The test-retest reliability of fecal incontinence severity and quality-of-life assessment tools.

BACKGROUND: The St. Mark's score and Cleveland Clinic score are widely used for assessing the severity of fecal incontinence, whereas the Rockwood quality of life scale is used to evaluate the impact on the quality of life of patients. OBJECTIVE: The aim of this study was to determine the intra- and interobserver reliability of these assessment tools. DESIGN: All patients were recruited prospectively. To assess intraobserver reliability each patient was asked to complete 4 assessments (the St. Mark's and Cleveland Clinic scores, the Rockwood scale, and a visual analog scale) at 2 time points: initially at recruitment (P1) and then 6 weeks later (P2). No alteration to medications or treatment occurred during this interval. For interobserver reliability, the St. Mark's and Cleveland Clinic scores were also completed by a physician (time point P1) and a nurse (time point P2). OUTCOME MEASURES: Intra- and interobserver reliability were determined by using an intraclass correlation coefficient. An intraclass correlation coefficient value of less than 0.40 indicates poor reliability, values in the range 0.40 to 0.75 indicate fair to good reliability, and a value of greater than 0.75 shows excellent reliability. RESULTS: Thirty-nine patients (34 female) with a median age of 65 years were studied. The intraclass correlation coefficient for intraobserver reliability for the Cleveland Clinic score at time points P1 and P2 was 0.858 (95% CI, 0.611-0.940); and for St. Mark's score, the intraclass correlation coefficient was 0.823 (95% CI, 0.556-0.922). The intraclass correlation coefficients for the quality-of-life domains ranged between 0.864 and 0.938, whereas the intraclass correlation coefficient for the visual analog scale was 0.958 (95% CI, 0.906-0.982). The interobserver reliability ranged from 0.795 to 0.945 for the Cleveland Clinic score and from 0.793 to 0.939 for the St. Mark's score. LIMITATIONS: Of the 39 patients recruited, only 31 patients completed the second assessment at time point P2. This increases the risk of nonresponse error in this study, which is a recognized limitation of mail-mode surveys. CONCLUSION: Current assessment tools for the severity of fecal incontinence and its impact on quality of life have an excellent intra- and interobserver reliability and remain a good objective measure of patients' symptoms (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A135).

Obesity-related hypertension and its remission following gastric bypass surgery - a review of the mechanisms and predictive factors.

It is well established that hypertension and obesity appear to be associated. The exact mechanism by which they are linked is unclear and remains a topic of a great deal of research. Current NICE guidelines recommend that patients with a BMI in excess of 35 kg/m(2) should be considered for bariatric surgery if they have a concomitant obesity-associated condition, of which hypertension is one. The commonest bariatric procedure in the UK is the Roux-en-Y gastric bypass, which has been shown to result in long-standing remission of hypertension in up to 93% of patients. This paper summarizes the existing literature on the main theories as to how obesity leads to hypertension as well as the literature concerning the effects of gastric bypass surgery on hypertension.

Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss?

Obesity has become an increasingly important health problem over the past 30 years. Presently around a quarter of the UK adult population are obese and this figure is set to increase further in the coming decades. The health consequences of obesity on multiple body systems have been well established as has the financial cost of the condition to both the individuals affected as well as to society as a whole. Bariatric surgery has been shown to be the only long term effective solution in terms of sustained weight loss and comorbidity resolution. The commonest bariatric procedure in the UK is the Roux-en-y gastric bypass which consistently results in the loss of 70%-80% of excess bodyweight. Results however are variable and in order to optimise resource allocation and avoid exposing patients unlikely to benefit from surgery to its inherent risks, much research has been done to try to identify those patients most likely to obtain a good result. The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a positive association with postoperative weight loss following bypass surgery. Although the remaining data are not based on level 1 evidence those other preoperatively identifiable factors which are associated with an improved outcome include Caucasian or Hispanic ethnicity, higher educational status, non-shift-work working patterns, female gender and divorced or single marital status. Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not been shown to have a significant impact. Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss; however, a history of sexual abuse or psychiatric illness has not been shown to have a lasting influence.

The adherence to the American Association for the Study of Liver Diseases 2018 guidelines in the management of hepatocellular carcinoma and its impact on survival.

Introduction: In two Korean and Italian studies, the adherence rate (AR) to ASSLD 2005 guidelines in the management of hepatocellular carcinoma (HCC) was 60%. In a US study, the AR to American Association for the Study of Liver Disease (AASLD) 2005 guidelines was 73.3%, 26.8%, 25.3%, and 58.8% for patients with Barcelona Clinic Liver Cancer (BCLC) Stage A, B, C, and D, respectively, and nonadherence to guidelines was associated with longer overall survival (OS) in patients with BCLC Stage D. Here, we explored the AR to AASLD 2018 guidelines and its impact on OS. Methods: Between 2017 and 2019, 148 unique treatment-naïve patients with HCC were identified. Patients were staged according to the BCLC staging system and their AR to AASLD 2018 guidelines was noted. OS was estimated using Kaplan-Meier method. Survivals among patients from different groups was compared using Log-rank test. Results: The overall AR to AASLD 2018 guidelines was 83%. The AR for BCLC Stages 0, A, B, C, and D were 100%, 97%, 77%, 77%, and 38%, respectively. In patients with BCLC Stage D, the OS of patients treated with modalities adherent versus nonadherent to AASLD 2018 guidelines was 0.03 vs. 5.2 months (P = 0.0005). Otherwise, adherence versus nonadherence to AASLD 2018 guidelines showed no statistically significant differences in OS for patients with BCLC Stages 0, A, B, and C. Conclusion: The overall AR to AASLD 2018 guidelines was 83%. Nonadherence to AASLD 2018 guidelines in patients with BCLC Stage D translated into better OS.

Converting emergency pilonidal abscess into an elective procedure.

BACKGROUND: Improvements in outcome after surgery for elective pilonidal sinus disease have yet to be matched for those presenting with acute disease. Traditional approaches to the management of acute pilonidal abscess have been associated with slow healing and significant loss of working time. OBJECTIVE: The aim of this study was to report our approach in which a temporizing intervention allows subsequent definitive treatment with low morbidity. DESIGN: This article presents a prospective cohort study. SETTING: This study was performed in acute admissions to the Surgical Unit in York Teaching Hospital. PATIENTS: Patients presenting with acute pilonidal abscess, not septic, immune-compromised, or diabetic, and without skin necrosis, underwent aspiration on the surgical ward. INTERVENTION: Aspiration of pilonidal abscess under local anesthetic was performed with the use of a wide-bore needle. The abscess cavity was drained to dryness, samples were sent to the laboratory for microbiology, and empirical oral antibiotics were commenced, covering anaerobes and aerobes. Review was arranged for within 7 days to plan elective excision and primary closure of the underlying pilonidal sinus. MAIN OUTCOME MEASURES: The primary outcomes measured were the number of days required to return to normal activities, response to treatment, and any residual inflammation. RESULTS: Fifty-six patients were referred with acute pilonidal abscess. Forty patients met the criteria for aspiration and empirical antibiotic treatment. All were allowed to go home the same day and were reviewed within a median of 5 days. Thirty-eight (38/40) patients demonstrated complete resolution of acute inflammation and were back to normal activities the following day. Fifteen patients subsequently underwent day-case excision and primary closure at a median of 9 weeks. Another 13 are awaiting surgery, and 10 patients have declined further treatment. Two (2/40) patients did not respond, one of whom did not receive the appropriate antibiotics. Both were managed with incision and drainage. CONCLUSIONS: Aspiration and antibiotic management of pilonidal abscess is effective in 95% of acute cases in preventing the need for emergent laying open and allows for subsequent elective surgery.

Incidental Discovery of a Left Ventricular Aneurysm After a Syncopal Episode.

A left ventricular aneurysm is a rare post myocardial infarction complication. Ventricular aneurysms form as post-ischemic cardiac remodeling creates a weaker, fibrotic area that may bulge outwards against interventricular pressures over time. Patients with ventricular aneurysms have increased mortality and are at higher risk of various cardiac complications, such as cardiac arrest, arrhythmias, thrombus formation, reduced cardiac output, or aneurysmal rupture. Prompt diagnosis and treatment are critically important in these patients. We highlight the hospital course of a patient with an extensive cardiac history presenting for syncope with the discovery of a left ventricular aneurysm. The radiographic features of the left ventricular aneurysm are described, as well as formation, risk factors, and complications.

Role of clinical pathway in improving the quality of care for patients with faecal incontinence: A randomised trial.

AIM: To assess the development and implementation of the Integrated Rapid Assessment and Treatment (IRAT) pathway for the management of patients with fecal incontinence and measure its impact on patients' care. METHODS: Patients referred to the colorectal unit in our hospital for the management of faecal incontinence were randomised to either the Standard Care pathway or the newly developed IRAT pathway in this feasibility study. The IRAT pathway is designed to provide a seamless multidisciplinary care to patients with faecal incontinence in a timely fashion. On the other hand, patients in the Standard Pathway were managed in the general colorectal clinic. Percentage improvements in St. Marks Incontinence Score, Cleveland Clinic Incontinence Score and Rockwood Faecal Incontinence Quality of Life Scale after completion of treatment in both groups were the primary outcome measures. Secondary endpoints were the time required to complete the management and patients' satisfaction score. χ2, Mann-Whitney-U and Kendall tau-c correlation coefficient tests were used for comparison of outcomes of the two study groups. A P value of 0.05 or less was considered significant. RESULTS: Thirty-nine patients, 34 females, consented to participate. Thirty-one (79.5%) patients completed the final assessment and were included in the outcome analysis. There was no significant difference in the quality of life scales and incontinence scores. Patients in the IRAT pathway were more satisfied with the time required to complete management (P = 0.033) and had stronger agreement that all aspects of their problem were covered (P = 0.006). CONCLUSION: Despite of the lack of significant difference in outcome measures, the new pathway has positively influenced patient's mindset, which was reflected in a higher satisfaction score.

Double-layered covered stent for the treatment of malignant oesophageal obstructions: Systematic review and meta-analysis.

AIM: To investigate the efficacy of double-layered covered stent in the treatment of malignant oesophageal obstructions. METHODS: A systematic review and meta-analysis was performed following the PRISMA process. PubMed (Medline), EMBASE (Excerpta Medical Database), AMED (Allied and Complementary medicine Database), Scopus and online content, were searched for studies reporting on the NiTi-S polyurethane-covered double oesophageal stent for the treatment of malignant dysphagia. Weighted pooled outcomes were synthesized with a random effects model to account for clinical heterogeneity. All studies reporting the outcome of palliative management of dysphagia due to histologically confirmed malignant oesophageal obstruction using double-layered covered nitinol stent were included. The level of statistical significance was set at α = 0.05. RESULTS: Six clinical studies comprising 250 patients in total were identified. Pooled technical success of stent insertion was 97.2% (95%CI: 94.8%-98.9%; I (2) = 5.8%). Pooled complication rate was 27.6% (95%CI: 20.7%-35.2%; I (2) = 41.9%). Weighted improvement of dysphagia on a scale of 0-5 scoring system was -2.00 [95%CI: -2.29%-(-1.72%); I (2) = 87%]. Distal stent migration was documented in 10 out of the 250 cases examined. Pooled stent migration rate was 4.7% (95%CI: 2.5%-7.7%; I (2) = 0%). Finally, tumour overgrowth was reported in 34 out of the 250 cases with pooled rate of tumour overgrowth of 11.2% (95%CI: 3.7%-22.1%; I (2) = 82.2%). No funnel plot asymmetry to suggest publication bias (bias = 0.39, P = 0.78). In the sensitivity analysis all results were largely similar between the fixed and random effects models. CONCLUSION: The double-layered nitinol stent provides immediate relief of malignant dysphagia with low rates of stent migration and tumour overgrowth.

Management and outcome of recurrent gallstone ileus: A systematic review.

AIM: To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI). METHODS: A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI. RESULTS: There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus. CONCLUSION: Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.

Prevalence of clostridium difficile in excluded colons.

Clostridium difficile infection is associated with substantial morbidity and mortality, increased duration of hospitalization, and a marked economic impact. Several case reports and case series have described C. difficile infection in excluded bowels or immediately after reversal of defunctioning ileostomy. The aim of this prospective study is to detect whether the excluded colon is associated with a higher rate of C. difficile colonization than the normal population, which may increase the risk of C. difficile infection. Patients with defunctioning loop ileostomy, undergoing closure of ileostomy to restore bowel continuity, were prospectively recruited. Two stool samples were collected from the ileostomy effluent before closure of ileostomy and two after the procedure including the first bowel movement. All samples were cultured for C. difficile and analyzed for toxins A and B by a Premier EIA test. Demographic data and possible confounding factors were observed and recorded. Twenty-fine adult patients were recruited to this study; five patients were subsequently excluded. Two patients had positive stool cultures for C. difficile in the postoperative samples and another patient developed clinical pseudomembranous colitis with positive toxin. This indicates a possible colonization rate of 3 to 38 per cent (95% confidence interval). Four observed cases out of the 20 subjects taking part in this study would confidently conclude that C. difficile colonization in the excluded colon is 6 to 44 per cent, i.e., higher than the incidence in the healthy adult population, which is 3 per cent. However, the findings of this study prompt larger and well-powered studies to confirm these findings.

The use of Permacol® injections for the treatment of faecal incontinence.

The aim of this study is to assess the safety and efficacy of Permacol(®) implant for the treatment of idiopathic faecal incontinence using a novel injection technique. Patients with idiopathic passive faecal incontinence were selected for trans-submucosal injection of Permacol(®) after assessment by anorectal physiology and endoanal ultrasonography. Clinical assessment and St. Mark's Incontinence Score were used to evaluate efficacy before and at two time points (1 and 2 years) after treatment. Rockwood Score were also used to determine quality of life before and after treatment. The Friedman and Chi-square tests were used to compare continuous and categorical data, respectively. A p value of <0.05 was deemed significant. Thirty-eight patients (24 female), median age 66 years, were recruited. At maximum clinical follow-up (median of 9 months), response to Permacol(®) injections was categorised as excellent, good, fair and poor in 12, 5, 4 and 17 patients, respectively. St. Mark's Score improved in 72 and 63 % of patients at 1 and 2 years, respectively. However, a smaller proportion of patients (39 and 27 %, respectively) achieved a 50 %, or more, improvement in Mark's Score. All four domains of Rockwood Quality of Life Score improved on first and second year follow-up, however, only two domains, coping and embarrassment, were statistically significant. Permacol(®) injection improved symptoms by >50 % in 39 and 27 % of patients on short and medium-term follow-ups, respectively. The trans-submucosal technique for injection of Permacol(®) in this study was safe with no significant adverse outcomes.