Management of the Rectal Stump after Subtotal Colectomy Operations for Inflammatory Bowel Disease in the Era of Immunologic Therapy: A Two-Centre Cohort Study.

INTRODUCTION: Inflammatory bowel disease (IBD) often requires surgical resection, such as subtotal colectomy operations to alleviate symptoms. However, IBD also has an inherently increased risk of colorectal dysplasia and cancer. Despite the well-accepted surveillance guidelines for IBD patients with an intact colon, contemporaneous decision-making models on rectal stump surveillance is sparse. This study looks at the fate of rectal stumps in IBD patients following subtotal colectomy. METHODS: This is a two-centre retrospective observational cohort study. Patients were identified from NHS Grampian and NHS Highland surgical IBD databases. Patients that had subtotal colectomy between January 01, 2010 and December 31, 2017 were included with the follow-up end date on April 1, 2021. Socio-demographics, diagnosis, medical and surgical management data were collected from electronic records. RESULTS: Of 250 patients who had subtotal colectomy procedures, only one developed a cancer in their rectal stump (0.4%) over a median follow-up of 80 months. A higher than expected 72% of patients had ongoing symptoms from their rectal stumps. Surveillance was varied and inconsistent. However, no surveillance, flexible sigmoidoscopy, or MRI identified dysplastic or neoplastic disease. CONCLUSION: Based on our results, we estimate that the prevalence of rectal cancer is lower than previously reported. Surveillance strategy of rectal stump varied as no current guidelines exist and hence is an important area for future study. Given the relatively low frequency of rectal cancer in these patients, and the low level of evidence available in this field, we would propose a registry-based approach to answering this important clinical question.

English translation and cross-cultural validation of the patient-reported outcome measurement-haemorrhoidal impact and satisfaction score (PROM-HISS).

AIM: The aim of this study was to translate the Dutch patient-reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS) to English and perform a cross-cultural validation. METHOD: The ISPOR good practice guidelines for the cross-cultural validation of PROMs were followed and included two steps: (1) Two forward and two backward translations. The forward translation concerned the translation from the source language (Dutch) to the target language (English), performed by two independent English speakers, one medical doctor and one nonmedical. Subsequently, a discussion about discrepancies in the reconciled version was performed by a stakeholder group. (2) Cognitive interviews were held with patients with haemorrhoidal disease (HD), probing the comprehensibility and comprehensiveness of the PROM-HISS. RESULTS: Discrepancies in the reconciled forward translation concerned the terminology of HD symptoms. Furthermore, special attention was paid to the response options, ranging from "not at all", indicating minor symptoms, to "a lot", implying many symptoms. Consensus among the stakeholder group about the final version of the translated PROM-HISS was reached. Interviews were conducted with 10 native English-speaking HD patients (30% female), with a mean age of 44 years (24-83) and primarily diagnosed with grade II HD (80%). The mean time to complete the PROM-HISS was 1 min 43 s. Patients showed a good understanding of the questions and response options, found all items relevant and did not miss important symptoms or topics. CONCLUSION: The translated English language PROM-HISS is a valid tool to assess symptoms of HD, its impact on daily activities and patient satisfaction with HD treatment.

Study of capsule endoscopy delivery at scale through enhanced artificial intelligence-enabled analysis (the CESCAIL study).

AIM: Lower gastrointestinal (GI) diagnostics have been facing relentless capacity constraints for many years, even before the COVID-19 era. Restrictions from the COVID pandemic have resulted in a significant backlog in lower GI diagnostics. Given recent developments in deep neural networks (DNNs) and the application of artificial intelligence (AI) in endoscopy, automating capsule video analysis is now within reach. Comparable to the efficiency and accuracy of AI applications in small bowel capsule endoscopy, AI in colon capsule analysis will also improve the efficiency of video reading and address the relentless demand on lower GI services. The aim of the CESCAIL study is to determine the feasibility, accuracy and productivity of AI-enabled analysis tools (AiSPEED) for polyp detection compared with the 'gold standard': a conventional care pathway with clinician analysis. METHOD: This multi-centre, diagnostic accuracy study aims to recruit 674 participants retrospectively and prospectively from centres conducting colon capsule endoscopy (CCE) as part of their standard care pathway. After the study participants have undergone CCE, the colon capsule videos will be uploaded onto two different pathways: AI-enabled video analysis and the gold standard conventional clinician analysis pathway. The reports generated from both pathways will be compared for accuracy (sensitivity and specificity). The reading time can only be compared in the prospective cohort. In addition to validating the AI tool, this study will also provide observational data concerning its use to assess the pathway execution in real-world performance. RESULTS: The study is currently recruiting participants at multiple centres within the United Kingdom and is at the stage of collecting data. CONCLUSION: This standard diagnostic accuracy study carries no additional risk to patients as it does not affect the standard care pathway, and hence patient care remains unaffected.

Evaluation of an Innovative Colon Capsule Endoscopy Service in Scotland From the Perspective of Patients: Mixed Methods Study.

BACKGROUND: Colonoscopy is the gold standard for lower gastrointestinal diagnostics. The procedure is invasive, and its demand is high, resulting in long waiting times. Colon capsule endoscopy (CCE) is a procedure that uses a video capsule to investigate the colon, meaning that it can be carried out in a person's own home. This type of "hospital-at-home" service could potentially reduce costs and waiting times, and increase patient satisfaction. Little is currently understood, however, about how CCE is actually experienced and accepted by patients. OBJECTIVE: The aim of this study was to capture and report patient experiences of the CCE technology (the capsule and associated belt and recorder) and of the new clinical pathway for the CCE service being rolled out as part of routine service in Scotland. METHODS: This was a mixed methods service evaluation of patient experiences of a real-world, deployed, managed service for CCE in Scotland. Two hundred and nine patients provided feedback via a survey about their experiences of the CCE service. Eighteen of these patients took part in a further telephone interview to capture more in-depth lived experiences to understand the barriers and opportunities for the further adoption and scaling up of the CCE service in a way that supports the patient experience and journey. RESULTS: Patients overall perceived the CCE service to be of significant value (eg, mentioning reduced travel times, reduced waiting times, and freedom to complete the procedure at home as perceived benefits). Our findings also highlighted the importance of clear and accessible information (eg, what to expect and how to undertake the bowel preparation) and the need for managing expectations of patients (eg, being clear about when results will be received and what happens if a further colonoscopy is required). CONCLUSIONS: The findings led to recommendations for future implementations of managed CCE services in National Health Service (NHS) Scotland that could also apply more widely (United Kingdom and beyond) and at a greater scale (with more patients in more contexts). These include promoting CCE with, for, and among clinical teams to ensure adoption and success; capturing and understanding reasons why patients do and do not opt for CCE; providing clear information in a variety of appropriate ways to patients (eg, around the importance of bowel preparation instructions); improving the bowel preparation (this is not specific to CCE alone); providing flexible options for issuing and returning the kit (eg, dropping off at a pharmacy); and embedding formative evaluation within the service itself (eg, capturing patient-reported experiences via surveys in the information pack when the equipment is returned).

ScotCap - A large observational cohort study.

AIM: The aim of this work was to evaluate the performance of colon capsule endoscopy (CCE) in a lower gastrointestinal diagnostic care pathway. METHOD: This large multicentre prospective clinical evaluation recruited symptomatic patients (patients requiring investigation of symptoms suggestive of colorectal pathology) and surveillance patients (patients due to undergo surveillance colonoscopy). Patients aged 18 years or over were invited to participate and undergo CCE by a secondary-care clinician if they met the referral criteria for a colonoscopy. The primary outcome was the test completion rate (visualization of the whole colon and rectum). We also measured the need for further tests after CCE. RESULTS: A total of 733 patients were invited to take part in this evaluation, with 509 patients undergoing CCE. Of these, 316 were symptomatic patients and 193 were surveillance patients. Two hundred and twenty-eight of the 316 symptomatic patients (72%) and 137 of the 193 surveillance patients (71%) had a complete test. It was found that 118/316 (37%) of symptomatic patients required no further test following CCE, while 103/316 (33%) and 81/316 (26%) required a colonoscopy and flexible sigmoidoscopy, respectively. Fifty-three of the 193 surveillance patients (28%) required no further test following CCE, while 104/193 (54%) and 30/193 (16%) required a colonoscopy and flexible sigmoidoscopy, respectively. No patient in this evaluation was diagnosed with colorectal cancer. Two patients experienced serious adverse events - one capsule retention with obstruction and one hospital admission with dehydration due to the bowel preparation. CONCLUSION: CCE is a safe, well-tolerated diagnostic test which can reduce the proportion of patients requiring colonoscopy, but the test completion rate needs to be improved to match that of lower gastrointestinal endoscopy.

Prevalence of repeat faecal immunochemical testing in symptomatic patients attending primary care.

AIM: The faecal immunochemical test (FIT) for faecal haemoglobin (f-Hb) helps determine the risk of colorectal cancer (CRC) and has been integrated into symptomatic referral pathways. 'Safety netting' advice includes considering referral for persistent symptoms, but no published data exists on repeated FITs. We aimed to examine the prevalence of serial FITs in primary care and CRC risk in these patients. METHOD: A multicentre, retrospective, observational study was conducted of patients with two or more consecutive f-Hb results within a year from three Scottish Health Boards which utilize FIT in primary care. Cancer registry data ensured identification of CRC cases. RESULTS: Overall, 135 396 FIT results were reviewed, of which 12 359 were serial results reported within 12 months (9.1%), derived from 5761 patients. Of these, 42 (0.7%) were diagnosed with CRC. A total of 3487 (60.5%) patients had two f-Hb < 10 µg/g, 944 (16.4%) had f-Hb ≥ 10 µg/g followed by <10 µg/g, 704 (12.2%) f-Hb < 10 µg/g followed by ≥10 µg/g and 626 (10.9%) had two f-Hb ≥ 10 µg/g. The CRC rate in each group was 0.1%, 0.4%, 1.4% and 4.0%, respectively. Seven hundred and thirty four patients submitted more than two FITs within a year. The likelihood of one or more f-Hb ≥ 10 µg/g rose from 40.4% with two samples to 100% with six, while the CRC rate fell from 0.8% to 0%. CONCLUSION: Serial FITs within a year account for 9.1% of all results in our Boards. CRC prevalence amongst symptomatic patients with serial FIT is lower than in single-FIT cohorts. Performing two FITs within a year for patients with persistent symptoms effectively acts as a safety net, while performing more than two within this timeframe is unlikely to be beneficial.

Simulation for technical skill acquisition in open vascular surgery.

BACKGROUND: Simulation has an increasingly prominent role in modern vascular surgery training. However, it is important to understand how simulation is most effectively delivered to best use the time and resources available. The aim of this narrative review is therefore to critically appraise open technical skill acquisition in the operating room environment and provide recommendations for the future development of evidence-based simulation for open vascular surgery. METHODS: A systematic search strategy was used to retrieve relevant studies from PubMed, Medline, Web of Science, EMBASE, and the Cochrane databases in July 2019. Included papers were independently screened by two reviewers. Data were subsequently extracted using a standardized proforma and thematically analyzed. RESULTS: Thirteen studies were included. All demonstrated that simulation is effective in improving confidence and/or competence in performing open technical skills when assessed by previously validated metrics. However, not all participants or course schedules achieved equal benefit, with distributed practice for junior trainees over several weeks achieving a greater improvement in technical skill compared with senior trainees or longer course schedules for some tasks. CONCLUSIONS: Simulation can be an effective adjunct to traditional operative experience for technical skill acquisition in open vascular surgery. Future work should focus on developing models to address a wider range of training needs, as well as further defining the optimum schedule for the style, content, and timing of simulation for specific learner groups.

Reducing surgical site infection rates in colorectal surgery - a quality improvement approach to implementing a comprehensive bundle.

AIM: Surgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre-, peri- and postoperative factors and multiple interventions can be combined into 'bundles'. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle. METHOD: This is a single-centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered. RESULTS: In the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013-2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015-2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection. CONCLUSION: A successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI.

Analysis of colectomy rates for ulcerative colitis in pre- and postbiological eras in Lothian, Scotland.

AIM: Biological treatment is effective in maintaining remission in ulcerative colitis (UC), although the effect on colectomy rates remains unclear. In the UK the use of antitumour necrosis factor and anti-α4ß7 treatments for maintenance therapy in UC was restricted until 2015. The aim of this study was to describe the impact that this change in the prescribing of biologicals had on colectomy rates for UC. METHOD: All patients (adult and paediatric) with a diagnosis of UC who received maintenance biological treatment and/or underwent a colectomy in Lothian, Scotland between 2005 and 2018 were identified. Linear and segmental regression analyses were used to identify the annual percentage change (APC) and temporal trends (statistical joinpoints) in biological prescription and colectomy rates. RESULTS: Rates of initiation of maintenance biological therapy increased from 0.05 per 100 UC patients in 2005 to 1.26 in 2018 (p < 0.001). Colectomy rates per 100 UC patients fell from 1.47 colectomies in 2005 to 0.44 in 2018 (p < 0.001). The APC for colectomy decreased by 4.1% per year between 2005 and 2014 and by 18.9% between 2014 and 2018. Temporal trend analysis (2005-2018) identified a significant joinpoint in colectomy rates in 2014 (p = 0.019). CONCLUSION: The use of maintenance biological therapy increased sharply following the change in guidance. This has been paralleled by a significant reduction in the rates of colectomy over the same time period.

Increasing Incidence of Young-Onset Colorectal Carcinoma A 3-Country Population Analysis.

BACKGROUND: The overall incidence of colorectal carcinoma is declining in Western populations; however, single country series demonstrate an increase in young-onset (<50 years) colorectal carcinoma. OBJECTIVE: The purpose of this study was to determine whether the pattern of increasing incidence of young-onset colorectal carcinoma is consistent across 3 Western populations. DESIGN: This is a population incidence study. SETTINGS: National cancer registries of New Zealand, Sweden, and Scotland were used. PATIENTS: The incidence of colorectal carcinoma was calculated from population data for 3 countries over 2 to 4 decades. MAIN OUTCOME MEASURES: The incidence of colorectal carcinoma was measured. Incidence rate ratios were determined and data were stratified by subsite (colon versus rectum), sex, and age (<50, 50-79, and ≥80 y). RESULTS: Overall colorectal carcinoma rates declined in New Zealand, remained stable in Scotland, and increased in Sweden. In all 3 populations, there was an increasing incidence of rectal carcinoma in those aged <50 years. Young-onset rectal carcinoma increased in New Zealand (1995-2012: incidence rate ratio = 1.18 (men) and 1.13 (women)), with declining incidence in all other age groups. Colon carcinoma did not increase in the population aged <50 years, with the exception of distal colonic carcinoma in men. Overall, rectal carcinoma incidence increased (1970-2014) in Sweden; however, increases in those <50 years of age exceeded increases in other age groups (incidence rate ratio = 1.14 (males) and 1.12 (females)). Distal colon carcinoma increases were most marked in the population aged <50 years. In Scotland (1990-2014), young-onset rectal carcinoma incidence increased (incidence rate ratio = 1.23 (males) and 1.27 (females)), with a smaller increase in colon carcinoma. LIMITATIONS: Limitations include its registry-based, population incidence research. CONCLUSIONS: This study shows an increase in young-onset rectal carcinoma in 3 national populations; this observation may provide a focus for looking at the role of environmental influences on the etiology of this increase and therefore to explore strategies for prevention. See Video Abstract at http://links.lww.com/DCR/B194. AUMENTO DE LA INCIDENCIA DE CARCINOMA COLORRECTAL DE INICIO JOVEN: UN ANÁLISIS DE POBLACIÓN DE TRES PAÍSES: La incidencia global de carcinoma colorrectal está disminuyendo en las poblaciones occidentales. Sin embargo, las series de un solo país demuestran un aumento en el carcinoma colorrectal de inicio joven (pacientes menores de 50 años).Determinar si el patrón de incidencia en aumento de carcinoma colorrectal de inicio joven es consistente en tres poblaciones occidentales.Estudio de incidencias de población en tres países.Registros nacionales de cáncer de Nueva Zelanda, Suecia y Escocia.la incidencia de carcinoma colorrectal se calculó a partir de datos de población de tres países durante dos o a cuatro décadas.Incidencia de carcinoma colorrectal. Se determinaron las tasas de incidencia y los datos se estratificaron por subsitio (colon versus recto), además de sexo y edad (<50, 50-79 y ≥ 80).las tasas generales de carcinoma colorrectal disminuyeron en Nueva Zelanda, se mantuvieron estables en Escocia y aumentaron en Suecia. En las tres poblaciones, hubo una incidencia creciente de carcinoma rectal en pacientes menores de 50 años. El carcinoma rectal de inicio juvenil aumentó en Nueva Zelanda (1995-2012): tasa de incidencia de 1,18 [varones] y 1,13 [mujeres], con una disminución de la incidencia en todos los demás grupos de edad. El carcinoma de colon no aumentó en la población de < 50 años, con la excepción del carcinoma de colon distal en hombres. En general, la incidencia de carcinoma rectal aumentó (1970-2014) en Suecia; sin embargo, los aumentos en aquellos de <50 años excedieron los aumentos en otros grupos de edad: tasa de incidencia 1.14 [hombres] y 1.12 [mujeres]. Los aumentos del carcinoma de colon distal fueron más marcados en la población de < 50 años. En Escocia (1990-2014), la incidencia de carcinoma rectal de inicio juvenil aumentó: relación de tasa de incidencia 1.23 [hombres] y 1.27 [mujeres], con un aumento menor en el carcinoma de colon.Investigación de incidencia poblacional basada en registros nacionales.Este estudio muestra un aumento en el carcinoma rectal de inicio joven en tres poblaciones nacionales. Esta observación puede indicar un enfoque para la examinación de influencias ambientales en la etiología de este aumento y, por lo tanto, explorar estrategias para la prevención. Consulte Video Resumen en http://links.lww.com/DCR/B194. (Traducción-Dr Adrián Ortega).

Experiences of wearing support garments by people living with a urostomy.

BACKGROUND: support garments are commonly worn by people with a urostomy but there are no published data about their experiences of doing so. AIMS: to identify the views of people living with a urostomy on the role of support garments. METHODS: a cross-sectional survey of the stoma population's experiences of support garments was conducted in 2018. Recruitment was by social media. The free-text responses provided by a sub-sample of 58 people out of 103 respondents with a urostomy, were analysed. FINDINGS: thematic analysis revealed four themes: physical self-management; psychosocial self-management; lifestyle; and healthcare advice and support. There were mixed feelings about the value of support garments. Many cited a sense of reassurance and confidence and being able to be more sociable and active; others reported discomfort and uncertainty about their value. CONCLUSION: these findings add new understanding of experiences of support garments and provide novel theoretical insights about life with a urostomy.

Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Optimum surgical intervention for low-grade haemorrhoids is unknown. Haemorrhoidal artery ligation (HAL) has been proposed as an efficacious, safe therapy while rubber band ligation (RBL) is a commonly used outpatient treatment. We compared recurrence after HAL versus RBL in patients with grade II-III haemorrhoids. METHODS: This multicentre, open-label, parallel group, randomised controlled trial included patients from 17 acute UK NHS trusts. We screened patients aged 18 years or older presenting with grade II-III haemorrhoids. We excluded patients who had previously received any haemorrhoid surgery, more than one injection treatment for haemorrhoids, or more than one RBL procedure within 3 years before recruitment. Eligible patients were randomly assigned (in a 1:1 ratio) to either RBL or HAL with Doppler. Randomisation was computer-generated and stratified by centre with blocks of random sizes. Allocation concealment was achieved using a web-based system. The study was open-label with no masking of participants, clinicians, or research staff. The primary outcome was recurrence at 1 year, derived from the patient's self-reported assessment in combination with resource use from their general practitioner and hospital records. Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year. This study is registered with the ISRCTN registry, ISRCTN41394716. FINDINGS: From Sept 9, 2012, to May 6, 2014, of 969 patients screened, 185 were randomly assigned to the HAL group and 187 to the RBL group. Of these participants, 337 had primary outcome data (176 in the RBL group and 161 in the HAL group). At 1 year post-procedure, 87 (49%) of 176 patients in the RBL group and 48 (30%) of 161 patients in the HAL group had haemorrhoid recurrence (adjusted odds ratio [aOR] 2·23, 95% CI 1·42-3·51; p=0·0005). The main reason for this difference was the number of extra procedures required to achieve improvement (57 [32%] participants in the RBL group and 23 [14%] participants in the HAL group had a subsequent procedure for haemorrhoids). The mean pain 1 day after procedure was 3·4 (SD 2·8) in the RBL group and 4·6 (2·8) in the HAL group (difference -1·2, 95% CI -1·8 to -0·5; p=0·0002); at day 7 the scores were 1·6 (2·3) in the RBL group and 3·1 (2·4) in the HAL group (difference -1·5, -2·0 to -1·0; p<0·0001). Pain scores did not differ between groups at 21 days and 6 weeks. 15 individuals reported serious adverse events requiring hospital admission. One patient in the RBL group had a pre-existing rectal tumour. Of the remaining 14 serious adverse events, 12 (7%) were among participants treated with HAL and two (1%) were in those treated with RBL. Six patients had pain (one treated with RBL, five treated with HAL), three had bleeding not requiring transfusion (one treated with RBL, two treated with HAL), two in the HAL group had urinary retention, two in the HAL group had vasovagal upset, and one in the HAL group had possible sepsis (treated with antibiotics). INTERPRETATION: Although recurrence after HAL was lower than a single RBL, HAL was more painful than RBL. The difference in recurrence was due to the need for repeat bandings in the RBL group. Patients (and health commissioners) might prefer such a course of RBL to the more invasive HAL. FUNDING: NIHR Health Technology Assessment programme.

Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial.

BACKGROUND: Two commonly performed surgical interventions are available for severe (grade II-IV) haemorrhoids; traditional excisional surgery and stapled haemorrhoidopexy. Uncertainty exists as to which is most effective. The eTHoS trial was designed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery. METHODS: The eTHoS trial was a large, open-label, multicentre, parallel-group, pragmatic randomised controlled trial done in adult participants (aged 18 years or older) referred to hospital for surgical treatment for grade II-IV haemorrhoids. Participants were randomly assigned (1:1) to receive either traditional excisional surgery or stapled haemorrhoidopexy. Randomisation was minimised according to baseline EuroQol 5 dimensions 3 level score (EQ-5D-3L), haemorrhoid grade, sex, and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery. The primary outcome was area under the quality of life curve (AUC) measured with the EQ-5D-3L descriptive system over 24 months, assessed according to the randomised groups. The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables. This trial is registered with the ISRCTN registry, number ISRCTN80061723. FINDINGS: Between Jan 13, 2011, and Aug 1, 2014, 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery). Stapled haemorrhoidopexy was less painful than traditional excisional surgery in the short term and surgical complication rates were similar between groups. The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months; mean difference -0·073 (95% CI -0·140 to -0·006; p=0·0342). EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery, the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group. 24 (7%) of 338 participants who received stapled haemorrhoidopexy and 33 (9%) of 352 participants who received traditional excisional surgery had serious adverse events. INTERPRETATION: As part of a tailored management plan for haemorrhoids, traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice. FUNDING: National Institute for Health Research Health Technology Assessment programme.

Development of a Patient-Specific 3D-Printed Liver Model for Preoperative Planning.

INTRODUCTION: Liver surgery is widely used as a treatment modality for various liver pathologies. Despite significant improvement in clinical care, operative strategies, and technology over the past few decades, liver surgery is still risky, and optimal preoperative planning and anatomical assessment are necessary to minimize risks of serious complications. 3D printing technology is rapidly expanding, and whilst appliactions in medicine are growing, but its applications in liver surgery are still limited. This article describes the development of models of hepatic structures specific to a patient diagnosed with an operable hepatic malignancy. METHODS: Anatomy data were segmented and extracted from computed tomography and magnetic resonance imaging of the liver of a single patient with a resectable liver tumor. The digital data of the extracted anatomical surfaces was then edited and smoothed, resulting in a set of digital 3D models of the hepatic vein, portal vein with tumor, biliary tree with gallbladder, and hepatic artery. These were then 3D printed. RESULTS: The final models of the liver structures and tumor provided good anatomical detail and representation of the spatial relationships between the liver tumor and adjacent hepatic structures and could be easily manipulated and explored from different angles. CONCLUSIONS: A graspable, patient-specific, 3D printed model of liver structures could provide an improved understanding of the complex liver anatomy and better navigation in difficult areas and allow surgeons to anticipate anatomical issues that might arise during the operation. Further research into adequate imaging, liver-specific volumetric software, and segmentation algorithms are worth considering to optimize this application.

Co-designing inflammatory bowel disease (Ibd) services in Scotland: findings from a nationwide survey.

BACKGROUND: The Scottish Government's ambition is to ensure that health services are co-designed with the communities they serve. Crohn's and Colitis UK and the Scottish Government acknowledged the need to review and update the current IBD care model. An online survey was conducted asking IBD patients about their experiences of the NHS care they receive. This survey was the first step of co-designing and developing a national strategy for IBD service improvement in Scotland. AIM: To explore IBD patients' experiences of current services and make recommendations for future service development. METHODS: This study was part of a wider cross-sectional on-line survey. Participants were patients with IBD across Scotland. 777 people with IBD took part in the survey. Thematic analysis of all data was conducted independently by two researchers. RESULTS: Three key themes emerged: Quality of life: Participants highlighted the impact the disease has on quality of life and the desperate need for IBD services to address this more holistically. IBD clinicians and access: Participants recognised the need for more IBD nurses and gastroenterologists along with better access to them. Those with a named IBD nurse reported to be more satisfied with their care. An explicit IBD care pathway: Patients with IBD identified the need of making the IBD care pathway more explicit to service users. CONCLUSIONS: Participants expressed the need for a more holistic approach to their IBD care. This includes integrating psychological, counselling and dietetic services into IBD care with better access to IBD clinicians and a more explicit IBD care pathway.

3D digital anatomy modelling - Practical or pretty?

BACKGROUND: With an increasing move towards digitalisation of medical records and medical teaching, such as online exams and webinars, one of the questions that persists asks 'is there a place for digital anatomy teaching and can it effectively replace the traditional teaching methods such as cadaveric dissection?' Cadaveric dissection has a number of benefits as a teaching method but it also has its limitations. Although these can be partially addressed by prosections and new more "life-like" fixatives, it does not address the lack of resources and the increasing pressure to be able to study and learn at home. METHODS: This paper reviews the literature with regards to the suitability of digital models for teaching and the wider uses a 3D digital anatomy model could have, such as postgraduate teaching, patient education and surgical planning. It also looks briefly at the learning model that anatomy as art contributes. RESULTS: The literature has scattered examples of digital models used for teaching at both undergraduate and postgraduate level, which demonstrate a number of positive outcomes, mostly surrounding user satisfaction and convenience. 3D modelling for patient education and operation planning has less exploration, and these papers generate a number of discussion points, mostly surrounding the practicality of digital models, which can be more time consuming and require the technology to be widely available and reliable. CONCLUSIONS: 3D digital anatomy is a useful adjunct to teaching and its use in patient education and operation planning have interesting possibilities still to be fully explored.