Background Eosinophilic oesophagitis (EoE)
is a chronic, inflammatory condition of the
oesophagus... more Background Eosinophilic oesophagitis (EoE) is a chronic, inflammatory condition of the oesophagus, characterised by intermittent dysphagia, food bolus obstruction (FBO) and histologically proven, eosinophil-mediated inflammation. EoE is identified in up to 50% of FBO presentations. Objective To evaluate the management of patients presenting with FBO to our centre against current clinical guidelines. Design A retrospective analysis of acute FBO was performed between January 2008 and August 2014. Patients were identified using the ICD 10 code T18.1, ‘foreign body in oesophagus’ in their electronic discharge document. Data were collected on admitting specialty, previous FBO, endoscopy findings, biopsy sites and findings, eosinophil count and diagnosis of EoE. Results 310 acute episodes of FBO were included in the final study cohort. 202 (65.2%) flexible oesophagogastroduodenoscopies (OGDs) were performed, with 50 (34.5%) of those occurring in those admitted under ENT (n=145), versus 28 (93.3%) and 124 (91.9%) in general medicine (n=30) and surgery (n=135), respectively. 80 (39.6%) had oesophageal biopsies taken, and 21 novel diagnoses of EoE were made (26.3% biopsyproven rate). Five (23.8%) of the novel diagnoses had a formal eosinophil count included in the histopathology report, and eight (38.1%) had up to three previous OGDs that had not diagnosed their condition of EoE. Conclusion Our study highlights wide variation in adherence to the guidelines for the management of FBO depending on admitting specialty. We advocate an FBO protocol involving single specialty management, flexible OGD, ≥6 biopsies from the upper and lower oesophagus, and standardisation of oesophageal biopsy reports with a formal eosinophil count.
We report a case of a young woman admitted electively for laparoscopic Nissen fundoplication, and... more We report a case of a young woman admitted electively for laparoscopic Nissen fundoplication, and again three days post-operatively as an emergency with profuse vomiting and abdominal pain. She underwent diagnostic laparoscopy, and a small gastric perforation was found at the site of the fundoplication and this was suture-repaired. On both admissions, she was ''screened'' for pregnancy as per current guidelines. On the second admission, following a CT scan, she was found to have a gravid uterus with a foetus of 16-18 weeks' gestation. In the opinion of the authors, this case highlights that current National Institute for Health and Care Excellence guidelines may be insufficient and could lead to unnecessary harm either to mother or foetus pre-, peri-or post-operatively.
Background: Determining the possibility of pregnancy and the documentation of pregnancy status ar... more Background: Determining the possibility of pregnancy and the documentation of pregnancy status are important considerations in the assessment of females of reproductive age when admitted to hospital. Objectives: Our aim was to determine the adequacy of the documentation of pregnancy status and possibility of pregnancy across multiple surgical specialties. Materials and methods: A prospective audit of surgical specialties (general, orthopaedics, urology, vascular, maxillo-facial, ENT, gynaecology and neurosurgery) within NHS Tayside, in May 2015. Results: A total of 129 females of reproductive age were admitted; 69 (53.5%) elective and 60 (46.5%) emergencies. Eighty-four patients (65%) were asked 'Is there any possibility of pregnancy?' Pregnancy status was documented in 74% of patients. Eleven (8.5%) patients were not asked about possibility of pregnancy and did not have a documented pregnancy status. Documentation of the use of contraception, sexual activity and date of last menstrual period was noted in 53 (41.1%), 31 (24.0%) and 66 (51.2%) patients, respectively. Conclusions: There is a wide variation in the documentation of pregnancy status and possibility of pregnancy amongst surgical specialties. This was not an issue in gynaecology but is an issue in ENT, maxillofacial, neurosurgery, vascular and general surgery. The reasons are unclear. Documentation of pregnancy status using ßhCG assays should be the gold standard, and national guidelines are required.
International Journal of Gynecology and Obstetrics, 2017
Objective: To determine the adequacy of assessing gynecologic history for females of reproductive... more Objective: To determine the adequacy of assessing gynecologic history for females of reproductive age (FRA) admitted to a general surgery department. Methods: The present prospective multicenter audit included FRA who were admitted for elective or emergency procedures to general surgery departments in Scotland between May 11 and May 25, 2015. Data were compared between patients who were admitted for elective and emergency treatment. Results: There were 530 FRA included from 18 centers, including 169 (31.9%) and 361 (68.1%) elective and emergency admissions, respectively. The date of last menstrual period was document for 203 (38.3%) patients, use of contraception for 149 (28.1%), sexual activity for 83 (15.7%), pregnancy status for 274 (51.7%), and the possibility of pregnancy for 237 (44.7%). A higher incidence of documented date of last menstrual period (P=0.002) and pregnancy status (P<0.001) were identified among emergency admissions, and the possibility of pregnancy was documented more commonly among elective admissions (P<0.001). Conclusions: Key factors required for gynecologic assessment were often not documented for FRA admitted to general surgery both as elective and emergency admissions. Surgical teams and medical undergraduates require educating regarding the importance of obtaining gynecologic history for all FRA. K E Y W O R D S Females of reproductive age; Gynecological history; Pregnancy status 1 | INTRODUCTION The admission of female patients to hospital presents the admitting team with a unique set of variables to consider, particularly for females of reproductive age (FRA). In addition to obtaining a standard medical history, the date of last menstrual period, use of contraception , pregnancy status, sexual activity, and other relevant gynecologic history details should also be considered. Documentation of pregnancy status takes on greater importance when surgery requiring general anesthesia is being considered, or when the patient could require exposure to ionizing radiation or the use of drug treatments that are contra-indicated in pregnancy. In the elective setting, current guidelines require that the possibility of pregnancy should be considered prior to surgery requiring a general anesthetic. 1 Surgery in the early stages of pregnancy constitutes a recognized risk to the fetus and this should form part of the informed consent process prior to undertaking such a procedure. 2-4 If surgery is required at all during pregnancy, the second trimester is considered to be the safest time. 5 With the widespread use of laparoscopic surgery for emergency conditions such as appendicitis and chole-cystitis, acceptable outcomes are now being reported particularly if surgery takes place before the third trimester of pregnancy. 6,7 In the
European Journal of Trauma and Emergency Surgery, 2019
Purpose A key step during laparoscopic appendicectomy is securing the appendiceal stump. This has... more Purpose A key step during laparoscopic appendicectomy is securing the appendiceal stump. This has traditionally been
achieved using vicryl endoloops, but increasing evidence suggests that the use of polymeric clips (Hem-o-lok) may be a
safe and viable method. Current evidence for its clinical use in laparoscopic appendicectomy is unknown. We performed a
systematic review of the literature examining the clinical outcomes of laparoscopic appendicectomy using polymeric clips
compared to other methods of stump closure.
Methods A systematic literature review based on PRISMA guidelines was performed using MEDLINE, PubMed, EMBASE
and Cochrane library databases between 2000 and 2017. All studies analysing appendiceal stump closure during laparoscopic
appendicectomy using polymeric clips compared to other methods of stump closure were included. The methodological quality
of the included studies was assessed using the Cochrane Handbook for Systematic Reviews. The review was registered
with the PROSPERO register of systematic reviews.
Results Ten studies were included, involving 702 patients, 7 of which were prospective studies and 1 a randomised control
trial. Polymeric clips were found to be the cheapest method (€20.47 average per patient) and also had the lowest rate of
complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of inpatient
stay were similar between groups.
Conclusions Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in
laparoscopic appendicectomy for acute appendicitis. Further high-quality evidence is required before polymeric clips can
be recommended as the gold standard for appendiceal stump closure.
Keywords Appendicectomy · Stump closure · Polymeric clips
Annals of the Royal College of Surgeons of England, 2018
INTRODUCTION The use of polymeric clips in securing the appendiceal stump has been increasingly r... more INTRODUCTION The use of polymeric clips in securing the appendiceal stump has been increasingly reported as a viable alternative to current methods in emergency laparoscopic appendicectomy. We evaluated the operative outcomes following the use of pol-ymeric clips versus endoscopic ligatures. The primary endpoint was operative time, with secondary outcomes including complications, inpatient stay, and cost analysis. MATERIALS AND METHODS Operative records were retrospectively analysed to identify patients undergoing laparoscopic appendi-cectomy between January 2014 and June 2015. Data collected included age, gender, body mass index, duration of surgery, length of hospital stay, antibiotic use, preoperative haematological and biochemical parameters, 30-day readmission rate and complications. RESULTS A total of 125 patients were included within the study, with 78 within the endoloop group and 47 in the polymeric clip group. There were no differences in age, gender, body mass index, hospital stay, antibiotic use, 30-day readmission rates or postop-erative complications. Operative time was significantly reduced in the polymeric clip group (59 vs. 68 minutes, P = 0.00751). The use of polymeric clips cost £21 compared with £49 for endoloops per operation, which rose to £70 if both clips and endoloops were used during the procedure. DISCUSSION Polymeric clips are a safe, viable and economical method for securing the appendiceal stump during laparoscopic appendicectomy. The clinical significance of nine minutes of reduced operating time in the polymeric clip cohort warrants further study with an adequately powered randomised controlled trial.
Background: Multiple disciplines have described an "after-hours effect" relating to worsened mort... more Background: Multiple disciplines have described an "after-hours effect" relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours.
on behalf of the SCOTTISH SURGICAL RESEARCH GROUP Introduction: The aim of our study was to ident... more on behalf of the SCOTTISH SURGICAL RESEARCH GROUP Introduction: The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice.
Arguments have been made to support both removing and leaving in situ a macroscopically normal ap... more Arguments have been made to support both removing and leaving in situ a macroscopically normal appendix. Treatment strategies however rely on the inability of surgeons to assess pathology. This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate. a b s t r a c t Background: Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy. Materials and methods: The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement. Results: The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n ¼ 496), histopathological assessment revealed pathology in a substantial proportion (n ¼ 138, 27.8%). Where surgeons assessed the appendix as being inflamed (n ¼ 2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed to-mography was associated with increased false positives. Conclusions: This multi-centre study suggests that surgeons' judgements of the intra-operative macro-scopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background With advances in laparoscopic instrumenta-tion and acquisition of advanced laparoscopi... more Background With advances in laparoscopic instrumenta-tion and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis. Methods A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions , and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications. Results Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peri-tonitis (OR 0.22, 95 % CI 0.06–0.76, P = 0.02), operating time (WMD,-22.27, 95 % CI-33.26 to-11.28, P \ 0.00001), postoperative hospital stay (WMD,-3.22; 95 % CI-4.52 to-1.92, P \ 0.00001), and median hospital expenses (SMD,-1.37, 95 % CI-1.96 to-0.77, P \ 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC ? BD) group when compared to TTD group (WMD,-2.68; 95 % CI-3.23 to-2.13, P \ 0.00001). Conclusions This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.
Background: Surgical mortality data are collected routinely in high-income countries, yet virtual... more Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low-or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle-and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low-and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low-compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov).
Background: Evidence-based interventions may reduce mortality in surgical patients. This study do... more Background: Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency. Methods: Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days). Results: Of a total of 5067 patients from 97 hospitals across the UK, 911 (18⋅0 per cent) fulfilled the criteria for sepsis, 165 (3⋅3 per cent) for severe sepsis and 24 (0⋅5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17⋅6–94⋅5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19⋅8 (i.q.r. 10⋅0–35⋅4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. Conclusion: Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent.
Objectives
Colorectal polyp cancers present clinicians
with a treatment dilemma. Decisions regar... more Objectives Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers.
Design This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancerrelated death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm.
Results 485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p<0.001) or lymphovascular invasion (OR 2.65, p=0.023).
Conclusion A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.
Background Documentation of pregnancy status (PS) is an integral component of the assessment of w... more Background Documentation of pregnancy status (PS) is an integral component of the assessment of women of reproductive age when admitted to hospital. Our aim was to determine how accurately PS was documented in a multicentre audit of female admissions to general surgery. Methods A prospective multicentre audit of elective and emergency admissions was performed in 18 Scottish centres between 08:00 on 11 May 2015 and 07:59 on 25 May 2015. The lower age limit was the minimum age for admission to the adult surgical ward and the upper age limit was 55 years. Results There were 2743 admissions, with 612 (22.3%) women of reproductive age. After 82 exclusions, the final total was 530: 169 (31.9%) elective and 361 (68.1%) emergency. Documentation of PS was achieved in 274 (51.7%) cases: 52 (30.8%) elective and 222 (61.5%) emergency. In 318 (88.1%) of the emergency admissions, the patient had abdominal pain. Of these, 211 (65.1%) had a documented PS. The possibility of pregnancy was established in 237 (44.7%) cases. Discussion Establishing the possibility of pregnancy before surgery is poor, particularly in the elective setting. Objective documentation of PS in the emergency setting in those with abdominal pain is also poor. Our study highlights an important safety issue in the management of female patients. We advocate electronic storage of pregnancy test results and new guidelines to cover both elective and emergency surgery. PS should form part of the pre-theatre safety brief and checklist. BACKGROUND
Background There is evidence to suggest that
patients undergoing treatment at weekends may
be sub... more Background There is evidence to suggest that patients undergoing treatment at weekends may be subject to different care processes and outcomes compared with weekdays. This study aimed to determine whether clinical outcomes from weekend appendicectomy are different from those performed on weekdays. Method Multicentre cohort study during May– June 2012 from 95 centres (89 within the UK). The primary outcome was the 30-day adverse event rate. Multilevel modelling was used to account for clustering within hospitals while adjusting for case mix to produce adjusted ORs and 95% CIs. Results When compared with Monday, there were no significant differences for other days of the week considering 30-day adverse events in adjusted models. On Sunday, rates of simple appendicitis were highest, and rates of normal (OR 0.62, 95% CI 0.42 to 0.90) and complex appendicitis (OR 0.65, 95% CI 0.46 to 0.93) lowest. This was accompanied by a 43% lower likelihood in use of laparoscopy on Sunday (OR 0.47, 95% CI 0.32 to 0.69), accompanied by the lowest level of consultant presence for the week. When pooling weekends and weekdays, laparoscopy use remained less likely at the weekend (OR 0.68, 95% CI 0.55 to 0.83), with no significant difference for 30-day adverse event rate (OR 1.01, 95% CI 0.80 to 1.29). Conclusions This study found that weekend appendicectomy was not associated with increased 30-day adverse events. It cannot rule out smaller increases that may be shown by larger studies. It further illustrated that patients operated on at weekends were subject to different care processes, which may expose them to risk.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P <0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P <0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P =0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P =0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background: Identification of variation in practice is a key step towards standardization of serv... more Background: Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy. Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome. Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66·3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8·7–100 per cent). A histologically normal appendix was removed in 20·6 per cent of patients (range in centres performing more than 25 procedures: 3·3–36·8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates. Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.
Background Eosinophilic oesophagitis (EoE)
is a chronic, inflammatory condition of the
oesophagus... more Background Eosinophilic oesophagitis (EoE) is a chronic, inflammatory condition of the oesophagus, characterised by intermittent dysphagia, food bolus obstruction (FBO) and histologically proven, eosinophil-mediated inflammation. EoE is identified in up to 50% of FBO presentations. Objective To evaluate the management of patients presenting with FBO to our centre against current clinical guidelines. Design A retrospective analysis of acute FBO was performed between January 2008 and August 2014. Patients were identified using the ICD 10 code T18.1, ‘foreign body in oesophagus’ in their electronic discharge document. Data were collected on admitting specialty, previous FBO, endoscopy findings, biopsy sites and findings, eosinophil count and diagnosis of EoE. Results 310 acute episodes of FBO were included in the final study cohort. 202 (65.2%) flexible oesophagogastroduodenoscopies (OGDs) were performed, with 50 (34.5%) of those occurring in those admitted under ENT (n=145), versus 28 (93.3%) and 124 (91.9%) in general medicine (n=30) and surgery (n=135), respectively. 80 (39.6%) had oesophageal biopsies taken, and 21 novel diagnoses of EoE were made (26.3% biopsyproven rate). Five (23.8%) of the novel diagnoses had a formal eosinophil count included in the histopathology report, and eight (38.1%) had up to three previous OGDs that had not diagnosed their condition of EoE. Conclusion Our study highlights wide variation in adherence to the guidelines for the management of FBO depending on admitting specialty. We advocate an FBO protocol involving single specialty management, flexible OGD, ≥6 biopsies from the upper and lower oesophagus, and standardisation of oesophageal biopsy reports with a formal eosinophil count.
We report a case of a young woman admitted electively for laparoscopic Nissen fundoplication, and... more We report a case of a young woman admitted electively for laparoscopic Nissen fundoplication, and again three days post-operatively as an emergency with profuse vomiting and abdominal pain. She underwent diagnostic laparoscopy, and a small gastric perforation was found at the site of the fundoplication and this was suture-repaired. On both admissions, she was ''screened'' for pregnancy as per current guidelines. On the second admission, following a CT scan, she was found to have a gravid uterus with a foetus of 16-18 weeks' gestation. In the opinion of the authors, this case highlights that current National Institute for Health and Care Excellence guidelines may be insufficient and could lead to unnecessary harm either to mother or foetus pre-, peri-or post-operatively.
Background: Determining the possibility of pregnancy and the documentation of pregnancy status ar... more Background: Determining the possibility of pregnancy and the documentation of pregnancy status are important considerations in the assessment of females of reproductive age when admitted to hospital. Objectives: Our aim was to determine the adequacy of the documentation of pregnancy status and possibility of pregnancy across multiple surgical specialties. Materials and methods: A prospective audit of surgical specialties (general, orthopaedics, urology, vascular, maxillo-facial, ENT, gynaecology and neurosurgery) within NHS Tayside, in May 2015. Results: A total of 129 females of reproductive age were admitted; 69 (53.5%) elective and 60 (46.5%) emergencies. Eighty-four patients (65%) were asked 'Is there any possibility of pregnancy?' Pregnancy status was documented in 74% of patients. Eleven (8.5%) patients were not asked about possibility of pregnancy and did not have a documented pregnancy status. Documentation of the use of contraception, sexual activity and date of last menstrual period was noted in 53 (41.1%), 31 (24.0%) and 66 (51.2%) patients, respectively. Conclusions: There is a wide variation in the documentation of pregnancy status and possibility of pregnancy amongst surgical specialties. This was not an issue in gynaecology but is an issue in ENT, maxillofacial, neurosurgery, vascular and general surgery. The reasons are unclear. Documentation of pregnancy status using ßhCG assays should be the gold standard, and national guidelines are required.
International Journal of Gynecology and Obstetrics, 2017
Objective: To determine the adequacy of assessing gynecologic history for females of reproductive... more Objective: To determine the adequacy of assessing gynecologic history for females of reproductive age (FRA) admitted to a general surgery department. Methods: The present prospective multicenter audit included FRA who were admitted for elective or emergency procedures to general surgery departments in Scotland between May 11 and May 25, 2015. Data were compared between patients who were admitted for elective and emergency treatment. Results: There were 530 FRA included from 18 centers, including 169 (31.9%) and 361 (68.1%) elective and emergency admissions, respectively. The date of last menstrual period was document for 203 (38.3%) patients, use of contraception for 149 (28.1%), sexual activity for 83 (15.7%), pregnancy status for 274 (51.7%), and the possibility of pregnancy for 237 (44.7%). A higher incidence of documented date of last menstrual period (P=0.002) and pregnancy status (P<0.001) were identified among emergency admissions, and the possibility of pregnancy was documented more commonly among elective admissions (P<0.001). Conclusions: Key factors required for gynecologic assessment were often not documented for FRA admitted to general surgery both as elective and emergency admissions. Surgical teams and medical undergraduates require educating regarding the importance of obtaining gynecologic history for all FRA. K E Y W O R D S Females of reproductive age; Gynecological history; Pregnancy status 1 | INTRODUCTION The admission of female patients to hospital presents the admitting team with a unique set of variables to consider, particularly for females of reproductive age (FRA). In addition to obtaining a standard medical history, the date of last menstrual period, use of contraception , pregnancy status, sexual activity, and other relevant gynecologic history details should also be considered. Documentation of pregnancy status takes on greater importance when surgery requiring general anesthesia is being considered, or when the patient could require exposure to ionizing radiation or the use of drug treatments that are contra-indicated in pregnancy. In the elective setting, current guidelines require that the possibility of pregnancy should be considered prior to surgery requiring a general anesthetic. 1 Surgery in the early stages of pregnancy constitutes a recognized risk to the fetus and this should form part of the informed consent process prior to undertaking such a procedure. 2-4 If surgery is required at all during pregnancy, the second trimester is considered to be the safest time. 5 With the widespread use of laparoscopic surgery for emergency conditions such as appendicitis and chole-cystitis, acceptable outcomes are now being reported particularly if surgery takes place before the third trimester of pregnancy. 6,7 In the
European Journal of Trauma and Emergency Surgery, 2019
Purpose A key step during laparoscopic appendicectomy is securing the appendiceal stump. This has... more Purpose A key step during laparoscopic appendicectomy is securing the appendiceal stump. This has traditionally been
achieved using vicryl endoloops, but increasing evidence suggests that the use of polymeric clips (Hem-o-lok) may be a
safe and viable method. Current evidence for its clinical use in laparoscopic appendicectomy is unknown. We performed a
systematic review of the literature examining the clinical outcomes of laparoscopic appendicectomy using polymeric clips
compared to other methods of stump closure.
Methods A systematic literature review based on PRISMA guidelines was performed using MEDLINE, PubMed, EMBASE
and Cochrane library databases between 2000 and 2017. All studies analysing appendiceal stump closure during laparoscopic
appendicectomy using polymeric clips compared to other methods of stump closure were included. The methodological quality
of the included studies was assessed using the Cochrane Handbook for Systematic Reviews. The review was registered
with the PROSPERO register of systematic reviews.
Results Ten studies were included, involving 702 patients, 7 of which were prospective studies and 1 a randomised control
trial. Polymeric clips were found to be the cheapest method (€20.47 average per patient) and also had the lowest rate of
complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of inpatient
stay were similar between groups.
Conclusions Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in
laparoscopic appendicectomy for acute appendicitis. Further high-quality evidence is required before polymeric clips can
be recommended as the gold standard for appendiceal stump closure.
Keywords Appendicectomy · Stump closure · Polymeric clips
Annals of the Royal College of Surgeons of England, 2018
INTRODUCTION The use of polymeric clips in securing the appendiceal stump has been increasingly r... more INTRODUCTION The use of polymeric clips in securing the appendiceal stump has been increasingly reported as a viable alternative to current methods in emergency laparoscopic appendicectomy. We evaluated the operative outcomes following the use of pol-ymeric clips versus endoscopic ligatures. The primary endpoint was operative time, with secondary outcomes including complications, inpatient stay, and cost analysis. MATERIALS AND METHODS Operative records were retrospectively analysed to identify patients undergoing laparoscopic appendi-cectomy between January 2014 and June 2015. Data collected included age, gender, body mass index, duration of surgery, length of hospital stay, antibiotic use, preoperative haematological and biochemical parameters, 30-day readmission rate and complications. RESULTS A total of 125 patients were included within the study, with 78 within the endoloop group and 47 in the polymeric clip group. There were no differences in age, gender, body mass index, hospital stay, antibiotic use, 30-day readmission rates or postop-erative complications. Operative time was significantly reduced in the polymeric clip group (59 vs. 68 minutes, P = 0.00751). The use of polymeric clips cost £21 compared with £49 for endoloops per operation, which rose to £70 if both clips and endoloops were used during the procedure. DISCUSSION Polymeric clips are a safe, viable and economical method for securing the appendiceal stump during laparoscopic appendicectomy. The clinical significance of nine minutes of reduced operating time in the polymeric clip cohort warrants further study with an adequately powered randomised controlled trial.
Background: Multiple disciplines have described an "after-hours effect" relating to worsened mort... more Background: Multiple disciplines have described an "after-hours effect" relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours.
on behalf of the SCOTTISH SURGICAL RESEARCH GROUP Introduction: The aim of our study was to ident... more on behalf of the SCOTTISH SURGICAL RESEARCH GROUP Introduction: The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice.
Arguments have been made to support both removing and leaving in situ a macroscopically normal ap... more Arguments have been made to support both removing and leaving in situ a macroscopically normal appendix. Treatment strategies however rely on the inability of surgeons to assess pathology. This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate. a b s t r a c t Background: Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy. Materials and methods: The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement. Results: The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n ¼ 496), histopathological assessment revealed pathology in a substantial proportion (n ¼ 138, 27.8%). Where surgeons assessed the appendix as being inflamed (n ¼ 2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed to-mography was associated with increased false positives. Conclusions: This multi-centre study suggests that surgeons' judgements of the intra-operative macro-scopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background With advances in laparoscopic instrumenta-tion and acquisition of advanced laparoscopi... more Background With advances in laparoscopic instrumenta-tion and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis. Methods A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions , and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications. Results Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peri-tonitis (OR 0.22, 95 % CI 0.06–0.76, P = 0.02), operating time (WMD,-22.27, 95 % CI-33.26 to-11.28, P \ 0.00001), postoperative hospital stay (WMD,-3.22; 95 % CI-4.52 to-1.92, P \ 0.00001), and median hospital expenses (SMD,-1.37, 95 % CI-1.96 to-0.77, P \ 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC ? BD) group when compared to TTD group (WMD,-2.68; 95 % CI-3.23 to-2.13, P \ 0.00001). Conclusions This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.
Background: Surgical mortality data are collected routinely in high-income countries, yet virtual... more Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low-or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle-and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low-and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low-compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov).
Background: Evidence-based interventions may reduce mortality in surgical patients. This study do... more Background: Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency. Methods: Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days). Results: Of a total of 5067 patients from 97 hospitals across the UK, 911 (18⋅0 per cent) fulfilled the criteria for sepsis, 165 (3⋅3 per cent) for severe sepsis and 24 (0⋅5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17⋅6–94⋅5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19⋅8 (i.q.r. 10⋅0–35⋅4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. Conclusion: Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent.
Objectives
Colorectal polyp cancers present clinicians
with a treatment dilemma. Decisions regar... more Objectives Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers.
Design This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancerrelated death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm.
Results 485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p<0.001) or lymphovascular invasion (OR 2.65, p=0.023).
Conclusion A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.
Background Documentation of pregnancy status (PS) is an integral component of the assessment of w... more Background Documentation of pregnancy status (PS) is an integral component of the assessment of women of reproductive age when admitted to hospital. Our aim was to determine how accurately PS was documented in a multicentre audit of female admissions to general surgery. Methods A prospective multicentre audit of elective and emergency admissions was performed in 18 Scottish centres between 08:00 on 11 May 2015 and 07:59 on 25 May 2015. The lower age limit was the minimum age for admission to the adult surgical ward and the upper age limit was 55 years. Results There were 2743 admissions, with 612 (22.3%) women of reproductive age. After 82 exclusions, the final total was 530: 169 (31.9%) elective and 361 (68.1%) emergency. Documentation of PS was achieved in 274 (51.7%) cases: 52 (30.8%) elective and 222 (61.5%) emergency. In 318 (88.1%) of the emergency admissions, the patient had abdominal pain. Of these, 211 (65.1%) had a documented PS. The possibility of pregnancy was established in 237 (44.7%) cases. Discussion Establishing the possibility of pregnancy before surgery is poor, particularly in the elective setting. Objective documentation of PS in the emergency setting in those with abdominal pain is also poor. Our study highlights an important safety issue in the management of female patients. We advocate electronic storage of pregnancy test results and new guidelines to cover both elective and emergency surgery. PS should form part of the pre-theatre safety brief and checklist. BACKGROUND
Background There is evidence to suggest that
patients undergoing treatment at weekends may
be sub... more Background There is evidence to suggest that patients undergoing treatment at weekends may be subject to different care processes and outcomes compared with weekdays. This study aimed to determine whether clinical outcomes from weekend appendicectomy are different from those performed on weekdays. Method Multicentre cohort study during May– June 2012 from 95 centres (89 within the UK). The primary outcome was the 30-day adverse event rate. Multilevel modelling was used to account for clustering within hospitals while adjusting for case mix to produce adjusted ORs and 95% CIs. Results When compared with Monday, there were no significant differences for other days of the week considering 30-day adverse events in adjusted models. On Sunday, rates of simple appendicitis were highest, and rates of normal (OR 0.62, 95% CI 0.42 to 0.90) and complex appendicitis (OR 0.65, 95% CI 0.46 to 0.93) lowest. This was accompanied by a 43% lower likelihood in use of laparoscopy on Sunday (OR 0.47, 95% CI 0.32 to 0.69), accompanied by the lowest level of consultant presence for the week. When pooling weekends and weekdays, laparoscopy use remained less likely at the weekend (OR 0.68, 95% CI 0.55 to 0.83), with no significant difference for 30-day adverse event rate (OR 1.01, 95% CI 0.80 to 1.29). Conclusions This study found that weekend appendicectomy was not associated with increased 30-day adverse events. It cannot rule out smaller increases that may be shown by larger studies. It further illustrated that patients operated on at weekends were subject to different care processes, which may expose them to risk.
Background: Appendicectomy for acute appendicitis in children may be performed in specialist cent... more Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P <0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P <0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P =0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P =0·091). Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
Background: Identification of variation in practice is a key step towards standardization of serv... more Background: Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy. Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome. Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66·3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8·7–100 per cent). A histologically normal appendix was removed in 20·6 per cent of patients (range in centres performing more than 25 procedures: 3·3–36·8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates. Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.
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Papers by Michael Wilson
is a chronic, inflammatory condition of the
oesophagus, characterised by intermittent
dysphagia, food bolus obstruction (FBO) and
histologically proven, eosinophil-mediated
inflammation. EoE is identified in up to 50% of
FBO presentations.
Objective To evaluate the management of patients
presenting with FBO to our centre against current
clinical guidelines.
Design A retrospective analysis of acute FBO was
performed between January 2008 and August
2014. Patients were identified using the ICD 10
code T18.1, ‘foreign body in oesophagus’ in
their electronic discharge document. Data were
collected on admitting specialty, previous FBO,
endoscopy findings, biopsy sites and findings,
eosinophil count and diagnosis of EoE.
Results 310 acute episodes of FBO were included
in the final study cohort. 202 (65.2%) flexible
oesophagogastroduodenoscopies (OGDs) were
performed, with 50 (34.5%) of those occurring
in those admitted under ENT (n=145), versus 28
(93.3%) and 124 (91.9%) in general medicine
(n=30) and surgery (n=135), respectively. 80
(39.6%) had oesophageal biopsies taken, and 21
novel diagnoses of EoE were made (26.3% biopsyproven
rate). Five (23.8%) of the novel diagnoses
had a formal eosinophil count included in the
histopathology report, and eight (38.1%) had up
to three previous OGDs that had not diagnosed
their condition of EoE.
Conclusion Our study highlights wide variation in
adherence to the guidelines for the management
of FBO depending on admitting specialty. We
advocate an FBO protocol involving single specialty
management, flexible OGD, ≥6 biopsies from the
upper and lower oesophagus, and standardisation
of oesophageal biopsy reports with a formal
eosinophil count.
achieved using vicryl endoloops, but increasing evidence suggests that the use of polymeric clips (Hem-o-lok) may be a
safe and viable method. Current evidence for its clinical use in laparoscopic appendicectomy is unknown. We performed a
systematic review of the literature examining the clinical outcomes of laparoscopic appendicectomy using polymeric clips
compared to other methods of stump closure.
Methods A systematic literature review based on PRISMA guidelines was performed using MEDLINE, PubMed, EMBASE
and Cochrane library databases between 2000 and 2017. All studies analysing appendiceal stump closure during laparoscopic
appendicectomy using polymeric clips compared to other methods of stump closure were included. The methodological quality
of the included studies was assessed using the Cochrane Handbook for Systematic Reviews. The review was registered
with the PROSPERO register of systematic reviews.
Results Ten studies were included, involving 702 patients, 7 of which were prospective studies and 1 a randomised control
trial. Polymeric clips were found to be the cheapest method (€20.47 average per patient) and also had the lowest rate of
complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of inpatient
stay were similar between groups.
Conclusions Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in
laparoscopic appendicectomy for acute appendicitis. Further high-quality evidence is required before polymeric clips can
be recommended as the gold standard for appendiceal stump closure.
Keywords Appendicectomy · Stump closure · Polymeric clips
Colorectal polyp cancers present clinicians
with a treatment dilemma. Decisions regarding whether
to offer segmental resection or endoscopic surveillance
are often taken without reference to good quality
evidence. The aim of this study was to develop a
treatment algorithm for patients with screen-detected
polyp cancers.
Design
This national cohort study included all patients
with a polyp cancer identified through the Scottish
Bowel Screening Programme between 2000 and 2012.
Multivariate regression analysis was used to assess the
impact of clinical, endoscopic and pathological variables
on the rate of adverse events (residual tumour in
patients undergoing segmental resection or cancerrelated
death or disease recurrence in any patient). These
data were used to develop a clinically relevant treatment
algorithm.
Results
485 patients with polyp cancers were included.
186/485 (38%) underwent segmental resection and
residual tumour was identified in 41/186 (22%). The
only factor associated with an increased risk of residual
tumour in the bowel wall was incomplete excision of the
original polyp (OR 5.61, p=0.001), while only
lymphovascular invasion was associated with an
increased risk of lymph node metastases (OR 5.95,
p=0.002). When patients undergoing segmental
resection or endoscopic surveillance were considered
together, the risk of adverse events was significantly
higher in patients with incomplete excision (OR 10.23,
p<0.001) or lymphovascular invasion (OR 2.65,
p=0.023).
Conclusion
A policy of surveillance is adequate for the
majority of patients with screen-detected colorectal polyp
cancers. Consideration of segmental resection should be
reserved for those with incomplete excision or evidence
of lymphovascular invasion.
patients undergoing treatment at weekends may
be subject to different care processes and
outcomes compared with weekdays. This study
aimed to determine whether clinical outcomes
from weekend appendicectomy are different
from those performed on weekdays.
Method Multicentre cohort study during May–
June 2012 from 95 centres (89 within the UK).
The primary outcome was the 30-day adverse
event rate. Multilevel modelling was used to
account for clustering within hospitals while
adjusting for case mix to produce adjusted ORs
and 95% CIs.
Results When compared with Monday, there
were no significant differences for other days of
the week considering 30-day adverse events in
adjusted models. On Sunday, rates of simple
appendicitis were highest, and rates of normal
(OR 0.62, 95% CI 0.42 to 0.90) and complex
appendicitis (OR 0.65, 95% CI 0.46 to 0.93)
lowest. This was accompanied by a 43% lower
likelihood in use of laparoscopy on Sunday (OR
0.47, 95% CI 0.32 to 0.69), accompanied by the
lowest level of consultant presence for the week.
When pooling weekends and weekdays,
laparoscopy use remained less likely at the
weekend (OR 0.68, 95% CI 0.55 to 0.83), with
no significant difference for 30-day adverse event
rate (OR 1.01, 95% CI 0.80 to 1.29).
Conclusions This study found that weekend
appendicectomy was not associated with
increased 30-day adverse events. It cannot rule
out smaller increases that may be shown by larger
studies. It further illustrated that patients operated
on at weekends were subject to different care
processes, which may expose them to risk.
by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in
children may differ between such units.
Methods: This multicentre observational study included all children (aged less than 16 years) who had
an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome
was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of
ultrasound imaging and laparoscopy, and consultant involvement in procedures.
Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general
surgery units (461 children) were included. Children treated in paediatric surgery units were younger
and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant
present at the procedure, and histologically advanced appendicitis than children treated in general
surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio
(OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P <0·001), and the difference persisted after
adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P <0·001).
Female sex and preoperative ultrasonography, but not age, were significantly associated with normal
appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The
unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units
(OR 1·90, 1·18 to 3·06; P =0·011). When adjusted for case mix and consultant presence at surgery, no
statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59,
0·93 to 2·73; P =0·091).
Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a
more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery
units. Service provision differs between paediatric and general surgery units.
determination of reliable quality markers. This study aimed to investigate variation in provision and
outcome of emergency appendicectomy.
Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was
performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate;
secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and
binary logistic regression models to identify patient- and hospital-related predictors of outcome.
Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was
performed in 66·3 per cent of patients (range in centres performing more than 25 appendicectomies
over the study period: 8·7–100 per cent). A histologically normal appendix was removed in 20·6 per
cent of patients (range in centres performing more than 25 procedures: 3·3–36·8 per cent). Funnel
plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy
rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently
associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day
morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates.
Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of
higher perforation rates.
Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among
hospitals. Organizational factors leading to this variation have been identified and should be addressed
to improve performance.
is a chronic, inflammatory condition of the
oesophagus, characterised by intermittent
dysphagia, food bolus obstruction (FBO) and
histologically proven, eosinophil-mediated
inflammation. EoE is identified in up to 50% of
FBO presentations.
Objective To evaluate the management of patients
presenting with FBO to our centre against current
clinical guidelines.
Design A retrospective analysis of acute FBO was
performed between January 2008 and August
2014. Patients were identified using the ICD 10
code T18.1, ‘foreign body in oesophagus’ in
their electronic discharge document. Data were
collected on admitting specialty, previous FBO,
endoscopy findings, biopsy sites and findings,
eosinophil count and diagnosis of EoE.
Results 310 acute episodes of FBO were included
in the final study cohort. 202 (65.2%) flexible
oesophagogastroduodenoscopies (OGDs) were
performed, with 50 (34.5%) of those occurring
in those admitted under ENT (n=145), versus 28
(93.3%) and 124 (91.9%) in general medicine
(n=30) and surgery (n=135), respectively. 80
(39.6%) had oesophageal biopsies taken, and 21
novel diagnoses of EoE were made (26.3% biopsyproven
rate). Five (23.8%) of the novel diagnoses
had a formal eosinophil count included in the
histopathology report, and eight (38.1%) had up
to three previous OGDs that had not diagnosed
their condition of EoE.
Conclusion Our study highlights wide variation in
adherence to the guidelines for the management
of FBO depending on admitting specialty. We
advocate an FBO protocol involving single specialty
management, flexible OGD, ≥6 biopsies from the
upper and lower oesophagus, and standardisation
of oesophageal biopsy reports with a formal
eosinophil count.
achieved using vicryl endoloops, but increasing evidence suggests that the use of polymeric clips (Hem-o-lok) may be a
safe and viable method. Current evidence for its clinical use in laparoscopic appendicectomy is unknown. We performed a
systematic review of the literature examining the clinical outcomes of laparoscopic appendicectomy using polymeric clips
compared to other methods of stump closure.
Methods A systematic literature review based on PRISMA guidelines was performed using MEDLINE, PubMed, EMBASE
and Cochrane library databases between 2000 and 2017. All studies analysing appendiceal stump closure during laparoscopic
appendicectomy using polymeric clips compared to other methods of stump closure were included. The methodological quality
of the included studies was assessed using the Cochrane Handbook for Systematic Reviews. The review was registered
with the PROSPERO register of systematic reviews.
Results Ten studies were included, involving 702 patients, 7 of which were prospective studies and 1 a randomised control
trial. Polymeric clips were found to be the cheapest method (€20.47 average per patient) and also had the lowest rate of
complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of inpatient
stay were similar between groups.
Conclusions Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in
laparoscopic appendicectomy for acute appendicitis. Further high-quality evidence is required before polymeric clips can
be recommended as the gold standard for appendiceal stump closure.
Keywords Appendicectomy · Stump closure · Polymeric clips
Colorectal polyp cancers present clinicians
with a treatment dilemma. Decisions regarding whether
to offer segmental resection or endoscopic surveillance
are often taken without reference to good quality
evidence. The aim of this study was to develop a
treatment algorithm for patients with screen-detected
polyp cancers.
Design
This national cohort study included all patients
with a polyp cancer identified through the Scottish
Bowel Screening Programme between 2000 and 2012.
Multivariate regression analysis was used to assess the
impact of clinical, endoscopic and pathological variables
on the rate of adverse events (residual tumour in
patients undergoing segmental resection or cancerrelated
death or disease recurrence in any patient). These
data were used to develop a clinically relevant treatment
algorithm.
Results
485 patients with polyp cancers were included.
186/485 (38%) underwent segmental resection and
residual tumour was identified in 41/186 (22%). The
only factor associated with an increased risk of residual
tumour in the bowel wall was incomplete excision of the
original polyp (OR 5.61, p=0.001), while only
lymphovascular invasion was associated with an
increased risk of lymph node metastases (OR 5.95,
p=0.002). When patients undergoing segmental
resection or endoscopic surveillance were considered
together, the risk of adverse events was significantly
higher in patients with incomplete excision (OR 10.23,
p<0.001) or lymphovascular invasion (OR 2.65,
p=0.023).
Conclusion
A policy of surveillance is adequate for the
majority of patients with screen-detected colorectal polyp
cancers. Consideration of segmental resection should be
reserved for those with incomplete excision or evidence
of lymphovascular invasion.
patients undergoing treatment at weekends may
be subject to different care processes and
outcomes compared with weekdays. This study
aimed to determine whether clinical outcomes
from weekend appendicectomy are different
from those performed on weekdays.
Method Multicentre cohort study during May–
June 2012 from 95 centres (89 within the UK).
The primary outcome was the 30-day adverse
event rate. Multilevel modelling was used to
account for clustering within hospitals while
adjusting for case mix to produce adjusted ORs
and 95% CIs.
Results When compared with Monday, there
were no significant differences for other days of
the week considering 30-day adverse events in
adjusted models. On Sunday, rates of simple
appendicitis were highest, and rates of normal
(OR 0.62, 95% CI 0.42 to 0.90) and complex
appendicitis (OR 0.65, 95% CI 0.46 to 0.93)
lowest. This was accompanied by a 43% lower
likelihood in use of laparoscopy on Sunday (OR
0.47, 95% CI 0.32 to 0.69), accompanied by the
lowest level of consultant presence for the week.
When pooling weekends and weekdays,
laparoscopy use remained less likely at the
weekend (OR 0.68, 95% CI 0.55 to 0.83), with
no significant difference for 30-day adverse event
rate (OR 1.01, 95% CI 0.80 to 1.29).
Conclusions This study found that weekend
appendicectomy was not associated with
increased 30-day adverse events. It cannot rule
out smaller increases that may be shown by larger
studies. It further illustrated that patients operated
on at weekends were subject to different care
processes, which may expose them to risk.
by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in
children may differ between such units.
Methods: This multicentre observational study included all children (aged less than 16 years) who had
an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome
was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of
ultrasound imaging and laparoscopy, and consultant involvement in procedures.
Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general
surgery units (461 children) were included. Children treated in paediatric surgery units were younger
and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant
present at the procedure, and histologically advanced appendicitis than children treated in general
surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio
(OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P <0·001), and the difference persisted after
adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P <0·001).
Female sex and preoperative ultrasonography, but not age, were significantly associated with normal
appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The
unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units
(OR 1·90, 1·18 to 3·06; P =0·011). When adjusted for case mix and consultant presence at surgery, no
statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59,
0·93 to 2·73; P =0·091).
Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a
more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery
units. Service provision differs between paediatric and general surgery units.
determination of reliable quality markers. This study aimed to investigate variation in provision and
outcome of emergency appendicectomy.
Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was
performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate;
secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and
binary logistic regression models to identify patient- and hospital-related predictors of outcome.
Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was
performed in 66·3 per cent of patients (range in centres performing more than 25 appendicectomies
over the study period: 8·7–100 per cent). A histologically normal appendix was removed in 20·6 per
cent of patients (range in centres performing more than 25 procedures: 3·3–36·8 per cent). Funnel
plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy
rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently
associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day
morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates.
Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of
higher perforation rates.
Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among
hospitals. Organizational factors leading to this variation have been identified and should be addressed
to improve performance.