatization, hospital anxiety, depression, and pain catastrophizing. Whole brain volumetry, cortical thickness analysis and voxel-based morphometry were carried out using Freesurfer and SPM. KEY RESULTS We observed decreases in gray matter density in the left and right dorsolateral prefrontal cortex (dlPFC), and in the mid-cingulate and motor cortex, and increases in the left (19, 20) and right (19, 38) Brodmann Areas. The average cortical thickness differed overall across groups (P = .002) and regionally: HSDD > ADD in the posterior cingulate cortex (P = .03), HSDD > LSDD in the dlPFC (P = .03) and in the ventrolateral PFC (P < .001). The thickness of the anterior cingulate cortex and of the mid-prefrontal cortex were also found to correlate with Pain Catastrophizing (Spearman's ρ = 0.24, P = .043 uncorrected and Spearman's ρ = 0.25, P = .03 uncorrected). CONCLUSION & INFERENCES This is the first study of structural gray matter abnormalities in diverticular disease patients. The data show brain differences in the pain network.
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Affiliation(s)
- A Pitiot
- Laboratory of Image & Data Analysis, Ilixa Ltd., Nottingham, UK
| | - J K Smith
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - D J Humes
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - J Garratt
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - S T Francis
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - P A Gowland
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - R C Spiller
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - L Marciani
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
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17
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Mashlab S, Large P, Laing W, Ng O, D’Auria M, Thurston D, Thomson S, Acheson AG, Humes DJ, Banerjea A. Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer. Ann R Coll Surg Engl 2018; 100:350-356. [PMID: 29543046 PMCID: PMC5956597 DOI: 10.1308/rcsann.2018.0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 01/12/2023] Open
Abstract
Introduction Anaemia is associated with cancer. In 2014 a new form was introduced in our department requesting a haemoglobin (Hb) result on every two-week wait referral for suspected colorectal cancer (CRC). The aim of this study was to review the impact of this intervention. In particular, the significance of any evidence of anaemia (without additional indices) was investigated. Methods A review was conducted of 1,500 consecutive suspected CRC referrals recorded prospectively over a 10-month period. Data on demographics, referral Hb, referral criteria and outcomes were analysed. Anaemia was defined according to World Health Organization criteria (Hb <120g/l for women, Hb <130g/l for men). Results Overall, 1,015 patients were eligible for inclusion in the study. Over a third (38.2%) were documented as anaemic on referral. These patients were three times more likely to be diagnosed with CRC than non-anaemic patients (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 1.87-5.57). Using a more stringent threshold (Hb <100g/l for women and <110g/l for men), they were four times more likely to have CRC (OR: 4.27, 95% CI: 2.35-7.75). Almost a quarter (23.7%) were actually anaemic at the time of referral but not referred with anaemia. In this subgroup, there was a 2.8-fold increase in risk of CRC diagnosis compared with non-anaemic patients (adjusted OR: 2.77, 95% CI: 1.55-4.95). Conclusions Nearly a quarter of patients not referred with iron deficiency anaemia had evidence of anaemia and this was still associated with a higher rate of CRC detection. A full blood count alone might help to risk stratify symptoms such as change in bowel habit in patients on urgent pathways and identify those cases most likely to benefit from invasive investigation.
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Affiliation(s)
- S Mashlab
- Nottingham University Hospitals NHS Trust, UK
| | - P Large
- Nottingham University Hospitals NHS Trust, UK
| | - W Laing
- Nottingham University Hospitals NHS Trust, UK
| | - O Ng
- Nottingham University Hospitals NHS Trust, UK
| | - M D’Auria
- Nottingham University Hospitals NHS Trust, UK
| | - D Thurston
- Nottingham University Hospitals NHS Trust, UK
| | - S Thomson
- Nottingham University Hospitals NHS Trust, UK
| | - AG Acheson
- Nottingham University Hospitals NHS Trust, UK
| | - DJ Humes
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - A Banerjea
- Nottingham University Hospitals NHS Trust, UK
| | - On behalf of the Nottingham Colorectal Service
- Non-author contributors: J Abercrombie, S Asgari, B Bharathan, R Briggs, H Edis, C Maxwell-Armstrong, K Mohiuddin, M Robinson, J Scholefield, K Thomas, K Walter, J Williams
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Humes DJ, Abdul-Sultan A, Walker AJ, Ludvigsson JF, West J. Duration and magnitude of postoperative risk of venous thromboembolism after planned inguinal hernia repair in men: a population-based cohort study. Hernia 2018; 22:447-453. [DOI: 10.1007/s10029-017-1716-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
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19
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Banerjea A, Voll J, Chowdhury A, Siddika A, Thomson S, Briggs R, Humes DJ. Straight-to-test colonoscopy for 2-week-wait referrals improves time to diagnosis of colorectal cancer and is feasible in a high-volume unit. Colorectal Dis 2017; 19:819-826. [PMID: 28342189 DOI: 10.1111/codi.13667] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/12/2017] [Indexed: 02/08/2023]
Abstract
AIM We have introduced 'straight-to-test' (STT) colonoscopy as part of our 2-week-wait (2WW) pathway to address increasing numbers of urgent referrals for colorectal cancer (CRC) within the National Health Service. In this study we evaluated the ability of this initiative to shorten the time to diagnosis of CRC. METHOD We amended our 2WW referral form to include performance status and comorbidities. General practitioners were asked to provide data on estimated glomerular filtration rate and full blood count/ferritin. Our 2WW referrals were screened by a colorectal consultant and a nurse specialist. Those deemed unsuitable for STT were offered outpatient assessment (OPA). RESULTS Of 553 2WW referrals screened, 352 were considered suitable, 65 of whom failed a telephone assessment or were uncontactable, and accordingly 287 were offered the STT pathway. The STT group was significantly younger than the OPA group (median 65.9 years vs 78.7 years; P < 0.0001). STT colonoscopy significantly reduced the time to first test (13 days vs 22 days; P < 0.0001) and tissue diagnosis from the referral date (17 days vs 24.5 days; P < 0.0001). Thirty-seven (6.8%) CRCs were detected. Proportionately fewer patients in the STT pathway were managed with 'best supportive care only' compared with patients attending OPA (one of 15 vs six of 22, respectively). STT colonoscopy obviated the need for clinic attendance before testing in 287 patients, representing a potential net cost benefit of at least £48 500 in 4 months. CONCLUSION STT colonoscopy was safe and effective for selecting out a group of symptomatic patients who could proceed straight to endoscopic examination and receive a diagnosis more rapidly.
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Affiliation(s)
- A Banerjea
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Voll
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Chowdhury
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Siddika
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Thomson
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R Briggs
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Epidemiology and Public Health, School of Community Health Sciences, University of Nottingham, Nottingham, UK
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20
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Elsey EJ, Griffiths G, Humes DJ, West J. Meta-analysis of operative experiences of general surgery trainees during training. Br J Surg 2017; 104:22-33. [PMID: 28000937 DOI: 10.1002/bjs.10396] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/20/2016] [Accepted: 08/24/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND General surgical training curricula around the world set defined operative numbers to be achieved before completion of training. However, there are few studies reporting total operative experience in training. This systematic review aimed to quantify the published global operative experience at completion of training in general surgery. METHODS Electronic databases were searched systematically for articles in any language relating to operative experience in trainees completing postgraduate general surgical training. Two reviewers independently assessed citations for inclusion using agreed criteria. Studies were assessed for quantitative data in addition to study design and purpose. A meta-analysis was performed using a random-effects model of studies with appropriate data. RESULTS The search resulted in 1979 titles for review. Of these, 24 studies were eligible for inclusion in the review and data from five studies were used in the meta-analysis. Studies with published data of operative experience at completion of surgical training originated from the USA (19), UK (2), the Netherlands (1), Spain (1) and Thailand (1). Mean total operative experience in training varied from 783 procedures in Thailand to 1915 in the UK. Meta-analysis produced a mean pooled estimate of 1366 (95 per cent c.i. 1026 to 1707) procedures per trainee at completion of training. There was marked heterogeneity between studies (I2 = 99·6 per cent). CONCLUSION There is a lack of robust data describing the operative experiences of general surgical trainees outside the USA. The number of surgical procedures performed by general surgeons in training varies considerably across the world.
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Affiliation(s)
- E J Elsey
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - G Griffiths
- Department of Vascular Surgery, Ninewells Hospital, Dundee, UK
| | - D J Humes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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21
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Smith JK, Marciani L, Humes DJ, Francis ST, Gowland P, Spiller RC. Anticipation of thermal pain in diverticular disease. Neurogastroenterol Motil 2016; 28:900-13. [PMID: 26970346 PMCID: PMC4879512 DOI: 10.1111/nmo.12790] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 01/06/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND The relative importance of peripheral nerve injury or central pain processing in painful diverticular disease (DD) is unclear. Functional magnetic resonance imaging (fMRI) has demonstrated that dysfunctional central pain processing predominates in irritable bowel syndrome (IBS). This study aims to identify anticipatory changes in symptomatic DD (SDD) compared to asymptomatic DD (ADD) and IBS patients. METHODS Gastrointestinal symptoms and somatization were evaluated via the Patient Health Question-12 Somatic Symptom and the SDD group divided into low (≤6 [LSDD]) and high (≥7 [HSDD]) somatization. Cued painful cutaneous thermal stimuli were delivered to the left hand and foot during fMRI. Fixed effect group analysis of the 'cued' anticipatory phase was performed. KEY RESULTS Within the right posterior insula, greater deactivation was found in the ADD compared to other groups. In emotion processing centers, anterior and middle insula, greater activation was identified in all patient compared to the ADD group, and in LSDD compared to IBS and HSDD groups. In comparison, amygdala deactivation was greater in ADD than the IBS and HSDD groups, and in LSDD vs HSDD groups. Descending nociceptive control centers, such as the superior medial frontal and orbitofrontal cortex, also showed greater deactivation in the ADD and LSDD compared to the HSDD and IBS groups. CONCLUSIONS & INFERENCES The HSDD group have altered anticipatory responses to thermal pain, similar to IBS group. The LSDD are similar to ADD group. This suggests underlying differences in pain pathophysiology, and the need for individualized treatment strategies to target the cause of their chronic pain.
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Affiliation(s)
- J. K. Smith
- Nottingham Digestive Diseases CentreSchool of MedicineUniversity of NottinghamNottinghamUK
| | - L. Marciani
- Nottingham Digestive Diseases CentreSchool of MedicineUniversity of NottinghamNottinghamUK,Sir Peter Mansfield Magnetic Resonance CentreSchool of Physics and AstronomyUniversity of NottinghamNottinghamUK
| | - D. J. Humes
- Nottingham Digestive Diseases CentreSchool of MedicineUniversity of NottinghamNottinghamUK,Nottingham Digestive Diseases Biomedical Research UnitNottingham University HospitalsUniversity of NottinghamNottinghamUK
| | - S. T. Francis
- Sir Peter Mansfield Magnetic Resonance CentreSchool of Physics and AstronomyUniversity of NottinghamNottinghamUK
| | - P. Gowland
- Sir Peter Mansfield Magnetic Resonance CentreSchool of Physics and AstronomyUniversity of NottinghamNottinghamUK
| | - R. C. Spiller
- Nottingham Digestive Diseases CentreSchool of MedicineUniversity of NottinghamNottinghamUK,Nottingham Digestive Diseases Biomedical Research UnitNottingham University HospitalsUniversity of NottinghamNottinghamUK
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22
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Humes DJ, Walker AJ, Hunt BJ, Sultan AA, Ludvigsson JF, West J. Risk of symptomatic venous thromboembolism following emergency appendicectomy in adults. Br J Surg 2016; 103:443-50. [DOI: 10.1002/bjs.10091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/30/2015] [Accepted: 11/23/2015] [Indexed: 12/25/2022]
Abstract
Abstract
Background
Appendicectomy is the commonest intra-abdominal emergency surgical procedure, and little is known regarding the magnitude and timing of the risk of venous thromboembolism (VTE) after surgery. This study aimed to determine absolute and relative rates of symptomatic VTE following emergency appendicectomy.
Methods
A cohort study was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data of patients who had undergone emergency appendicectomy from 2001 to 2011. Crude rates and adjusted incidence rate ratios (IRRs) for VTE were calculated using Poisson regression, compared with baseline risk in the year before appendicectomy.
Results
A total of 13 441 patients were identified, of whom 56 (0·4 per cent) had a VTE in the first year after surgery. The absolute rate of VTE was highest during the in-hospital period, with a rate of 91·29 per 1000 person-years, which was greatest in those with a length of stay of 7 days or more (267·12 per 1000 person-years). This risk remained high after discharge, with a 19·1- and 6·6-fold increased risk of VTE in the first and second months respectively after discharge, compared with the year before appendicectomy (adjusted IRR: month 1, 19·09 (95 per cent c.i. 9·56 to 38·12); month 2, 6·56 (2·62 to 16·44)).
Conclusion
The risk of symptomatic VTE following appendicectomy is relatively high during the in-hospital admission and remains increased after discharge. Trials of extended thromboprophylaxis are warranted in patients at particularly high risk.
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Affiliation(s)
- D J Humes
- Division of Epidemiology and Public Health, School of Medicine, Queens Medical Centre Campus, University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Biomedical Research Unit, Queens Medical Centre Campus, University of Nottingham, Nottingham, UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - A J Walker
- Division of Epidemiology and Public Health, School of Medicine, Queens Medical Centre Campus, University of Nottingham, Nottingham, UK
| | - B J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A A Sultan
- Division of Epidemiology and Public Health, School of Medicine, Queens Medical Centre Campus, University of Nottingham, Nottingham, UK
| | - J F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, Queens Medical Centre Campus, University of Nottingham, Nottingham, UK
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Abstract
INTRODUCTION Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery. METHODS A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria. RESULTS From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes. In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies. CONCLUSIONS The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.
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Affiliation(s)
- E H Gemmill
- Nottingham University Hospitals NHS Trust , UK
| | - D J Humes
- Nottingham University Hospitals NHS Trust , UK
| | - J A Catton
- Nottingham University Hospitals NHS Trust , UK
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Ban L, Tata LJ, Humes DJ, Fiaschi L, Card T. Decreased fertility rates in 9639 women diagnosed with inflammatory bowel disease: a United Kingdom population-based cohort study. Aliment Pharmacol Ther 2015; 42:855-66. [PMID: 26250873 DOI: 10.1111/apt.13354] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/13/2015] [Accepted: 07/17/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Clinical studies have reported reduced fertility in women with inflammatory bowel disease (IBD). AIM To compare fertility rates in women with IBD to those in women without IBD and assess whether the relative fertility differed following IBD diagnosis, flares and surgery. METHODS Women aged 15-44 years in 1990-2010 were identified from a UK primary care database. We estimated overall and age-specific fertility rates by 5-year age bands for women with and without IBD. We used Poisson regression to calculate adjusted fertility rate ratios (AFRR), adjusted for age, smoking and socioeconomic deprivation. RESULTS There were 46.2 live births per 1000 person-years [95% confidence interval (95% CI); 44.6-47.9] in 9639 women with IBD and 49.3 (95% CI 49.2-49.5) in 2 131 864 without (AFRR: 0.93; 95% CI: 0.89-0.96). Excluding periods of contraception use, the AFRR was 0.99 (95% CI: 0.95-1.03). Before diagnosis, the AFRR for women with ulcerative colitis (UC) was 1.07 (95% CI: 0.99-1.16) and was 0.88 (95% CI: 0.81-0.97) for women with CD. After diagnosis, AFRRs were 0.87 (95% CI: 0.82-0.94) for CD and 0.92 (95% CI: 0.86-1.00) for UC. The fertility rate was lower following flares (AFRR: 0.70; 95% CI: 0.59-0.82) or surgery (AFRR: 0.84; 95% CI: 0.77-0.92). Women with pouch and non-pouch surgery had similar overall fertility though the reduction after surgery was greater for pouches (AFRR: 0.48; 95% CI: 0.23-0.99). CONCLUSIONS Women with Crohn's disease have marginally lower fertility rates. These rates decreased following flares and surgical interventions. Fertility rates returned almost to normal when women were not prescribed contraception but the reduction following surgical intervention remained. As the lifetime effect of pouch vs. nonpouch surgery on fertility is small, the reduction post-pouch surgery should be interpreted with caution.
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Affiliation(s)
- L Ban
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - L J Tata
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - D J Humes
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - L Fiaschi
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - T Card
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
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Humes DJ, Walker AJ, Blackwell J, Hunt BJ, West J. Variation in the risk of venous thromboembolism following colectomy. Br J Surg 2015; 102:1629-38. [DOI: 10.1002/bjs.9923] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/01/2015] [Accepted: 07/22/2015] [Indexed: 02/05/2023]
Abstract
Abstract
Background
Guidelines recommend extended thromboprophylaxis following colectomy for malignant disease, but not for non-malignant disease. The aim of this study was to determine absolute and relative rates of venous thromboembolism (VTE) following colectomy by indication, admission type and time after surgery.
Methods
A cohort study of patients undergoing colectomy in England was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data (2001–2011). Crude rates and adjusted hazard ratios (HRs) were calculated for the risk of first VTE following colectomy using Cox regression analysis.
Results
Some 12 388 patients were identified; 312 (2·5 per cent) developed VTE after surgery, giving a rate of 29·59 (95 per cent c.i. 26·48 to 33·06) per 1000 person-years in the first year after surgery. Overall rates were 2·2-fold higher (adjusted HR 2·23, 95 per cent c.i. 1·76 to 2·50) for emergency compared with elective admissions (39·44 versus 25·78 per 1000 person-years respectively). Rates of VTE were 2·8-fold higher in patients with malignant disease versus those with non-malignant disease (adjusted HR 2·84, 2·04 to 3·94). The rate of VTE was highest in the first month after emergency surgery, and declined from 121·68 per 1000 person-years in the first month to 25·65 per 1000 person-years during the rest of the follow-up interval. Crude rates of VTE were similar for malignant and non-malignant disease (114·76 versus 120·98 per 1000 person-years respectively) during the first month after emergency surgery.
Conclusion
Patients undergoing emergency colectomy for non-malignant disease have a similar risk of VTE as patients with malignant disease in the first month after surgery.
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Affiliation(s)
- D J Humes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
- National Institute for Health Research Nottingham Digestive Disease Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - A J Walker
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J Blackwell
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - B J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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Walker AJ, West J, Card TR, Humes DJ, Grainge MJ. Variation in the risk of venous thromboembolism in people with colorectal cancer: a population-based cohort study from England. J Thromb Haemost 2014; 12:641-9. [PMID: 24977288 PMCID: PMC4230392 DOI: 10.1111/jth.12533] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with colorectal cancer are at high risk of developing venous thromboembolism(VTE), and recent international guidelines have advised extended prophylaxis for some of these patients following surgery or during chemotherapy. However, our understanding of which patients are at increased risk, and to what extent, is limited. OBJECTIVES To determine absolute and relative rates of VTE among patients with colorectal cancer according to Dukes stage, surgical intervention,and chemotherapy. METHODS We analyzed data from four linked databases from 1997 to 2006: the Clinical Practice Research Datalink, linked to Hospital Episode Statistics, Cancer Registry data, and Office for National Statistics cause of death data, all from England. Rates were compared by the use of Cox regression. RESULTS There were 10 309 patients with colorectal cancer, and 555 developed VTE (5.4%). The incidence varied by Dukes stage, being three-fold higher among Dukes D patients than among Dukes A patients (hazard ratio [HR] 3.08, 95% confidence interval [CI] 1.95–4.84), and 40% higher for those receiving chemotherapy than for those not receiving chemotherapy(HR 1.39, 95% CI 1.14–1.69). The risk following surgery varied by stage of disease and chemotherapy, with Dukes A patients having a low incidence of VTE (0.74%; 95% CI 0.28–1.95) at 6 months,with all events occurring within 28 days of surgery, as compared with Dukes B and Dukes C patients, whose risk at 6 months was ~ 2%. CONCLUSION Twenty-eight days of prophylaxis following surgery for colorectal cancer is appropriate for Dukes A patients. However, Dukes B and Dukes C patients receiving postoperative chemotherapy have a longer duration of risk.
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Humes DJ, Spiller RC. Review article: The pathogenesis and management of acute colonic diverticulitis. Aliment Pharmacol Ther 2014; 39:359-70. [PMID: 24387341 DOI: 10.1111/apt.12596] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 07/18/2013] [Accepted: 12/09/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute diverticulitis, defined as acute inflammation associated with a colonic diverticulum, is a common emergency presentation managed by both surgeons and physicians. There have been advances in both the medical and the surgical treatments offered to patients in recent years. AIM To review the current understanding of the aetiology and treatment of acute diverticulitis. METHODS A search of PubMed and Medline databases was performed to identify articles relevant to the aetiology, pathogenesis and management of acute diverticulitis. RESULTS There are 75 hospital admissions per year for acute diverticulitis per 100,000 of the population in the United States. Recent reports suggest a 26% increase in admissions over a 7-year period. Factors predisposing to the development of acute diverticulitis include obesity, smoking, diet, lack of physical activity and medication use such as aspirin and nonsteroidal anti-inflammatory drugs. The condition is associated with a low mortality of about 1% following medical therapy, rising to 4% in-hospital mortality in those requiring surgery. There is limited evidence on the efficacy of individual antibiotic regimens, and antibiotic treatment may not be required in all patients. The rates of recurrence reported for patients with acute diverticulitis following medical management vary from 13% to 36%. The surgical management of those patients who fail medical treatment has moved towards a laparoscopic nonresectional approach; however, the evidence supporting this is limited. CONCLUSIONS Further high-quality randomised controlled trials are required of both medical and surgical treatments in patients with acute diverticulitis, if management is to be evidence-based.
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Affiliation(s)
- D J Humes
- Nottingham Digestive Diseases Centre and Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK
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Humes DJ, Radcliffe RS, Camm C, West J. Population-based study of presentation and adverse outcomes after femoral hernia surgery. Br J Surg 2013; 100:1827-32. [DOI: 10.1002/bjs.9336] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2013] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Rates of emergency admission with femoral hernia are high compared with those for other hernias. This study aimed to determine the modes and consequences of presentation to primary care before admission to hospital.
Methods
This was a population-based cohort study using healthcare records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics data from 1997 to 2007. Length of hospital stay, bowel resection rates and 30-day mortality were calculated.
Results
A total of 885 patients (690 female, 78.0 per cent) underwent femoral hernia repair, with 406 operations (45·9 per cent) performed as an emergency. The majority of patients who were admitted as an emergency (331, 81·5 per cent) presented to the general practitioner for the first time with symptoms of a hernia in the 7 days before admission, compared with just ten (2·1 per cent) of 479 patients admitted electively (P < 0·001). The median (i.q.r.) length of stay for patients undergoing elective surgery was 1 (0–2) day compared with 5 (3–9) days for those having an emergency repair (P < 0·001). Adverse events were more common among patients operated on as emergency, with 94 (23·2 per cent) having a small bowel resection compared with one (0·2 per cent) who had elective surgery. There were no deaths within 30 days in the elective group, but seven (1·7 per cent) in the emergency group.
Conclusion
A large proportion of patients with femoral hernia present late to primary care and are operated on as an emergency, with worse outcomes.
Presented to the Annual Meeting of the Society of Academic and Research Surgery, Nottingham, UK, January 2012; published in abstract form as Br J Surg 2012; 99(Suppl 4): 18
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Affiliation(s)
- D J Humes
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
- Division of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
| | - R S Radcliffe
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - C Camm
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - J West
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
- Division of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
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Tang J, Humes DJ, Gemmil E, Welch NT, Parsons SL, Catton JA. Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages. Ann R Coll Surg Engl 2013; 95:323-8. [PMID: 23838493 DOI: 10.1308/003588413x13629960046039] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes. METHODS Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 - July 2009) and after (August 2009 - July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality. RESULTS There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann-Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008-2009 to 6 (16.7%) in 2009-2010 (chi-squared test, p<0.0001). CONCLUSIONS The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.
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Affiliation(s)
- J Tang
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Humes DJ, Simpson J, Smith J, Sutton P, Zaitoun A, Bush D, Bennett A, Scholefield JH, Spiller RC. Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation. Neurogastroenterol Motil 2012; 24:318-e163. [PMID: 22276853 DOI: 10.1111/j.1365-2982.2011.01863.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [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: 12/28/2022]
Abstract
BACKGROUND Recurrent abdominal pain is reported by a third of patients with diverticulosis, particularly those with previous episodes of acute diverticulitis. The current understanding of the etiology of this pain is poor. Our aim was to assess visceral sensitivity in patients with diverticular disease and its association with markers of previous inflammation and neuropeptides. METHODS Patients with asymptomatic and symptomatic diverticular disease underwent a flexible sigmoidoscopy and biopsy followed 5-10 days later by visceral sensitivity testing with barostat-mediated rectal distension. Inflammation was assessed by staining of serotonin (5HT) and CD3 positive cells. mRNA levels of tumor necrosis factor alpha (TNF α) and interleukin-6 (IL-6) were quantitated using RT-PCR. Neuropeptide expression was assessed from percentage area staining with substance P (SP) and mRNA levels of the neurokinin 1 & 2 receptors (NK1 & NK2), and galanin 1 receptor (GALR1). KEY RESULTS Thirteen asymptomatic and 12 symptomatic patients were recruited. The symptomatic patients had a lower first reported threshold to pain (28.4 mmHg i.q.r 25.0-36.0) than the asymptomatic patients (47 mmHg i.q.r 36.0-52.5, P < 0.001). Symptomatic patients had a higher median overall pain rating for the stimuli than the asymptomatic patients (P < 0.02). Symptomatic patients had greater median relative expression of NK1 and TNF alpha mRNA compared with asymptomatic patients. There was a significant correlation between barostat VAS pain scores and NK 1 expression (Figure 4, r(2) 0.54, P < 0.02). CONCLUSIONS & INFERENCES Patients with symptomatic diverticular disease exhibit visceral hypersensitivity, and this may be mediated by ongoing low grade inflammation and upregulation of tachykinins.
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Affiliation(s)
- D J Humes
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK.
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Smith JK, Humes DJ, Head KE, Bush D, White TP, Stevenson CM, Brookes MJ, Marciani L, Spiller RC, Gowland PA, Francis ST. fMRI and MEG analysis of visceral pain in healthy volunteers. Neurogastroenterol Motil 2011; 23:648-e260. [PMID: 21507149 DOI: 10.1111/j.1365-2982.2011.01712.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although many studies of painful rectal stimulation have found activation in the insula, cingulate, somatosensory, prefrontal cortices and thalamus, there is considerable variability when comparing functional magnetic resonance imaging (fMRI) results. Multiple factors may be responsible, including the model used in fMRI data analysis. Here, we assess the temporal response of activity to rectal barostat distension using novel fMRI and magnetoencephalography (MEG) analysis. METHODS Liminal and painful rectal barostat balloon inflation thresholds were assessed in 14 female healthy volunteers. Subliminal, liminal and painful 40s periods of distension were applied in a pseudo-randomized paradigm during fMRI and MEG neuroimaging. Functional MRI data analysis was performed comparing standard box-car models of the full 40s of stimulus (Block) with models of the inflation (Ramp-On) and deflation (Ramp-Off) of the barostat. Similar models were used in MEG analysis of oscillatory activity. KEY RESULTS Modeling the data using a standard Block analysis failed to detect areas of interest found to be active using Ramp-On and Ramp-Off models. Ramp-On generated activity in anterior insula and cingulate regions and other pain-matrix associated areas. Ramp-Off demonstrated activity of a network of posterior insula, SII and posterior cingulate. Active areas were consistent with those identified from MEG data. CONCLUSIONS & INFERENCES In studies of visceral pain, fMRI model design strongly influences the detected activity and must be accounted for to effectively explore the fMRI data in healthy subjects and within patient groups. In particular a strong cortical response is detected to inflation and deflation of the barostat, rather than to its absolute volume.
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Affiliation(s)
- J K Smith
- School of Physics and Astronomy, Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
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Spiller RC, Humes DJ, Campbell E, Hastings M, Neal KR, Dukes GE, Whorwell PJ. The Patient Health Questionnaire 12 Somatic Symptom scale as a predictor of symptom severity and consulting behaviour in patients with irritable bowel syndrome and symptomatic diverticular disease. Aliment Pharmacol Ther 2010; 32:811-20. [PMID: 20629976 DOI: 10.1111/j.1365-2036.2010.04402.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Anxiety, depression and nongastrointestinal symptoms are often prominent in irritable bowel syndrome (IBS), but their relative value in patient management has not been quantitatively assessed. We modified the Patient Health Questionnaire 15 (PHQ-15) by excluding three gastrointestinal items to create the PHQ-12 Somatic Symptom (PHQ-12 SS) scale. AIMS To compare the value of the PHQ-12 SS scale with the Hospital Anxiety and Depression (HAD) scale in predicting symptoms and patient behaviour in IBS and diverticular disease. METHODS We compared 151 healthy volunteers (HV), 319 IBS patients and 296 patients with diverticular disease (DD), 113 asymptomatic [ASYMPDD] and 173 symptomatic DD (SYMPDD). RESULTS Patient Health Questionnaire 12 SS scores for IBS and SYMPDD were significantly higher than HV. Receiver-operator curves showed a PHQ-12 SS >6, gave a sensitivity for IBS of 66.4% with a specificity of 94.7% and a positive likelihood ratio (PLR) = 13.2, significantly better than that associated with an HAD anxiety score >7, PLR = 3.0 and depression score >7 PLR = 6.5. PHQ-12 SS correlated strongly with IBS severity scale and GP visits in both IBS and DD. CONCLUSION The PHQ-12 SS scale is a useful clinical tool which correlates with patient behaviour in both IBS and symptomatic DD.
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Affiliation(s)
- R C Spiller
- Nottingham Digestive Diseases Centre, University Hospital, UK.
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Macafee DAL, Humes DJ, Bouliotis G, Beckingham IJ, Whynes DK, Lobo DN. Prospective randomized trial using cost–utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease. Br J Surg 2009; 96:1031-40. [DOI: 10.1002/bjs.6685] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
This randomized controlled trial compared the cost–utility of early laparoscopic cholecystectomy with that for conventional management of newly diagnosed acute gallbladder disease.
Methods
Adults admitted to hospital with a first episode of biliary colic or acute cholecystitis were randomized to an early intervention group (36 patients, operation within 72 h of admission) or a conventional group (36, elective cholecystectomy 3 months later). Costs were measured from a National Health Service and societal perspective. Quality-adjusted life year (QALY) gains were calculated 1 month after surgery.
Results
The mean(s.d.) total costs of care were £5911(2445) for the early group and £6132(3244) for the conventional group (P = 0·928), Mean(s.d.) societal costs were £1322(1402) and £1461(1532) for the early and conventional groups respectively (P = 0·732). Visual analogue scale scores of health were 72·94 versus 84·63 (P = 0·012) and the mean(s.d.) QALY gain was 0·85(0·26) versus 0·93(0·13) respectively (P = 0·262). The incremental cost per additional QALY gained favoured conventional management at a cost of £3810 per QALY gained.
Conclusion
In this pragmatic trial, the cost–utilities of both the early and conventional approaches were similar, but the incremental cost per additional QALY gained favoured conventional management. Registration number: ISRCTN81663421 (http://www.controlled-trials.com).
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Affiliation(s)
- D A L Macafee
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - D J Humes
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - G Bouliotis
- Trent Research and Development Support Unit, Nottingham, UK
| | - I J Beckingham
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - D K Whynes
- School of Economics, University of Nottingham, Nottingham, UK
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
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Simpson J, Sundler F, Humes DJ, Jenkins D, Scholefield JH, Spiller RC. Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms. Neurogastroenterol Motil 2009; 21:847-e58. [PMID: 19453515 DOI: 10.1111/j.1365-2982.2009.01308.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Some patients with colonic diverticula suffer recurrent abdominal pain and exhibit visceral hypersensitivity, though the mechanism is unclear. Prior diverticulitis increases the risk of being symptomatic while experimental colitis in animals increases expression of neuropeptides within the enteric nervous system (ENS) which may mediate visceral hypersensitivity. Our aim was to determine the expression of neuropeptides within the ENS in diverticulitis (study 1) and in patients with symptomatic disease (study 2). Study 1 - Nerves in colonic resection specimens with either acute diverticulitis (AD, n = 16) or chronic diverticulitis (CD, n = 16) were assessed for neuropeptide expression recording % area staining with protein gene product (PGP9.5), substance P (SP), neuropeptide K (NPK), pituitary adenylate cyclase activating polypeptide (PACAP), vasoactive intestinal polypeptide (VIP) and galanin. Study 2 - Seventeen symptomatic and 15 asymptomatic patients with colonic diverticula underwent flexible sigmoidoscopy and multiple peridiverticular mucosal biopsies. Study 1- Neural tissue, as assessed by PGP staining was increased to a similar degree in circular muscle in both AD and CD. The CD specimens showed significant increases in the immunoreactivity of SP, NPK and galanin in both mucosal and circular muscle layer compared with controls. Study 2 - Mucosal histology was normal and PGP9.5 staining was similar between groups however patients with symptomatic diverticular disease demonstrated significantly higher levels of SP, NPK, VIP, PACAP and galanin within the mucosal plexus. Patients with symptomatic diverticular disease exhibit increased neuropeptides in mucosal biopsies which may reflect resolved prior inflammation, as it parallels the changes seen in acute and chronic diverticulitis.
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Affiliation(s)
- J Simpson
- Department of General Surgery, Wolfson Digestive Diseases Centre, University Hospital, Nottingham, UK.
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Simpson J, Humes DJ, O'Rourke EJ, James PD, Acheson AG. Rigler on the roof. Rigler's sign. Gut 2008; 57:798, 836. [PMID: 18477680 DOI: 10.1136/gut.2006.110015] [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] [Indexed: 12/08/2022]
Affiliation(s)
- J Simpson
- Wolfson Digestive Diseases Centre, Division of Gastrointestinal Surgery, E/West Block, Queens Medical Centre, Nottingham NG7 2UH, UK.
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Simpson J, Sundler F, Humes DJ, Jenkins D, Wakelin D, Scholefield JH, Spiller RC. Prolonged elevation of galanin and tachykinin expression in mucosal and myenteric enteric nerves in trinitrobenzene sulphonic acid colitis. Neurogastroenterol Motil 2008; 20:392-406. [PMID: 18208479 DOI: 10.1111/j.1365-2982.2007.01037.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diverticulitis causes recurrent abdominal pain associated with increased mucosal expression of mucosal galanin and substance P (SP). We studied changes in mucosal and myenteric plexus neuropeptides in adult rats using a model of colonic inflammation, trinitrobenzenesulphonic acid colitis. We assessed the effects on the pan-neuronal markers protein gene product 9.5 (PGP9.5) and neurofilament protein, as well as specific neuropeptides at 1, 2, 3, 4, 6, 8, 10 and 14 weeks. Following the acute injury there was macroscopic resolution of inflammation but minor microscopic abnormalities persisted. Percent area stained of mucosal PGP9.5 fell initially but average levels on days 21 and 28 levels were significantly elevated (P < 0.001), returning to normal by day 42. Percent area staining of PGP9.5 in the muscle rose immediately and remained significantly elevated at 70 days (P < 0.001). SP, neuropeptide K and galanin followed a similar overall pattern. SP to PGP9.5 ratio was significantly increased in the muscle both acutely (days 1-28) and in the long term (days 70 and 98), whereas the galanin to PGP9.5 ratio was significantly increased in the mucosa throughout the study. Low-grade chronic inflammation after an acute initial insult causes a persistent increase in the expression of galanin in the mucosa and SP in muscle layer.
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Affiliation(s)
- J Simpson
- Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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Abstract
BACKGROUND The importance of psychological factors in symptom expression in diverticulosis is unknown. This follow-up study assessed the relative importance of colonic and psychological factors in symptom expression. METHODS Patients with barium enema-proven diverticula were sent a bowel symptom questionnaire in 1999 and again in 2006 with additional psychological questionnaires included. RESULTS Some 170 of 261 initial responders were eligible for follow-up and 124 (72.9 per cent) provided complete replies. Forty-two (33.9 per cent) of 124 respondents experienced recurrent abdominal pain a median of 3.5 (interquartile range (i.q.r.) 2.00-9.25) days per month, with a median duration of 1 (i.q.r. 0.7-2) h. Multivariable analysis identified a history of acute diverticulitis (odds ratio 3.98; P = 0.010) and a raised score on the Hospital Anxiety and Depression Scale (odds ratio 2.53; P = 0.030) as the best predictors of recurrent pain. CONCLUSION Psychological and colonic factors are important in symptom expression in diverticulosis.
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Affiliation(s)
- D J Humes
- Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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Affiliation(s)
- D J Humes
- Division of Gastrointestinal Surgery, Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
| | - J Simpson
- Division of Gastrointestinal Surgery, Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
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