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R J Nicholls

Publications and source records attributed to R J Nicholls.

At least 19 recordsLinked to original sources
PubMed2007

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis.

OBJECTIVE: Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation. METHOD: The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available. RESULTS: Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120-528 (median 246) and 16-216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years. CONCLUSION: Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis.

Adenocarcinoma↗
PubMed2006

Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection.

BACKGROUND AND METHODS: The comparative benefits and drawbacks of straight coloanal anastomosis (CAA), colonic J-pouch and coloplasty anastomosis after anterior resection are uncertain. Studies published between 1986 and 2005 of colonic J-pouch versus transverse coloplasty or straight CAA were analysed. Endpoints included postoperative complications, and functional and physiological outcomes measured within 6 months, 1 year and 2 years or more after the procedure. A random-effect model was used to aggregate the study endpoints and assess heterogeneity. RESULTS: Thirty-five studies containing 2240 patients (1066 straight CAA, 1050 J-pouch and 124 coloplasty) were included. There was no significant difference in postoperative complications between the three groups. There was a significant reduction in the frequency of defaecation per day by 1.88, 1.35 and 0.74 motions at the three time intervals in the J-pouch group compared with the straight CAA group. Faecal urgency was less prevalent in patients with a J-pouch than those with a straight CAA (odds ratio 0.27 at 6 months or less and 0.21 at 1 year). There was no difference in functional outcome between J-pouch and coloplasty anastomosis. CONCLUSIONS: The colonic J-pouch provided functional benefits over straight anastomosis with no increase in postoperative complications. Coloplasty appeared to have similar benefits but further studies are required for validation.

Anal Canal↗
PubMed2006

Long-term results of abdominal salvage surgery following restorative proctocolectomy.

BACKGROUND: This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS: Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS: One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION: Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.

Adolescent↗
PubMed2006

Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis.

BACKGROUND: Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better. METHODS: This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life. RESULTS: Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent). CONCLUSION: Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP.

Adenomatous Polyposis Coli↗
PubMed2006

A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis.

OBJECTIVE: Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC). METHODS: Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies. RESULTS: Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1-5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177). CONCLUSIONS: Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained.

Colectomy↗
PubMed2006

Pre-pouch ileitis: a disease of the ileum in ulcerative colitis after restorative proctocolectomy.

OBJECTIVE: Ileal inflammation in ulcerative colitis can occur as backwash ileitis or prestomal ileitis. After restorative proctocolectomy (RPC), ileal inflammation may be present in the pouch (pouchitis) but inflammation proximal to the pouch in the neo-terminal ileum, so called pre-pouch ileitis (PI), has also been observed. As pouchitis is increasingly common and PI can mimic it, our aim was to characterize this condition. SUBJECTS AND METHODS: A review of prospectively collected data on 571 inflammatory bowel disease patients undergoing follow-up after RPC in a single centre over 22 years was performed. The histology of biopsy material was reviewed and staining for colonic mucosal phenotypic changes was undertaken. It was not routine practice to prospectively assess all patients for pre-pouch ileitis when the database was constructed. RESULTS: Of 19 patients with inflammation of the pre-pouch neo-terminal ileum (NTI) identified three had Crohn's disease and one a NSAID stricture. The remaining 15 had a characteristic diffuse inflammation extending from the NTI-pouch junction proximally: pre-pouch ileitis. The inflammation extended proximally for up to 50 cm. Fistula formation was seen in only one. Seven (47%) of 15 had pouchitis but only two had suffered backwash ileitis pre-operatively. Seven responded to medical therapy and four to surgery. The histological appearances including staining for colonic phenotypic change were similar in PI and pouchitis. CONCLUSION: Pre-pouch ileitis is uncommon. As the patients' previous diagnosis of UC was confirmed and there was no radiological or histological evidence of Crohn's disease, PI appears to have a distinct pathogenesis from Crohn's disease.

Adolescent↗
PubMed2005

Simulated electron energy loss spectra from a C70 crystal.

Electron energy loss spectra are simulated for a C70 crystalline structure. It is found that the simulated spectrum is similar to the unoccupied density of states of a C70 molecule, indicating that the crystalline structure has only a small effect on the spectrum. Unlike the case of a single molecule, however, the main contribution to the second peak in the spectrum cannot be ascribed as being due to the equatorial atoms.

Journal Article↗
PubMed2005

Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis.

INTRODUCTION: The present study aims to evaluate the short-term and long-term outcomes of patients undergoing restorative proctocolectomy (RPC) for Crohn's disease (CD) and Indeterminate colitis (IC) and to identify factors associated with adverse outcomes. METHODS: A descriptive study of 52 patients with CD or IC from a total of 1652 patients undergoing primary or salvage RPC in a single tertiary referral centre between 1978 and 2003. Primary outcomes were ileal pouch failure (excision or indefinite diversion), adverse events and functional outcomes (bowel frequency, urgency and continence). RESULTS: Patients with IC or IC favouring ulcerative colitis (Group 1, n = 26) had a pouch failure rate of 11.5%vs 57.5% for patients with CD or IC favouring CD (Group 2, n = 26). Pouch salvage surgery was undertaken in 15 patients with a 13.3% failure rate. Patients in Group 2 were 2.6 times more likely (95% CI: 0.96-7. No significant differences were evident between CD and IC patients with regards to pelvic sepsis (19.2%vs 15.4%), anastomotic stricture (23.1%vs 21.7%), small bowel obstruction (26.9%vs 26.9%) or pouchitis (15.4%vs 11.5%). The 24-h bowel frequency (7.5 vs 8), faecal urgency, daytime or night time incontinence were similar between patients with CD or IC..17) to develop a pouch-related fistula than patients in Group 1. DISCUSSION: Crohn's disease and to a great extent indeterminate colitis favouring CD were both associated with high failure rates and postoperative pouch-related fistula rates. Despite these problems, functional outcomes for patients with CD or IC were similar. Patients with IC should remain candidates for RPC but careful pre-operative assessment is advised to exclude clinical signs favouring the diagnosis of CD. The complications associated with failure are extensive and the option of reconstructive surgery in patients with CD should be questioned.

Adolescent↗
PubMed2005

Effect of sacral neuromodulation for faecal incontinence on sexual activity.

INTRODUCTION: Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. PATIENTS AND METHODS: Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a 'Sex Life Questionnaire' at their follow up visit to ascertain whether there was any improvement in this aspect of their life. RESULTS: Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35-61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1-55) to 1.5 (0-8.5) (P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1-100) and the percentage improvement was inversely correlated to age (r = -0.834, P = 0.005). CONCLUSION: SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients.

Adult↗
PubMed2004

Long-term outcome following loose-seton technique for external sphincter preservation in complex anal fistula.

BACKGROUND: This study determined the long-term outcome after use of the loose-seton technique (LST) to eradicate complex fistula in ano. METHODS: Twenty patients whose complex fistula in ano was treated by the LST a minimum of 10 years previously were assessed by case-note review, supplemented where necessary by mailed and telephone interview. RESULTS: Eighteen patients had a trans-sphincteric and two a suprasphincteric fistula. There were seven supralevator and 12 ischiorectal secondary extensions. At short-term follow-up, a median of 6 months following seton removal, perianal sepsis had been eradicated in 13 of 20 patients. However, the long-term success rate of the LST was lower than that noted in the short term (four versus 13 of 20). Sixteen patients had persisting or recurrent sepsis, necessitating further surgery in 13. In the long term, external sphincter division was necessary to control sepsis in seven of the 20 patients compared with three of 20 patients at short-term follow-up. The rate of relapse in those with Crohn's disease and cryptoglandular fistula in ano was similar (five of six versus 11 of 14; P = 1.000). The fistula recurred in seven, 11 and 15 patients at 6, 15 and 60 months respectively after seton removal. CONCLUSION: The success rate of the LST for complex fistula in ano falls over time. Counselling before seton removal should emphasize that, although most patients do not require sphincter division and some are cured by this technique, many patients develop further sepsis that usually requires surgery.

Adult↗
PubMed2004

Tumour morphology as a predictor of outcome after local excision of rectal cancer.

BACKGROUND: The aim of this study was to determine whether the morphology of rectal cancer predicts outcome following treatment by local excision, and whether morphology should therefore be added to the criteria presently used for case selection. METHODS: The hospital notes and histological findings of 91 patients who had undergone a local surgical procedure for rectal cancer were reviewed retrospectively. Eight patient and tumour characteristics including morphology were analysed with respect to 5-year survival, local recurrence and cancer-specific death within 5 years. Morphology was divided into four types: polypoid, sessile, ulcerated and flat raised. RESULTS: Survival and local recurrence were significantly better for patients with exophytic (polypoid and sessile) carcinomas than for those with non-exophytic (ulcerated and flat raised) lesions. Multivariate logistic regression analysis showed that age, depth of invasion, lymphatic invasion and venous invasion were significant predictors of outcome. The exophytic group included significantly more stage T1 and fewer T2 and T3 cancers, and a significantly smaller proportion of tumours that showed venous and lymphatic invasion than the non-exophytic group. CONCLUSION: Morphology is a clinical guide to prognosis after local excision. Non-exophytic cancers are associated with high-risk histopathological features that render tumours of this type unsuitable for local excision.

Humans↗
PubMed2004

Sacral nerve stimulation for faecal incontinence in the UK.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective therapy for faecal incontinence. Published studies derive largely from single centres and there is a need to determine the broader applicability of this procedure. METHODS: Prospective data were collected for all patients undergoing SNS in the UK. Records were reviewed to determine the outcome of treatment. RESULTS: In three UK centres 59 patients underwent peripheral nerve evaluation, with 46 (78 per cent) proceeding to permanent implantation. Of these 46 patients (40 women) all but two had improved continence at a median of 12 (range 1-72) months. Faecal incontinence improved from a median (range) of 7.5 (1-78) to 1 (0-39) episodes per week (P < 0.001). Urgency improved in all but five of 39 patients in whom ability to defer defaecation was determined, improving from a median of 1 (range 0-5) to 10 (range from 1 to more than 15) min (P < 0.001). Maximum anal squeeze pressure and sensory function to rectal distension changed significantly. Significant improvement occurred in general health (P = 0.024), mental health (P = 0.008), emotional role (P = 0.034), social function (P = 0.013) and vitality (P = 0.009) subscales of the Short Form 36 health survey questionnaire. There were no major complications. One implant was removed. CONCLUSION: SNS is a safe and effective treatment, in the medium to long term, for faecal incontinence when conservative treatment has failed.

Adult↗
PubMed2004

Systematic review of sacral nerve stimulation for faecal incontinence and constipation.

BACKGROUND AND METHOD: This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). RESULTS: From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. CONCLUSION: SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.

Constipation↗
PubMed2004

Indications for colorectal resection for adenoma before and after polypectomy.

Adenomas presenting in colon and rectum require different strategies. Those in the rectum are accessible to local endoanal excision while those in the colon can be removed by endoscopic polypectomy. Essentially the decision in both cases centres around the risk of malignancy. Does the tumour itself contain a focus of malignancy? Where invasion has been demonstrated in the tumour, are the regional lymph nodes involved? Rectal adenomas can be assessed by clinical examination, rectal ultrasound and magnetic resonance imaging. Colonic adenomas on the other hand, are assessed by endoscopic appearances amplified by chromo- and zoom-endoscopy techniques and by endoscopic endosonography. In both locations the decision for surgical resection may be necessary in two clinical circumstances: the preoperative assessment of invasion and following the histopathology report where invasion has been demonstrated. With any adenoma with malignant change, a surgical opinion should be obtained. The decision for surgery depends on the risk of failure of the local excision balanced by the risk of morbidity and mortality following major surgery. Patients' wishes in the light of discussion of clinical and pathological prognostic factors are crucial in making the decision. Surgery is more frequently applied for early colonic than rectal cancers. This is due to two main factors: resective colonic surgery has less complications and mortality than anterior resection and transanal local excision may be more radical than endoscopic colonic polypectomy because it excises the full-thickness rectal wall.

Adenoma↗
PubMed2004

Restorative proctocolectomy in patients with ulcerative colitis having a recto-vaginal fistula.

OBJECTIVE: Recto-vaginal fistula is a rare complication of ulcerative colitis. There are few reports of restorative proctocolectomy carried out in patients with ulcerative colitis having a rectovaginal fistula. We report our experience with this condition. PATIENTS AND METHODS: Between 1 January 1976 and 31 December 2001, 838 patients underwent restorative proctocolectomy for ulcerative colitis at one hospital. These included 400 women of whom 4 (1%) had an already present rectovaginal fistula. We reviewed all patients who presented with a rectovaginal fistula. These patients were contacted by telephone to establish function and satisfaction. RESULTS: The mean age was 30.0 years (range 19-39 years). The mean age at onset of ulcerative colitis was 21.5 years (range 13-34 years). One patient was asymptomatic, the fistula being discovered at operation. In the other three patients the recto-vaginal fistula had occurred at a mean of 108 months (range 72-192 months) after the onset of ulcerative colitis. Three of four patients had had previous episodes of acute severe disease. Three patients had a narrow rectum with deep ulceration. The mean distance between the anorectal junction and the site of fistulation was 2.7 cm (range 0-7 cm). Three patients had a three-stage and one patient a two-stage procedure. Mean follow-up after closure of the loop ileostomy was 107 months (range 17-276 months). All patients were treated successfully but 2 (50%) had a recurrence at 156 and 40 months after the closure of the loop ileostomy. One patient was diverted and the fistula was closed by a subsequent transanal repair and the other patient was treated with success by temporary loose seton technique. Two patients had excellent functional results whereas two other had some difficulties in continence. Nevertheless all patients were satisfied with the outcome. CONCLUSIONS: Patients with ulcerative colitis and a recto-vaginal fistula can be successfully treated by restorative proctocolectomy, nevertheless they are at risk of late recurrence of the fistula.

Adult↗
PubMed2004

Human lymphocyte stimulation with pouchitis flora is greater than with flora from a healthy pouch but is suppressed by metronidazole.

BACKGROUND/AIMS: The gut flora may play an important role in the pathogenesis of inflammatory bowel disease. An ileal reservoir or pouch can be created to replace the excised rectum after proctocolectomy. In patients with ulcerative colitis this is subject to inflammation and termed pouchitis. Using bacteria from patients the authors sought evidence for the presence rather than the identity of a pathogenic species in pouchitis, and for its absence in healthy pouches by the differential effect on lymphocyte proliferation. METHODS: An ex vivo cell culture assay was used in which peripheral blood mononuclear cells or lamina propria mononuclear cells were cultured with sterile sonicates of gut flora from patients with or without pouchitis in the presence of antigen presenting cells. RESULTS: Sonicated pouchitis flora produced a consistent and intense proliferation of the mononuclear cells but that produced by sonicates from healthy pouches was minimal (p = 0.012 or 0.018, peripheral blood or lamina propria mononuclear cells). Preparation of the sonicates with the antibiotic metronidazole abolished their stimulatory ability (p = 0.005, peripheral blood mononuclear cells). In separate assays neither direct addition of metronidazole nor of its hydroxy metabolite affected the mononuclear cells' proliferation with alternative stimuli. CONCLUSIONS: These results strongly support a bacterial aetiology for pouchitis.

Adolescent↗
PubMed2004

Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis.

BACKGROUND: Ten to 15% of patients with pouchitis experience refractory or recurrent disease. The aim of this study was to evaluate the effectiveness of a single daily high dose probiotic preparation (VSL#3) in maintaining antibiotic induced remission, and quality of life (QOL), for one year in such patients. METHODS: Patients with pouchitis at least twice in the previous year or requiring continuous antibiotics, associated with a pouchitis disease activity index (PDAI) > or =7 (0 = perfect; 18 = worst), in whom remission was induced by four weeks of combined metronidazole and ciprofloxacin, were randomised to receive VSL#3 6 g or placebo once daily for one year or until relapse. Symptomatic, endoscopic, and histological evaluations were made before, and two and 12 months after randomisation or at the time of relapse. Remission was defined as a clinical PDAI < or =2 and endoscopic PDAI < or =1. Relapse was defined as an increased clinical PDAI score > or =2 and increased endoscopic PDAI score > or =3. QOL was assessed using the inflammatory bowel disease questionnaire (IBDQ). RESULTS: Thirty six patients were randomised: 20 to VSL#3 and 16 to placebo. Remission was maintained at one year in 17 patients (85%) on VSL#3 and in one patient (6%) on placebo (p<0.0001). The IBDQ score remained high in the VSL#3 group (p = 0.3) but deteriorated in the placebo group (p = 0.0005). CONCLUSION: The once daily high dose probiotic VSL#3 is effective in maintaining antibiotic introduced remission for at least a year in patients with recurrent or refractory pouchitis. This is associated with a high level of quality of life.

Adult↗