Nikhil Lal - Academia.edu (original) (raw)
Papers by Nikhil Lal
Ejso, Nov 1, 2019
Background: Lymph node dissection is the gold standard treatment for those with metastatic deposi... more Background: Lymph node dissection is the gold standard treatment for those with metastatic deposits in regional lymph nodes despite conferring significant morbidity, with complication rates between 30-40% in the literature. Anecdotally in our unit, therapeutic anti-coagulation pre-operatively appeared to increase complications. The aim was to establish the complication rate within our regional plastic surgery unit following lymph node dissection and whether this increased in patients anti-coagulated pre-operatively. Method: Retrospective patient list was generated from patients undergoing regional lymph node dissection between January-December 2018. Database was compiled with patient demographics, procedures, complications and re-intervention. Unpaired t-test was performed to determine significance. Results: 47 patients underwent regional lymph node dissection. 6 were anti-coagulated with either LMWH or NOAC. Primary malignancies included melanoma (n¼31), breast carcinoma (n¼10), SCC (n¼4) and Merkels cell carcinoma (n¼1). The complication rate was 40.4% with a re-intervention rate of 78.94%. Patients with primary melanoma had the highest complication rate at 45.16%. Those undergoing inguinal dissection had the highest morbidity based on anatomical location at 50%. Patients on anticoagulation experienced a complication rate of 66.66% (p 0.1678). Conclusions: Overall, complication rates were comparable with those in the literature. Complications were more frequent in those with a primary melanoma, which is likely due to a higher median age and associated comorbidities. Those anti-coagulated pre-operatively were shown to have a higher complication rate. However, due to small sample size, this was not statistically significant. It is hypothesised this may explained by a higher rate of comorbidities associated with anti-coagulation requirement. 73.
Journal of Medical Screening, Apr 16, 2020
Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from color... more Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London. Methods: A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake. Results: Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01). Conclusion: This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.
Perspectives in Public Health
Aims: Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnic... more Aims: Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnicity is suggested to play a role; however, there is no high-level evidence to support this. We aim to clarify the impact of Ethnicity on CRC screening uptake and our barriers to its understanding. Methods: A systematic review to identify studies reporting on the participation of ethnic minorities in CRC screening worldwide was performed. MEDLINE, Embase, Scopus and Google Scholar databases up until 31 May 2019 were searched. Compliance with screening according to ethnic groups and screening modality was evaluated compared to the ‘White’ control group. Results: Twenty-two studies were included in the review reporting on 2,084,213 patients. Substantial variation in categorisation of ethnicities (40 sub-categories), screening modality studied and confounding factors accounted for was observed. 8/15 studies for ‘Blacks’, 10/13 for ‘Hispanics’, 2/2 for ‘Asians’ and 1/1 for ‘South East Asians’ ...
Supplemental material, MSC916206 Supplemental Material for The impact of socioeconomic deprivatio... more Supplemental material, MSC916206 Supplemental Material for The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London by Nikhil Lal, Harpreet KSI Singh, Azeem Majeed and Nikhil Pawa in Journal of Medical Screening
Colorectal Disease, 2021
AimColorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poore... more AimColorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.MethodResults of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.ResultsA total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjuste...
Anaesthesia, 2021
SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...
Anaesthesia, 2021
SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...
Journal of Medical Screening, 2020
Objective Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality ... more Objective Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London. Methods A retrospective review of the “Vanguard RM Informatics” database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014–2017). The postcodes of the general practices were used to obtain the deprivation data via the “Indices of Deprivation” database. A Spearman’s rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake. Results Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioni...
European Journal of Surgical Oncology, 2019
Background: Lymph node dissection is the gold standard treatment for those with metastatic deposi... more Background: Lymph node dissection is the gold standard treatment for those with metastatic deposits in regional lymph nodes despite conferring significant morbidity, with complication rates between 30-40% in the literature. Anecdotally in our unit, therapeutic anti-coagulation pre-operatively appeared to increase complications. The aim was to establish the complication rate within our regional plastic surgery unit following lymph node dissection and whether this increased in patients anti-coagulated pre-operatively. Method: Retrospective patient list was generated from patients undergoing regional lymph node dissection between January-December 2018. Database was compiled with patient demographics, procedures, complications and re-intervention. Unpaired t-test was performed to determine significance. Results: 47 patients underwent regional lymph node dissection. 6 were anti-coagulated with either LMWH or NOAC. Primary malignancies included melanoma (n¼31), breast carcinoma (n¼10), SCC (n¼4) and Merkels cell carcinoma (n¼1). The complication rate was 40.4% with a re-intervention rate of 78.94%. Patients with primary melanoma had the highest complication rate at 45.16%. Those undergoing inguinal dissection had the highest morbidity based on anatomical location at 50%. Patients on anticoagulation experienced a complication rate of 66.66% (p 0.1678). Conclusions: Overall, complication rates were comparable with those in the literature. Complications were more frequent in those with a primary melanoma, which is likely due to a higher median age and associated comorbidities. Those anti-coagulated pre-operatively were shown to have a higher complication rate. However, due to small sample size, this was not statistically significant. It is hypothesised this may explained by a higher rate of comorbidities associated with anti-coagulation requirement. 73.
British Journal of Cancer, 2022
Background The mechanism underlying improved survival in non-metastatic colon cancer with higher ... more Background The mechanism underlying improved survival in non-metastatic colon cancer with higher lymph node (LN) yield is unknown. This study aimed to identify whether molecular features in the primary tumour were predictive of LN yield. Methods Clinical, genomic, transcriptomic, proteomic and methylation data of non-metastatic, colon cancers studied in The Cancer Genome Atlas were interrogated for associations with LN yield. Based on maximal survival effects, patients were segregated into high (>15) and low (≤15) LN yield. Gene set enrichment analysis was performed on transcriptomic changes to identify biological processes associated with LN yield. Correlations were validated in an independent set of Stage II colon cancers. Results High LN yield was found predictive of overall and disease-free survival. There was no association of higher LN yield and increasing nodal positivity. High LN yield was strongly linked with gene expression changes associated with the adaptive and dendr...
Techniques in coloproctology, 2016
Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described ... more Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI. We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale. Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12-16) (preoperative) to ...
International Journal of Surgery, 2019
BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on... more BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI. MATERIALS AND METHOD A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. RESULT Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo. CONCLUSION SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.
Annals of Surgery, 2019
Objective: To compare techniques for rectal cancer resection. Summary Background Data: Different ... more Objective: To compare techniques for rectal cancer resection. Summary Background Data: Different surgical approaches exist for mesorectal excision. Methods: Systematic literature review and Bayesian network meta-analysis performed. Results: Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. Conclusions: The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
Acta Chirurgica Belgica, 2019
Aim: To perform a review of the literature reporting on randomised controlled trials (RCTs) compa... more Aim: To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults. Methods: A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI. Results: The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ TM versus Durasphere V R. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions. Conclusions: The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.
BMJ open, Jan 30, 2014
To evaluate the safety profile of nicergoline compared with placebo and other active agents from ... more To evaluate the safety profile of nicergoline compared with placebo and other active agents from published randomised controlled trials. Systematic review and meta-analysis of nicergoline compared with placebo and other active agents across various indications. MEDLINE, Medline-in-process, Cochrane, EMBASE, EMBASE alerts, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR) and Cochrane Methodology Register (CMR) for all the randomised controlled trials, open-label or blinded, in adults treated with nicergoline. Studies published until August 2013 were included. 29 studies were included for data extraction. The studies included in this review were majorly from European countries and mostly in cerebrovascular disease (n=15) and dementia (n=8). The treatment withdrawals were comparatively lower in the nicergoline group as compared with the placebo group (RR=0.92; 95% CI 0.7 to 1.21) and other active comparators (RR=0.45; 95% CI 0.10 ...
International Journal of Health Care Quality Assurance, 2018
PurposeA clinical audit is a key component of the clinical governance framework. The rate of audi... more PurposeA clinical audit is a key component of the clinical governance framework. The rate of audit completion in general surgery has not been investigated. The purpose of this paper is to assess the rates of audit activity and completion and explore the barriers to successful audit completion.Design/methodology/approachThis was a multi-centre study evaluating current surgical audit practice. A standardised audit proforma was designed. All clinical audits in general surgery during a two-year period were identified and retrospectively reviewed. Data held by the audit departments were collated, and individual audit teams were contacted to verify the data accuracy. Audit teams failing to complete the full audit cycle with a re-audit were asked to explain the underlying reasons behind this.FindingsOf the six trusts approached, two refused to participate, and one failed to initiate the project. A total of 39 audits were registered across three surgical directorates. Only 15 out of 39 audi...
Ejso, Nov 1, 2019
Background: Lymph node dissection is the gold standard treatment for those with metastatic deposi... more Background: Lymph node dissection is the gold standard treatment for those with metastatic deposits in regional lymph nodes despite conferring significant morbidity, with complication rates between 30-40% in the literature. Anecdotally in our unit, therapeutic anti-coagulation pre-operatively appeared to increase complications. The aim was to establish the complication rate within our regional plastic surgery unit following lymph node dissection and whether this increased in patients anti-coagulated pre-operatively. Method: Retrospective patient list was generated from patients undergoing regional lymph node dissection between January-December 2018. Database was compiled with patient demographics, procedures, complications and re-intervention. Unpaired t-test was performed to determine significance. Results: 47 patients underwent regional lymph node dissection. 6 were anti-coagulated with either LMWH or NOAC. Primary malignancies included melanoma (n¼31), breast carcinoma (n¼10), SCC (n¼4) and Merkels cell carcinoma (n¼1). The complication rate was 40.4% with a re-intervention rate of 78.94%. Patients with primary melanoma had the highest complication rate at 45.16%. Those undergoing inguinal dissection had the highest morbidity based on anatomical location at 50%. Patients on anticoagulation experienced a complication rate of 66.66% (p 0.1678). Conclusions: Overall, complication rates were comparable with those in the literature. Complications were more frequent in those with a primary melanoma, which is likely due to a higher median age and associated comorbidities. Those anti-coagulated pre-operatively were shown to have a higher complication rate. However, due to small sample size, this was not statistically significant. It is hypothesised this may explained by a higher rate of comorbidities associated with anti-coagulation requirement. 73.
Journal of Medical Screening, Apr 16, 2020
Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from color... more Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London. Methods: A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake. Results: Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01). Conclusion: This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.
Perspectives in Public Health
Aims: Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnic... more Aims: Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnicity is suggested to play a role; however, there is no high-level evidence to support this. We aim to clarify the impact of Ethnicity on CRC screening uptake and our barriers to its understanding. Methods: A systematic review to identify studies reporting on the participation of ethnic minorities in CRC screening worldwide was performed. MEDLINE, Embase, Scopus and Google Scholar databases up until 31 May 2019 were searched. Compliance with screening according to ethnic groups and screening modality was evaluated compared to the ‘White’ control group. Results: Twenty-two studies were included in the review reporting on 2,084,213 patients. Substantial variation in categorisation of ethnicities (40 sub-categories), screening modality studied and confounding factors accounted for was observed. 8/15 studies for ‘Blacks’, 10/13 for ‘Hispanics’, 2/2 for ‘Asians’ and 1/1 for ‘South East Asians’ ...
Supplemental material, MSC916206 Supplemental Material for The impact of socioeconomic deprivatio... more Supplemental material, MSC916206 Supplemental Material for The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London by Nikhil Lal, Harpreet KSI Singh, Azeem Majeed and Nikhil Pawa in Journal of Medical Screening
Colorectal Disease, 2021
AimColorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poore... more AimColorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.MethodResults of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.ResultsA total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjuste...
Anaesthesia, 2021
SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...
Anaesthesia, 2021
SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...
Journal of Medical Screening, 2020
Objective Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality ... more Objective Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London. Methods A retrospective review of the “Vanguard RM Informatics” database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014–2017). The postcodes of the general practices were used to obtain the deprivation data via the “Indices of Deprivation” database. A Spearman’s rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake. Results Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioni...
European Journal of Surgical Oncology, 2019
Background: Lymph node dissection is the gold standard treatment for those with metastatic deposi... more Background: Lymph node dissection is the gold standard treatment for those with metastatic deposits in regional lymph nodes despite conferring significant morbidity, with complication rates between 30-40% in the literature. Anecdotally in our unit, therapeutic anti-coagulation pre-operatively appeared to increase complications. The aim was to establish the complication rate within our regional plastic surgery unit following lymph node dissection and whether this increased in patients anti-coagulated pre-operatively. Method: Retrospective patient list was generated from patients undergoing regional lymph node dissection between January-December 2018. Database was compiled with patient demographics, procedures, complications and re-intervention. Unpaired t-test was performed to determine significance. Results: 47 patients underwent regional lymph node dissection. 6 were anti-coagulated with either LMWH or NOAC. Primary malignancies included melanoma (n¼31), breast carcinoma (n¼10), SCC (n¼4) and Merkels cell carcinoma (n¼1). The complication rate was 40.4% with a re-intervention rate of 78.94%. Patients with primary melanoma had the highest complication rate at 45.16%. Those undergoing inguinal dissection had the highest morbidity based on anatomical location at 50%. Patients on anticoagulation experienced a complication rate of 66.66% (p 0.1678). Conclusions: Overall, complication rates were comparable with those in the literature. Complications were more frequent in those with a primary melanoma, which is likely due to a higher median age and associated comorbidities. Those anti-coagulated pre-operatively were shown to have a higher complication rate. However, due to small sample size, this was not statistically significant. It is hypothesised this may explained by a higher rate of comorbidities associated with anti-coagulation requirement. 73.
British Journal of Cancer, 2022
Background The mechanism underlying improved survival in non-metastatic colon cancer with higher ... more Background The mechanism underlying improved survival in non-metastatic colon cancer with higher lymph node (LN) yield is unknown. This study aimed to identify whether molecular features in the primary tumour were predictive of LN yield. Methods Clinical, genomic, transcriptomic, proteomic and methylation data of non-metastatic, colon cancers studied in The Cancer Genome Atlas were interrogated for associations with LN yield. Based on maximal survival effects, patients were segregated into high (>15) and low (≤15) LN yield. Gene set enrichment analysis was performed on transcriptomic changes to identify biological processes associated with LN yield. Correlations were validated in an independent set of Stage II colon cancers. Results High LN yield was found predictive of overall and disease-free survival. There was no association of higher LN yield and increasing nodal positivity. High LN yield was strongly linked with gene expression changes associated with the adaptive and dendr...
Techniques in coloproctology, 2016
Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described ... more Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI. We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale. Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12-16) (preoperative) to ...
International Journal of Surgery, 2019
BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on... more BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI. MATERIALS AND METHOD A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. RESULT Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo. CONCLUSION SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.
Annals of Surgery, 2019
Objective: To compare techniques for rectal cancer resection. Summary Background Data: Different ... more Objective: To compare techniques for rectal cancer resection. Summary Background Data: Different surgical approaches exist for mesorectal excision. Methods: Systematic literature review and Bayesian network meta-analysis performed. Results: Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. Conclusions: The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
Acta Chirurgica Belgica, 2019
Aim: To perform a review of the literature reporting on randomised controlled trials (RCTs) compa... more Aim: To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults. Methods: A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI. Results: The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ TM versus Durasphere V R. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions. Conclusions: The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.
BMJ open, Jan 30, 2014
To evaluate the safety profile of nicergoline compared with placebo and other active agents from ... more To evaluate the safety profile of nicergoline compared with placebo and other active agents from published randomised controlled trials. Systematic review and meta-analysis of nicergoline compared with placebo and other active agents across various indications. MEDLINE, Medline-in-process, Cochrane, EMBASE, EMBASE alerts, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR) and Cochrane Methodology Register (CMR) for all the randomised controlled trials, open-label or blinded, in adults treated with nicergoline. Studies published until August 2013 were included. 29 studies were included for data extraction. The studies included in this review were majorly from European countries and mostly in cerebrovascular disease (n=15) and dementia (n=8). The treatment withdrawals were comparatively lower in the nicergoline group as compared with the placebo group (RR=0.92; 95% CI 0.7 to 1.21) and other active comparators (RR=0.45; 95% CI 0.10 ...
International Journal of Health Care Quality Assurance, 2018
PurposeA clinical audit is a key component of the clinical governance framework. The rate of audi... more PurposeA clinical audit is a key component of the clinical governance framework. The rate of audit completion in general surgery has not been investigated. The purpose of this paper is to assess the rates of audit activity and completion and explore the barriers to successful audit completion.Design/methodology/approachThis was a multi-centre study evaluating current surgical audit practice. A standardised audit proforma was designed. All clinical audits in general surgery during a two-year period were identified and retrospectively reviewed. Data held by the audit departments were collated, and individual audit teams were contacted to verify the data accuracy. Audit teams failing to complete the full audit cycle with a re-audit were asked to explain the underlying reasons behind this.FindingsOf the six trusts approached, two refused to participate, and one failed to initiate the project. A total of 39 audits were registered across three surgical directorates. Only 15 out of 39 audi...