Khurram Khan

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study

BackgroundColonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors.MethodsPatients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012–2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded.Results364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; pxa0=xa00.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20–0.60 95% CI and 0.47; 0.25–0.88, respectively).ConclusionLesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

Are we meeting current standards in medicines reconciliation? A study in a District General Hospital.

Abstract Introduction: Inadequate medicines reconciliation on admission is often identified as a major cause of patient morbidity, with poor access to patients regular medications often cited as a barrier to care. In the surgical admission unit of our district general hospital, drug charts are completed by junior doctors who do not have access to the Emergency Care Summary (ECS) thus making it difficult to accurately complete admission drug charts. Methods: Our initial measurement of all acute surgical admissions revealed that 49% of patients had an accurate medicines reconciliation upon admission, increasing to 75% within 24 hours of admission. It was clear from this data that our current practice needed improvement in order to ensure patient safety. Resultantly the junior medical staff were provided with ECS accounts and teaching to aid the process of medicines reconciliation. Results: Following the introduction of access to ECS and junior doctor education, a further two data cycles were completed. On the first cycle, the number of accurately completed drug charts increased to 62% on admission and 86% at 24 hours. After the second cycle 57% were complete on admission increasing to 84% at 24 hours. Conclusion: Our project has shown that by providing junior doctors with medicines reconciliation education and access to patients’ pre-admission medications through a nationwide electronic system resulted in a considerable increase in the completion of medicine reconciliation.

THD and mucopexy: Efficacy and controversy

Aims Transanal haemorrhoidal dearterialisation and mucopexy has evolved in recent years as a popular minimally invasive non-excisional surgery for symptomatic prolapsing haemorrhoids. The long-term outcome of this procedure however, remains to be established. We aim to analyse the long-term outcome of THD-mucopexy in the management of prolapsing haemorrhoids based on the evidence of a prospective data from a single institution. Methods A prospective data was collected on 100 consecutive cases of grade 3 and 4 symptomatic haemorrhoids between the period 03/2010 and 06/2015 who underwent the procedure as a day case under general anaesthetic. Overall median follow up was for two years with average age of 54.4 ranges from 34 to 79 and gender ratio of 61% Male and 39% Female. Pre-and postoperative symptoms were assessed with a view to evaluate the nature of complications and long-term recurrence rate. Results Preop Post op (6 weeks) Post op (6 months) P value Bleeding 74 (74%) 9 9 P<0.0001 Prolapse 31 (31%) 6 7 P<0.0001 Perianal pain 15 (15%) 3 2 P = 0.006 Discharge 5 (5%) 1 0 P = 0.21 Itching 2 (2%) 0 0 P = 0.47 Anal fissure (Healed) 4 (4%) 0 4 P = 0.71 Postoperative complications Bleeding 7 (7%) Pain 5 (5%) Urgency 1 (1%) Fistula 1 (1%) Discharge 2 (2%) Infection 3 (3%) Recurrence rate– 13 (13%) Conclusion THD mucopexy is a safe and effective minimally invasive modality for prolapsing symptomatic haemorrhoids with acceptable complication rates and a recurrence rate of 13% majority of which could be dealt with a repeat procedure. Long terms follow up and randomised (THD VS Haemorrhoidectomy) multicentre trials are warranted to compare its efficacy with that of conventional excisional surgery.

Defunctioning stoma- a prognosticator for leaks in low rectal restorative cancer resection: A retrospective analysis of stoma database

Aims Low anterior resection (LAR) has higher risk of anastomotic leak with its attendant morbidity -mortality. De-functioning loop ileostomy (DLI), claimed to mitigate the consequences of anastomotic leak, has been questioned in recent years. This study aims to evaluate the impact of ileostomy on LAR. Methods A retrospective analysis of stoma database. 136 patients with stoma (March 2011–July 2015) were assessed. Data was analysed in respect to LAR anastomotic leak rate, impact on morbidity-mortality, short and long-term stoma complications, rate of ileostomy reversal and reasons for non-reversal. Results 45 patients had loop ileostomy for LAR. Male (28) to female (17) ratio was 1.65:1 with median age of 69 (IQR: 56-75.5). Only 3 anastomotic leaks (3/45, 6.5%) occurred, all treated conservatively with no mortality. 29 had reversal, average reversal time is 10 months (3–24) and 5 awaiting. Reasons for non-reversal included patients choice (7), death from cardiac cause (1), chemotherapy (1), unfit for surgery (1) and failed reversal (1). Acute complications included high output & reversible AKI (1), bleeding (3) and minor complications (6) as skin excoriation, separation and appliance issues. Parastomal hernia was repaired during reversal (12/15). Conclusions De-functioning ileostomy for LAR is a safe procedure with low morbidity. Most stomas are reversible. Series highlights a late reversal contrary to the nationally recommended guidelines. Most interestingly, the study demonstrated de-functioning mitigated clinical consequences of anastomotic leak to an extent that reoperation was avoidable, in keeping with recent meta-analysis indicating a significantly low anastomotic leakage rates and reoperation. Larger study is invaluable to substantiate findings.

The One-Stop Aortic Surveillance Clinic

Background The principle of interval ultrasound surveillance of small abdominal aortic aneurysms (AAA) is well established. The fundamental principle of surveillance is that repair of AAA is a serious undertaking and the risk of the operation outweighs the risk of rupture in aneurysms less than 5.5 cm. Surveillance is well established but requires multiple visits to both the surgical clinic and the ultrasound department. Report This report presents a system whereby the vascular surgeon is trained in the process of aortic sonography with a view to one-stop clinic assessment. After training of the main investigators in aortic sonography, the surgeons performed scans on the aortas of 80 consecutive patients and compared the scan result with the subsequent formal scan. Discussion Surgical and radiographer scans correlate very closely. It is believed that the one-stop aortic surveillance model is safe, accurate, and improves both the patient journey and clinic throughput.

From cadavers to clinical practice: the anatomy of lifelong learning.

Background Much has been postulated about the perceived deterioration of anatomy knowledge amongst graduates. Little is known about levels of confidence in, and educational needs concerning, clinical anatomy knowledge amongst foundation year doctors. Aims To establish foundation year doctors’ perceptions of anatomy related to: importance to career, confidence in anatomy knowledge and its application, preferred methods of teaching. Secondarily, to determine impact of an integrated clinical approach to anatomy teaching on foundation year doctors’ level of knowledge and confidence in its clinical application of anatomy. Methods A course teaching anatomy through common surgeries and related radiology was delivered to foundation year doctors. A pre- and post-course assessment based on anatomy competence score assessed holistic knowledge acquisition. Foundation year doctors’ perceptions of anatomy and course satisfaction were measured through questionnaire. Results Confidence in applying anatomy knowledge was low. The average pre- and post-course assessment score increased from 55% to 81%; 92.86% felt an integrated clinical approach to anatomy teaching improved their confidence on the subject and 58.62% felt it improved their clinical skills. Conclusion This study identified a need for ongoing educational support for foundation year doctors regarding anatomy teaching. An integrated clinical approach to teaching anatomy proved both highly relevant and popular, as well as an effective teaching approach.