Staff Publication

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons (2015)

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Type of publication:
Journal article

Author(s):
Malhotra R., Norris J.H., Sagili S., *Al-Abbadi Z., Avisar I.

Citation:
Orbit, November 2015, vol./is. 34/6(314-319)

Abstract:
To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. Methods: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. Results: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 +/- 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 +/- 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 +/- 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% i n the previous 2 years. In cases that failed, video-analysis highlighted in adequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling , bone removal and posture. Conclusion: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

A rare case of vulval myxoid chondrosarcoma (2015)

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Type of publication:
Conference abstract

Author(s):
*Abdelsalam H., *Malcolm A.

Citation:
Journal of Pathology, September 2015, vol./is. 237/(S46)

Abstract:
Introduction: Primary Extraskeletal Myxoid Chondrosaroma (EMC) of the vulva is a rare mesenchymal neoplasm. The myxoid tumour differential diagnosis on a core biopsy can be quite challenging. To date, few cases have been reported in the literature. Case Report: A 42-year old woman noticed a swelling on the right side of the labia, thought to be a Bartholin's cyst i n 2011. She was managed conservatively. She had drainage and marsupialization under general anaesthesia. This resulted in extreme bruising of the vulva. This was managed with antibiotics and non-steroidal anti-inflammatory medication, and it resolved after 3 weeks. Six months later, the patient presented again with a persistent vulval mass. A biopsy was obtained under general anaesthesia, and it showed a myxoid tumour with differential diagnosis of low grade chondroid tumour. An MRI was performed to assess the extent of the disease. The tumour was excised. At surgery, a 7 x 5 cm lobulated, extremely vascular vulval tumour was found. The tumour was inseparable from the inferior pubic ramus of the pelvic bone. A complete macroscopic resection was obtained. Histology confirmed low grade myxoid chondrosarcoma. Conculsion: Vulval lesions with unusual characteristics or insidious evolution in the labia majora or Bartholin's glands area should be carefully and pr omptly investigated. Differential diagnosis of myxoid tumours in the vulva should include myxoid chondrosarcoma amongst other diagnoses.

Anterior approach white-line advancement: a hybrid technique for ptosis correction (2015)

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Type of publication:
Journal article

Author(s):
*Sagili S.

Citation:
Ophthalmic Plastic and Reconstructive Surgery , 2015, vol./is. 31/6(478-481)

Abstract:
Purpose: To describe the technique of anterior approach white-line advancement for correction of ptosis. Methods: Retrospective review of consecutive cases that underwent anterior approach white-line advancement for correction of aponeurotic ptosis. In this technique, the posterior surface of the levator aponeurosis (white line) is accessed through a skin crease incision (anterior approach) and advanced toward the tarsal plate. Surgery was considered successful if the following 3 criteria were simultaneously met: postoperative upper margin reflex distance of >2 and <4.5 mm, inter-eyelid height asymmetry of <1 mm, and satisfactory eyelid contour. Written informed consent was obtained from all the patients and the study was HIPPA compliant. Results: Twenty patients (29 eyelids) were included in this study. Mean postoperative follow up was 1.25 months (1 to 6 months). Mean preoperative margin reflex distance was 0.38 mm (.1 to 2 mm) and the mean postoperative margin reflex distance was 3.16 mm (2 to 4 mm). Eighteen patients (90% ) fulfilled the criteria set for success. The patients rated the outcome of surgery as follows: 80% completely satisfied and 20% significantly improved. Conclusion: Anterior approach white-line advancement is a hybrid technique that incorporates the principles of both anterior and posterior approach ptosis correction techniques. The posterior surface of levator aponeurosis (white line) is exposed and advanced toward the superior border of tarsal plate with minimal disruption of eyelid anatomy including the orbital septum and preaponeurotic fat pad. Hence, this technique can achieve superior cosmetic results similar to a posterior approach procedure, without the need for a conjunctival incision.

Breast reconstruction changes: coping mechanisms in breast cancer survivors (2015)

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Type of publication:
Oral presentation

Author(s):
*Blossom Lake, *Heidi Fuller, *Sarah Rastall, *Tamoor Usman

Citation:
San Antonio Breast Cancer Symposium, December 2015

Abstract:
Background: Breast cancer is the commonest malignancy in women. Survivorship care for breast cancer patients needs to be individualised. A key component is recognition that coping mechanisms can be changed by treatment. The aims of this study were to see how women who have had immediate breast reconstruction and mastectomy, compared to those who have mastectomy alone cope and if there were significant differences in coping styles.

Methods: A cohort study using a standardised questionnaire the Brief Cope Scale. Inclusion criteria: all women who had had immediate breast reconstruction and mastectomy in Shropshire from 2003 to 2014 for node negative ductal carcinoma in situ or invasive breast cancer. Each index patient was matched for year of diagnosis, adjuvant therapy and age to one woman who had mastectomy alone.

Results: Questionnaires were sent to 234 patients, with a 58% response rate. Significantly more patients from the reconstruction cohort coped by active coping (T value 1.66, P value 0.04). Significantly less patients coped by active venting in the reconstruction cohort (T value 1.71, P value 0.04).

Conclusion: Breast reconstruction changes coping styles of breast cancer patients, understanding this allows clinicians to individualise survivorship care.

Axillary overtreatment for minimal axillary disease in breast cancer, a 5 year audit of ipsilateral arm lymphoedema ; the real cost to patient and health service (2015)

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Type of publication:
Poster presentation

Author(s):
*Blossom Lake, Jayne Gittins, *Tamoor Usman

Citation:
European Journal of Surgical Oncology Nov 2015 41(11):p s267

Abstract:
NICE guidelines state that axillary node clearance (ANC) is the treatment of choice for the positive axilla, with up to 30% morbidity of lymphoedema. In contrast ASCO guidelines state that patients with 1 / 2 sentinel lymph node positive who have breast conserving surgery with breast radiotherapy should not have ANC. The recent ABS Consensus highlighted the need to minimise overtreatment of minimally involved malignant axilla. The aim of this audit was assess the cost of overtreatment in terms of lymphoedema.

International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways (2015)

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Type of publication:
Journal article

Author(s):
Cordell H.J., Han Y., Mells G.F., Li Y., Hirschfield G.M., Greene C.S., Xie G., Juran B.D., Zhu D., Qian D.C., Floyd J.A.B., Morley K.I., Prati D., Lleo A., Cusi D., Gershwin M.E., Anderson C.A., Lazaridis K.N., Invernizzi P., Seldin M.F., Sandford R.N., Amos C.I., Siminovitch K.A., Schlicht E.M., Lammert C., Atkinson E.J., Chan L.L., De Andrade M., Balschun T., Mason A.L., Myers R.P., Zhang J., Milkiewicz P., Qu J., Odin J.A., Luketic V.A., Bacon B.R., Bodenheimer H.C., Liakina V., Vincent C., Levy C., Gregersen P.K., Almasio P.L., Alvaro D., Andreone P., Andriulli A., Barlassina C., Battezzati P.M., Benedetti A., Bernuzzi F., Bianchi I., Bragazzi M.C., Brunetto M., Bruno S., Casella G., Coco B., Colli A., Colombo M., Colombo S., Cursaro C., Croce L.S., Crosignani A., Donato M.F., Elia G., Fabris L., Ferrari C., Floreani A., Foglieni B., Fontana R., Galli A., Lazzari R., Macaluso F., Malinverno F., Marra F., Marzioni M., Mattalia A., Montanari R., Morini L., Morisco F., Mousa Hani S., Muratori L., Muratori P., Niro G.A., Palmieri V.O., Picciotto A., Podda M., Portincasa P., Ronca V., Rosina F., Rossi S., Sogno I., Spinzi G., Spreafico M., Strazzabosco M., Tarallo S., Tarocchi M., Tiribelli C., Toniutto P., Vinci M., Zuin M., Ch'Ng C.L., Rahman M., Yapp T., Sturgess R., Healey C., Czajkowski M., Gunasekera A., Gyawali P., Premchand P., Kapur K., Marley R., Foster G., Watson A., Dias A., Subhani J., Harvey R., McCorry R., Ramanaden D., Gasem J., Evans R., Mathialahan T., Shorrock C., Lipscomb G., Southern P., Tibble J., Gorard D., Palegwala A., Carbone M., Dawwas M., Alexander G., Dolwani S., Prince M., Foxton M., Elphick D., Mitchison H., Gooding I., Karmo M., Saksena S., Mendall M., Patel M., Ede R., Austin A., Sayer J., Hankey L., Hovell C., Fisher N., Carter M., Koss K., Piotrowicz A., Grimley C., Neal D., Lim G., Levi S., Ala A., Broad A., Saeed A., Wood G., Brown J., Wilkinson M., Gordon H., Ramage J., Ridpath J., Ngatchu T., Grover B., Shaukat S., Shidrawi R., Abouda G., Ali F., Rees I., Salam I., Narain M., Brown A., Taylor-Robinson S., Williams S., Grellier L., Banim P., Das D., Chilton A., Heneghan M., Curtis H., Gess M., Drake I., Aldersley M., Davies M., Jones R., McNair A., Srirajaskanthan R., Pitcher M., Sen S., Bird G., Barnardo A., Kitchen P., Yoong K., Chirag O., Sivaramakrishnan N., MacFaul G., Jones D., Shah A., Evans C., Saha S., Pollock K., Bramley P., Mukhopadhya A., Fraser A., Mills P., Shallcross C., Campbell S., Bathgate A., Shepherd A., Dillon J., Rushbrook S., Przemioslo R., Macdonald C., Metcalf J., Shmueli U., Davis A., Naqvi A., Lee T., Stephen D., Collier J., Klass H., Ninkovic M., Cramp M., Sharer N., Aspinall R., Goggin P., Ghosh D., Douds A., Hoeroldt B., Booth J., Williams E., Hussaini H., Stableforth W., Ayres R., Thorburn D., Marshall E., Burroughs A., Mann S., Lombard M., Richardson P., Patanwala I., Maltby J., Brookes M., Mathew R., Vyas S., Singhal S., Gleeson D., Misra S., *Butterworth J., George K., Harding T., Douglass A., Panter S., Shearman J., Bray G., Butcher G., Forton D., McLindon J., Cowan M., Whatley G., Mandal A., Gupta H., Sanghi P., Jain S., Pereira S., Prasad G., Watts G., Wright M., Neuberger J., Gordon F., Unitt E., Grant A., Delahooke T., Higham A., Brind A., Cox M., Ramakrishnan S., King A., Collins C., Whalley S., Li A., Fraser J., Bell A., Wong V.S., Singhal A., Gee I., Ang Y., Ransford R., Gotto J., Millson C., Bowles J., Harrison M., Galaska R., Kendall J., Whiteman J., Lawlor C., Gray C., Elliott K., Mulvaney-Jones C., Hobson L., Van Duyvenvoorde G., Loftus A., Seward K., Penn R., Maiden J., Damant R., Hails J., Cloudsdale R., Silvestre V., Glenn S., Dungca E., Wheatley N., Doyle H., Kent M., Hamilton C., Braim D., Wooldridge H., Abrahams R., Paton A., Lancaster N., Gibbins A., Hogben K., Desousa P., Muscariu F., Musselwhite J., McKay A., Tan L., Foale C., Brighton J., Flahive K., Nambela E., Townshend P., Ford C., Holder S., Palmer C., Featherstone J., Nasseri M., Sadeghian J., Williams B., Thomas C., Rolls S.-A., Hynes A., Duggan C., Jones S., Crossey M., Stansfield G., MacNicol C., Wilkins J., Wilhelmsen E., Raymode P., Lee H.-J., Durant E., Bishop R., Ncube N., Tripoli S., Casey R., Cowley C., Miller R., Houghton K., Ducker S., Wright F., Bird B., Baxter G., Keggans J., Hughes M., Grieve E., Young K., Williams D., Ocker K., Hines F., Innes C., Valliani T., Fairlamb H., Thornthwaite S., Eastick A., Tanqueray E., Morrison J., Holbrook B., Browning J., Walker K., Congreave S., Verheyden J., Slininger S., Stafford L., O'Donnell D., Ainsworth M., Lord S., Kent L., March L., Dickson C., Simpson D., Longhurst B., Hayes M., Shpuza E., White N., Besley S., Pearson S., Wright A., Jones L., Gunter E., Dewhurst H., Fouracres A., Farrington L., Graves L., Marriott S., Leoni M., Tyrer D., Martin K., Dali-Kemmery L., Lambourne V., Green M., Sirdefield D., Amor K., Colley J., Shinder B., Jones J., Mills M., *Carnahan M., Taylor N., Boulton K., Tregonning J., Brown C., Clifford G., Archer E., Hamilton M., Curtis J., Shewan T., Walsh S., Warner K., Netherton K., Mupudzi M., Gunson B., Gitahi J., Gocher D., Batham S., Pateman H., Desmennu S., Conder J., Clement D., Gallagher S., Orpe J., Chan P., Currie L., O'Donohoe L., Oblak M., Morgan L., Quinn M., Amey I., Baird Y., Cotterill D., Cumlat L., Winter L., Greer S., Spurdle K., Allison J., Dyer S., Sweeting H., Kordula J.

Citation:
Nature Communications, September 2015, vol./is. 6/, 2041-1723

Abstract:
Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined5 x 108) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

Vein graft aneurysms following popliteal aneurysm repair are more common than we think (2015)

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Type of publication:
Journal article

Author(s):
*Sharples A., *Kay M., *Sykes T., *Fox A., *Houghton A.

Citation:
Vascular, October 2015, vol./is. 23/5(494-497)

Abstract:
True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts (P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance.

Endocervical Crypt Involvement by CIN2-3 as a Predictor of Cytology Recurrence After Excisional Cervical Treatment. (2015)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios, *Panikkar, Jane, *Underwood, Martyn, Blundell, Sue, *Sahu, Banchita, *Blackmore, Jill, *Reed, Nicholas

Citation:
Journal of Lower Genital Tract Disease, Oct 2015, vol. 19, no. 4, p. 311-318

Abstract:
The primary objective was to determine whether endocervical crypt involvement (ECI) by cervical intraepithelial neoplasia (CIN) on the excised cervical tissue after large loop excision of the transformation zone (LLETZ) represents a predictor of cytology recurrence. Secondary objective was to identify the ability of a pretreatment cervical punch biopsy to predict cytology recurrence. This was a case series study conducted in an NHS hospital. Women with LLETZ treatment performed over a 2-year period (2010-2011) were identified through our colposcopy database. Women with previous cervical treatment, cervical cancer on cone histopathology, or missing follow-up data were excluded. A group of 526 eligible women was identified over the study period. Crypt involvement was not a predictor of recurrence in the total sample. However, in the subgroup of women with CIN2-3 on pretreatment punch biopsy and with ECI on cone specimen in comparison to those without ECI, we identified an increased risk for overall cytology recurrence (HR, 3.1; 95% CI, 1.04-9.28; P = 0.043) and a trend for increased risk of high-grade cytology recurrence (HR, 4.62; 95% CI, 0.84-25.28; P = 0.07). A pretreatment punch biopsy showing crypt involvement by CIN2-3 was indicative of women at risk for abnormal cytology after excision. In women with CIN2-3 on pretreatment punch biopsy and ECI on excised tissue, the high-grade cytology recurrence was significantly reduced if more than 1.9 cm of cervix was removed. It seems that the presence of crypt involvement on the excised cervix in the subgroup of women with CIN2-3 on pretreatment punch biopsy is predictive of cytology recurrence.

Protein biomarkers in the rectal mucosa: a novel test for colorectal cancer? (2015)

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Type of publication:
Conference abstract

Author(s):
*Lacy-Colson J., Norwood M., Murray C., Booth J.

Citation:
Gut, June 2015, vol./is. 64/(A529-A530)

Abstract:
Introduction: Earlier detection of colorectal cancer is a clinical priority. Currently very high numbers of patients are referred for colonoscopy under the 2 week rule system, with a pick up rate for cancer of 1:20 or less putting a major strain on endoscopy units investigating large numbers of the worried well. The aim of this study was to assess the correlation of protein biomarkers captured from the rectal mucosa with the presence or absence of colorectal cancer. Method We conducted a case control study of 20 patients with colorectal cancer, and 20 controls. All patients had been referred to colorectal outpatients with potentially worrying symptoms; presence or absence of cancer was determined by colonoscopy or CT virtual colonoscopy. A novel sampling device, OriColTM, was employed to collect samples of rectal mucosa for biomarker analysis. The device incorporates a nitrile membrane which, following insertion into the unprepared rectum via a standard proctoscope, is inflated to make contact with the rectal mucosa for a period of 10 s. Upon deflation and retraction of the membrane, a preservation buffer is added to preserve the sample prior to analysis. Sampling can be performed in an outpatient setting in under 2 min and has been shown to be well tolerated in >2500 patients. The levels of various antibodies, haemoglobin and carcinoembryonic antigen were analysed using conventional ELISA techniques. Statistical analysis of the trial results was performed using the Wilcoxon test for non-parametric comparisons with two sided p values. The area under the receiver operating characteristic (ROC) curve for distinguishing between the two diagnostic groups, together with its confidence interval, was calculated for each biomarker. Logistic regression analyses were used to investigate the performance of different combinations of biomarkers. This study was conducted with appropriate research ethics committee approval. Results Univariate analyses identified five candidate predictive biomarkers for colorectal cancer. All combinations of two and three predictors were investigated using logistic regression. The best performing combination of biomarkers was haemoglobin and IgA. The area under the ROC curve for this best linear combination was 0.86. Conclusion We suggest that ELISA analysis protein biomarkers collected with the OriColTM device offers a potentially useful and cost-effective pre-colonoscopy screening tool in patients referred under the 2 week rule criteria. Data from this pilot study suggests that a sensitivity of >95% can be achieved while massively reducing the number of patients requiring urgent colonoscopy to exclude a diagnosis of cancer.

Link to full-text: http://gut.bmj.com/content/64/Suppl_1/A529.2.full.pdf+html