Thesis
The work for my thesis was done as a member of the acute lung injury team, researching the pathophysiology and immuno-pharmacological management of gram negative sepsis and sepsis-induced acute lung injury. A porcine model provided a versatile and comprehensive medium for looking at a large number of pulmonary and cardiovascular parameters affected by systemic gram negative (Pseudomonas) infection. It also allowed measurement of serum levels of a number of cytokines and eicosanoids, as well as affording a look at an array of granulocyte functions.
By utilising a monoclonal antibody to TNF I was able to study the consequences of TNF deficient sepsis, on the evolution of cardiopulmonary derangement’s, neutrophil activation and acute lung injury in the experimental model.
Nutrition and Intestinal Failure:
I have been interested in surgical nutrition and its relationship to gut barrier function, gut origin sepsis and multiple organ failure. Within the Department of Surgery at St James Hospital, I pursued an early, aggressive enteral nutrition program in postoperative and critically ill patients. In particular, examining the role of enteral nutrition and its effects on gut barrier function and clinical sepsis, trying to establish some of the immunological and biological backgrounds to the beneficial effects seen by other workers. A randomised clinical trial of enteral vs parenteral feeding in acute pancreatitis demonstrated that not only is it possible to enterally feed patients with acute pancreatitis but that these patients do better in terms of the acute phase response, disease severity and clinical outcome. These observations have been extended to patients undergoing major resectional surgery and a further randomised clinical trial of enteral versus parenteral feeding in these patients has been completed.
A randomised clinical trial of enteral vs parenteral feeding in acute pancreatitis demonstrated that not only is it possible to enterally feed patients with acute pancreatitis but that these patients do better in terms of the acute phase response, disease severity and clinical outcome. These observations have been extended to patients undergoing major resectional surgery and a further randomised clinical trial of enteral versus parenteral feeding in these patients has been completed.
More recently I have been involved in the nutritional and surgical management of patients with Type II and Type III intestinal failure. Many aspects of the management of these complex patients remain uncertain. As lead surgeon for the nationally funded Intestinal Failure Unit at St Mark’s hospital and now at UCLH, I have been involved in clinical research aimed at better defining how best to manage these problems.
Abdominal Wall Reconstruction:
With the emergence of new techniques and the evolution of a subspecialty in Abdominal Wall Reconstruction, coupled with our considerable experience of abdominal wall defects resulting from management of intestinal failure and ECF, we are increasingly interested in mechanisms of herniation and hernia repair. We have established the first Abdominal Wall Unit in the U.K. at UCLH and have just been successful in our application for a National ‘Research for patient benefit’ government grant aimed at the accurate radiological investigation and classification of abdominal defects in an attempt to ‘prognostically model’ hernia recurrence. We are also interested in the effects of various ‘component separation’ techniques on muscle quality defined but MRI and abdominal wall function.
We have established the first Abdominal Wall Unit in the U.K. at UCLH and have just been successful in our application for a National ‘Research for patient benefit’ government grant aimed at the accurate radiological investigation and classification of abdominal defects in an attempt to ‘prognostically model’ hernia recurrence. We are also interested in the effects of various ‘component separation’ techniques on muscle quality defined but MRI and abdominal wall function.
Enhanced Recovery and Surgical Outcome:
Many of the research areas above have at their core the theme of ‘improving surgical outcomes’. Since moving to UCLH I have set up a collaborative effort with surgery and critical care at Guy’s and St Thomas’ and the Whittington hospitals attempting to draw together many aspects of surgical care into an enhanced surgical treatment and recovery program. We are examining the efficacy of defined pre, intra and postoperative protocols on patients recovery and length of stay. Specific areas of research include preoperative cardio respiratory testing (CPX) and specific physiological and molecular markers of outcome.
I was the local principal investigator for a randomized control study looking at the ability of CPX testing compared to ‘anaesthetic eyeball’ to influence surgical recovery and outcome. The study was also funded by a Research for Patient Benefit Government grant.
