James A Gossage

Guy's and St Thomas' NHS Foundation Trust, Londinium, England, United Kingdom

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Publications (40)201.11 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The molecular genetic relationship between esophageal adenocarcinoma (EAC) and its precursor lesion, Barrett's esophagus, is poorly understood. Using whole-genome sequencing on 23 paired Barrett's esophagus and EAC samples, together with one in-depth Barrett's esophagus case study sampled over time and space, we have provided the following new insights: (i) Barrett's esophagus is polyclonal and highly mutated even in the absence of dysplasia; (ii) when cancer develops, copy number increases and heterogeneity persists such that the spectrum of mutations often shows surprisingly little overlap between EAC and adjacent Barrett's esophagus; and (iii) despite differences in specific coding mutations, the mutational context suggests a common causative insult underlying these two conditions. From a clinical perspective, the histopathological assessment of dysplasia appears to be a poor reflection of the molecular disarray within the Barrett's epithelium, and a molecular Cytosponge technique overcomes sampling bias and has the capacity to reflect the entire clonal architecture.
    Nature Genetics 07/2015; DOI:10.1038/ng.3357 · 29.35 Impact Factor
  • CM Iezzi · JA Gossage · AR Davies · SK Archer
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    ABSTRACT: Introduction Patients who have undergone a transhiatal oesophagectomy (THO) are at risk of pharyngeal dysphagia and subsequent aspiration due to potential disruption in deglutitive biomechanics and/or neuropraxic injury to the recurrent laryngeal nerve. An evaluation was conducted of a new multidisciplinary enhanced recovery pathway (ERP) where all patients undergoing oesophagectomy with cervical anastomosis are seen both pre and post operatively by Speech and Language Therapy (SLT). Method All patients undergoing THO are provided with pre operative counselling and assessment to exclude pre morbid pharyngeal dysphagia. A clinical exam is conducted on day two post surgery and an SLT assisted water soluble swallow (WSS) is conducted on day three, enabling evaluation of deglutitive biomechanics, effectiveness of postural strategies in eliminating aspiration, in conjunction with assessment of anastomic integrity. Data on all patients who underwent THO between February 2014–February 2015 were collected to evaluate SLT intervention, incidence of pharyngeal dysphagia and patient outcomes using the Functional Oral Intake Scale (FOIS). Results 42 patients underwent THO. No patients had pre-morbid pharyngeal dysphagia. Post operatively 62% (n = 26) of patients presented with pharyngeal dysphagia on radiological examination with reduced hyolaryngeal excursion, reduced epiglottic deflection and opening of the upper oesophageal sphincter. 38.1% (n = 16) patients were identified at bedside assessment as high risk of aspiration and pharyngeal dysphagia was confirmed on WSS. In 100% of these (n = 16) no aspiration occurred when a chin tuck strategy was recommended at onset of WSS. A further 10 patients aspirated on WSS; a chin tuck strategy was recommended and this was effective in eliminating aspiration in 80% (n = 8). All patients were able to commence sips of clear fluid on day three if anastomotic leak was excluded despite pharyngeal dysphagia and aspiration risk with implementation of postural techniques. Overall, 90.5% (n = 38) of patients were tolerating oral intake at time of discharge (FOIS score > 6). Four patients with anastomotic leaks were excluded from outcome measures. Conclusion Results suggest that involvement of SLT in ERP helps identify patients at risk of aspiration and introduction of strategies e.g. chin tuck can eliminate aspiration which may improve patient care. Further research is indicated to determine the effect of SLT input on patient outcomes. Disclosure of interest None Declared.
    Gut 06/2015; 64(Suppl 1):A122.2-A123. DOI:10.1136/gutjnl-2015-309861.251 · 14.66 Impact Factor
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    ABSTRACT: Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients. Paper-based survey. Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013. A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated. Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147). UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
    Journal of Surgical Education 04/2015; 72(4). DOI:10.1016/j.jsurg.2015.01.019 · 1.38 Impact Factor
  • Journal of Clinical Oncology 02/2015; 33(9). DOI:10.1200/JCO.2014.59.9506 · 18.43 Impact Factor
  • A. Walker · T. Holme · M. Kelly · J. Gossage · R. Mason
    International Surgical Congress of the; 01/2015
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    ABSTRACT: Background: In adults, colon interposition is a rare operation used when a gastric pull-up is not available. There is very little data published on outcomes from this procedure. Aims: 1. Identify the number of colon interpositions performed in the UK over the last 12 years. 2. To question the surgeons performing them on their techniques and problems. 3. To gain quality of life data on the patients from the largest centres. Methods: 1. Analysis of Healthcare Episode Statistics (HES) data to identify centres undertaking colon interposition. 2. An online survey of UK consultants, identifying current methods and experiences. 3. A quality of life survey of patients who have undergone colonic interposition (SF-36v2 with additional GI questions.) Results: HES data reported 279 interpositions since 2001, 18 of which were paediatric. The two largest units were St Thomas’ and Birmingham with 39 and 40 cases respectively. Thirty-four surgeons replied to our survey (79% response rate). Most surgeons used left-sided colon with 81% preferring substernal placement. Anastomotic leak and stricture were the main postoperative problems. Five surgeons reported polyp formation within the colonic interposition. The quality of life survey was performed on patients from the two largest centres with a 56% response rate. 21% patients had physical quality of life scores above the population average and 46% had mental scores above population average. All patients had early satiety to some extent and 80% had dysphagia. 76% regularly take reflux medication. There was a mean weight loss of 13⋅1% body weight (10⋅6 kg) since before their illness. 16% patients still relied on a feeding tube for nutrition. Twenty patients had substernal placement of colon, 3 had subcutaneous and 2 posterior mediastinal. These groups had similar physical quality of life outcomes, but those with subcutaneous placement had significantly worse Emotional Role scores (p=<0⋅004) and Mental Summary Scores (p=<0⋅001) than those with substernal placements. Conclusion: Colon interposition has a high risk of early complications but can result in an acceptable quality of life in the long term. These patients are complex and require multi-disciplinary input from specialist surgeons, gastroenterologists, dieticians and psychologists.
    Abstracts of the association of upper gastrointestinal surgeons of great britain and ireland, annual meeting 18-19 september 2014, Brighton; 09/2014
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    ABSTRACT: Purpose: Neoadjuvant chemotherapy is established in the management of most resectable esophageal and esophagogastric junction adenocarcinomas. However, assessing the downstaging effects of chemotherapy and predicting response to treatment remain challenging, and the relative importance of tumor stage before and after chemotherapy is debatable. Methods: We analyzed consecutive resections for esophageal or esophagogastric junction adenocarcinomas performed at two high-volume cancer centers in London between 2000 and 2010. After standard investigations and multidisciplinary team consensus, all patients were allocated a clinical tumor stage before treatment, which was compared with pathologic stage after surgical resection. Survival analysis was conducted using Kaplan-Meier analysis and Cox regression analysis. Results: Among 584 included patients, 400 patients (68%) received neoadjuvant chemotherapy. Patients with downstaged tumors after neoadjuvant chemotherapy experienced improved survival compared with patients without response (P < .001), and such downstaging (hazard ratio, 0.43; 95% CI, 0.31 to 0.59) was the strongest independent predictor of survival after adjusting for patient age, tumor grade, clinical tumor stage, lymphovascular invasion, resection margin status, and surgical resection type. Patients downstaged by chemotherapy, compared with patients with no response, experienced lower rates of local recurrence (6% v. 13%, respectively; P = .030) and systemic recurrence (19% v. 29%, respectively; P = .027) and improved Mandard tumor regression scores (P = .001). Survival was strongly dictated by stage after neoadjuvant chemotherapy, rather than clinical stage at presentation. Conclusion: The stage of esophageal or esophagogastric junction adenocarcinoma after neoadjuvant chemotherapy determines prognosis rather than the clinical stage before neoadjuvant chemotherapy, indicating the importance of focusing on postchemotherapy staging to more accurately predict outcome and eligibility for surgery. Patients who are downstaged by neoadjuvant chemotherapy benefit from reduced rates of local and systemic recurrence.
    Journal of Clinical Oncology 09/2014; 32(27). DOI:10.1200/JCO.2014.55.9070 · 18.43 Impact Factor
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    ABSTRACT: Neoadjuvant chemotherapy is established in the management of most resectable esophageal and esophagogastric junction adenocarcinomas. However, assessing the downstaging effects of chemotherapy and predicting response to treatment remain challenging, and the relative importance of tumor stage before and after chemotherapy is debatable.
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    ABSTRACT: Cancer genome sequencing studies have identified numerous driver genes, but the relative timing of mutations in carcinogenesis remains unclear. The gradual progression from premalignant Barrett's esophagus to esophageal adenocarcinoma (EAC) provides an ideal model to study the ordering of somatic mutations. We identified recurrently mutated genes and assessed clonal structure using whole-genome sequencing and amplicon resequencing of 112 EACs. We next screened a cohort of 109 biopsies from 2 key transition points in the development of malignancy: benign metaplastic never-dysplastic Barrett's esophagus (NDBE; n=66) and high-grade dysplasia (HGD; n=43). Unexpectedly, the majority of recurrently mutated genes in EAC were also mutated in NDBE. Only TP53 and SMAD4 mutations occurred in a stage-specific manner, confined to HGD and EAC, respectively. Finally, we applied this knowledge to identify high-risk Barrett's esophagus in a new non-endoscopic test. In conclusion, mutations in EAC driver genes generally occur exceptionally early in disease development with profound implications for diagnostic and therapeutic strategies.
    Nature Genetics 06/2014; 46(8):837-43. DOI:10.1038/ng.3013 · 29.35 Impact Factor
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    ABSTRACT: The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO. This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion. Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in-hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage. There was no difference in survival or tumour recurrence for TTO and THO.
    British Journal of Surgery 04/2014; 101(5). DOI:10.1002/bjs.9456 · 5.54 Impact Factor
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    ABSTRACT: Accurate selection of patients for radical treatment of esophageal cancer is essential to avoid early recurrence and death (ERD) after surgery. We sought to evaluate a large series of consecutive resections to assess factors that may be associated with this poor outcome. This was a cohort study including 680 patients operated for esophageal cancer between 2000 and 2010. The poor outcome group comprised 100 patients with tumor recurrence and death within 1 year of surgery. The comparison group comprised 267 long-term survivors, defined as those surviving more than 3 years from surgery. Pathological characteristics associated with poor outcome were analyzed using logistic regression to determine odds ratios (OR) and 95% confidence intervals (CI). On the adjusted model T stage and N stage predicted poor survival, with the greatest risk being patients with locally advanced tumors and three or more involved lymph nodes (OR 10.6, 95% CI 2.8-40.0). Poor differentiation (OR 2.8, 95% CI 1.4-5.5), chemotherapy response (OR 3.6, 95% CI 1.2-10.6), and involved resection margins (OR 2.7, 95% CI 1.2-6.0) were all significant independent prognostic markers in the multivariable model. There was a trend toward worse survival with lymphovascular invasion (OR 2.0, 95% CI 0.9-4.2) and low albumin (OR 1.9, 95% CI 0.8-4.4) but not of statistical significance in the adjusted model. Esophageal cancer patients with poorly differentiated tumors and three or more involved lymph nodes have a particularly high risk of ERD after surgery. Accurate risk stratification of patients may identify a group who would be better served by alternative oncological treatment strategies. J. Surg. Oncol. © 2013 Wiley Periodicals, Inc.
    Journal of Surgical Oncology 04/2014; 109(5). DOI:10.1002/jso.23511 · 3.24 Impact Factor
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    ABSTRACT: The influence of reoperation on long-term prognosis is unknown. In this large population-based cohort study, it was aimed to investigate the influence of a reoperation within 30 days of oesophageal cancer resection on survival even after excluding the initial postoperative period. This was a nationwide population-based retrospective cohort study. All hospitals performing oesophageal cancer resections during the study period (1987-2010) in Sweden. Patients operated for oesophageal cancer with curative intent in 1987-2010. Adjusted HRs of all cause, early and late mortality up to 5 years after reoperation following oesophageal cancer resection. Among 1822 included patients, the 200 (11%) who were reoperated had a 27% increased HR of all-cause mortality (adjusted HR 1.27, 95% CI 1.05 to 1.53) and 28% increased HR of disease-specific mortality (adjusted HR 1.28, 95% CI 1.04 to 1.59), compared to those not reoperated. Reoperation for anastomotic insufficiency in particular was followed by an increased mortality (adjusted HR 1.82, 95% CI 1.19 to 2.76). This large and population-based nationwide cohort study shows that reoperation within 30 days after primary oesophageal resection was associated with increased mortality, even after excluding the initial 3 months after surgery. This finding stresses the need to consider any actions that might prevent complications and reoperation after oesophageal cancer resection.
    BMJ Open 03/2014; 4(3):e004648. DOI:10.1136/bmjopen-2013-004648 · 2.27 Impact Factor
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    ABSTRACT: Sarcopenia and changes in body composition following neoadjuvant chemotherapy (NAC) may affect clinical outcome. We assessed the associations between CT body composition changes following NAC and outcomes in oesophageal cancer. A total of 35 patients who received NAC followed by oesophagectomy, and underwent CT assessment pre- and post-NAC were included. Fat mass (FM), fat-free mass (FFM), subcutaneous fat to muscle ratio (FMR) and visceral to subcutaneous adipose tissue ratio (VA/SA) were derived from CT. Changes in FM, FFM, FMR, VA/SA and sarcopenia were correlated to chemotherapy dose reductions, postoperative complications, length of hospital stay (LOS), circumferential resection margin (CRM), pathological chemotherapy response, disease-free survival (DFS) and overall survival (OS). Nine (26 %) patients were sarcopenic before NAC and this increased to 15 (43 %) after NAC. Average weight loss was 3.7 % ± 6.4 (SD) in comparison to FM index (-1.2 ± 4.2), FFM index (-4.6 ± 6.8), FMR (-1.2 ± 24.3) and VA/SA (-62.3 ± 12.7). Changes in FM index (p = 0.022), FMR (p = 0.028), VA/SA (p = 0.024) and weight (p = 0.007) were significant univariable factors for CRM status. There was no significant association between changes in body composition and survival. Loss of FM, differential loss of VA/SA and skeletal muscle were associated with risk of CRM positivity. • Changes in CT body composition occur after neoadjuvant chemotherapy in oesophageal cancer. • Sarcopenia was more prevalent after neoadjuvant chemotherapy. • Fat mass, fat-free mass and weight decreased after neoadjuvant chemotherapy. • Changes in body composition were associated with CRM positivity. • Changes in body composition did not affect perioperative complications and survival.
    European Radiology 02/2014; 24(5). DOI:10.1007/s00330-014-3110-4 · 4.01 Impact Factor
  • Cara R. Baker · Matthew J. Forshaw · James A. Gossage · R. Ng · Robert C. Mason
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    ABSTRACT: Background The consequences of major conduit necrosis following oesophagectomy are devastating. Jejunal interposition with vascular supercharging is an alternative reconstructive method if colon is unavailable. Aims of this study were to review the long-term outcome and quality of life of patients undergoing this surgery in our tertiary unit. Methods Patients undergoing oesophageal reconstruction with supercharged jejunum were identified and retrospective review of hospital notes performed. Each patient was then interviewed for follow up data and quality of life assessment using the EORTC QLQ-C30 questionnaire. Results Six patients (5 men) (median age 59 years (range 34–72) underwent supercharged pedicled jejunal (SPJ) interposition from May 2005–August 2010. Indications for surgery were loss of both gastric and colonic conduits following surgery for oesophageal cancer (n = 4), loss of gastric conduit and previous colectomy (n = 1) and lastly, gastric and colonic infarction in a strangulated paraoesophageal hernia (n = 1). Median time to reconstruction was 12 months [6–15 range]. There were no in-hospital deaths. Median postoperative stay was 46 days [13–118]. Three patients required surgical re-intervention for leak, sepsis and reflux, respectively. Median follow up was 6.5 years [range 7–102 months]. One patient died seven months following surgery due to respiratory complications. On follow up, 5 patients have an enteral diet without supplemental nutrition, maintaining weight and good quality of life scores. Conclusions Supercharged jejunal interposition is a suitable alternative conduit for delayed oesophageal replacement in patients with otherwise limited reconstructive options. Good functional outcomes can be achieved despite formidable technical challenges in this group.
    The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 02/2014; 13(4). DOI:10.1016/j.surge.2014.01.004 · 2.18 Impact Factor
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    AUGIS; 01/2014
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    ABSTRACT: Background: Reflux frequently occurs after a gastric conduit has replaced the resected esophagus. In this Swedish population-based cohort study, the potential antireflux effects of using cervical anastomosis, intrathoracic antireflux anastomosis, or pyloric drainage, and a risk of dysphagia due to cervical anastomosis and intrathoracic antireflux anastomosis were studied. Methods: Patients undergoing esophagectomy with gastric conduit reconstruction in 2001-2005 were included. Reflux symptoms and dysphagia were assessed 6 months and 3 years postoperatively using a validated questionnaire (EORTC QLQ-OES18). The study exposures were cervical anastomosis, antireflux anastomosis, and pyloric drainage procedure. Multivariable logistic regression and propensity-adjusted analyses based on multinomial logistic regression estimated odds ratios (OR) with 95 % confidence intervals (CI), adjusted for potential confounding. Results: A total of 304 patients were included in the study. Adjusted ORs for reflux symptoms were 0.9 (95 % CI 0.3-2.2) for patients with a cervical anastomosis compared to patients with an intrathoracic anastomosis, 0.9 (95 % CI 0.4-2.0) for patients with an antireflux anastomosis versus patients with a conventional anastomosis, and 1.5 (95 % CI 0.9-2.6) for patients after pyloric drainage versus patients without such a pyloric drainage procedure. Dysphagia was not statistically significantly increased after cervical anastomosis or antireflux anastomosis. ORs were virtually similar 3 years after surgery. No interactions were identified. The propensity analyses rendered similar results as the logistic regression models, except for a possibly increased dysphagia with a cervical anastomosis. Conclusions: Cervical anastomosis, antireflux anastomosis, and pyloric drainage do not seem to prevent reflux symptoms 6 months or 3 years after esophagectomy for cancer with a gastric conduit.
    Annals of Surgical Oncology 06/2013; 20(11). DOI:10.1245/s10434-013-3041-3 · 3.93 Impact Factor
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    Cara R Baker · James A Gossage · Robert C Mason
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    ABSTRACT: We present a 52-year-old gentleman with an unusual cause of progressive dysphagia, namely due to extrinsic lower oesophageal compression from a cystic mass of the posterior mediastinum. Cystic masses in adults are uncommon, and there is a wide differential diagnosis. This includes neoplastic, such as germ cell tumour (cystic teratoma), and non-neoplastic aetiologies. The later include foregut duplication cysts, lymphatic malformations, infective (hydatid), simple mediastinal cysts or pseudocysts. Management is principally surgical with complete excision, or alternatively, in cases of benign cysts, marsupialization or decompression. In our patient, a simple mediastinal cyst was diagnosed and this case is the first description of a totally transabdominal approach to mediastinal cyst decompression by a Roux-en-Y cyst-jejunostomy.
    03/2013; 2013(3). DOI:10.1093/jscr/rjs042
  • Gut 05/2012; 61(Suppl 2):A253-A254. DOI:10.1136/gutjnl-2012-302514c.168 · 14.66 Impact Factor
  • JA Gossage · M J Forshaw
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    ABSTRACT: Approximately, 50,000 cholecystectomies are performed annually in the United Kingdom resulting in a number of negligence claims referred to the NHS Litigation Authority (NHSLA). The aim of this study was to assess the prevalence and outcomes of claims reported to the NHSLA after laparoscopic cholecystectomy performed in England between 1995 and 2008. Data were requested from the NHSLA on all claims related to laparoscopic cholecystectomy which occurred in England between 1995 and 2008. A review of the data provided by the NHSLA data identified over 300 claims in this time period. Of the claims identified, 244 have been completed. Common bile duct injury (41%), bile leak (12%), bowel injury (9%), haemorrhage (9%) and fatality (9%) were the most frequent types of claim. Common bile duct injury resulted in the highest proportion of successful claims (86%) and the largest sums paid to the claimant (average £65,000). Common bile duct injury is the most common claim to the NHSLA after laparoscopic cholecystectomy and results in the highest proportion of successful claims and the largest sums paid to the claimant.
    International Journal of Clinical Practice 12/2010; 64(13):1832-5. DOI:10.1111/j.1742-1241.2009.02200.x · 2.57 Impact Factor
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    ABSTRACT: The aim of this study is to report our experience gained after attempted colonic stenting for colonic obstruction from extracolonic cancer. METHOD This is a retrospective study of all patients who had attempted colonic stenting for obstructing extracolonic cancer in a district general hospital from November 1998 to November 2008. During the study period, a total of 12 stent procedures were carried out in 11 patients with colonic obstruction from extracolonic cancer and were analysed further. These represented 8.5% of a total of 141 stent procedures performed in 130 patients. Fluoroscopic technique was used alone. The median age was 73 years with a range from 47 to 88 years. The underlying malignancy was ovarian in five, urinary bladder in one, kidney in one, prostatic in one, breast in one, cholangiocarcinoma in one and carcinoid in one. The technical and clinical success rate was 42% and 25%, respectively. The 30-day mortality rate was 36%. Stent-related complications included one perforation. The colostomy formation rate was 45%. Only two patients survived over a month with a stent and without a subsequent colostomy. The median survival time was 2 months. The 3-, 6- and 12-month survival rate was 36%, 18% and 9%, respectively. Our experience does not support the routine use of colonic stenting for extracolonic cancer obstructing the colon. A more realistic approach is necessary including either the acceptance that the obstruction represents a life-ending event or proceeding immediately to a colostomy. Decisions should be individualised and stenting used after recognising its shortcomings.
    International Journal of Colorectal Disease 04/2010; 25(7):851-4. DOI:10.1007/s00384-010-0941-6 · 2.45 Impact Factor

Publication Stats

280 Citations
201.11 Total Impact Points


  • 2006–2015
    • Guy's and St Thomas' NHS Foundation Trust
      • • Upper Gastrointestinal Surgical Unit
      • • Department of Histopathology/Cytology
      Londinium, England, United Kingdom
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 2014
    • King's College London
      Londinium, England, United Kingdom
    • Karolinska Institutet
      • Department of Molecular Medicine and Surgery
      Сольна, Stockholm, Sweden
  • 2008–2014
    • ICL
      Londinium, England, United Kingdom
    • Kent Hospital
      Warwick, Rhode Island, United States
  • 2008–2010
    • East Sussex Healthcare NHS Trust
      Eastbourne, England, United Kingdom