Evaluating unmet needs in patients undergoing surgery for colorectal cancer: a patient reported outcome measures study.

AIM: Patient reported outcome measures (PROMs) are self-reported measures of patients' health status or health-related quality of life at a single point in time. We aimed to evaluate the use of a colorectal PROM and conducted a focus group to further explore this and other unmet needs in our patient population treated surgically for colorectal cancer. METHOD: A multidisciplinary research group consisting of colorectal surgeons, nurse specialists, psychologists, sociologists and patient representatives devised a composite tool of new and existing outcome measures which was piloted in our local population (n = 35). Participants were subsequently invited to attend a semi-structured focus group during which the PROM was reviewed and an unmet needs analysis was performed. Thematic analysis of focus group transcripts was undertaken for emergent themes. RESULTS: Initial consensus was for a tool including the EQ-5D, Functional Assessment of Cancer Therapy - Colorectal (FACT-C), the distress thermometer, a validated measure of stigma, an unmet needs analysis, and questions assessing the psychological impact of cancer. Median and interquartile range values suggested that all metrics were discriminatory with the exception of FACT-C. All participants agreed that the tool was acceptable and reflected the current state of their health and emotions. Thematic analysis of focus group transcripts identified four major themes: physical symptoms, emotional response, information provision and coping mechanisms. CONCLUSION: Through expert consensus, local piloting and patient focus groups we have evaluated a novel PROM for colorectal cancer. Furthermore, through our direct engagement with patients we have identified several unmet needs which we are currently exploring within the clinical service.

Video-assisted anal fistula treatment: a high volume unit initial experience.

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Initial UK experience with transversus abdominis muscle release for posterior components separation in abdominal wall reconstruction of large or complex ventral hernias: a combined approach by general and plastic surgeons.

Introduction Large, complicated ventral hernias are an increasingly common problem. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Methods The study is a retrospective review of patients undergoing TAMR performed synchronously by gastrointestinal and plastic surgeons. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8kg/m2 (range 19.0-34.4kg/m2). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average transverse distance between the recti was 13cm (3-20cm). Median operative time was 383 minutes (150-550 minutes) and mesh size was 950cm2 (532-2400cm2). Primary midline fascial closure was possible in all cases, with no bridging. Median length of hospital stay was 7.5 days (4-17 days). Three developed minor abdominal wall wound complications. At median review of 24 months (18-37 months), there have been no significant wound problems, mesh infections or explants, and none has developed recurrence of their midline ventral hernia. Visual analogue scales revealed high patient satisfaction levels overall and with their final aesthetic appearance. Conclusions We believe that TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good results.

Rectal mucocoele following subtotal colectomy for colitis.

We present a unique case of a rectal mucocoele affecting a patient several years after his subtotal colectomy for ulcerative colitis. This was secondary to both a benign anorectal stenosis and a benign mucus secreting rectal adenoma. This case highlights the importance of surveillance in such patients.

Neutrophil to lymphocyte ratio predicts perioperative mortality following open elective repair of abdominal aortic aneurysms.

OBJECTIVES: This study assesses the predictive value of neutrophil to lymphocyte ratio (NLR) in relation to 30-day and overall mortality following open abdominal aortic aneurysm (AAA) repairs. In addition, it assess assesses any correlation between NLR and age, size of the AAA and gender. METHODS: Patients undergoing elective or urgent open repair of their AAA by a single surgeon during a 10-year period were included. A pre-operative NLR of >5 was regarded as abnormal. RESULTS: 350 consecutive patients underwent AAA repair. 52 had an NLR>5. 30-day mortality rate was 12/52 (23%) in the NLR>5 group and 20/298 (6.7%) in the NLR<5 group (p = 0.0007). All deaths in the NLR>5 group were due to myocardial infarction. The median NLR was higher in those that died within 30 days at 4.2 [IQR: 2.6-7.5] versus 2.8 [IQR: 2.1-3.8] (p = 0.0001). Overall mortality at 10 years, in the NLR>5 group - 26/52 (50%) was significantly greater than that of the NLR<5 group - 102/298 (34.2%) (p = 0.043). Median NLR of those dying during follow-up was significantly higher in those with a baseline NLR>5 at 3.2 (IQR 2.5-4.6) versus 2.6 (IQR: 2.0-3.6) in those surviving (p = 0.00004). No difference was found between NLR and age, aneurysm size or gender. CONCLUSION: Pre-operative NLR>5 appears to be a significant predictor of both 30-day mortality and long-term outcome in elective and urgent open AAA surgery. It is plausible the NLR is identifying a group with sub-clinical cardiovascular disease at risk of peri-operative myocardial infarction.

Long-term clinical outcome following lower limb arterial angioplasty.

INTRODUCTION: The aim of this study was to determine the clinical outcome of lower limb arterial angioplasty in a busy district general hospital practice. PATIENTS AND METHODS: All angioplasties performed from January 1999 to December 2004 were identified and data collected included cardiovascular risk factors, indications for and complications of angioplasty, limb salvage and patient survival rates, and clinically significant re-stenoses. RESULTS: 471 interventions were performed in 385 patients (231 men, 154 women). The median age was 67.9 years (range: 39-93 years). Indications for angioplasty were critical ischaemia (n=247, 52%) and lifestyle-limiting intermittent claudication (n=224, 48%). Stenotic lesions accounted for 378 (80%) cases and occlusion for 93 (20%). Radiological success was obtained in 417 (88.5%), improving to 93.6% if only those in whom access was achieved were included. Post-angioplasty complications were observed in 42/471 (9.1%) of interventions. The actual patient survival at 1, 2, and 3 years was 87.4%, 85.1% and 83.2% respectively. Indication for angioplasty and the number of lesions present were identified as risk factors for outcome on multivariate analysis. The cumulative post-angioplasty patency rates at 1, 2 and 3 years were 86.0%, 83.1% and 81.6% respectively. The only factor associated with patency was the mode of presentation. CONCLUSIONS: Angioplasty for lower limb peripheral vascular disease can be performed safely and efficaciously with a high technical success rate and a low complication rate. The patient survival and post-angioplasty patency data reflect the progressive and multi-site nature of the underlying disease process.

Extra-anatomical bypass grafting--a single surgeon's experience.

INTRODUCTION: Extra-anatomical bypass grafting is a recognised method of lower limb re-vascularisation in high-risk patients who cannot tolerate aortic cross clamping, or in those with a hostile abdomen. We present a single surgeon series of such procedures and determine relevant outcomes. PATIENTS AND METHODS: A retrospective review was performed on a prospectively maintained database of patients undergoing femoro-femoral or axillo-femoral bypass surgery between 1986 and 2004. RESULTS: Patency rates for femoral (n = 28; 32%) versus axillary (n = 59; 68%) bypass procedures at 1 month, 1, 3 and 5 years were (92% vs 93%), (69% vs 85%), (60% vs 72%) and (55% vs 67%), respectively. Patient survival rates for the corresponding procedures and time intervals were (96% vs 90%), (96% vs 67%), (85% vs 45%) and (73% vs 38%) and revealed a significantly lower survival rate in those undergoing axillary procedures (P = 0.002). Limb salvage rates were calculated at (100% vs 91%), (96% vs 84%), (96% vs 81%) and (92% vs 81%) with no statistically significant difference found between the two groups (P = 0.124). Two-thirds of the patients who required major amputation died within 12 months of surgery. CONCLUSIONS: Acceptable 30-day morbidity, long-term primary patency and survival rates are obtainable in patients suitable for extra-anatomical bypass surgery despite having significant co-morbidities. We have shown 5-year patency rates in those that survive axillary procedures to be as good as those undergoing femoral procedures. Furthermore, surviving patients who evade amputation within a year have an excellent chance of long-term limb salvage.

In vitro assays for botulinum toxin and antitoxins.

Clostridium botulinum produces several powerful neuroparalytic toxins which, although rare in food-poisoning instances, are generally fatal. A considerable amount of effort has therefore been made by the food industry to ensure that food treatment processes adequate to prevent growth and toxin production by Cl. botulinum. Laboratory mice and guinea-pigs are presently used extensively both for the assay of botulinum toxins and for the development and assessment of vaccines used to protect laboratory workers. An amplified ELISA, using a monoclonal antibody, has been developed for botulinum type A toxin with a sensitivity similar to that of the mouse acute toxicity test. The immunoassay has been found to be applicable to the detection of toxin in foodstuffs and could replace the currently used mouse bioassay in many laboratories. Immunoassays have also been developed for the detection of antibodies to botulinum toxins. A preliminary study has shown that antibody titres to botulinum types A and B toxins in sera taken from immunised personnel, as measured by ELISA, showed limited correlation with those measured by the toxin neutralisation test in mice. A more extensive study should determine whether the latter test can be replaced by the ELISA.

Monoclonal antibody-based immunoassay for type A Clostridium botulinum toxin is comparable to the mouse bioassay.

A monoclonal antibody (BA11) has been produced against Clostridium botulinum type A neurotoxin by the fusion of myeloma cells (P3 NS1/1-Ag4-1) with spleen cells from BALB/c mice immunized with botulinum type A neurotoxoid. The antibody bound specifically to botulinum type A neurotoxin, showing no cross-reactivity with types B and E botulinum toxins or with any of several other bacterial toxins tested. The monoclonal antibody did not bind to botulinum type A neurotoxin which had been denatured with sodium dodecyl sulfate and bound only weakly to each of the separated heavy and light subunits of the neurotoxin, suggesting a conformational requirement for the antigenic determinant of the antibody. A sensitive immunoassay for C. botulinum type A toxin with monoclonal antibody BA11 in conjunction with an enzyme amplication system has been developed which allows detection of 5 to 10 mouse 50% lethal doses ml-1 of purified neurotoxin. The assay was equally sensitive when applied to the detection of crude toxin in food stuffs; the average value for the minimum level of detectable toxin in extracts of tinned salmon or corned beef was 9 +/- 3.1 mouse 50% lethal doses ml-1.

Upper limb anthropometry: the value of measurement variance studies.

If a test involves subjective evaluation then different observers will record different findings. This is true of upper limb anthropometry. Unless the interobserver measurement variation is quantified then the detection of real, rather than apparent, measurement changes is hindered. This paper uses a new statistical approach to interpret apparent measurement changes in the presence of observer variation.

The assessment of protein-calorie malnutrition in patients with gastrointestinal cancer.

Daily protein and calorie intake, three plasma protein estimations, two upper limb anthropometric measurements, and estimated weight loss were all determined in 31 patients attending a surgical oncology outpatient department. The patients, who had had prior resection of a gastrointestinal cancer, could be divided into three groups depending on (i) the absence of clinically detectable tumour; (ii) the presence of clinically detectable tumour with survival over the ensuing four-month period; and (iii) clinically detectable tumour without survival over the ensuing four-month period. The variables least able to discriminate between these groups, and to interrelate to the other variable in a cross-correlation matrix, were the dietary intake data and the estimated weight loss. It is concluded that protein-calorie malnutrition can be adequately assessed in patients with advanced cancer from studies of the plasma albumin, prealbumin, transferrin, arm fat area, and arm muscle area.