Abhiram Sharma

Manchester University NHS Foundation Trust | UHSM · Department of surgery

Aim Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low “take‐off”. Methods A prospective study of patients with RI and ERP attending...

BACKGROUND Sacral Neuromodulation is an effective treatment for faecal incontinence in the long-term. Efficacy is typically assessed using bowel diary, symptom severity, or quality of life questionnaires and ‘success’ defined as >50% improvement in these measures. Patient satisfaction may however be a more meaningful and individualised measure of t...

Background The functional lumen imaging probe (FLIP) is a test of anal sphincter distensibility under evaluation by specialist centers. Two measurement protocols termed “stepwise” and “ramp” are used, risking a lack of standardization. This study aims to compare the performance of these protocols to establish if there are differences between them....

Background Faecal incontinence (FI) is common, with a significant impact on quality of life. Percutaneous tibial nerve stimulation (PTNS) is a therapy for FI; however, its role has recently been questioned. Here we report the short-term clinical and manometric outcomes in a large tertiary centre. Methods A retrospective review of a prospective PTN...

Introduction Faecal incontinence (FI) is a common condition with a significant impact on quality of life (QoL). Neuromodulation treatments delivered by members of the multidisciplinary team including sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) are options for FI refractory to conservative management. The aim of t...

Background: Symptomatic haemorrhoids (SH) are a common condition; however, conventional outpatient treatment, including rubber band ligation, is contraindicated in patients receiving concurrent anticoagulation. Injection sclerotherapy (IST) has been proposed as a treatment option for these patients. Methods: A retrospective review of case notes...

BACKGROUND Sacral neuromodulation is an effective treatment for fecal incontinence. OBJECTIVE This study aimed to assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices. DESIGN This is an observational study of patients treated for more than 5 years. A positive outcome was defined as a...

Background The maintenance of fecal continence depends upon coordinated interactions between the pelvic floor, anorectum, and anal sphincter complex orchestrated by central and peripheral neural activities. The current techniques to objectively measure anorectal function rely on fixed diameter catheters placed inside the anal canal with a rectal ba...

Introduction High-resolution anorectal manometry (HRAM) is an established assessment modality. Novel techniques, such as the Functional lumen imaging probe (EndoFLIP) and Anal Acoustic Reflectometry (AAR) are currently predominantly considered research tools. However, there is recognised, and well-documented, discordance between HRAM parameters, sy...

Introduction The diameter of high-resolution anorectal manometry (HRAM) catheters vary from 2.6mm up to 10.75mm for some high-definition devices. Other catheter-based physiology assessment tools such as the Functional lumen imaging probe (FLIP) use of a probe with a starting diameter of 3mm. Anal acoustic reflectometry (AAR) however is a ‘catheter-...

Introduction Conventional “catheter-based” anorectal physiology systems may influence anal canal pressures by stretching the sphincters thereby increasing tension. Anal acoustic reflectometry (AAR) is a “catheter-less” technique as the flexible thin catheter does not distort the anal canal. The aim of this study was to explore whether the size of r...

Introduction We have suggested that mean Opening Pressure (Op) recorded during Anal Acoustic Reflectometry (AAR) predominantly represents IAS function however, the extent remains unknown. The aim was to investigate this by excluding the external anal sphincter during general anaesthetic (GA) with confirmed neuromuscular blockade (NMB). Method Pati...

Background The recto‐anal inhibitory reflex (RAIR) is currently measured using anorectal manometry catheters, which may distort the anal canal. Anal acoustic reflectometry (AAR) is considered a catheter free technique for evaluating physiological function of the anal canal, however, it has yet to be used to elicit RAIR. For RAIR to be measured with...

Aim The recto‐anal inhibitory reflex (RAIR) is currently measured using manometry catheters, potentially distorting the anal canal. Anal Acoustic Reflectometry is considered a catheter free technique, primarily measuring internal anal sphincter function. We sought to determine if RAIR could be measured using AAR. Method Patients aged 18 and over a...

Background: Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods: In...

Background: Anal acoustic reflectometry (AAR) is a technique for measuring the physiological profile of the anal canal, primarily the internal anal sphincter. Evaluation of a new continuous method, recently developed for the urethra, would enable its future application for investigation of rectal reflexes. Methods: Patients aged 18 and over with...

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open m...

Background: Anal acoustic reflectometry investigates the opening and closing function of the anal canal using reflected sound waves to measure a cross-sectional area at different pressures. Anal acoustic reflectometry is reliable and repeatable, distinguishes between continence and incontinence and between subgroups of incontinence, correlates wit...

Background Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters. Methods Fifty patients with FI underwent 30 min of PTNS treatm...

There are concerns regarding early years' training for junior doctors in Trauma & Orthopaedic Surgery (T&O) in the United Kingdom. Our primary objective was to audit the clinical activities undertaken by junior doctors working in Trauma & Orthopaedic (T&O) surgery in the National Health Service (NHS) in a typical workweek. A secondary objective was...

Total mesorectal excision (TME) is now the standard surgical technique for management of rectal cancer. This involves dissection in a well-defined anatomical plane with an embryological basis. TME has improved results of rectal cancer surgery all over the world. TME can safely be performed laparoscopically and the use of robot for TME is also gaini...

Aim: The aim of this study is to determine the occurrence of surgical revision in a cohort of patients treated with sacral nerve stimulation (SNS) for faecal incontinence and constipation and to establish the types of procedures performed and indications for surgery. Method: From the years 2002 to 2014, 125 patients were identified who had under...

Background: Sacral nerve stimulation (SNS) is a minimally invasive surgical technique that plays an important role in the treatment of disorders of the bladder and bowel. Permanent SNS implantation under local anaesthesia (LA) offers many advantages.

Introduction Anal acoustic reflectometry (AAR) is a new test that uses reflected sound waves to investigate patients with faecal incontinence (FI). AAR methodology and variables of opening pressure (OP), opening elastance (OE), closing pressure (CP), closing elastance (CE), hysteresis (HY), squeeze opening pressure (SOP) and squeeze opening elastan...

Introduction Posterior tibial nerve stimulation (PTNS) is a new neuromodulation treatment for faecal incontinence (FI). Our aim of this study was to establish if PTNS is effective, and for which subgroups of FI and whether it influences manometry variables. Method Prospective observational cohort study in a tertiary pelvic floor unit. Patients rece...

Introduction: Transanal minimally invasive surgery (TAMIS) was first developed in 2009. TAMIS allows removal of benign polyps and early stage mid/distal rectal cancers (T1/T2 N0) without the use of invasive surgery. The technique requires the use of a single port device transanally and allows the use of conventional laparoscopic instruments. Indic...

Purpose. Surgical site infections (SSIs) remain a significant problem after laparotomies. The aim of this review was to assess the evidence on the efficacy of subcutaneous wound drainage in reducing SSI. Methods . MEDLINE database was searched. Studies were identified and screened according to criteria to determine their eligibility for meta-analys...

Purposes: Several reports have described a relationship between tumor volume and oncological outcomes for certain cancers. There is paucity of similar data for rectal cancer. We conducted this study to establish whether tumor volume, mesorectal volume, and the tumor volume to mesorectal volume ratio (TV/MRV), evaluated by magnetic resonance imagin...

Aim The objective of this study was to review the fate of the rectal stump following total colectomy for ulcerative colitis and evaluate the risk of rectal cancer. Methods A review of operative and pathological databases identified 103 patients who had undergone total abdominal colectomy for ulcerative colitis between 1987 and 2008. Those who had s...

Background: Complications following reversal of Hartmann's procedure are common, with morbidity rates of up to 50 per cent, and a mortality rate as high as 10 per cent. This is based on case series with heterogeneous data collection and analysis. This study determined risk factors for complications following Hartmann's reversal. Methods: Patient...

Background. Sacral neuromodulation (SN) is an emerging treatment for constipation. This review evaluates the mechanism of action, techniques, efficacy, and adverse effects of SN in the management of constipation. Methods. Electronic searches for studies describing the use of SN were performed in PubMed, MEDLINE and Embase. Abstracts were reviewed a...

: Surgical cases that include trainees are associated with worse outcomes in comparison with those that include attending surgeons alone. : This study aimed to identify whether resident involvement in partial colectomy was associated with worse outcomes when evaluated by surgical approach and resident experience. : This is a retrospective study usi...

Background: Studies have shown an association between baseline quality of life (Qol) and survival in advanced cancers. The aim of this study was to investigate their predictive value in long term survival after elective colorectal cancer resection. Methods: A consecutive series of patients undergoing elective colorectal cancer surgery for nonmet...

Introduction: Compared to subcutaneous fat, visceral fat is more metabolically active, leading to chronic inflammation and tumorigenesis. The aim of this study is to describe the effect of visceral obesity on colorectal cancer outcomes using computed tomography (CT) imaging to measure visceral fat. Materials and methods: We conducted a retrospec...

Objective: The aim of this study was to delineate the impact of smoking on postoperative outcomes after colorectal resection for malignant and benign processes. Background: Studies to date have implicated smoking as a risk factor for increased postoperative complications. However, there is a paucity of data on the effects of smoking after colore...

Background: There is a paucity of quality data on the effects of chronic kidney disease in abdominal surgery. The aim of this study was to define the risk and outcome predictors of bowel resection in stage 5 chronic kidney disease using a large national clinical database. Methods: The American College of Surgeons National Surgical Quality Improv...

Aim An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a la...

Objective Gastrointestinal conditions requiring surgical intervention are becoming increasingly frequent in adults with cystic fibrosis (CF) as life expectancy increases. In addition, patients with CF are at risk of specific gastrointestinal complications associated with their disease. This includes distal intestinal obstruction syndrome (DIOS), wh...

Background Lymph node ratio (LNR) has been shown to be an independent prognostic factor in stage III colorectal cancer. Abdominoperineal resection (APR) of rectum is historically associated with poorer oncological outcomes compared to other colorectal resections, and significance of LNR in this group of patients has not been studied. Objective Our...

Abdominoperineal excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated. This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jac...

Constipation is a common multifactorial gastrointestinal symptom with quality of life implications. Sacral neuromodulation has been used in the management of severe constipation with mixed results. The aim of this study was to review our experience of sacral neuromodulation as a treatment for chronic constipation and develop a chronic constipation...

INTRODUCTION: It has been suggested that changes to the organisation of the National Health Service (NHS), and changes in clinical practice, are associated with increased burnout in health care professionals. It has also been suggested that dealing with patients who have cancer is particularly demanding. Coping strategies used in response to work-r...

Female gender is associated with longer survival after treatment for colorectal cancer (CRC). Reasons behind this phenomenon are not entirely clear. In addition, higher interleukin-6 (IL-6) and interleukin-1 (IL-1) levels have been found to be associated with poorer prognosis in CRC patients. The aim of this study was to investigate if cytokine lev...

Objectives: Incident reporting is an important part of clinical governance. The aims of this study were to survey incident reporting behavior in surgical trainees and compare the results with a previous study. Methods: A questionnaire was used to collect data regarding critical incident reporting from surgical trainees working in 1 National Health...

It has been suggested that dealing with cancer is associated with increased stress and burnout in health-care professionals. The aim of this study is to examine the prevalence of psychiatric morbidity and burnout in surgeons working in the National Health Service (NHS), and the putative relationship between psychiatric morbidity, burnout and the am...

It has been suggested that changes to the organization of the National Health Service (NHS) and clinical practices in dealing with cancer are associated with increased stress and burnout in healthcare professionals. The aim of this study, therefore, was to evaluate stress and burnout in colorectal surgeons (surgeons) and colorectal clinical nurse s...

Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS. A consecutive series of 110 eligible patients undergoing elective resection for colorectal cancer were invited to participate in the study. A...

Colorectal cancer (CRC) is one of the most common cancers in the UK. Quality of life (QoL) is increasingly being recognised as an important endpoint in the management of CRC. Publications describing QoL in CRC were identified using Medline (PubMed) and PsychINFO. Reference lists of these articles were used to identify other relevant publications. S...

Multidisciplinary teams (MDTs) are an integral part of the National Cancer Plan. However, there is surprisingly little empirical research on how these are perceived by colorectal surgeons (CRSs) and colorectal clinical nurse specialists (CNSs). The purpose of this study therefore was to obtain the views of a national cohort of CRSs and CNSs regardi...

Vascular endothelial growth factor (VEGF) and psychosocial factors have both been shown to have independent prognostic value in colorectal cancer. Recently, an association between VEGF and psychosocial factors has been reported in patients with ovarian cancer. A consecutive series of eligible patients undergoing elective resection for colorectal ca...

Measurement of quality of life (QoL) is assuming increasing importance in cancer care. Predictors of early postoperative QoL after colorectal cancer resection are not clear and the aim of this study was to identify these factors. A consecutive series of eligible patients undergoing elective resection for colorectal cancer were invited to participat...

Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits. We reviewed our prospective database of patients undergoing TEM excision of a rectal...

Local recurrence after curative excision for rectal cancer is frequently regarded as a failure of surgery. The macroscopic quality of the excised mesorectum after total mesorectal excision has been proposed as a means of assessment of the adequacy of surgery. This study was designed to determine the utility of mesorectal grading in prediction of lo...

The quality of surgical excision is held to be a major determinant of outcome following surgery for rectal cancer. Macroscopic examination of the excised mesorectum allows for reproducible assessment of the quality of surgery. We aimed to determine whether quality of excision undertaken by colorectal trainees under supervision was comparable with t...

Treatment of anal fissures has changed dramatically in the past decade. This is primarily due to a better understanding of its pathophysiology and the implications of the various available options. Only a few anal fissures fail to respond to medical therapy. Sphincterotomy and anal dilatation have fallen out of favour due to the risk of incontinenc...

Treatment of anal fissures has changed dramatically in the past decade. Only a few fail to respond to medical therapy. Sphincterotomy and anal dilatation have fallen out of favour due to the risk of incontinence. Island flaps have been proposed to address this, but 60--70% of flap donor sites break down with complications. We proposed that using a...

Extensive research into the molecular biology of colorectal cancer has identified a plethora of molecular markers reputed to provide independent prognostic information. p53 mutational status has been associated with both improved and reduced survival; however, tumors expressing a particular phenotype associated with defective mismatch repair consis...

Clinical governance and incident reporting are central to government plans to promote patient safety in the NHS. The Department of Health has acknowledged deficiencies in systematic learning from adverse events within the NHS in the past and has proposed changes to the incident reporting system.

Without Abstract

Malignant tracheoesophageal fistula is a pre terminal condition in oesophageal cancer and is associated with significant patient distress. Various treatment options have been described and the general consensus is to use stents to cover them and relieve patient symptoms. We describe a case in which a modified Wilson-Cook prosthesis was successfully...

Local excision is increasingly being used to treat rectal cancer. It appears to be an attractive option because of low morbidity and excellent functional results. Controversies remain regarding available techniques, selection criteria and results with or without adjuvant therapy. Role of salvage therapy remains uncertain. This review examines avail...