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Parker SG, Blake H, Zhao S, van Dellen J, Mohamed S, Albadry W, Akhtar H, Franczak B, Jakkalasaibaba R, Rothnie A, Thomas R. An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients. Ann R Coll Surg Engl 2024; 106:29-35. [PMID: 36927113 PMCID: PMC10757872 DOI: 10.1308/rcsann.2022.0167] [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] [Accepted: 12/12/2022] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting. METHODS From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed. RESULTS Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care. DISCUSSION A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.
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Affiliation(s)
- SG Parker
- Croydon Health Services NHS Trust, UK
| | - H Blake
- Croydon Health Services NHS Trust, UK
| | - S Zhao
- Croydon Health Services NHS Trust, UK
| | | | - S Mohamed
- Croydon Health Services NHS Trust, UK
| | - W Albadry
- St George’s University Hospitals NHS Foundation Trust, UK
| | - H Akhtar
- Croydon Health Services NHS Trust, UK
| | | | | | - A Rothnie
- Croydon Health Services NHS Trust, UK
| | - R Thomas
- Croydon Health Services NHS Trust, UK
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van Dellen J, Carapeti EA, Darakhshan AA, Datta V, George ML, McCorkell S, Williams AB. Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis. Colorectal Dis 2019; 21:1079-1089. [PMID: 31095879 DOI: 10.1111/codi.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/16/2019] [Indexed: 12/15/2022]
Abstract
AIM This was a prospective cohort study to determine the intrinsic non-modifiable factors influencing length of stay (LOS) in unselected consecutive patients undergoing elective colorectal surgery within an enhanced recovery pathway. METHODS This study interrogated a prospective database of consecutive elective procedures from October 2006 to April 2011 at a tertiary referral academic hospital in the UK to identify independent predictors of prolonged length of stay (pLOS). pLOS was defined as longer than median length of stay (mLOS). Differences in determinants were identified in three groups of increasing operative complexity. RESULTS In all, 872 procedures were identified and ranged from a simple ileostomy reversal to complex total pelvic exenteration. Preoperative anaemia and American Society of Anesthesiologists (ASA) Grade III+ predicted pLOS in stoma reversal surgery patients (n = 191, mLOS 4 days). In colonic and small bowel surgery (n = 444, mLOS 8 days), an open procedure, new stoma formation, planned critical care admission and ASA III+ predicted pLOS. New stoma formation and planned critical care admission predicted pLOS in patients undergoing pelvic rectal surgery (n = 237, mLOS 11 days). pLOS was associated with significantly higher morbidity across Dindo-Clavien grades and a longer time to postoperative functional recovery and discharge. CONCLUSIONS Operative complexity is associated with longer LOS even with an established enhanced recovery pathway in place. Intrinsic non-modifiable predictors of pLOS differ with operative complexity, and this should be taken into account when planning benchmarking and research across units.
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Affiliation(s)
- J van Dellen
- King's College London, London, UK.,Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E A Carapeti
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A A Darakhshan
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - V Datta
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M L George
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S McCorkell
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Affiliation(s)
- R Lane
- West London Clinical Neurosciences Centre, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - H Jenkins
- West London Clinical Neurosciences Centre, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - J van Dellen
- West London Clinical Neurosciences Centre, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - P Davies
- John Radcliffe Hospital, Oxford, UK
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Gnanalingham KK, Colquhoun I, van Dellen J. Temporal lobe seizures: unusual presentation of a giant unruptured posterior communicating artery aneurysm. Br J Neurosurg 2009; 17:370-1. [PMID: 14579909 DOI: 10.1080/02688690310001601324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- K K Gnanalingham
- Department of Neurosurgery and Neuroradiology, Charing Cross Hospital, London, UK.
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Datta G, Gnanalingham KK, van Dellen J, O'Neill K. The role of parenteral nutrition as a supplement to enteral nutrition in patients with severe brain injury. Br J Neurosurg 2009; 17:432-6. [PMID: 14635748 DOI: 10.1080/02688690310001611224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Enteral nutrition (EN) is the preferred and safe route of feeding in surgical patients incapable of self-nutrition. We describe three patients with severe brain insult and recurrent sepsis, who despite the early introduction of EN, remained hypoalbuminaemic, hypoproteinaemic and developed peripheral oedema. This state persisted, despite increasing the caloric and protein intake via the enteral route. However, after a short course of supplemental parenteral nutrition (PN), albumin and total protein levels improved, with resolution of peripheral oedema. We hypothesize that, in certain critically ill neurosurgical patients on EN, gastrointestinal malabsorption may underlie a persistently low serum albumin, total protein and peripheral oedema. A short course of supplemental PN may help to reverse this and a normal regimen of EN can then be continued.
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Affiliation(s)
- G Datta
- Department of Neurosurgery, Charing Cross Hospital, London, UK
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Davidson SJ, O’Neal K, van Dellen J, Roncaroli F, Brock C, Waldman A. A study of feasibility for setting up a dedicated brain tumor registry. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.12514] [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: 11/20/2022] Open
Abstract
12514 Background: Population-based tumor registries represent an invaluable resource for monitoring incidence and prevalence of cancer. Nevertheless, data generated is not always useful for deciding treatment protocols or running translational/clinical research. This is particularly true for rare cancers such as primary brain tumors. Moreover, benign or low grade tumors are usually excluded and information such as quality of life and efficacy of treatment not followed up. Finally, there is no agreement on the minimum dataset required. Here, we investigated the difficulties of setting up a dedicated BTR that can be supportive of research. Methods: We audited 1000 consecutive histologically proven adult cases operated between 1995–2005. This group included 734 gliomas, 246 meningiomas and 20 ependymomas. As minimum dataset, we considered demographics, presenting symptoms, site, neuroimaging findings, pathology/WHO grade, extent of surgery, post-operative treatment, relapses and cause of death. To avoid capture/recapture errors we cross-referenced four independent databases (histopathology, imaging, Cancer Specialist and hospital patient database). Results: Overall availability of data was 80% in 1995–2000 and 95% in 2000–2005 when electronic notes were introduced. Missing data were as follow: demographics: 0%; symptoms: 20%; site and neuroimaging 15%; incorrect diagnosis or grade update; 20%; extent of surgery: 5%; post-operative treatment: 15%; follow-up: 10%: cause of death: 15%. Data could not be interpreted in 20% of cases due to transcription errors and use of abbreviations. Conclusion: To fulfil requirements for clinical/translational research (GNOSIS), BTR needs i) dedicated national registries; ii) specialist and professional data collection; iii) registration at the time of pathological diagnosis. No significant financial relationships to disclose.
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Affiliation(s)
- S. J. Davidson
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - K. O’Neal
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - J. van Dellen
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - F. Roncaroli
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - C. Brock
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - A. Waldman
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
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Abstract
Many peptide hormones and neurotransmitters have been detected in human neuronal tissue. The localisation of atrial natriuretic peptide (ANP) in the human brain was considered to be both interesting and relevant to the understanding of neurochemistry and brain water-electrolyte homeostasis. This vasoactive peptide hormone has been localised in rat and frog neuronal tissue. In the present study, we report the immunohistochemical localisation of ANP in autopsy samples of human brain tissue employing the avidin-biotin-peroxidase complex technique, using an antibody against a 28 amino acid fragment of human ANP. The most intense staining of immunoreactive ANP was detected in the neurones of preoptic, supraoptic and paraventricular nuclei of the hypothalamus, epithelial cells of the choroid plexus and ventricular ependymal lining cells. Immunoreactive neurones were also observed in the median eminence, lamina terminalis, infundibular and ventromedial nuclei of the hypothalamus, and in neurones of the brain stem, thalamic neurones and some neurones of the caudate nucleus. The network of ANP cells in numerous hypothalamic centres may regulate the salt and water balance in the body through a hypothalamic neuro-endocrine control system. ANP in the brain may also modulate cerebral fluid homeostasis by autocrine and paracrine mechanisms.
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Affiliation(s)
- D M Raidoo
- Department of Physiology, Faculty of Medicine, University of Natal, Congella, Durban, South Africa.
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Abstract
The dynamic changes in regional cerebral blood flow (rCBF), induced by a developing intracerebral hematoma, were studied in eight anesthetized monkeys. Hematomas were generated by allowing femoral arterial blood to enter the caudate nucleus via a stereotactically implanted needle. Intracranial pressure peaked at 51 +/- 8 mmHg at 3 minutes after the ictus, and remained high throughout the 3-hour procedure. Cerebral blood flow was significantly reduced in all brain regions for 1 hour after the ictus. The lowest rCBF values were recorded in the immediate clot penumbra and were below threshold levels for ischemic neuronal damage for 90 minutes after the hemorrhage.
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Affiliation(s)
- R Bullock
- Department of Neurosurgery, Wentworth Hospital, Durban, South Africa
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Froman C, van Dellen J, Lipschitz R, Schmaman A. Experience with meningiomas in the Transvaal African. Afr J Med Sci 1973; 4:289-92. [PMID: 4749182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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