New NICE Medical technologies guidance MTG36: Peristeen transanal irrigation system for managing bowel dysfunction

Peristeen transanal irrigation system for managing bowel dysfunction


Evidence-based recommendations on the Peristeen transanal irrigation system for managing bowel dysfunction.
Published February 2018
Next review 2021


Full guidance available at : https://www.nice.org.uk/guidance/mtg36

Oesophago-gastric cancer: assessment and management in adults [NG 83]

New:  NICE guideline

1.1 Information and support

1.2 Organisation of services

1.3 Assessment after diagnosis

1.4 Radical treatment

1.5 Palliative management

1.6 Nutritional support

1.7 Follow-up

Glyoxalase 1 copy number variation in patients with well differentiated gastro-entero-pancreatic neuroendocrine tumours (GEP-NET)

Oncotarget. 2017 Aug 16;8(44):76961-76973. doi: 10.18632/oncotarget.20290. eCollection 2017 Sep 29.

Background: The glyoxalase-1 gene (GLO1) is a hotspot for copy-number variation (CNV) in human genomes. Increased GLO1 copy-number is associated with multidrug resistance in tumour chemotherapy, but prevalence of GLO1 CNV in gastro-entero-pancreatic neuroendocrine tumours (GEP-NET) is unknown.

Conclusions: GLO1 copy-number was increased in a large percentage of patients with GEP- NET and correlated positively with increased Glo1 protein in tumour tissue. Analysis of GLO1 copy-number variation particularly in patients with midgut NET could be a novel prognostic marker for tumour progression.

UHCW Research: Kaltsas G, James S, Gopalakrishnan K, Fisk A, Dimitriadis GK, Grammatopoulos DK and Weickert MO

Screening for malnutrition in patients with gastro-entero-pancreatic neuroendocrine tumours: a cross-sectional study

BMJ Open. 2016 May 4;6(5):e010765. doi: 10.1136/bmjopen-2015-010765.

OBJECTIVES: To investigate whether screening for malnutrition using the validated malnutrition universal screening tool (MUST) identifies specific characteristics of patients at risk, in patients with gastro-entero-pancreatic neuroendocrine tumours (GEP-NET).

CONCLUSIONS: Given the frequency of patients identified at malnutrition risk using MUST in our relatively large and diverse GEP-NET cohort and the clinical implications of detecting malnutrition early, we recommend routine use of malnutrition screening in all patients with GEP-NET, and particularly in patients who are treated with long-acting somatostatin analogues.

UHCW Research: Qureshi SA, Burch N, Hattersley JG, Khan S, Gopalakrishnan K, Darby C, Wong JL, Davies L, Fletcher S, Shatwell W, Sothi S, Randeva HS, Dimitriadis GK and Weickert MO.

Upper GI Cancer Resection: How Much Blood Do We Need to Give and When?

International Journal of Surgery (INT J SURG), Nov2017 Supplement 1; 47: S93-S93.

Many upper GI centres routinely crossmatch blood for patients undergoing gastric or oesophageal resection. British Society of Haematology (BSH) guidelines state that at least half of the units of compatible blood provided should be used in surgery. We aimed to quantify the utilisation of cross matched blood within a tertiary Upper GI centre where we routinely crossmatch 4 units of blood prior to resection.

UHCW Research: Krishnamoorthy, A., Wall, R., Munasinghe, A., Khatri, C., Tan, L.C. and Menon, V.

NIHR Signal Low FODMAP diet may improve irritable bowel symptoms more than other diets

Adults with irritable bowel syndrome (IBS) who followed a low FODMAP diet had fewer symptoms than those who followed standard dietary advice. They scored their symptoms about 50 points better on a 500 point scale.

The low FODMAP diet is an emerging approach for IBS. It is based on the theory that certain carbohydrates can expand or ferment in the gut and cause symptoms for some people.

From the NIHR Dissemination Centre

Domperidone prolongs oral to duodenal transit time in video capsule endoscopy

European Journal of Clinical Pharmacology; Heidelberg (Dec 2017): 1-4.
Domperidone is thought to accelerate gastric emptying via D2 receptor antagonism at the gastro-oesophageal and gastro-duodenal junctions. Listed in the BNF as a prokinetic anti-emetic, it has been used in video capsule endoscopy (VCE) to accelerate capsule delivery to the small intestine. We audited VCEs performed at UHCW from 2011, when as standard practice, domperidone was given pre-VCE, to 2012, after its discontinuation due to doubts about its effectiveness.

UHCW Research: Mcfarlane, Michael, Liu, B and Nwokolo, C

Glandular Morphometrics for Objective Grading of Colorectal Adenocarcinoma Histology Images

Scientific reports Vol. 7, Iss. 1, (December 4, 2017): 16852.
Determining the grade of colon cancer from tissue slides is a routine part of the pathological analysis. In the case of colorectal adenocarcinoma (CRA), grading is partly determined by morphology and degree of formation of glandular structures. Achieving consistency between pathologists is difficult due to the subjective nature of grading assessment. An objective grading using computer algorithms will be more consistent, and will be able to analyse images in more detail. In this paper, we measure the shape of glands with a novel metric that we call the Best Alignment Metric (BAM). We show a strong correlation between a novel measure of glandular shape and grade of the tumour. We used shape specific parameters to perform a two-class classification of images into normal or cancerous tissue and a three-class classification into normal, low grade cancer, and high grade cancer. The task of detecting gland boundaries, which is a prerequisite of shape-based analysis, was carried out using a deep convolutional neural network designed for segmentation of glandular structures. A support vector machine (SVM) classifier was trained using shape features derived from BAM. Through cross-validation, we achieved an accuracy of 97% for the two-class and 91% for three-class classification.

UHCW Research: Snead, David 

Point-of-care and home faecal calprotectin tests for monitoring treatment response in inflammatory bowel disease [MIB132]

New medtech innovation briefing from NICE:

Elevated faecal calprotectin (FC) is a marker of intestinal inflammation, including that caused by inflammatory bowel disease (IBD). NICE diagnostics guidance recommends FC testing for the diagnosis of IBD; this briefing summarises the available information on the use of FC to monitor treatment response in patients with IBD.

There are 3 types of FC test available: point of care (used by healthcare professionals), home use (used by patients or carers) and laboratory (used by laboratory scientists). This briefing includes only point‑of‑care and home‑use tests because laboratory tests are widely available in the NHS, although their usage varies.

Regorafenib for previously treated unresectable or metastatic gastrointestinal stromal tumours [TA488]

New technology appraisal guidance from NICE:

Evidence-based recommendations on on regorafenib (Stivarga) for previously treated gastrointestinal stromal tumours in adults.

Regorafenib is recommended as an option for treating unresectable or metastatic gastrointestinal stromal tumours in adults whose disease has progressed on, or who are intolerant to, prior treatment with imatinib and sunitinib, only if:

• their Eastern Cooperative Oncology Group (ECOG) performance status is 0 to 1 and
• the company provides regorafenib with the discount agreed in the patient access scheme.

Meta-analysis of randomised trials comparing the use of prophylactic mesh to standard midline closure in the reduction of incisional herniae

Hernia December 2017, Volume 21, Issue 6, pp 843–853

Purpose Incisional hernia (IH) is common complication following laparotomy. Research suggests that the use of a prophylactic mesh can reduce the rate of IH. We performed an updated meta-analysis to better understand the evidence regarding prevention of IH using prophylactic mesh.

UHCW Research: R. Payne and S. Ward

NIHR Signal Faecal transplant effectively treats recurrent or unresponsive Clostridium difficile

Using a faecal microbiota transplant cured 92% of people with Clostridium difficile that had recurred or had not responded to antibiotics. Faecal transplant also had a lower risk of treatment failure than the antibiotic vancomycin.
C. difficile is a potentially serious infection of the gut that can occur after a course of antibiotics unbalances the gut bacteria. Faecal transplant uses the diluted faeces of a healthy person delivered into the guts of the person with C. difficile to rebalance their gut bacteria.
Administering the transplant via colonoscopy or enema was more effective than via a stomach tube. This may help patients to overcome the aesthetic qualities of this treatment.
This review revealed many variations in how transplants were prepared and administered, so further work is needed to find the best preparation and volume.
From the NIHR Dissemination Centre

Transforming gastroenterology elective care services

This handbook from NHS England has been created to to support the improvement of local health and care systems for gastroenterology elective care services.

Warning over surgery delays for thousands of patients

A leading surgeon was warned thousands of patients are not being prioritised for gallbladder surgery after pancreatitis – despite the risk of the condition returning that in some cases could kill them.

To obtain this article please send a request to libraryw@uhcw.nhs.uk

Ramucirumab (Cyramza) + capecitabine or 5-FU + cisplatin for gastric cancer of GOJ – treatment naïve for palliative chemotherapy

Ramucirumab is a treatment used for patients with advanced gastric cancer or gastro-oesophageal cancer who have progressed after prior treatment with certain types of chemotherapies. Ramucirumab acts by stopping tumour growth by slowing formation of new blood vessels and the blood supply that feeds tumours. Ramucirumab is being developed to be given in combination with other chemotherapies (capecitabine and cisplatin) to treat unresectable, locally advanced or metastatic gastric cancer of gastro-oesophageal junction which are HER2-negative.

From the NIHR Innovation Observatory

Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival

Postgraduate Medical Journal Published Online First: 03 November 2017. doi: 10.1136/postgradmedj-2017-135276

 

Antithrombotic drugs are often stopped following acute upper gastrointestinal bleeding (AUGIB) and frequently not restarted. The practice of antithrombotic discontinuation on discharge and its impact on outcomes are unclear.

The aim of this study was to assess whether restarting antithrombotic therapy, prior to hospital discharge for AUGIB, affected clinical outcomes.

UHCW Research: Monika Widlak

Emerging role of thalidomide in the treatment of gastrointestinal bleeding

Frontline Gastroenterology Published Online First: 02 November 2017. doi: 10.1136/flgastro-2017-100870

Thalidomide was initially synthesised in 1954 and marketed as a sedative and antiemetic for morning sickness. It was withdrawn in 1961 due to the realisation that it was teratogenic with over 10 000 children born with congenital abnormalities. Since then it has been used for treatment of dermatological and oncological conditions, including myeloma. In 1994, it was found to have a potent antiangiogenic effect via downregulation of vascular endothelial growth factor (VEGF). This has led to its use in gastrointestinal bleeding, as vascular abnormalities such as angiodysplasia have been found to have elevated VEGF levels. This article will review the current evidence of the use of thalidomide in bleeding associated with gastrointestinal vascular malformations, including angiodysplasia, gastric cancer and radiation-induced proctitis.

UHCW Research: Michael McFarlane, Lauren O’Flynn, Rachel Ventre and Benjamin R Disney

Acid reflux drugs linked to increased stomach cancer risk

"A drug commonly used to treat acid reflux is linked to a more than doubled risk of developing stomach cancer," reports The Guardian.

Researchers wanted to investigate whether there's a link between medicines known as proton pump inhibitors (PPIs) and stomach cancer. Widely used PPIs include esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole.

PPIs are used to treat acid reflux and protect the stomach lining, have been linked to stomach cancer before.

But they're also used to treat H. pylori, a bacterial infection that can also cause reflux-like symptoms and is known to raise the risk of stomach cancer. This somewhat complicates the picture.

Researchers from Hong Kong studied 63,397 people who'd been treated for stomach infection with H. pylori bacteria.

Even after the bacteria had been killed, those who took PPIs on a long-term basis were more likely to be diagnosed with stomach cancer in the following 7 to 8 years of follow-up.

Because of the study design, we can't tell if PPIs were the cause of the increased stomach cancer risk. It could also have been down to other factors. It's important to keep the results in proportion. Long-term use of PPIs was linked to around 4 additional stomach cancers cases per 10,000 people per year.

Volixibat for non-alcoholic steatohepatitis (NASH)

Currently, there are no approved therapies for the treatment of NASH, but doctors recommend dietary changes and exercise to prevent or slow disease progression. Volixibat is a new experimental once-daily oral tablet that may improve NASH by targeting and blocking a protein (apical sodium-dependent bile acid transporter) found in the liver. This is thought to improve liver function by reducing the amount of cholesterol (fatty substance) in this organ. If licensed, volixibat has the potential to establish itself as a single-agent and the first treatment specifically for NASH.


From the NIHR Innovation Observatory

A4250 for progressive familial intrahepatic cholestasis

Progressive familial intrahepatic cholestasis (PFIC) is a rare, inherited condition that usually begins in infancy. The condition affects the liver, hindering or stopping the flow of bile from the liver. Bile flow is needed for fats, nutrients and vitamins to be absorbed into the body, and also to help the body get rid of toxins. Problems absorbing fats and nutrients can lead to poor weight gain and slower growth, and excess toxins in the body can lead to jaundice and itching, which can have a large impact on the quality of life of the patient and their family. There is no cure for this condition, and current treatments can only reduce the symptoms and slow down damage to the liver. It is not known how many people have this condition, but around 35 genetic tests are carried out each year for this condition.
The drug A4250 works in a new way that directly targets the part of the gut that allows bile to flow into the liver. By stopping bile from coming into the liver, bile levels are reduced, slowing down damage to the liver and reducing the symptoms of jaundice and itching. Because the drug acts directly on the gut, it has the potential to reduce the side-effects that occur with current medicines, such as problems with vitamin absorption. The drug is taken by mouth as a capsule.


From the NIHR Innovation Observatory