Richard Cohen

Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures

Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohns strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies.

UK guideline on transition of adolescent and young persons with chronic digestive diseases from paediatric to adult care

The risks of poor transition include delayed and inappropriate transfer that can result in disengagement with healthcare. Structured transition care can improve control of chronic digestive diseases and long-term health-related outcomes. These are the first nationally developed guidelines on the transition of adolescent and young persons (AYP) with chronic digestive diseases from paediatric to adult care. They were commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology under the auspices of the Adolescent and Young Persons (A&YP) Section. Electronic searches for English-language articles were performed with keywords relating to digestive system diseases and transition to adult care in the Medline (via Ovid), PsycInfo (via Ovid), Web of Science and CINAHL databases for studies published from 1980 to September 2014. The quality of evidence and grading of recommendations was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The limited number of studies in gastroenterology and hepatology required the addition of relevant studies from other chronic diseases to be included. These guidelines deal specifically with the transition of AYP living with a diagnosis of chronic digestive disease and/or liver disease from paediatric to adult healthcare under the following headings; 1. Patient populations involved in AYP transition 2. Risks of failing transition or poor transition 3. Models of AYP transition 4. Patient and carer/parent perspective in AYP transition 5. Surgical perspective

Indocyanine green fluorescence imaging in colorectal surgery: overview, applications, and future directions

Indocyanine green fluorescence imaging is a surgical tool with increasing applications in colorectal surgery. This tool has received acceptance in various surgical disciplines as a potential method to enhance surgical field visualisation, improve lymph node retrieval, and decrease the incidence of anastomotic leaks. In colorectal surgery specifically, small studies have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion, and its use might affect the incidence of anastomotic leaks. Controlled trials are ongoing to validate these conclusions. The number of new indications for indocyanine green continues to increase, including innovative options for detecting and guiding management of colorectal metastasis to the liver. These advances could offer great value for surgeons and patients, by improving the accuracy and outcomes of oncological resections.

Gut symptoms in diabetics correlate with components of the rectoanal inhibitory reflex, but not with pudendal nerve motor latencies or systemic autonomic neuropathy.

Fecal incontinence (FI) occurs in up to 20% of diabetes mellitus (DM) patients. Rectoanal inhibitory reflex (RAIR) is an enteric anorectal reflex that reflects the integrity of mechanisms in the physiology of FI. We aimed to investigate whether diabetic patients with FI, not constipation, had prolongation of RAIR and altered gut‐specific autonomic tone.

A Model of Basic Surgical Skills Course to Supplement the Training of Foundation-Year Doctors by Efficient Use of Local Resources.

INTRODUCTIONnThis study investigates the efficiency of teaching basic surgical skills to foundation-year doctors and medical students by using local resources.nnnMETHODSnA course comprising 4 workshops, once a week, of 3 hours duration per session was delivered using local education center facilities and using the local faculty of consultants and surgical trainees. Teaching methods include practical skill stations supplemented with short didactic lectures and group discussion. Precourse and postcourse assessments were completed by candidates and analyzed to measure outcomes of the course both subjectively and objectively.nnnRESULTSnA total number of 20 participants completed the course. On completion of the course, (1) participants theoretical knowledge improved significantly (p < 0.0001), as measured by multiple-choice questions, and scores improved by 35% (mean 44%, standard deviation = 16%) before the course compared to (mean = 79%, standard deviation = 13) after the course; (2) the level of confidence in knowledge and skills was measured by a questionnaire on a scale of 1 to 5, and there was a significant (p < 0.0001) improvement on postcourse assessment (mean difference = 1.5, 95% CI: 0.7-2.4); and (3) practical skills such as suture position, knot tying, and wound apposition significantly improved after the course, χ(2) (2) = 16, p < 0.001; χ(2) (2) = 18, p < 0.001; and χ(2) (2) = 22, p < 0.0001, respectively.nnnCONCLUSIONnEffective delivery of basic surgical skills to foundation-year doctors by using local resources can be achieved at low cost.

OC-001 Endoscopic balloon dilatation for crohn’s disease strictures: a systematic review and meta-analysis

Introduction Endoscopic balloon dilatation (EBD) is a recognised treatment for symptomatic Crohn’s strictures. Several case studies report its short term and long term efficacy. A systematic analysis of the literature is needed to define overall efficacy and inform future study design. The primary objective was to examine symptomatic response, technical response and adverse events of EBD. The impact of stricture characteristics on outcome was also explored. Method A systematic search was performed in accordance with PRISMA guidelines. The quality of individual studies was assessed using the Newcastle-Ottawa Scale. The results were expressed as a per patient analysis using the proportion of patients within a group and a per study analysis using pooled event rates across studies. The random effects model was expressed as forest plots and summative statistics. Heterogeneity across studies was assessed numerically (I2). The mean value of pooled outcomes was used to create two groups (< or ≥ the pooled mean event rate [PMER]), to compare the effect of the proportion of patients within each group (e.g. stricture activity and type) on outcome. Results Twenty-five studies were included: 1089 patients and 2664 dilatations. The grade for quality ranged from 2 to 6. The proportion of patients with symptomatic and technical response was 63.9% (393/615) and 92.6% (403/435) respectively. The proportion of patients with perforation was 2.6% (18/700). The PMER for symptomatic response was 74.8% (95% CI: 69.9–79.3%; I2: 0%), technical response was 90.6% (95% CI: 87.8–92.8%; I2: 11.7%), complications was 6.4% (95% CI: 5.0–8.2; I2: 4.0%), and perforation was 3% (95% CI: 2.2–4.0%; I2: 0%). The proportion of patients with active strictures demonstrating a < PMER and ≥ PMER for symptomatic response was 73% vs 60% respectively. The proportion of patients with active strictures demonstrating a ≥ PMER and < PMER for perforation was 62% and 36% respectively. The proportion of patients with anastomotic strictures demonstrating a < PMER and ≥ PMER for technical response was 83% and 75% respectively. Conclusion EBD for symptomatic Crohn’s strictures shows high efficacy with a low complication rate. Efficacy may be affected by active inflammation and previous surgery. Variation exists in the quality of reporting of the studies. Further well designed comparative studies capturing differential effects of stricture types are needed. Disclosure of interest None Declared.

Anorectal toxicity of external beam radiotherapy in the treatment of prostate cancer

Introduction: Maximising radiotherapy dosage is associated with better tumour response in prostate cancer. High dose three-dimensional conformal radiotherapy (3D CRT) has allowed dose escalation to be safely achieved and the current standard dose in the UK with this technique is 74 Grays (Gy). Documenting normal tissue tolerance is critical and forms the basis of this prospective study of anorectal toxicity. Patients and methods: Seventeen consecutive men (median age 72 (range 50–79) years) with localised or locally advanced prostate cancer treated with 74 Gy of 3D CRT were studied. Wexner incontinence scores, comprehensive anorectal physiology and endoanal ultrasound were measured before and four months after completing treatment. Results: Wexner incontinence scores increased from a median of 0 to 1 (range 0–6) with treatment (p=0.001). Patients developed faecal urgency (7/17), passive faecal loss (5/17) or a combination of both (3/17) as new anorectal symptoms. No patients reported episodes of frank faecal incontinence. A significant decline in rectal mucosal electrosensitivity (mean (standard deviation (SD)) thresholds increasing from 24.7 (10.7) to 34.3 (9.3) mA after treatment, p=0.003) and an increase in rectal elastance (mean (SD) of 0.056 (0.03) mm Hg/ml to 0.078 (0.036) mm Hg/ml pre- and post-treatment respectively, p=0.0181) was seen. No changes in anal canal manometry, rectal distension volumes and endoanal ultrasound were noted. Conclusions: Early anorectal symptoms are common after 3D CRT for prostate cancer. Rectal injury is evident with an increase in wall stiffness and a decrease in mucosal sensitivity. Longer term studies monitoring anorectal toxicity are warranted.