Richard Brady, our communications chair, took time out to interview Mr Dale Vimalachandran, about the upcoming launch of the ESCP supported, international DAMASCUS study for which he is one of the Chief Investigators. Dale is a colorectal surgeon at The Countess of Chester NHS foundation trust, Honorary Senior Lecturer at the University of Liverpool and colorectal SSL lead for Royal College of Surgeons of England.
Richard Brady: Hi Dale. Why did you decide to research this area?
Dale Vimalachandran: Hi Richard. In essence, diverticulitis is a very common condition which we see a lot of as colorectal surgeons. The incidence of diverticulitis is growing, and it is a particularly poorly researched area of colorectal surgery. From a UK perspective, we do very little research and most research has traditionally come from Scandinavia, rather than the UK, and we are very keen to address this. We had the feeling that we needed more evidence to support treatment and to inform us of the outcomes that are really important to our patients.
RB: Tell us about the background to the DAMASCUS study?
DV: I was originally interested in acute diverticulitis, particularly the group that does not justify a laparotomy or antibiotic treatment - the group that we treat conservatively but keep bouncing in and out of hospital with flares and admissions. My question was whether we should be more aggressive with this particular patient group. When we looked, the literature was quite sparse for this patient group. When we started to develop a funding application, we realised we needed data on all patients presenting with acute diverticulitis to gain a better idea of the denominator of patients presenting to hospitals with acute diverticulitis. Additionally, studies which had reported up to then using HES type data revealed variation in both initial treatment and outcomes when comparing US versus Australasia and UK figures. We felt that a proper, prospective international audit was required, due to the limitations of such retrospective approaches. Damascus is that international audit.
RB: How was it funded?
DV: It was funded initially by Bowel Disease Research Foundation and as part of that work we undertook a BDRF Diverticulitis Patient Information day on 15th January 2020, at the Royal College of Surgeons England, London. This was very useful and well attended with a lot of patients with diverticulitis and we had long session of exploratory discussions about what actually mattered to them in the treatment and outcome of their disease. Interestingly, patients were not actually that bothered about surgery and stoma formation and many said they wish they had undergone surgery earlier. What was also good to learn was that patients were very interested in us understanding better the biologic basis of disease.
RB: So where are you with launch?
DV: Our key date is 1st October 2020 which is the official start date of DAMASCUS. This is a rolling start across sites as they come online; due to local Covid surges and local approvals processes it was not possible to have all of the sites start at one time. The roll out will be over 3-6 months. Sites will recruit for 6 months and then follow-up patients for 6 months. We estimate the study will end in about 18 months.
RB: What are the key findings you are looking for?
DV: Our main aim is to understand the overall variation in practice and what, if any, co-variates (e.g. region of treatment, patient or disease factors) are related to treatment failure (defined as escalation of in initial treatment).
RB: How do sites get involved?
DV: They can follow us on twitter for updates @damascus_study or register an interest at
RB: What is the next stage?
DV: Well we are running a biological sub-study to DAMASCUS, called EXPLODE, which will look at the epigenetic associations of various types of diverticulitis. This will involve Frank McDermott and is funded via the Bowel and Cancer Research charity. We are looking to access six sites from the DAMASCUS study and do simultaneous genetic studies - essentially trying to find associations with mild versus perforating disease.
RB: Any other future studies?
DV: We are working on a qualitative study to make the distinction between ‘what are the goals of treatment?’ versus ‘what do patients actually want?’ clear. We need better outcome measures and we will only achieve these through a better understanding of the patient-related outcomes. We are also looking to use online tools to better facilitate understanding patient outcomes in this study to tell whether their aims were met.
If patients are interested in contributing to that study they can contact our Damascus email address
RB: What do you think the most important change will be in the next 5 years?
DV: I think this research and other realisations will lead to potentially more surgery and earlier surgery, and that a stoma will no longer be seen as a failure of treatment. If you listen to the patients, it is often regarded as a lifesaving procedure.
Useful link: https://www.thedukesclub.org.uk/research/dukes-collaborative/damascus-study/
