Sushil Maslekar

Surgery, Clinical Trials, Gastroenterology



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    ABSTRACT: This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilisation of the splenic flexure without the need for re-draping or compromise of port placement. A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilisation RESULTS: The technique was used in 12 patients. There were no adverse intra- or postoperative events. The mean (range) operation time was 10 (8 - 12) minutes. This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intraoperative footage demonstrating the benefits of the patient's position. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Colorectal Disease 03/2015; 17(5). DOI:10.1111/codi.12942 · 2.35 Impact Factor
  • Sushil Maslekar · Euh-Wing Toh · Robert Adair · John P Bate · Ian Botterill ·
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    ABSTRACT: Anorectal varices are an uncommon but significant source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise. A systematic literature search was carried out to identify articles on anorectal varices and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices. Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures such as endoscopic band ligation to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure. As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices This article is protected by copyright. All rights reserved.
    Colorectal Disease 09/2013; 15(12). DOI:10.1111/codi.12417 · 2.35 Impact Factor
  • S Maslekar · K Smith · D Harji · B Griffiths · P M Sagar ·
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    ABSTRACT: : Fecal incontinence is a distressing condition that is difficult to treat. Injection of bulking agents has been used to treat passive fecal incontinence. However, no long-term results are available. : The aim of this study was to assess the long-term clinical effectiveness of intra-anal injection of collagen for passive fecal incontinence. : This research is a retrospective cohort study from a prospectively collected database : This investigation took place in a high-volume tertiary colorectal department. : All patients who underwent intra-anal injection of collagen for passive fecal incontinence with internal sphincter dysfunction between January 2006 and December 2009 were included in the study. Data including demographic details, preoperative anorectal physiology, and outcome measures were collected prospectively and maintained in a database : The primary outcomes measured were the Cleveland Clinic Florida incontinence score and the responses to a subjective patient satisfaction questionnaire before the procedure and at subsequent follow-up visits. Data were analyzed by using SPSS v19.0. : One hundred patients (70 female; mean age, 61 years (range, 36-82)) were followed up for a minimum duration of 36 months. Fifty-six patients (56%) had an improvement in fecal incontinence score from a mean of 14 (range, 9-18) to a mean of 8 (range, 5-14). A total of 68% reported subjective improvement in symptoms. Thirty-eight patients (38%) required a repeat injection of collagen, and a further 15 patients required a third injection. The median interval between the first and final injection was 12 months (range, 4-16 months). Age was the only independent predictor of successful outcome (p = 0.032). There was no morbidity. : This study was limited by its nonrandomized retrospective design. : Injection of collagen into the internal anal sphincter is simple, safe, and effective in patients with passive fecal incontinence, although repeat injections are necessary in approximately half of the patients.
    Diseases of the Colon & Rectum 03/2013; 56(3):354-9. DOI:10.1097/DCR.0b013e3182805276 · 3.75 Impact Factor
  • D P Harji · P M Sagar · K Boyle · S Maslekar · B Griffiths · D R McArthur ·
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    ABSTRACT: Background: Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer. Methods: Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences. Results: Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection). Conclusion: Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.
    British Journal of Surgery 02/2013; 100(3). DOI:10.1002/bjs.8991 · 5.54 Impact Factor
  • S Maslekar · P M Sagar · D Harji · C Bruce · B Griffiths ·
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    ABSTRACT: Pouch-vaginal fistulae affect 6 % of women after ileal pouch-anal anastomosis. Such fistulae significantly impact on the patient's quality of life and present a technical challenge to the surgeon. Although several operative approaches have been described, results from a number of case series are variable and associated with significant rates of failure. As a result, there remains a lack of consensus in the literature with regard to the management of this troublesome problem. The purpose of this article is to review the results of surgical intervention and to provide a clinical algorithm that gives a structured approach to the management of pouch-vaginal fistulae.
    Techniques in Coloproctology 09/2012; 16(6). DOI:10.1007/s10151-012-0885-7 · 2.04 Impact Factor
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    ABSTRACT: The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection. A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained. Four hundred and twenty-four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection. Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.
    Colorectal Disease 02/2012; 14(8):e477-85. DOI:10.1111/j.1463-1318.2012.02992.x · 2.35 Impact Factor
  • S Maslekar · P M Sagar · A I D Mavor · D Harji · C Bruce ·

    Techniques in Coloproctology 11/2011; 17(1). DOI:10.1007/s10151-011-0787-0 · 2.04 Impact Factor
  • B Griffiths · D Harji · S Maslekar · C Bruce · P M Sagar ·

    Techniques in Coloproctology 11/2011; 16(5):401-2. DOI:10.1007/s10151-011-0775-4 · 2.04 Impact Factor
  • D P Harji · S Maslekar · C Bruce · P M Sagar ·

    Techniques in Coloproctology 06/2011; 15(4):483-5. DOI:10.1007/s10151-011-0705-5 · 2.04 Impact Factor
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    S Maslekar · G Miller ·

    Annals of The Royal College of Surgeons of England 04/2011; 93(3):260. DOI:10.1308/003588411X12851639107395g · 1.27 Impact Factor
  • S. Maslekar · A. B. Gardiner · J. R. T. Monson · G. S. Duthie ·
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    ABSTRACT: Aim Artificial neural networks (ANNs) are computer programs used to identify complex relations within data. Routine predictions of presence of colorectal pathology based on population statistics have little meaning for individual patient. This results in large number of unnecessary lower gastrointestinal endoscopies (LGEs – colonoscopies and flexible sigmoidoscopies). We aimed to develop a neural network algorithm that can accurately predict presence of significant pathology in patients attending routine outpatient clinics for gastrointestinal symptoms.Method Ethics approval was obtained and the study was monitored according to International Committee on Harmonisation – Good Clinical Practice (ICH-GCP) standards. Three-hundred patients undergoing LGE prospectively completed a specifically developed questionnaire, which included 40 variables based on clinical symptoms, signs, past- and family history. Complete data sets of 100 patients were used to train the ANN; the remaining data was used for internal validation. The primary output used was positive finding on LGE, including polyps, cancer, diverticular disease or colitis. For external validation, the ANN was applied to data from 50 patients in primary care and also compared with the predictions of four clinicians.Results Clear correlation between actual data value and ANN predictions were found (r = 0.931; P = 0.0001). The predictive accuracy of ANN was 95% in training group and 90% (95% CI 84–96) in the internal validation set and this was significantly higher than the clinical accuracy (75%). ANN also showed high accuracy in the external validation group (89%).Conclusion Artificial neural networks offer the possibility of personal prediction of outcome for individual patients presenting in clinics with colorectal symptoms, making it possible to make more appropriate requests for lower gastrointestinal endoscopy.
    Colorectal Disease 11/2010; 12(12):1254 - 1259. DOI:10.1111/j.1463-1318.2009.02005.x · 2.35 Impact Factor
  • S. Maslekar · M. Hughes · A. Gardiner · J. R. T. Monson · G. S. Duthie ·
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    ABSTRACT: Aim  Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.Method  Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction.Results  Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores.Conclusion  This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.
    Colorectal Disease 09/2010; 12(10):1033 - 1038. DOI:10.1111/j.1463-1318.2009.01989.x · 2.35 Impact Factor
  • Sushil Maslekar · Philip Waudby · Ged Avery · J R T Monson · Graeme Scott Duthie ·
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    ABSTRACT: The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy.
    Surgical Endoscopy 09/2009; 24(1):89-93. DOI:10.1007/s00464-009-0553-9 · 3.26 Impact Factor
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    ABSTRACT: Aim Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes). Method One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer’s Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure. Results The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference −0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability. Conclusion Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.
    Colorectal Disease 07/2009; 13(1):48 - 57. DOI:10.1111/j.1463-1318.2009.01988.x · 2.35 Impact Factor
  • S Maslekar · G Avery · G S Duthie ·
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    ABSTRACT: Quality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow-up X-rays in objectively documenting completion and correlation with pathology miss rates. A total of 82 patients undergoing colonoscopy by trained colonoscopists had an endomucosal clip applied to the most proximal bowel reached. A plain abdominal X-ray was performed while there was still a pneumocolon, and the clip position was assessed by a blinded radiologist to determine objective completion rates. Repeat colonoscopies were performed in patients with incomplete procedures. Pathology and endoscopy database were also reviewed to identify missed lesions at a median follow-up of 6 years. These were correlated with colonoscopy completions. The clip was found in caecum of 76 (93%), ascending-colon in three (3.6%), hepatic flexure in one (1.2%) and splenic flexure in two (2.4%) patients. The endoscopist opinion was incorrect in six incomplete colonoscopies. A total of 33 patients underwent repeat colonoscopies over the median 6-year follow-up. Three adenomas and one carcinoma were missed in the incomplete group and were subsequently picked up in repeat endoscopies. Only one adenoma was truly missed in complete colonoscopies, providing an overall miss rate of 1.3%. Use of endomucosal clips with follow-on abdominal X-ray is a safe and effective method of determining completion of colonoscopy. This technique is also an excellent objective measure of quality assurance of completion and miss rates in colonoscopy, especially when combined with an audit to determine the missed lesions at two years postprocedure.
    Colorectal Disease 05/2009; 12(7):651-6. DOI:10.1111/j.1463-1318.2009.01874.x · 2.35 Impact Factor
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    S Maslekar · A Gardiner · M Hughes · B Culbert · G S Duthie ·
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    ABSTRACT: Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam-fentanyl for colonoscopy. Some 131 patients undergoing elective colonoscopy were included. Patients completed a Hospital Anxiety and Depression questionnaire, letter cancellation tests and pain scores on a 100-mm visual analogue scale before, immediately after the procedure and at discharge. They also completed a satisfaction survey at discharge and 24 h after the procedure. Sixty-five patients were randomized to receive Entonox and 66 to midazolam-fentanyl. Completion rates were similar (94 versus 92 per cent respectively; P = 0.513). Patients receiving Entonox had a shorter time to discharge. They reported significantly less pain (mean score 16.7 versus 40.1; P < 0.001), and showed better recovery of psychomotor function immediately after the procedure and at discharge. Patient satisfaction was higher among patients who received Entonox (median score 96 versus 89; P = 0.001). Entonox provides better pain relief and faster recovery than midazolam-fentanyl and so is more effective for colonoscopy.
    British Journal of Surgery 04/2009; 96(4):361-8. DOI:10.1002/bjs.6467 · 5.54 Impact Factor
  • S Maslekar · S Anwar ·
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    ABSTRACT: Recently there have been significant advances in the management of patients with rectal cancer, attributed mainly to advances in surgical techniques and pre- and postoperative therapy. This review addresses some of these advances and their impact on the prognosis for rectal cancer patients.
    British journal of hospital medicine (London, England: 2005) 01/2009; 69(12):681-5. DOI:10.12968/hmed.2008.69.12.681 · 0.38 Impact Factor
  • A Suppiah · S Maslekar · A Alabi · J E Hartley · J R T Monson ·
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    ABSTRACT: The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations. PubMed and MEDLINE search was performed. Strongest level of evidence (Level II) favoured TEM over RR and laparoscopic resection in term of mortality and morbidity. There was no difference in recurrence at follow-up of 41 and 56 months but neither study was adequately powered to detect a difference in recurrence/survival. Three retrospective case comparisons (Level III) also favoured TEM over RR but were subject to selection bias. Twenty eight published case series (Level IV) reported varying results due to different cancer stages, study population, full excision, adjuvant therapy and treatment indication. The oncological outcomes in TEM are similar to RR in highly selected cases but with far less mortality (near 0%), morbidity, blood loss, hospital stay and genitourinary/gastrointestinal dysfunction. TEM alone (+/- adjuvant therapy) appears sufficient for 'favourable' T1 tumours. 'Unfavourable' T1 or T2 tumours require adjuvant treatment. TEM should only be used for palliation in T3+ cancers. Seven functional studies reported significant transient dysfunction following TEM with full clinical recovery within a year. TEM is cost-effective providing sufficient cases are performed. Significant heterogeneity limits conclusions from current literature. A trial is required. Alternate end-points to local recurrence may be required in assessing the optimal surgical approach, which balances disease control with quality of life, and probability of noncancer related death.
    Colorectal Disease 06/2008; 10(4):314-27; discussion 327-9. DOI:10.1111/j.1463-1318.2007.01448.x · 2.35 Impact Factor
  • Sushil Maslekar · Philip Waudby · Graeme Duthie ·

    Gastrointestinal Endoscopy 04/2007; 65(5). DOI:10.1016/j.gie.2007.03.969 · 5.37 Impact Factor
  • Sushil Maslekar · Balaji Pa · John E. Hartley · Brian Culbert · Graeme Duthie ·

    Gastrointestinal Endoscopy 04/2007; 65(5). DOI:10.1016/j.gie.2007.03.046 · 5.37 Impact Factor

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