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INTRODUCTION: The first wave of the COVID-19 pandemic led to an unprecedented time for the management of colorectal cancer, with uncertainty as to cancer-specific risks and the circumventing of gold standard oncological strategies. Our study aimed to acquire a snapshot of the practice of multidisciplinary team (MDT) management and variability in response to rapidly emerging guidelines. METHODS: The survey was disseminated to 150 colorectal cancer MDTs across England and Wales taken from the National Bowel Cancer Audit data set between 15 April and 30 June 2020 for completion by colorectal surgeons. RESULTS: Sixty-seven MDTs responded to the survey. Fifty-seven centres reported that they continued to perform colorectal cancer resections during the initial lockdown period. Fifty centres (74.6%) introduced routine preoperative COVID-19 testing and 50 (74.6%) employed full personal protective equipment for elective cases. Laparoscopic resections were continued by 25 centres (42.1%), whereas 28 (48.3%) changed to an open approach. Forty-nine (79.0%) centres reported experiencing patient-led surgical cancellations in 0-25% of their listings. If surgery was delayed significantly then 24 centres (38.7%) employed alternative neoadjuvant therapy, with short-course radiotherapy being their preferred adjunct of choice for rectal cancer. Just over 50% of the MDTs stated that they were uncomfortable or very uncomfortable with their management strategies. CONCLUSIONS: Our study demonstrates variability in the MDT management of colorectal cancer during the initial COVID-19 lockdown, incorporating adaptive patient behaviour and initially limited data on oncological safety profiles leading to challenging decision-making.
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COVID-19 , Neoplasias del Recto , COVID-19/epidemiología , COVID-19/prevención & control , Prueba de COVID-19 , Control de Enfermedades Transmisibles , Humanos , Pandemias/prevención & controlRESUMEN
INTRODUCTION: To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures. METHOD: All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate. RESULTS: In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients. CONCLUSION: Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.
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COVID-19 , Colectomía/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Pandemias , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reino Unido/epidemiologíaAsunto(s)
COVID-19/epidemiología , Consentimiento Informado , Procedimientos Quirúrgicos Operativos/ética , COVID-19/prevención & control , COVID-19/transmisión , Infección Hospitalaria/etiología , Infección Hospitalaria/prevención & control , Conocimientos, Actitudes y Práctica en Salud , Humanos , Consentimiento Informado/ética , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Encuestas y Cuestionarios , Reino UnidoRESUMEN
INTRODUCTION: Pilonidal disease is a chronic condition involving the sacrococcygeal area. It can have a significant impact on quality of life, social activities and occupation. Surgery is the mainstay of treatment. However, laser depilation has been proposed as an adjunct to surgery and has shown improved results in some studies. We present our experience of laser depilation in the treatment of pilonidal disease in a district general hospital setting in the UK. MATERIALS AND METHODS: A prospectively maintained database of all consecutive patients who received laser depilation after elective surgery for pilonidal disease was analysed. Patients were offered a minimum of two sessions of laser depilation. The primary outcome measure was disease recurrence. Evidence of new symptoms or signs of pilonidal disease after one year from the latest surgical intervention was defined as recurrent disease. Data are presented as medians with interquartile ranges. RESULTS: A total of 64 patients underwent laser depilation after elective surgery between 1 June 2013 and 1 June 2018; 57 were eligible for final analysis. Sixty-five per cent of patients received six or more sessions of laser treatment. There were no short- or long-term complications related to laser depilation. Patients who had more than two sessions of laser depilation showed an improved recurrence rate. Overall, recurrence rate in our series was 12% at a median follow-up of 172 weeks. CONCLUSION: Laser depilation is a safe and effective adjunct to surgery in minimising the recurrence of pilonidal disease. Patients with primary pilonidal disease and those who are undergoing minimally invasive surgery may also benefit from adjuvant laser depilation. Further high-quality control trials are required to assess its efficacy and safety.
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Remoción del Cabello/métodos , Terapia por Láser/métodos , Seno Pilonidal/prevención & control , Prevención Secundaria/métodos , Adolescente , Adulto , Femenino , Hospitales de Distrito , Hospitales Generales , Humanos , Masculino , Persona de Mediana Edad , Seno Pilonidal/cirugía , Estudios Prospectivos , Reino Unido , Adulto JovenRESUMEN
PURPOSE: Porcine acellular dermal matrix (PADM) has been promoted as a suitable material for the reinforcement of the abdominal wall in Ventral Hernia Working Group (VHWG) Grade 3/4 wounds by Ventral Hernia Working Group et al. (Surgery 148(3):544-548). We describe our experience of, and assess the mechanisms for the failure of PADM (PermacolTM) in intestinal and abdominal wall reconstruction (AWR) for enterocutaneous fistulation (ECF). METHODS: All patients referred to our unit who had PADM used for AWR and ECF were studied from a prospectively maintained database. Follow-up data until 31/12/2018 were analysed. PADM was explanted at further surgery and examined histologically. RESULTS: 13 patients, (median age-58.5 years) underwent AWR with PADM reinforcement. Twelve of these (92%) patients had developed abdominal wall defects (AWD) and ECF following complications of previous surgery. Six patients underwent fistula takedown and AWR with PADM, of which 5(83%) refistulated. Seven patients referred to us had already undergone similar procedures in their referring hospitals and had also refistulated. Median (range) time to fistulation after AWR with PADM was 17 (7-240) days. In all cases, PADM had been used to bridge the defect and placed in direct contact with bowel. At reconstructive surgery for refistulation, PADM was inseparable from multiple segments of small intestine, necessitating extensive bowel resection. Histological examination confirmed that the PADM almost completely integrated with the seromuscular layer of the small intestine. CONCLUSION: PADM may become inseparable from serosa of the human small intestinal serosa when it is left in the abdomen during reconstructive surgery. This technique is associated with recurrent intestinal fistulation and intestinal failure and should be avoided if at all possible.
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Dermis Acelular/efectos adversos , Colágeno/efectos adversos , Hernia Ventral/cirugía , Herniorrafia/efectos adversos , Fístula Intestinal/etiología , Pared Abdominal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Animales , Femenino , Herniorrafia/métodos , Humanos , Fístula Intestinal/cirugía , Intestino Delgado/cirugía , Masculino , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Recurrencia , Reoperación , Estudios Retrospectivos , Mallas Quirúrgicas/efectos adversosRESUMEN
PURPOSE: Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients. METHODS: All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database. RESULTS: 35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series. CONCLUSION: Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients.
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Reservorios Cólicos , Ileostomía , Adolescente , Adulto , Femenino , Estudios de Seguimiento , Hospitales de Alto Volumen , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/epidemiología , Reoperación , Estudios Retrospectivos , Centros de Atención Terciaria , Adulto JovenRESUMEN
INTRODUCTION: Endoscopic treatment for pilonidal disease was initially described by Meinero in 2013. This minimally invasive technique has both technical and aesthetic advantages. The diagnostic application helps identify the anatomy of the pilonidal disease and the operative phase ablates and cleans the infected cavity. Our aim was to study the short-term outcomes of endoscopic treatment for pilonidal disease and to evaluate complications and recurrence rates. MATERIALS AND METHODS: A prospectively maintained database of all consecutive patients who underwent endoscopic treatment for pilonidal disease by a single surgeon in a district general hospital from 1 November 2014 to 31 March 2018 was analysed. Follow-up was available until 30 September 2018. RESULTS: A total of 74 patients (56 men) underwent endoscopic treatment for pilonidal disease. The median age was 21 years (range 16-62 years). All patients underwent the procedure as daycase procedures, seven under local anaesthesia. There were no immediate postoperative complications and no return to theatre or readmission within 90 days. On a median follow-up of 52 weeks (range 2-114 weeks), 57 patients healed completely and 8 lost to follow-up. We achieved primary healing rates of 67% (44/66) and delayed healing rate of 77% (51/66). CONCLUSIONS: Endoscopic treatment for pilonidal disease is a safe and effective minimally invasive technique that should be considered as first-line treatment in selected cases of pilonidal sinus disease, thereby reducing morbidity related to conventional procedures.
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Endoscopía/efectos adversos , Seno Pilonidal/cirugía , Complicaciones Posoperatorias/epidemiología , Adolescente , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Selección de Paciente , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND AIM: The retroperitoneal tumor (RPT) service in the North West costal region of England was centralized in May 2011 by the merger of the Merseyside, Cheshire and Lancashire, Cumbria sarcoma networks. Our aim was to analyze the impact of centralization of services on patient outcomes. METHODS: An analysis from 01/12/2004 to 30/11/2017 was undertaken from prospectively maintained database and electronic patient records; follow-up was until 30/04/2018. This time period encompassed 6.5 years before and after centralization of services took place. Survival analysis was done for Retroperitoneal Sarcomas (RPS) and also compared the impact of centralization. RESULTS: 72 patients (27 men), median age 69 (21-90) years) underwent 95 operations with an intention to excise RPS. Overall there were 52 (54.7%) multi-visceral resections (MVR). 91/95 (95.8%) patients with primary tumors had surgery with a curative (R0/1) intent. 30-day and 90-day operative mortality was 3.2% (n = 3) and 4.2% (n = 4) respectively. The 5-year survival for patients undergoing resection for RPTs was 51.3%. 79 (83.1%) of the resections in this series occurred in the 6.5-years post-centralization with an increase in MVR between the two time points (p < 0.0006). Despite the more radical nature of surgery post-centralization, there was no difference in 5-year survival for RPS patients when compared to pre-centralization, p = 0.575. However the 5-yr survival post-centralization compared favorability to national outcomes. CONCLUSION: Centralization in the management of RPS has resulted in an increase in resection rates and more complex MVRs, without compromising R0/1 resection rates; peri-operative mortality or overall survival.
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Atención a la Salud/organización & administración , Neoplasias Retroperitoneales/cirugía , Sarcoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Neoplasias Retroperitoneales/mortalidad , Sarcoma/mortalidad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
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.
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Endoscopía Gastrointestinal , Fístula Rectal/cirugía , Cirugía Asistida por Video , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/métodos , Endoscopía Gastrointestinal/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Prospectivos , Cirugía Asistida por Video/efectos adversos , Cirugía Asistida por Video/métodos , Cirugía Asistida por Video/estadística & datos numéricosRESUMEN
BACKGROUND/OBJECTIVES: Chronic radiation enteritis (RE) has been reported in up to 20% of patients receiving pelvic radiotherapy and can lead to intestinal failure (IF), accounting for 3.9% of new registrants for home parenteral nutrition (HPN) in the UK annually. Our aim is to report nutritional and survival outcomes for patients with RE referred to a national IF unit. SUBJECTS/METHODS: A retrospective study of all new admissions over a 13-year period at the Intestinal Failure Centre, Manchester, UK. Data are presented as median (range). RESULTS: Twenty-three (3.8%) of 611 patients were admitted with IF secondary to RE. The primary site of malignancy was genitourinary in 17 (74%) patients. Radiotherapy was administered 9.5 (1-42) years previously. Patients underwent 2 (1-5) laparotomies prior to intestinal failure unit (IFU) admission. Twelve (52%) patients were admitted with intestinal obstruction and 11 (48%) with intractable weight loss and/or high output fistulae/stomas. Additional conditions contributing to IF were noted in 11 (48%) patients. Twenty-two (96%) patients had 2 (1-5) laparotomies prior to IFU referral. At discharge, 5 (22%) patients resumed oral diet without the need for artificial nutrition support, 3 (13%) required enteral feeding and 13 (56%) commenced HPN. The 10-year survival of the patient cohort was 48.2%. CONCLUSIONS: Surgical intervention is infrequently required, whereas the majority of patients with IF secondary to RE require long-term HPN. The judicious use of surgery in selected patients, coupled with an aggressive medical strategy to detect and treat contributing factors, and optimal enteral feeding may allow a modest proportion of patients with IF secondary to RE to achieve independence from PN.
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Enteritis/etiología , Enfermedades Intestinales/etiología , Enfermedades Intestinales/terapia , Radioterapia/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Fístula Intestinal/etiología , Fístula Intestinal/cirugía , Fístula Intestinal/terapia , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/terapia , Masculino , Persona de Mediana Edad , Terapia Nutricional , Nutrición Parenteral en el Domicilio , Estudios Retrospectivos , Síndrome del Intestino Corto/etiología , Síndrome del Intestino Corto/cirugía , Síndrome del Intestino Corto/terapia , Resultado del Tratamiento , Reino Unido , Neoplasias Urogenitales/radioterapiaRESUMEN
BACKGROUND: Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap. METHODS: The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3-23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204-792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10-174) weeks. RESULTS: Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy. CONCLUSION: Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.
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Pared Abdominal/cirugía , Fístula Cutánea/cirugía , Fístula Intestinal/cirugía , Sepsis/cirugía , Colgajos Quirúrgicos , Adulto , Fístula Cutánea/complicaciones , Femenino , Humanos , Fístula Intestinal/complicaciones , Tiempo de Internación , Masculino , Persona de Mediana Edad , Músculo Cuádriceps/trasplante , Estudios Retrospectivos , Muslo , Trasplante Autólogo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
The objective of this study was to improve the oral bioavailability and therapeutic efficacy of albendazole (ABZ) employing solid dispersion and cyclodextrin complexation techniques. Solid dispersion (dispersion) was prepared using ABZ and polyvinylpyrrolidone (PVP) polymer (1:1 weight ratio). Ternary inclusion complex (ternary complex) was prepared using ABZ, hydroxypropyl beta-cyclodextrin (HPbetaCD) and L-tartaric acid (1:1:1 molar ratio). In rabbits with high gastric acidity (gastric pH approximately 1), ternary complex and solid dispersion showed a bioavailability enhancement of 3.2 and 2.4 fold respectively, compared to a commercial suspension (p < 0.05). The rise in gastric pH (pH > 5) caused a 62% reduction in AUC (area under the plasma level curve) for the commercial suspension, whereas the reduction in case of PVP dispersion and ternary complex was only 43% and 37% respectively. The rapid absorption of the drug from solid dispersion and ternary complex was reflected in improved anthelmintic efficacy against the systemic phases of Trichinella spiralis. The ternary complex was significantly more efficient than solid dispersion and exhibited the highest larvicidal activity (90%) at a dose of 50 mg x kg(-1) (p < 0.05). These results suggest that the bioavailability and therapeutic efficacy of the ternary complex might be high even if there is a great variation in the gastric pH.
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Albendazol/farmacología , Albendazol/farmacocinética , Antihelmínticos/farmacología , Antihelmínticos/farmacocinética , Albendazol/administración & dosificación , Animales , Antihelmínticos/administración & dosificación , Disponibilidad Biológica , Química Farmacéutica , Ciclodextrinas/química , Interpretación Estadística de Datos , Excipientes , Determinación de la Acidez Gástrica , Concentración de Iones de Hidrógeno , Conejos , Trichinella spiralis/efectos de los fármacosRESUMEN
The main aim of the study was to investigate the mechanisms of the stabilizing effect of poly(vinylpyrrolidone) (PVP) on amorphous albendazole (ABZ). Solid dispersions of ABZ with PVP polymers and with a copolymer containing poly(vinylacetate) (PVP/VA) were prepared using the solvent casting method. The effects of PVP molecular weight, composition and content on the crystallization of ABZ from the amorphous state were investigated using differential scanning calorimetry. Stability of the amorphous drug with respect to isothermal crystallization was studied at different polymer concentrations and storage temperatures. Solid dispersions were found to be X-ray amorphous and exhibited a single glass transition temperature (Tg). Onset of crystallization and extent of inhibition increased with concentration and molecular weight of the homopolymer. In spite of its having a higher molecular weight, replacement of about 40% of vinylpyrrolidone monomers with vinylacetate groups (as in the copolymer) resulted in reduced inhibition of crystallization. ABZ crystallized from the amorphous state in the absence of polymer even when stored below the Tg. The solvent casting method greatly reduced the requirement for polymer to achieve X-ray amorphous solid dispersions. Such dispersions exhibited a significant increase in induction time and reduction in the rate of crystallization at polymer concentrations as low as 5% and at temperatures as high as 70 degrees C. Factors other than mobility, such as drug-polymer hydrogen bonding' were also found to be involved in crystallization inhibition.