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Nzenwa IC, Pathak S, Knight SR, Mowbray NG, O’Reilly D, Jones RP. Postoperative surveillance after surgery for colorectal liver metastasis: a cross-sectional study. Ann R Coll Surg Engl 2024; 106:213-218. [PMID: 37218655 PMCID: PMC10904262 DOI: 10.1308/rcsann.2023.0027] [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: 03/21/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Colorectal liver metastases (CRLM) are associated with a high recurrence rate after surgery. There is paucity of high-quality evidence regarding the nature and overall benefit of surveillance after hepatectomy for CRLM. As part of a broader programme of research, this study aimed to assess current strategies for surveillance after liver resection for CRLM and outline surgeons' opinions regarding the benefit of postoperative surveillance. METHODS An online survey was sent to clinicians performing surgery for CRLM at tertiary hepatobiliary centres in the UK. RESULTS There were responses from a total of 23 centres (88% response rate); 15/23 centres used standardised surveillance protocols for all patients. Most centres followed patients up at six months, but there is variation in postoperative surveillance at 3, 9, 18 and beyond 60 months. Patient comorbidities, indeterminate findings on imaging, margin status and assessment of recurrence risk were identified as the major factors influencing personalised surveillance strategies. There was clear clinician equipoise regarding the costs and benefits of surveillance. CONCLUSION There is heterogeneity in postoperative follow-up for CRLM in the UK. High-quality prospective studies and randomised trials are necessary to elucidate the value of postoperative surveillance and identify optimal follow-up strategies.
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Affiliation(s)
| | - S Pathak
- Leeds Teaching Hospitals NHS Trust, UK
| | | | | | - D O’Reilly
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - RP Jones
- Liverpool University Hospitals NHS Foundation Trust, UK
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Mowbray NG, Griffiths R, Akbari A, Hutchings H, Jenkins G, Al-Sarireh B. The Impact of a Centralised Pancreatic Cancer Service: a Case Study of Wales, UK. J Gastrointest Surg 2022; 26:367-375. [PMID: 34506014 DOI: 10.1007/s11605-020-04612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/11/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The centralisation of pancreatic cancer (PC) services still varies worldwide. This study aimed to assess the impact that a centralisation has had on patients in South Wales, UK. METHODS A retrospective cohort analysis of patients in South Wales, UK, with PC prior to (2004-2009), and after (2010-2014) the formation of a specialist centre. Patients were identified using record linkage of electronic health records. RESULTS The overall survival (OS) of all 3413 patients with PC increased from a median (IQR) 10 weeks (3-31) to 11 weeks (4-35), p = 0.038, after centralisation. The OS of patients undergoing surgical resection or chemotherapy alone did not improve (93 weeks (39-203) vs. 90 weeks (50-95), p = 0.764 and 33 weeks (20-57) vs. 33 weeks (19-58), p = 0.793). Surgical resection and chemotherapy rates increased (6.1% vs. 9.2%, p < 0.001 and 19.7% vs. 27.0%, p < 0.001). The 30-day mortality rate trended downwards (7.2% vs. 3.6%, p = 0.186). The percentage of patients who received no treatment reduced (75.2% vs. 69.6%, p < 0.001). CONCLUSION The centralisation of PC services in South Wales is associated with a small increase in OS and a larger increase in PC treatment utilisation. It is concerning that many patients still fail to receive any treatments.
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Affiliation(s)
- Nicholas G Mowbray
- Swansea University Medical School, Swansea, SA2 8QA, UK. .,Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 6NL, UK.
| | - Rowena Griffiths
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Health Data Research UK, Swansea University, Swansea, SA2 8PP, UK
| | - Ashley Akbari
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Health Data Research UK, Swansea University, Swansea, SA2 8PP, UK
| | | | | | - Bilal Al-Sarireh
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 6NL, UK
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Abstract
INTRODUCTION The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.
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Affiliation(s)
| | - L Hurt
- Morriston Hospital, Swansea, UK
| | | | - N Reeves
- University Hospital of Wales, Cardiff, UK
| | | | | | - J Cornish
- University Hospital of Wales, Cardiff, UK
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Mowbray NG, Ansell J, Horwood J, Cornish J, Rizkallah P, Parker A, Wall P, Spinelli A, Torkington J. Safe management of surgical smoke in the age of COVID-19. Br J Surg 2020; 107:1406-1413. [PMID: 32363596 PMCID: PMC7267397 DOI: 10.1002/bjs.11679] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [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: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/21/2022]
Abstract
Background The COVID-19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery. Methods The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff. Results Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set-up, patient movement and operating theatre equipment when producing a COVID-19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non-filter devices, are discussed in detail. Conclusion There is not enough evidence to quantify the risks of COVID-19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis.
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Affiliation(s)
- N G Mowbray
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - J Ansell
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - J Horwood
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - J Cornish
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - P Rizkallah
- School of Medicine, Cardiff University, Cardiff, UK
| | - A Parker
- School of Medicine, Cardiff University, Cardiff, UK
| | - P Wall
- Isca Healthcare Research, Caerleon, UK
| | - A Spinelli
- Department of General and Minimally Invasive Surgery, Istituto Clinico Humanitas, Rozzano, Italy
| | - J Torkington
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
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Mowbray NG, Ben-Ismaeil B, Hammoda M, Shingler G, Al-Sarireh B. The microbiology of infected pancreatic necrosis. Hepatobiliary Pancreat Dis Int 2018; 17:456-460. [PMID: 30197163 DOI: 10.1016/j.hbpd.2018.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 01/16/2018] [Accepted: 07/31/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) continues to cause significant morbidity and mortality, especially when it leads to infected pancreatic necrosis (IPN). Modern treatment of IPN frequently involves prolonged courses of antibiotics in combination with minimally invasive therapies. This study aimed to update the existing evidence base by identifying the pathogens causing IPN and therefore aid future selection of empirical antibiotics. METHODS Clinical data, including microbiology results, of consecutive patients with IPN undergoing minimally invasive necrosectomy at our institution between January 2009 and July 2016 were retrospectively reviewed. RESULTS The results of 40 patients (22 males and 18 females, median age 60 years) with IPN were reviewed. The etiology of AP was gallstones, alcohol, dyslipidemia and unknown in 31, 2, 2 and 5 patients, respectively. The most frequently identified microbes in microbiology cultures were Enterococcus faecalis and faecium (22.5% and 20.0%) and Escherichia coli (20.0%). In 19 cases the cultures grew multiple organisms. The antibiotics with the least resistance amongst the microbiota were teicoplanin (5.0%), linezolid (5.6%), ertapenem (6.5%), and meropenem (7.4%). CONCLUSION The carbapenem antibiotics, ertapenem and meropenem provide good antimicrobial cover against the common, mainly enteral, microorganisms causing IPN. Culture and sensitivity results of acquired samples should be regularly reviewed to adjust prescribing and monitor for emergence of resistance.
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Affiliation(s)
- Nicholas G Mowbray
- Swansea University, Medical School, Singleton Park Campus, Swansea, SA2 8PP, UK.
| | - Bassam Ben-Ismaeil
- Abertawe Bro-Morgannwg University Health Board, Public Health Wales Microbiology ABM, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Mohammed Hammoda
- Abertawe Bro-Morgannwg University Health Board, Department of Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Guy Shingler
- Abertawe Bro-Morgannwg University Health Board, Department of Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Bilal Al-Sarireh
- Abertawe Bro-Morgannwg University Health Board, Department of Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
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Mowbray NG, Griffith D, Hammoda M, Shingler G, Kambal A, Al-Sarireh B. A meta-analysis of the utility of the neutrophil-to-lymphocyte ratio in predicting survival after pancreatic cancer resection. HPB (Oxford) 2018; 20:379-384. [PMID: 29336893 DOI: 10.1016/j.hpb.2017.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 11/13/2017] [Revised: 12/12/2017] [Accepted: 12/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) is thought to reflect cancer disease burden. To assess the prognostic ability of the NLR on overall survival in patients with resectable, pancreatic cancer a meta-analysis of published literature was undertaken. METHOD A systematic review was performed independently by two authors using PubMed, Ovid MEDLINE and Embase databases. Included studies detailed the pre-operative NLR and overall survival of pancreatic cancer patients. RESULTS Of the 214 studies retrieved using the search strategy, 8 studies involving 1519 patients were included in the meta-analysis. Only one study did not find a statistically significant association between a high NLR and OS. The pooled Hazard Ratio was 1.77 (95% CI [1.45-2.15]; p < 0.01). The NLR cut-off values ranged from 2 to 5. There was low to moderate inter-study heterogeneity (I2 = 31%; p = 0.17), a low risk of intra-study bias, and potentially 3 unpublished (negative) studies. CONCLUSIONS A high pre-operative NLR indicates a worse prognosis than in patients with a low NLR. There is potential to use the NLR to direct therapies. A specific cut-off value has not been established from this study and so further research is required.
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Affiliation(s)
| | - David Griffith
- Royal Devon & Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Mohammed Hammoda
- Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK
| | - Guy Shingler
- Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK
| | - Amir Kambal
- Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK
| | - Bilal Al-Sarireh
- Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK
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Lee CHA, Shingler G, Mowbray NG, Al-Sarireh B, Evans P, Smith M, Usatoff V, Pilgrim C. Surgical outcomes for duodenal adenoma and adenocarcinoma: a multicentre study in Australia and the United Kingdom. ANZ J Surg 2017; 88:E157-E161. [PMID: 28122405 DOI: 10.1111/ans.13873] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/03/2016] [Accepted: 11/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is often required in patients with duodenal adenoma and adenocarcinoma and these patients generally have soft pancreatic texture and small pancreatic ducts, the two most significant factors associated with post-operative pancreatic fistula (POPF). The aims of the study were to evaluate the rate of POPF and long-term outcomes for patients with duodenal adenoma and adenocarcinoma who underwent curative resection. METHODS This retrospective study (2004-2014) examined patients treated surgically with non-ampullary duodenal tumours (NADTs) in two hepatopancreaticobiliary units in Victoria, Australia, and Swansea, UK. RESULTS There were 49 resections performed including 33 pancreaticoduodenectomies, five pancreas-preserving total duodenectomies and 11 segmental duodenal resections. Median length of follow-up was 23.5 months. Final histopathology revealed 18 duodenal adenomas and 31 adenocarcinomas. POPF rate for NADTs was 28.9% (of which 54.5% were grade C) compared to 14.5% for all other pathologies. Grade C POPF was associated with poorer survival outcomes (hazard ratio = 6.73; P = 0.005). The 5-year overall survival for patients with duodenal adenocarcinoma was 66.5%. CONCLUSION Due to the soft pancreatic texture and small pancreatic duct, pancreatic resection for NADTs is associated with a high rate of POPF which contributes to reduced survival. Nevertheless, surgery is associated with favourable 5-year survival compared to pancreatic resection for pancreatic adenocarcinoma.
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Affiliation(s)
- Chun Hin Angus Lee
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia
| | - Guy Shingler
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Nicholas G Mowbray
- Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Bilal Al-Sarireh
- Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Peter Evans
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Upper GI/HPB Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Val Usatoff
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Upper GI/HPB Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia
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