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Allen P.B.,Ulster Hospital | Peyrin-Biroulet L.,University of Lorraine
Current Opinion in Gastroenterology | Year: 2013

PURPOSE OF REVIEW: The inflammatory bowel diseases (IBDs) are chronic disabling conditions. Despite the benefits of anti-tumor necrosis factor (TNF)-α agents in improving quality of life and reducing the need for surgeries, overall only one-third of patients are in clinical remission at 1 year and loss of response is frequent. It seems clear that treatment must go beyond alleviation of symptoms in IBD. It is important that treatment targets in IBD will ensure mucosal healing and deep remission. RECENT FINDINGS: The induction of deep remission might be the best way to alter the natural course of these diseases by preventing disability and bowel damage. New disability indices and the new Crohn's disease damage score have recently been developed and they can be used to evaluate the long-term effect on patients and as new endpoints in trials. Early intervention with disease-modifying anti-IBD drugs (DMAIDs) should be considered in patients with poor prognostic factors. SUMMARY: New therapeutic targets in IBD patients who failed anti-TNF-α therapy are urgently required, and tofacitinib, vedolizumab and ustekinumab appear to be the most promising drugs. Herein, we review the new and current trends in IBD therapy, with the final aim of changing disease course and patients' lives by both improving quality of life and avoiding disability. © 2013 Wolters Kluwer Health | Lippincott Williams &Wilkins.

Dasari B.V.M.,Belfast Health and Social Care Trust | Neely D.,Belfast Health and Social Care Trust | Kennedy A.,Belfast Health and Social Care Trust | Spence G.,Ulster Hospital | And 3 more authors.
Annals of Surgery | Year: 2014

OBJECTIVE: The aim of this review was to assess the safety and effectiveness of esophageal stents in the management of benign esophageal perforation and in the management of esophageal anastomotic leaks. BACKGROUND: Benign esophageal perforation and postoperative esophageal anastomotic leak are often encountered. Endoscopic placement of esophageal stent across the site of leakage might help control the sepsis and reduce the mortality and morbidity. METHODS: All the published case series reporting the use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous esophageal perforations, and iatrogenic esophageal perforations were identified from MEDLINE, EMBASE, and PubMed (1990-2012). Primary outcomes assessed were technical success rates and complete healing rates. Secondary outcomes assessed were stent migration rates, stent perforation rates, duration of hospital stay, time to stent removal, and mortality rates. A pooled analysis was performed and subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS: A total of 27 case series with 340 patients were included. Technical and clinical success rates of stenting were 91% and 81%, respectively. Stent migration rates were significantly higher with plastic stents than with metallic stents (40/148 vs 13/117 patients, respectively; P = 0.001). Patients with metallic stents had significantly higher incidence of postprocedure strictures (P = 0.006). However, patients with plastic stents needed significantly higher number of reinterventions (P = 0.005). Mean postprocedure hospital stay varied from 8 days to 51 days. There was no significant difference in the primary or secondary outcomes when stenting was performed for anastomotic leaks or perforations. CONCLUSIONS: Endoscopic management of esophageal anastomotic leaks and perforations with the use of esophageal stents is technically feasible. It seems to be safe and effective when performed along with mediastinal or pleural drainage. Esophageal stent can, therefore, be considered as a treatment option in the management of patients who present early after esophageal perforation or anastomotic leak with limited mediastinal or pleural contamination. Copyright © 2014 by Lippincott Williams & Wilkins.

Neligan P.C.,University of Washington | Lannon D.A.,Ulster Hospital
Clinics in Plastic Surgery | Year: 2010

The pedicled anterolateral thigh flap is a useful addition to our armamentarium. It provides excellent cover for defects in the lower abdomen, pelvis, and perineum. It also has the added advantage of not sacrificing any muscle, thereby minimizing the risk for donor morbidity. This article reviews the major applications of the proximally pedicled anterolateral thigh flap, describes the technique of flap harvest, and discusses techniques of flap transposition as well as pointing out some potential hazards. © 2010 Elsevier Inc.

Tennyson C.,Ulster Hospital | Lee R.,Cardiothoracic Surgery Unit | Attia R.,Guys and St Thomas Hospital London
Interactive Cardiovascular and Thoracic Surgery | Year: 2013

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was is there a role for HbAlc in predicting morbidity and mortality outcomes after coronary artery bypass surgery? Eleven studies presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies presented analyse the relationship between preoperative HbAlc levels and postoperative outcomes following coronary artery bypass graft (CABG) in diabetic, non-diabetic or mixed patient groups. Four studies found significant increases in early and late mortality at higher HbAl c levels, regardless of a preoperative diagnosis of diabetes. One study demonstrated that 30-day survival outcomes were significantly worse in patients with previously undiagnosed diabetes and elevated HbAlc compared with those with good control [HbAl c > 6%; odds ratio 1.53, confidence interval (CI) (1.24-1.91); P = 0.0005]. However, four studies of early mortality outcomes in diabetic patients only showed no significant differences between patients with normal and those with deranged HbAlc levels (P= 0.99). There were mixed reports on morbidity outcomes. Three studies identified a significant increase in infectious complications in patients with poorly controlled HbAlc, two of which were irrespective of previous diabetic status [deep sternal wound infection (P = 0.014); superficial sternal wound infection (P = 0.007) and minor infections (P = 0.006) in poorly controlled diabetics only]. Four studies presented outcomes for total length of stay (LOS). Three of these papers looked specifically at diabetic patients, of which two found no significant differences in length of stay between good and poor preoperative glycaemic control [LOS: P= 0.59 and 0.86 vs P < 0.001]. However, elevated HbAlc vs normal HbAlc was associated with prolonged stay in hospital and in intensive care unit (ICU) in patients irrespective of previous diabetic status [total LOS (P< 0.001)]. Elevated HbAlc levels were also a significant predictor of reduced intraoperative insulin sensitivity in diabetic patients (R =-0.527; P< 0.001). Furthermore, higher HbAlc levels were associated with a reduced incidence of postoperative atrial fibrillation (P = 0.001). We conclude that elevated HbA1 c is a strong predictor of mortality and morbidity irrespective of previous diabetic status. In particular, the mortality risk for CABG is quadrupled at HbAl c levels > 8.6%. Some studies have called into question the predictive value of HbAl c on short-term outcomes in well-controlled diabetics; however, long-term outcomes in this population have not been reported.

Linden D.,Ulster Hospital | Linden K.,Ulster Hospital | Oparka J.,Royal Infirmary
Interactive Cardiovascular and Thoracic Surgery | Year: 2014

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with resectable non-small-cell lung cancer, is video-assisted thoracoscopic segmentectomy a suitable alternative to thoracotomy and segmentectomy in terms of morbidity and equivalence of resection?' Altogether 232 papers were found as a result of the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Only one study compared the survival rates of video-assisted thoracoscopic surgery (VATS) and open surgery and found no significant difference in overall (P = 0.605) and disease-free (P = 0.996) survival between these groups. The mean length of hospital stay was reported as shorter following VATS when compared with open surgery in all of the studies looking at this outcome. The greatest difference in length of hospital stay reported was 4.8 days (VATS 3.5 days and open 8.3 days). The duration of chest tube placement was also universally reported as shorter in patients having VATS procedures when compared with open procedures. Two studies compared the number of lymph nodes that could be sampled when completing this operation by VATS using an open approach and neither found there to be a significant difference between these numbers. Using the evidence collected, we conclude that anatomical segmentectomy performed by VATS is a safe and effective alternative to conventional techniques in the surgical management of non-small-cell lung cancer. We are aware that the current evidence is limited and existing studies all examine small numbers of patients. Unfortunately, at present there is no blinded randomized control trial comparing these two surgical methods. There is also no study comparing the utility of each method for differing anatomical locations of segments. This should be kept in mind when interpreting the results of the studies presented. © 2014 The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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