National Open Abdomen Audit (NOAA) - protocol for an observational audit of the use and management of the open abdomen in secondary care across Great Britain and Ireland.

AIM: Use of open abdomen (OA) remains an important life-saving manoeuvre in the management of trauma and the abdominal catastrophe. The National Open Abdomen Audit (NOAA) is an audit project investigating the indications, management, and subsequent outcomes of OA treatment throughout the UK. The aim is to generate a snapshot of practice which will inform the management of future patients and potentially reduce the significant harm that can be associated with OA. METHODS AND ANALYSIS: NOAA is a collaborative, prospective observational audit recruiting patients from across Great Britain and Ireland. The study will open from July 2023 with rolling recruitment across participating sites. All adult patients who leave theatre with an OA will be included and followed-up for 90 days. The primary objective is to prospectively audit the national variability in the management of the OA. Secondary outcomes include the treatment modality used for OA, indication, outcome of treatment and complications, including mortality and development of intestinal failure. All data will be recorded and managed using the secure REDCap electronic data capture and analysed using Stata (version 16.1). Results will be reported in accordance with the STROBE statement. CONCLUSION: Results will be used to formulate a practical clinical guideline on when to implement an OA along with a stepwise management plan once initiated to reduce the associated morbidity and mortality. It is hoped that participation in this study will facilitate education of surgeons with a "trickle down" effect on all members of the surgical team and remove variability in the management.

Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence.

BACKGROUND: Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed. OBJECTIVE: We aimed to compare anal inserts and percutaneous tibial nerve stimulation. DESIGN: This was an investigator-blinded randomized pilot study. SETTINGS: The study was conducted at a large tertiary care hospital. PATIENTS: Adult patients with passive or mixed fecal incontinence were recruited. INTERVENTIONS: Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months. MAIN OUTCOME MEASURES: The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability. RESULTS: Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group. LIMITATIONS: A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation. CONCLUSIONS: Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov No. NCT04273009. ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL: ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.

Screening for Squamous Cell Anal Cancer in HIV Positive Patients: A Five-Year Experience.

AIM: Potential screening modalities for early diagnosis of squamous cell anal cancer (SCC) in HIV patients include digital anorectal examination (DARE), anal Papanicolaou testing (Pap test), human papilloma virus (HPV) co-testing, and high-resolution anoscopy. The aim of this study was to demonstrate the results of a five-year screening program for SCC in HIV patients. MATERIALS AND METHODS: We conducted a retrospective study on 204 HIV patients who underwent a screening program for SCC from October 2010 to January 2015. All patients were screened by DARE, anal Pap test, including HPV test and cytology, and high-resolution video-proctoscopy (HR-VPS) with and without acetic acid 3%. Depending on macroscopic appearance and biopsies, patients underwent observation or treatment. Median follow-up was 36 months. RESULTS: Cytologic abnormalities (Cyt+) for high-risk HPV genotypes were recorded in 34% of patients. HR-VPS was positive in 59 patients (29%), of whom 13 patients (22%) were positive for warts; the rest have typical features of anal intraepithelial neoplasia (AIN). Sixteen (8%) patients had AIN (AIN I-III) and underwent wide local excision, ablation, or imiquimod. Absence of progression was recorded. Fourteen patients (7%) had SCC: eight (57%) with no evidence of recurrence, two (14%) had recurrence, and four (29%) died from metastatic disease. CONCLUSIONS: Our data demonstrated a successful screening program in preventing SCC in HIV patients. We demonstrate the advantages of progression towards SCC. Moreover, we used a new screening tool, the HR-VPS, a low-cost and manageable instrument to collect patients' long-term data.

Single Port Laparoscopic Surgery for Complex Crohn's Disease Is Safe with a Lower Conversion Rate.

PURPOSE: Single port laparoscopic surgery (SPLS) is a technique which is increasing in popularity. The benefit of SPLS in complex Crohn's disease (CD), which includes a significant cohort of young patients sometimes needing multiple operations, has not been comprehensively assessed. This study analyses our early experience with this technique. METHODS: Patients who underwent SPLS for CD were included. Data were collected prospectively from January 2013 to December 2015. Ileocolic resections, right hemicolectomy, small bowel stricturoplasties, and resections were included in the complex CD cohort. Primary and redo operations were analyzed separately. RESULTS: Forty-five patients were included in the study (39 ileocolic resections and 6 small bowel stricturoplasty/resections). Of the total, 27 were primary resections and 18 were redo resections. The median age was 41 years (range 14-72 years), and the median hospital stay was 8 days (range 3-28 days). The total complication rate was 35.5% most of which were Clavien-Dindo type 1 and 2. There was no difference in operating time, average blood loss, conversion rates, complication rate, and hospital stay, between those who had primary or redo surgery. CONCLUSIONS: SPLS can be performed safely in patients with complex CD even in redo surgery. There may be some technical advantages to the procedure in this group of patients.

Determining Predictors for Intra-abdominal Septic Complications Following Ileocolonic Resection for Crohn's Disease-Considerations in Pre-operative and Peri-operative Optimisation Techniques to Improve Outcome.

BACKGROUND AND AIMS: Intra-abdominal septic complications [IASC] following ileocolonic resection for Crohn's disease are common. Determining risk factors for these complications can aid pre-operative and peri-operative strategies to reduced morbidity. This study aims to determine the incidence and predictors of intra-abdominal septic complications following ileocolonic resection for Crohn's disease. METHODS: A single-centre, retrospective study was conducted. The clinical case notes of patients with histopathologically proven Crohn's disease, who underwent an ileocolonic resection as a one-stage or two-stage procedure, were reviewed. The primary endpoint was the formation of intra-abdominal septic complications within a 30-day post-operative time frame. RESULTS: Overall 163 patients underwent 175 ileocolonic procedures. Post-operative intra-abdominal septic complications were demonstrated in 9% [13/142] of one-stage procedures and 12% [4/33] of two-stage procedures [p = 0.2]. Post-operative IASCs following a one-stage procedure demonstrated associations with smokers [p = 0.004], intraoperative abdominal sepsis [p = 0.005], concomitant upper gastrointestinal Crohn's [p = 0.015], the presence of peri-operative anaemia [p = 0.037], hypoalbuminaemia [< 25g/l] [p = 0.04], and histologically involved margins [p = 0.001]. Multivariate analysis demonstrated the presence of intra-abdominal sepsis (hazard ratio [HR] 8.6, 95% confidence interval [CI]: 1.2 60.1] and the use of peri-operative biologicals [HR 24.6, 95% CI: 2.0-298] as independent predictors of post-operative intra-abdominal septic complications. CONCLUSIONS: This study highlights specific variables that may be contributory to poor outcome. These findings may be important when optimising patients for surgery, as well as planning an appropriate operative strategy. Further prospective studies and a larger sample size are required to validate these findings.

A novel endovascular treatment for long-standing high-flow arteriovenous fistula.

We describe a novel use of an Amplatzer III plug device (St. Jude Medical, St. Paul, Minn) in the treatment of a traumatic arteriovenous fistula between the innominate vein and the origin of the left common carotid artery causing symptomatic right heart failure. A review of the literature indicates this is the first case to describe the use of the Amplatzer III device in this way. We demonstrate immediate closure of fistula radiologically and complete symptomatic resolution at short-term follow-up.

Modulation of interleukin signalling and gene expression in cardiac myocytes by endothelin-1.

The related inflammatory cytokines, interleukin- (IL-) 1beta and IL-33, are both implicated in the response of the heart to injury. They also activate mitogen-activated protein kinases (MAPKs) in cardiac myocytes. The hypertrophic Gq protein-coupled receptor agonist endothelin-1 is a potentially cardioprotective peptide and may modulate the inflammatory response. Endothelin-1 also stimulates (MAPKs) in cardiac myocytes and promotes rapid changes in expression of mRNAs encoding intercellular and intracellular signalling components including receptors for IL-33 (ST2) and phosphoprotein phosphatases. Prior exposure to endothelin-1 may specifically modulate the response to IL-33 and, more globally, influence MAPK activation by different stimuli. Neonatal rat ventricular myocytes were exposed to IL-1beta or IL-33 with or without pre-exposure to endothelin-1 (5h) and MAPK activation assessed. IL-33 activated ERK1/2, JNKs and p38-MAPK, but to a lesser degree than IL-1beta. Endothelin-1 increased expression of soluble IL-33 receptors (sST2 receptors) which may prevent binding of IL-33 to the cell-surface receptors. However, pretreatment with endothelin-1 only inhibited activation of p38-MAPK by IL-33 with no significant influence on ERK1/2 and a small increase in activation of JNKs. Inhibition of p38-MAPK signalling following pretreatment with endothelin-1 was also detected with IL-1beta, H(2)O(2) or tumour necrosis factor alpha (TNFalpha) indicating an effect intrinsic to the signalling pathway. Endothelin-1 pretreatment suppressed the increase in expression of IL-6 mRNA induced by IL-1beta and decreased the duration of expression of TNFalpha mRNA. Coupled with the general decrease in p38-MAPK signalling, we conclude that endothelin-1 attenuates the cardiac myocyte inflammatory response, potentially to confer cardioprotection.