Publications by authors named "Andrew Emmanuel"

25 Publications

  • Page 1 of 1

Near-focus narrow-band imaging classification of villous atrophy in suspected celiac disease: development and international validation.

Gastrointest Endosc 2021 12 3;94(6):1071-1081. Epub 2021 Jul 3.

King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK.

Background And Aims: There are no agreed-on endoscopic signs for the diagnosis of villous atrophy (VA) in celiac disease (CD), necessitating biopsy sampling for diagnosis. Here we evaluated the role of near-focus narrow-band imaging (NF-NBI) for the assessment of villous architecture in suspected CD with the development and further validation of a novel NF-NBI classification.

Methods: Patients with a clinical indication for duodenal biopsy sampling were prospectively recruited. Six paired NF white-light endoscopy (NF-WLE) and NF-NBI images with matched duodenal biopsy sampling including the bulb were obtained from each patient. Histopathology grading used the Marsh-Oberhuber classification. A modified Delphi process was performed on 498 images and video recordings by 3 endoscopists to define NF-NBI classifiers, resulting in a 3-descriptor classification: villous shape, vascularity, and crypt phenotype. Thirteen blinded endoscopists (5 expert, 8 nonexpert) then undertook a short training module on the proposed classification and evaluated paired NF-WLE-NF-NBI images.

Results: One hundred consecutive patients were enrolled (97 completed the study; 66 women; mean age, 51.2 ± 17.3 years). Thirteen endoscopists evaluated 50 paired NF-WLE and NF-NBI images each (24 biopsy-proven VAs). Interobserver agreement among all validators for the diagnosis of villous morphology using the NF-NBI classification was substantial (κ = .71) and moderate (κ = .46) with NF-WLE. Substantial agreement was observed between all 3 NF-NBI classification descriptors and histology (weighted κ = 0.72-.75) compared with NF-WLE to histology (κ = .34). A higher degree of confidence using NF-NBI was observed when assessing the duodenal bulb.

Conclusions: We developed and validated a novel NF-NBI classification to reliably diagnose VA in suspected CD. There was utility for expert and nonexpert endoscopists alike, using readily available equipment and requiring minimal training. (Clinical trial registration number: NCT04349904.).
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http://dx.doi.org/10.1016/j.gie.2021.06.031DOI Listing
December 2021

Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence.

Gastrointest Endosc 2021 08 13;94(2):368-375. Epub 2021 Feb 13.

Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK.

Background And Aims: EMR of large (≥2 cm) nonpedunculated colorectal polyps (LNPCPs) is associated with high rates of recurrent/residual adenoma, possibly because of microadenoma left at the margin of resection. Data supporting this mechanism are required. We aimed to determine the incidence of residual microadenoma at the defect margin and base after EMR.

Methods: We performed a retrospective observational study of patients undergoing EMR of large LNPCPs with the lateral defect margin further resected using the EndoRotor device (Interscope Medical, Inc, Worcester, Mass, USA) after confirming no visible residual adenomatous tissue. Aspects of the defect base were also resected in selected patients. Patients underwent surveillance at 3 to 6 months.

Results: Resection of the normal defect margin was performed in 41 patients and of aspects of the base in 21 patients. Mean lesion size was 43.0 mm (range, 20-130). Microscopic residual lesion was detected in the margin of apparently normal mucosa in 8 cases (19%). In 7 cases this was an adenoma, and in 1 case a serrated lesion was found at the margin of a resected tubular adenoma. Microscopic residual lesion was detected at the base in 5 of 21 cases. Residual/recurrent adenoma was detected in 2 patients. Neither had residual microadenoma at the lateral margin or base detected after the primary resection.

Conclusions: Microscopic residual adenoma after wide-field EMR was detected in 19% of cases at the apparently normal defect margin and at the resection base in 5 of 21 cases. This study confirms the presence of residual microadenoma after resection of LNPCPs, providing evidence for the mechanism of recurrence.
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http://dx.doi.org/10.1016/j.gie.2021.02.010DOI Listing
August 2021

Artificial intelligence in luminal endoscopy.

Ther Adv Gastrointest Endosc 2020 Jan-Dec;13:2631774520935220. Epub 2020 Jun 23.

Department of Interdisciplinary Endoscopy, University Hospital Mainz, 55131 Mainz, Germany.

Artificial intelligence is a strong focus of interest for global health development. Diagnostic endoscopy is an attractive substrate for artificial intelligence with a real potential to improve patient care through standardisation of endoscopic diagnosis and to serve as an adjunct to enhanced imaging diagnosis. The possibility to amass large data to refine algorithms makes adoption of artificial intelligence into global practice a potential reality. Initial studies in luminal endoscopy involve machine learning and are retrospective. Improvement in diagnostic performance is appreciable through the adoption of deep learning. Research foci in the upper gastrointestinal tract include the diagnosis of neoplasia, including Barrett's, squamous cell and gastric where prospective and real-time artificial intelligence studies have been completed demonstrating a benefit of artificial intelligence-augmented endoscopy. Deep learning applied to small bowel capsule endoscopy also appears to enhance pathology detection and reduce capsule reading time. Prospective evaluation including the first randomised trial has been performed in the colon, demonstrating improved polyp and adenoma detection rates; however, these appear to be relevant to small polyps. There are potential additional roles of artificial intelligence relevant to improving the quality of endoscopic examinations, training and triaging of referrals. Further large-scale, multicentre and cross-platform validation studies are required for the robust incorporation of artificial intelligence-augmented diagnostic luminal endoscopy into our routine clinical practice.
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http://dx.doi.org/10.1177/2631774520935220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315657PMC
June 2020

Multimodal Endoscopic Assessment Guides Treatment Decisions for Rectal Early Neoplastic Tumors.

Dis Colon Rectum 2020 03;63(3):326-335

Department of Colorectal Surgery, King's College Hospital National Health Service Foundation Trust, London, United Kingdom.

Background: There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment.

Objective: We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions.

Design: This was a retrospective study.

Setting: The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer.

Patients: A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer.

Main Outcome Measures: Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported.

Results: After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up.

Limitations: This was a retrospective study from a tertiary referral unit.

Conclusions: Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.
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http://dx.doi.org/10.1097/DCR.0000000000001587DOI Listing
March 2020

Response.

Gastrointest Endosc 2019 09;90(3):542

Department of Colorectal Surgery, King's College Hospital, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK.

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http://dx.doi.org/10.1016/j.gie.2019.05.017DOI Listing
September 2019

The future of endoscopy: Advances in endoscopic image innovations.

Dig Endosc 2020 May 22;32(4):512-522. Epub 2019 Aug 22.

Department of Medicine, University Hospital Mainz, Mainz, Germany.

The latest state of the art technological innovations have led to a palpable progression in endoscopic imaging and may facilitate standardisation of practice. One of the most rapidly evolving modalities is artificial intelligence with recent studies providing real-time diagnoses and encouraging results in the first randomised trials to conventional endoscopic imaging. Advances in functional hypoxia imaging offer novel opportunities to be used to detect neoplasia and the assessment of colitis. Three-dimensional volumetric imaging provides spatial information and has shown promise in the increased detection of small polyps. Studies to date of self-propelling colonoscopes demonstrate an increased caecal intubation rate and possibly offer patients a more comfortable procedure. Further development in robotic technology has introduced ex vivo automated locomotor upper gastrointestinal and small bowel capsule devices. Eye-tracking has the potential to revolutionise endoscopic training through the identification of differences in experts and non-expert endoscopist as trainable parameters. In this review, we discuss the latest innovations of all these technologies and provide perspective into the exciting future of diagnostic luminal endoscopy.
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http://dx.doi.org/10.1111/den.13481DOI Listing
May 2020

Outcomes of endoscopic resection of large colorectal lesions subjected to prior failed resection or substantial manipulation.

Int J Colorectal Dis 2019 Jun 3;34(6):1033-1041. Epub 2019 Apr 3.

Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK.

Purpose: Injudicious attempts at resection and extensive sampling of large colorectal adenomas prior to referral for endoscopic resection (ER) are common. This has deleterious effects, but little is known about the outcomes following ER. We retrospectively analysed the outcomes of ER of large adenomas previously subjected to substantial manipulation.

Method: ER of large (≥ 2 cm) colorectal adenomas were grouped according to level of manipulation: prior attempted resection, heavy manipulation (≥ six biopsies or tattoo under lesion) or minimal manipulation (< six biopsies). Outcomes were compared between groups. Independent predictors of outcomes were identified using multiple logistic regression.

Results: Five hundred forty-two lesions (mean size 53.7 mm) were included. Two hundred sixty-five (49%) had been subjected to prior attempted resection or heavy manipulation, 151 (28%) to minimal manipulation, and 126 (23%) were not previously manipulated. ESD techniques were used more frequently than EMR after substantial manipulation. There were no differences in initial success of ER (99%, 98%, 98%, p = 0.71). Prior attempted resection was independently associated with recurrence (OR 2.2, 95% CI 1.1-4.5, p = 0.03) and negatively associated with en bloc resection (OR 0.29, 95% CI 0.1-0.7, p = 0.004). Regardless of level of prior manipulation, there were no differences in sustained endoscopic cure with > 95% of patients overall free from recurrence and avoiding surgery at last follow-up.

Conclusion: There is a substantial burden of injudicious lesion manipulation before referral, which makes recurrence more likely and en bloc resection less likely. However, with appropriate expertise, sustained successful endoscopic treatment is achievable for the vast majority of patients treated in a specialist unit.
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http://dx.doi.org/10.1007/s00384-019-03285-3DOI Listing
June 2019

Risk factors for early and late adenoma recurrence after advanced colorectal endoscopic resection at an expert Western center.

Gastrointest Endosc 2019 07 27;90(1):127-136. Epub 2019 Feb 27.

Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK; King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK.

Background And Aims: Few large Western series examine risk factors for recurrence after endoscopic resection (ER) of large (≥20 mm) colorectal laterally spreading tumors. Recurrence beyond initial surveillance is seldom reported, and differences between residual/recurrent adenoma and late recurrence are not scrutinized. We report the incidence of recurrence at successive surveillance intervals, identify risk factors for recurrent/residual adenoma and late recurrence, and describe the outcomes of ER of recurrent adenomas.

Methods: Recurrence was calculated for successive surveillance periods after colorectal ER. Multiple logistic regression was used to identify independent risk factors for recurrent/residual adenoma and late recurrence (≥12 months).

Results: Six hundred twenty colorectal ERs were performed, and 456 eligible patients (98%) had completed 3- to 6-month surveillance. Residual/recurrent adenoma (3-6 months) was detected in 8.3%, at 12 months in 6.1%, between 24 and 36 months in 6.4%, and after 36 months in 13.5%. Independent risk factors for residual/recurrent adenoma were piecemeal resection (odds ratio [OR], 13.0; P = .01), adjunctive argon plasma coagulation (OR, 2.4; P = .01), and lesion occupying ≥75% of the luminal circumference (OR, 5.6; P < .001) and for late recurrence were lesion size >60 mm (OR, 6.3; P < .001) and piecemeal resection (OR, 4.4; P = .04). Of 66 patients with recurrence, 5 required surgery, 8 left the treatment pathway, 20 are still receiving ER or surveillance, and 33 had ER with normal subsequent surveillance.

Conclusions: Recurrence occurs at successive periods of surveillance after ER even beyond 3 years. Aside from piecemeal resection, risk factors for residual/recurrent adenoma and late recurrence are different. Recurrence can be challenging to treat, but surgery is rarely required.
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http://dx.doi.org/10.1016/j.gie.2019.01.031DOI Listing
July 2019

Endoscopic resection of colorectal circumferential and near-circumferential laterally spreading lesions: outcomes and risk of stenosis.

Int J Colorectal Dis 2019 May 19;34(5):829-836. Epub 2019 Feb 19.

Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK.

Purpose: Almost any colorectal superficial neoplastic lesion can be treated by endoscopic resection (ER) but very little is known about outcomes of ER leaving circumferential or near-circumferential mucosal defects. We report the outcomes of ER leaving ≥ 75% circumferential mucosal defects performed in a western expert centre.

Methods: Five hundred eighty-seven ERs of large colorectal lesions ≥ 20 mm were grouped according to the extent of the mucosal defect and comparisons made between those with < 75% and ≥ 75% defects. Independent predictors of stenosis were identified.

Results: Forty-seven patients had ER leaving ≥ 75% circumference defect, most located at or distal to the rectosigmoid, with ≥ 90% defects in 5 and 100% in 11. There were no significant colonic muscle injuries in patients with ≥ 75% defect and no differences in post-procedure bleeding (OR 1.6, 95% CI 0.2-13.7, p = 0.64) between patients with ≥ 75% and < 75% defects. Stenosis developed in 9 patients. ≥ 90% circumference defect was the only independent risk factor for stenosis (OR 286, p < 0.001). Three of 4 patients with asymptomatic stenosis had successful expectant management. The remainder were treated with dilatation. Recurrence was more likely in those with ≥ 75% defect (OR 7.9, 95% CI 3.8-16.4, p < 0.001) but was managed with further ER in all but 2 cases.

Conclusion: ER of colorectal lesions resulting in defects ≥ 75% of the luminal circumference is challenging but safe and effective when performed in an expert centre. The only independent predictor of stenosis is ≥ 90% circumference defect but some patients improve with expectant management; therefore, pre-emptive intervention may not be warranted.
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http://dx.doi.org/10.1007/s00384-019-03254-wDOI Listing
May 2019

A Randomized Crossover Trial of Conventional vs Virtual Chromoendoscopy for Colitis Surveillance: Dysplasia Detection, Feasibility, and Patient Acceptability (CONVINCE).

Inflamm Bowel Dis 2019 05;25(6):1096-1106

King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK.

Background: Chromoendoscopy (CE) is the recommended surveillance technique for colitis, but uptake has been limited and the literature provides scant information on patient experience (PE); imperative to adherence to surveillance programmes. Virtual CE (VCE) by Fujinon Intelligent Colour Enhancement digitally reconstructs mucosal images in real time, without the technical challenges of CE. We performed a multifaceted randomized crossover trial (RCT) to evaluate study feasibility and obtain preliminary comparative procedural and PE data.

Methods: Patients were randomized to undergo either CE with indigo carmine or VCE as the first procedure. After 3-8 weeks, participants underwent colonoscopy with the second technique. Patient recruitment/retention, missed dysplasia, prediction of dysplasia, and contamination (memory/sampling of the first procedure) were recorded. PE was assessed by validated questionnaires, and pain was assessed using a visual analog scale (mm).

Results: Sixty patients were recruited, and 48 patients (first procedure: 23 VCE, 25 CE) completed the trial (retention 80%) with no episodes of contamination. Eleven dysplastic lesions were detected in n = 7/48 (14.5%). VCE missed 1 lesion, and CE missed 2 lesions in n = 2 (data of VCE vs CE, respectively, for dysplasia diagnostic accuracy: 93.94% [85.2%-98.32%] vs 76.9% [66.9%-98.2%]; examination time [minutes]: 14 +/- 4 vs 20 +/- 7 (95% confidence interval, 3.5 to 8; P < 0.001); pain (mm): 27.4 +/- 17.5 vs 34.7 +/- 18; patient preference: 67% [n = 31] vs 33% [n = 15] in n = 46; P < 0.001).

Conclusions: This is the first RCT to include validated PE in a colitis surveillance program. VCE is safe, technically easier, quicker, and more comfortable test, with dysplasia detection at least as good as that of CE, overcoming many barriers to the wider adoption of CE. This trial may serve as a successful foundation for a a multicenter trial to confirm the value of VCE for colitis surveillance.
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http://dx.doi.org/10.1093/ibd/izy360DOI Listing
May 2019

Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center.

Dis Colon Rectum 2018 08;61(8):955-963

King's Institute of Therapeutic Endoscopy, King's College Hospital, National Health Service Foundation Trust, London, United Kingdom.

Background: Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm.

Objective: We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions.

Design: This was a retrospective study.

Settings: The study was conducted in a tertiary referral unit for interventional endoscopy.

Patients: A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm.

Main Outcome Measures: Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission.

Results: Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%).

Limitations: This was a retrospective study.

Conclusions: Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.
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http://dx.doi.org/10.1097/DCR.0000000000001144DOI Listing
August 2018

Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer.

World J Surg 2018 11;42(11):3755-3764

Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK.

Background: Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma.

Methods: A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications.

Results: Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma.

Conclusion: Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas.

Study Registration: Registered at www.researchregistry.com (UIN: researchregistry3412).
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http://dx.doi.org/10.1007/s00268-018-4672-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6182750PMC
November 2018

Elective endoscopic clipping for the treatment of symptomatic diverticular disease: a potential for 'cure'.

Gut 2019 04 5;68(4):582-584. Epub 2018 May 5.

King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1136/gutjnl-2017-315509DOI Listing
April 2019

Using Endoscopic Submucosal Dissection as a Routine Component of the Standard Treatment Strategy for Large and Complex Colorectal Lesions in a Western Tertiary Referral Unit.

Dis Colon Rectum 2018 Jun;61(6):743-750

King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, United Kingdom.

Background: Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited.

Objectives: This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach.

Design: This was a retrospective study.

Setting: The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom.

Patients: A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients.

Main Outcome Measures: Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection.

Results: One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection.

Limitations: This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded.

Conclusion: Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.
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http://dx.doi.org/10.1097/DCR.0000000000001081DOI Listing
June 2018

Outcomes of Endoscopic Resections of Large Laterally Spreading Colorectal Lesions in Inflammatory Bowel Disease: a Single United Kingdom Center Experience.

Inflamm Bowel Dis 2018 05;24(6):1196-1203

King's Institute of Therapeutic Endoscopy.

Background: The SCENIC consensus statement recommends endoscopic resection of all visible dysplasia in inflammatory bowel disease, but patients with large or complex lesions may still be advised to have colectomy. This article presents outcomes for large nonpolypoid resections associated with colitis at our institution.

Methods: Data including demographics, clinical history, lesion characteristics, method of resection, and postresection surveillance were collected prospectively in patients with visible lesions within colitic mucosa from January 2011 to November 2016. Resection techniques included endoscopic mucosal resection , endoscopic submucosal dissection (ESD), and hybrid ESD. Surveillance with magnification chromoendoscopy was performed at 3 months, 1-year postresection, and annually thereafter.

Results: Fifteen lesions satisfied the inclusion criteria in 15 patients. Mean lesion size was 48.3+/-21.7 (20-90) mm. All lesions were non-polypoid with distinct margins and no ulceration. 73% lesions were scarred of which 64% had undergone prior instrumentation. En bloc resection was achieved in n=6. Presumed endoscopic diagnosis was confirmed histopathologically in all resected lesions. One case of perforation and another with bleeding were both managed endoscopically. Median follow-up was 28 months (12-35) with no recurrence.

Conclusion: This cohort series demonstrates that endoscopic resection of large non-polypoid lesions associated with colitis is feasible and safe using an array of resection methods supporting the role of advanced endoscopic therapeutics for the management of colitis associated dysplasia in a western tertiary endoscopic center.
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http://dx.doi.org/10.1093/ibd/izx113DOI Listing
May 2018

Combining eastern and western practices for safe and effective endoscopic resection of large complex colorectal lesions.

Eur J Gastroenterol Hepatol 2018 May;30(5):506-513

King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK.

Background: Endoscopic resection of large colorectal polyps is well established. However, significant differences in technique exist between eastern and western interventional endoscopists. We report the results of endoscopic resection of large complex colorectal lesions from a specialist unit that combines eastern and western techniques for assessment and resection.

Patients And Methods: Endoscopic resections of colorectal lesions of at least 2 cm were included. Lesions were assessed using magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion-specific approach to resection with endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was used. Surveillance endoscopy was performed at 3 (SC1) and 12 (SC2) months.

Results: Four hundred and sixty-six large (≥20 mm) colorectal lesions (mean size 54.8 mm) were resected. Three hundread and fifty-six were resected using endoscopic mucosal resection and 110 by ESD or hybrid ESD. Fifty-one percent of lesions had been subjected to previous failed attempts at resection or heavy manipulation (≥6 biopsies). Nevertheless, endoscopic resection was deemed successful after an initial attempt in 98%. Recurrence occurred in 15% and could be treated with endoscopic resection in most. Only two patients required surgery for perforation. Nine patients had postprocedure bleeding; only two required endoscopic clips. Ninety-six percent of patients without invasive cancer were free from recurrence and had avoided surgery at last follow-up.

Conclusion: Combining eastern and western practices for assessment and resection results in safe and effective organ-conserving treatment of complex colorectal lesions. Accurate assessment before and after resection using magnification chromoendoscopy and a lesion-specific approach to resection, incorporating ESD where appropriate, are important factors in achieving these results.
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http://dx.doi.org/10.1097/MEG.0000000000001086DOI Listing
May 2018

Colorectal endoscopic submucosal dissection: patient selection and special considerations.

Clin Exp Gastroenterol 2017 13;10:121-131. Epub 2017 Jul 13.

King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK.

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.
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http://dx.doi.org/10.2147/CEG.S120395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516776PMC
July 2017

Peroral endoscopic myotomy: a literature review and the first UK case series.

Clin Med (Lond) 2017 Feb;17(1):22-28

King's Institute of Therapeutic Endoscopy, London, UK.

Peroral endoscopic myotomy (POEM) is an established treatment for primary achalasia. It has gained endorsement from the American Society for Gastrointestinal Endoscopy with increasing clinical acceptance since the first procedure, performed in Japan in 2008. The first successful POEM in the UK was performed in November 2013 at King's College Hospital and this article presents the first UK case series. Prospective data were collected at 3 and 12-24 months for consecutive patients undergoing POEM. Post-POEM gastro-oesophageal reflux health-related quality of life scale (GORD-HRQoL) score was recorded. Statistical comparisons were made using paired non-parametric testing. In an initial series of 33 consecutive prospectively followed patients (12 female; 49.5±13 years; median follow-up 9 (3-28) months; 58% having had previous intervention), a 91% success rate has been achieved at 3 months. To date, 16 patients have reached the 12-month time point, with 13 (81%) sustaining response. This case series compares well with international cohorts and demonstrates excellent long-term safety and favourable efficacy.
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http://dx.doi.org/10.7861/clinmedicine.17-1-22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297590PMC
February 2017

Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: is it worth that extra effort? A review of the literature.

Int J Colorectal Dis 2016 Apr 30;31(4):797-804. Epub 2016 Jan 30.

Department of Colorectal Surgery, King's College Hospital, King's College Hospital NHS Foundation Trust, 2nd Floor Hambelden Wing, Denmark Hill, London, SE5 9RS, UK.

Purpose: Recent interest in complete mesocolic excision (CME) with central vascular ligation (CVL) or extended (D3) lymphadenectomy (EL) for curative resection of colon cancer has been driven by published series from experienced practitioners showing excellent survival outcomes and low recurrence rates. In this article, we attempt to clarify the role of CME or EL in modern colorectal surgery.

Methods: A narrative review of the evidence for CME and EL in the curative treatment of colon cancer.

Results: The principal of CME surgery, similar to total mesorectal excision (TME) for rectal cancer, is the removal of all lymphatic, vascular, and neural tissue in the drainage area of the tumour in a complete mesocolic envelope with intact mesentery, peritoneum and encasing fascia. Extended (D3) lymphadenectomy (EL) is based on similar principles. Sound anatomical and oncological arguments are made to support the principles of removing the tumor contained within an intact mesocolic facial envelope together with an extended lymph node harvest. Excellent oncological outcomes with minimal morbidity and mortality have been reported. This has led to calls for the standardisation of surgery for colon cancer using CME. However, there is conflicting evidence regarding the prognostic benefit of greater lymph node harvests and the evidence for an oncological benefit of CME is limited by methodology flaws and several potential confounding factors.

Conclusions: Although there is a reasonable anatomical and oncological basis for these techniques, there are no randomised controlled trials from which to draw confident conclusions and there is insufficient consistent high quality evidence to recommend widespread adoption of CME.
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http://dx.doi.org/10.1007/s00384-016-2502-0DOI Listing
April 2016

A EWTD Compliant Rotation Schedule Which Protects Elective Training Opportunities Is Safe and Provides Sufficient Exposure to Emergency General Surgery: A Prospective Study.

Surg Res Pract 2015 2;2015:735129. Epub 2015 Nov 2.

Department of General Surgery, Princess Royal University Hospital, Kings College NHS Foundation Trust, Farnborough Common, Orpington, Kent BR6 8ND, UK.

Introduction. Training opportunities have decreased dramatically since the introduction of the European Working Time Directive (EWTD). In order to maximise training we introduced a rotation schedule in which registrars do not work night shifts and elective training opportunities are protected. We aimed to determine the safety and effectiveness of this EWTD compliant rotation schedule in achieving exposure of trainees to acute general surgical admissions and operations. Methods. A prospective study of consecutive emergency surgical admissions over a 6-month period. Exposure to acute admissions and operative procedures and patient outcomes during day and night shifts was compared. Results. There were 1156 emergency admissions covering a broad range of acute conditions. Significantly more patients were admitted during the day shift and almost all emergency procedures were performed during the day shift (2.1 versus 0.3, p < 0.001). A registrar was the primary operating surgeon in 49% of cases and was directly involved in over 65%. There were no significant differences between patients admitted during the day and night shifts in mortality rate, length of stay, admission to ICU, requirement for surgery, or readmission rates. Conclusion. A EWTD compliant rotation schedule that protects elective training opportunities is safe for patients and provides adequate exposure to training opportunities in emergency surgery.
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http://dx.doi.org/10.1155/2015/735129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644834PMC
November 2015

The effect of acetabular inclination on metal ion levels following metal-on-metal hip arthroplasty.

J Arthroplasty 2014 Jan 4;29(1):186-91. Epub 2013 Jun 4.

Lourdes Orthopaedic Hospital, Kilcreene, Kilkenny, Republic of Ireland.

Acetabular inclination angles have been suggested as a principal determinant of circulating metal ion levels in metal-on-metal hip arthroplasties. We aimed to determine whether inclination angle correlates with ion levels in arthroplasties using the Articular Surface Replacement (ASR) system. Patients undergoing ASR arthroplasties had blood metal ion levels and radiograph analysis performed a mean of 3.2 years after surgery. Inclination angle showed only a weak correlation with cobalt (r=0.21) and chromium (r=0.15) levels. The correlation between inclination angle and cobalt levels was significant only with small femoral components, although it was still weak. Multiple regression showed a complex interaction of factors influencing ion levels but inclination angle accounted for little of this variation. We conclude that the acetabular inclination angle is not a meaningful determinant of metal ion levels in ASR arthroplasties.
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http://dx.doi.org/10.1016/j.arth.2013.04.022DOI Listing
January 2014

Who will be sicker in the morning? Changes in the Simple Clinical Score the day after admission and the subsequent outcomes of acutely ill unselected medical patients.

Eur J Intern Med 2011 Aug 8;22(4):375-81. Epub 2011 Apr 8.

Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland.

Background: All doctors are haunted by the possibility that a patient they reassured yesterday will return seriously ill tomorrow. We examined changes in the Simple Clinical Score (SCS) the day after admission, factors that might influence these changes and the relationship of these changes to subsequent clinical outcome.

Method: The SCS was recorded in 1165 patients on admission and again the following day (i.e. 25.0±15.8 h later). The abilities of 51 variables that might predict changes in the SCS were examined.

Results: The day after admission 16.1% of patients had been discharged home, 31.4% had decreased their SCS by 2.4±1.6 points, 38.6% had an unchanged SCS, 12.0% had increased their SCS by 2.1±1.7 points and 1.2% had died. Patients with an increased SCS had higher in-hospital mortality (10% vs. 1.1%, OR 10.1, p<.001) and a longer length of stay (9.4±9.6 vs. 5.6±7.0 days, p<.001). There was no consistent association between the SCS recorded at admission and SCS increase. Only nursing home residence, heart failure and a Medical Admission Risk System laboratory data score>0.09 were found to be independent predictors of SCS increase.

Conclusion: The SCS of 12% of patients increases the day after admission to hospital, which is associated with a ten-fold increase of in-hospital mortality. Low SCS risk patients are just as likely to have a SCS increase as high risk patients.
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http://dx.doi.org/10.1016/j.ejim.2011.03.005DOI Listing
August 2011

The value of hyperbilirubinaemia in the diagnosis of acute appendicitis.

Ann R Coll Surg Engl 2011 Apr;93(3):213-7

Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland.

Introduction: No reliably specific marker for acute appendicitis has been identified. Although recent studies have shown hyperbilirubinaemia to be a useful predictor of appendiceal perforation, they did not focus on the value of bilirubin as a marker for acute appendicitis. The aim of this study was to determine the value of hyperbilirubinaemia as a marker for acute appendicitis.

Materials And Methods: A retrospective analysis of appendicectomies performed in two hospitals (n=472). Data collected included laboratory and histological results. Patients were grouped according to histology findings and comparisons were made between the groups.

Results: The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (p<0.001). More patients with simple appendicitis had hyperbilirubinaemia on admission (30% vs 12%) and the odds of these patients having appendicitis were over three times higher (odds ratio: 3.25, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 91% for acute appendicitis. Patients with appendicitis who had a perforated or gangrenous appendix had higher mean bilirubin levels (p=0.01) and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 70%. The specificities of white cell count and C-reactive protein were less than hyperbilirubinaemia for simple appendicitis (60% and 72%) and perforated or gangrenous appendicitis (19% and 36%).

Conclusions: Hyperbilirubinaemia is a valuable marker for acute appendicitis. Patients with hyperbilirubinaemia are also more likely to have appendiceal perforation or gangrene. Bilirubin should be included in the assessment of patients with suspected appendicitis.
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http://dx.doi.org/10.1308/147870811X566402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291137PMC
April 2011

Assessing the need for hospital admission by the Cape Triage discriminator presentations and the simple clinical score.

Emerg Med J 2010 Nov 31;27(11):852-5. Epub 2010 May 31.

Nenagh Hospital, Nenagh, Ireland.

Aim: There is uncertainty about how to assess unselected acutely ill medical patients at the time of their admission to hospital. This study examined the use of the Simple Clinical Score (SCS) and the medically relevant Cape Triage discriminator clinical presentations to determine the need for admission to an acute medical unit.

Method: A prospective study of 270 unselected consecutive acute medical admissions. On presentation to hospital patients were grouped into one of 5 risk classes according to their SCS and to one of four Cape Triage colour-coded risk discriminator presentations (CTP).

Results: 221 (82%) patients had an urgent or very urgent CTP. Although 60 patients were deemed very low risk by the SCS at the time of admission, only 13 of these patients a delayed priority CTP. All but three of the 95 patients in high SCS risk classes did not have an urgent or very urgent CTP. The ability of the CTP to predict outcomes was inferior to the SCS--the AUROC for in-hospital death was 0.94 for the SCS and 0.64 for CTP.

Conclusion: Nearly all patients in the highest risk SCS classes were detected as urgent or very urgent by the CTP. However, most patients admitted in the lowest risk SCS class also were considered urgent or very urgent by the CTP and, therefore, had presentations that justified admission. Although CTP predict outcome poorly they can be used together with the SCS to rapidly assess the need for admission and to prioritise management.
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http://dx.doi.org/10.1136/emj.2009.086256DOI Listing
November 2010

Transepidermal water loss does not correlate with skin barrier function in vitro.

J Invest Dermatol 2002 May;118(5):871-5

Department of Biomedical Sciences, CBD Porton Down, Salisbury, Wiltshire, UK.

The purpose of this study was to investigate the relationship between transepidermal water loss and skin permeability to tritiated water (3H2O) and the lipophilic penetrant sulfur mustard in vitro. No correlation was found between basal transepidermal water loss rates and the permeability of human epidermal membranes to 3H2O (p = 0.72) or sulfur mustard (p = 0.74). Similarly, there was no correlation between transepidermal water loss rates and the 3H2O permeability of full-thickness pig skin (p = 0.68). There was no correlation between transepidermal water loss rate and 3H2O permeability following up to 15 tape strips (p = 0.64) or up to four needle-stick punctures (p = 0.13). These data indicate that transepidermal water loss cannot be unconditionally ascribed to be a measure of skin barrier function. It is clear that further work should be conducted to interpret the significance of measuring transepidermal water loss by evaporimetry.
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http://dx.doi.org/10.1046/j.1523-1747.2002.01760.xDOI Listing
May 2002
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