Improved fistula plug outcome depends on the type of plug: a single-centre retrospective study.

AIM: Fistula-in-ano is a common condition that is potentially difficult to treat. In recent years 'sphincter-sparing' procedures have increased in popularity due to the lower rates of reported complications, such as incontinence. One such treatment is the fistula plug, which has seen varied success compared with other techniques. There are currently several plugs on the market and it is possible that difference in outcomes could be linked to the type of plug used. The aim of this study was to compare healing and complication rates between two fistula plugs in a single tertiary referral centre in the UK. METHOD: We conducted a single-centre retrospective analysis of all patients over the age of 18 years who underwent elective fistula plug insertion, with two different fistula plugs over a 13-year period. RESULTS: A total of 113 patients underwent fistula plug insertion (plug A n = 90; plug B n = 23). Plug B had been on the market for the final 4 years of the study period, hence the differing patient numbers. There was no difference in patient demographics, fistula type or aetiology of the fistula between the two plugs. Plug B had a significantly higher fistula healing rate compared with plug A (56.5% vs. 12.2%; p < 0.005). A quarter of all patients experienced a complication, 93% being those who had fistula plug A inserted. The most common complication was extrusion of the plug within 72 h of insertion. CONCLUSION: This study demonstrated significantly different outcomes according to the type of fistula plug used. Whilst current randomized controlled trials have not found a significant difference in healing rates when comparing one type of fistula plug to other treatment modalities, this study suggests that plug type may influence efficacy.

EAES, SAGES, and ESCP rapid guideline: bowel preparation for minimally invasive colorectal resection.

BACKGROUND: Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline. OBJECTIVE: The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej . CONCLUSION: This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders. Guideline registration number PREPARE-2023CN045.

Management of Acutely Symptomatic Hernia (MASH) study.

BACKGROUND: Acutely symptomatic abdominal wall and groin hernias are a common reason for acute surgical hospital admissions. There are limited data to guide the treatment of these patients. This study aimed to assess outcomes of emergency hernia surgery and identify common management strategies, to improve care for these high-risk patients. METHODS: A 20-week, national multicentre, collaborative, prospective cohort study (NCT04197271) recruited adults with acutely symptomatic abdominal wall and groin hernias across the UK. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing were collected. Follow-up telephone calls at 30 and 90 days were used to assessed complications and quality of life. Descriptive analyses were undertaken to describe the population and outcomes. RESULTS: Twenty-three hospitals recruited 272 eligible patients. Inguinal (37.8 per cent) and umbilical (37.1 per cent) hernias were the most common. Some 13.9 per cent were awaiting elective surgery and 12.8 per cent had previously declined intervention. CT was performed in 47.1 per cent and 81.3 per cent underwent surgical management. Open repairs were carried out in 93.5 per cent, and 92.5 per cent of these were performed under general anaesthesia. Four of 13 laparoscopic procedures were converted to open surgery. Mesh was used in 55.1 per cent of repairs, typically synthetic non-absorbable (87.4 per cent). Complications were infrequent; surgical-site infection (9.4 per cent), delirium (3.2 per cent), and pneumonia (2.3 per cent) were the most common. The 90-day mortality rate was 4.9 per cent. Immediate surgical management was associated with a significant improvement in quality of life at 30 days (median score 0.73-0.82). CONCLUSION: There is variation in the investigation, management, and surgical technique used to treat acutely symptomatic abdominal wall and groin hernias in the UK. The optimal management strategy for specific acute presentations remains to be established. Presented to the Association of Surgeons in Training Conference, Birmingham, UK, March 2021, the Association of Surgeons of Great Britain and Ireland Congress, May 2021, the World Society of Emergency Surgery, Edinburgh, UK, September 2021, and the European Hernia Society Congress, Copenhagen, Denmark, October 2021.

Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff.

AIM: Guidelines benefit patients and clinicians by distilling evidence into easy-to-read recommendations. The literature around the management of haemorrhoids is immense and guidelines are invaluable to improve treatment integrity and patient outcomes. We identified current haemorrhoid guidelines and assessed them for quality and consistency. METHODS: A systematic search of the literature from January 2011 to October 2021 was carried out. Guidelines identified were assessed for quality using the AGREE II instrument and for consistency in terms of tabulated treatment recommendations. RESULTS: During this period nine guidelines were identified worldwide. The general quality was poor with only one guideline considered of high enough quality for use. In general, expert selection criteria for guideline development groups were vaguely defined. There were inconsistencies in the interpretation of the published evidence leading to variation in treatment recommendations. DISCUSSION: Fewer, higher quality guidelines, with more consistent results, are needed. Particular attention should be given to defining the selection of experts involved.

Surgical site infections after emergency hernia repair: substudy from the Management of Acutely Symptomatic Hernia (MASH) study.

INTRODUCTION: Acutely symptomatic abdominal wall and groin hernias (ASH) are a common acute surgical presentation. There are limited data to guide decisions related to surgical repair technique and use of antibiotics, which can be driven by increased risk of surgical site infection (SSI) in this group. This study aims to report rates of SSI following ASH repair and explore the use of patient-reported outcome measure reporting in this setting. METHODS: An 18-week, UK-based, multicentre prospective cohort study (NCT04197271) recruited adults with ASH. This study reports operatively managed patients. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing (Bluebelle score) were collected. Descriptive analyses were performed to estimate event rates of SSI and regression analysis explored the relationship between Bluebelle scores and SSI. The 30 and 90-day follow-up visits assessed complications and quality of life. RESULTS: The MASH study recruited 273 patients, of whom 218 were eligible for this study, 87.2 per cent who underwent open repair. Mesh was used in 123 patients (50.8 per cent). Pre- and postoperative antibiotics were given in 163 (67.4 per cent) and 28 (11.5 per cent) patients respectively. There were 26 reported SSIs (11.9 per cent). Increased BMI, incisional, femoral, and umbilical hernia were associated with higher rates of SSI (P = 0.006). In 238 patients, there was a difference in healthy utility values at 90 days between patients with and without SSI (P = 0.025). Also, when analysing 191 patients with Bluebelle scores, those who developed an SSI had higher Bluebelle values (P < 0.001). CONCLUSION: SSI is frequent in repair of acutely symptomatic hernia and correlates with BMI and site of hernia.

Malnutrition, nutritional interventions and clinical outcomes of patients with acute small bowel obstruction: results from a national, multicentre, prospective audit.

OBJECTIVE: The aim of this study was to assess the nutritional status of patients presenting with small bowel obstruction (SBO), along with associated nutritional interventions and clinical outcomes. DESIGN: Prospective cohort study. SETTING: 131 UK hospitals with acute surgical services. PARTICIPANTS: 2069 adult patients with a diagnosis of SBO were included in this study. The mean age was 67.0 years and 54.7% were female. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was in-hospital mortality. Secondary outcomes recorded included: major complications (composite of in-hospital mortality, reoperation, unplanned intensive care admission and 30-day readmission), complications arising from surgery (anastomotic leak, wound dehiscence), infection (pneumonia, surgical site infection, intra-abdominal infection, urinary tract infection, venous catheter infection), cardiac complications, venous thromboembolism and delirium. RESULTS: Postoperative adhesions were the most common cause of SBO (49.1%). Early surgery (<24 hours postadmission) took place in 30.0% of patients, 22.0% underwent delayed operation and 47.9% were managed non-operatively. Malnutrition as stratified by Nutritional Risk Index was common, with 35.7% at moderate risk and 5.7% at severe risk of malnutrition. Dietitian review occurred in just 36.4% and 55.9% of the moderate and severe risk groups. In the low risk group, 30.3% received nutritional intervention compared with 40.7% in moderate risk group and 62.7% in severe risk group. In comparison to the low risk group, patients who were at severe or moderate risk of malnutrition had 4.2 and 2.4 times higher unadjusted risk of in-hospital mortality, respectively. Propensity-matched analysis found no difference in outcomes based on use or timing of parenteral nutrition. CONCLUSIONS: Malnutrition on admission is associated with worse outcomes in patients with SBO, and marked variation in management of malnutrition was observed. Future trials should focus on identifying effective and cost-effective nutritional interventions in SBO.

UK-based, multisite, prospective cohort study of small bowel obstruction in acute surgical services: National Audit of Small Bowel Obstruction (NASBO) protocol.

INTRODUCTION: Small bowel obstruction (SBO) is a common indication for emergency laparotomy in the UK, which is associated with a 90-day mortality rate of 13%. There are currently no UK clinical guidelines for the management of this condition. The aim of this multicentre prospective cohort study is to describe the burden, variation in management and associated outcomes of SBO in the UK adult population. METHODS AND ANALYSIS: UK hospitals providing emergency general surgery are eligible to participate. This study has three components: (1) a clinical preference questionnaire to be completed by consultants providing emergency general surgical care to assesses preferences in diagnostics and therapeutic approaches, including laparoscopy and nutritional interventions; (2) site resource profile questionnaire to indicate ease of access to diagnostic services, operating theatres, nutritional support teams and postoperative support including intensive care; (3) prospective cohort study of all cases of SBO admitted during an 8-week period at participating trusts. Data on diagnostics, operative and nutritional interventions, and in-hospital mortality and morbidity will be captured, followed by data validation. ETHICS AND DISSEMINATION: This will be conducted as a national audit of practice in conjunction with trainee research collaboratives, with support from patient representatives, surgeons, anaesthetists, gastroenterologists and a clinical trials unit. Site-specific reports will be provided to each participant site as well as an overall report to be disseminated through specialist societies. Results will be published in a formal project report endorsed by stakeholders, and in peer-reviewed scientific reports. Key findings will be debated at a focused national meeting with a view to quality improvement initiatives.

The TONK score: a tool for assessing quality in trauma and orthopaedic note-keeping.

INTRODUCTION: Medical case notes are the only lasting interpretation of a patient-physician interaction and are important for good quality patient care. Accurate, legible and contemporaneous note-keeping is important however it can be substandard. This can lead to errors in handover of patients and to medicolegal vulnerability. We present a comprehensive auditing tool for Trauma & Orthopaedics medical case notes and our experience in using it over the last 12 months. PATIENTS AND METHODS: The TONK score was developed from a pre-existing system with some additions for Trauma & Orthopaedic case notes, with the incorporation of a legibility scoring system. An initial audit was carried out evaluating the case notes for each team against the TONK score. In order to evaluate the reproducibility of this score, we employed the Cohen's Kappa coefficient and noted substantial agreement. The individual team scores were analysed and the audit cycle completed four months later with the provision of feedback. RESULTS: Our first audit revealed a mean of 81 with a range from 70 to 90. Subsequent audits over the next two quarters revealed mean scores in excess of 90. Significant improvement has been noted in all areas of documentation and it has been decided to conduct this audit every six months in our department. CONCLUSIONS: The TONK score is an easy, quick and reproducible tool, which aims to eliminate the weaknesses in Trauma & Orthopaedic medical note-keeping. It emphasises the medicolegal importance of accurate medical note-keeping to doctors at all levels of training.

A UK perspective on smartphone use amongst doctors within the surgical profession.

INTRODUCTION: Hospitals are increasingly looking for mobile solutions to meet their information technology needs. Medical professionals are using personal mobile devices to support their work, because of limitations in both time and space. Our aims were to assess smartphone use amongst UK surgical doctors, the prevalence of medical app use and online activity. METHODS: A thirteen-item questionnaire was derived to identify the proportion of surgical doctors of all grades using smartphones within the workplace. The following factors were evaluated: use of medical apps; use of online medical resources and if users were willing to use their own smartphone for clinical use. RESULTS: A total of 341 participants were surveyed with a complete response rate: 93.5% of which owned a smartphone, with 54.2% of those owning medical apps and 86.2% using their device to access online medical resources. Junior doctors were more likely to use medical apps over their senior colleagues (p = 0.001) as well as access the Internet on their smartphone for medical information (p < 0.001). Overall, 79.3% stated that they would be willing to use their smartphone for clinical use, which was found not to be dependent on seniority (p = 0.922). CONCLUSION: Online resources contribute significantly to clinical activities with the majority of smartphone users willing to use their own device. The information gathered from this study can aid developers to create software dedicated to the smartphone operating systems in greatest use and to potentially increase the use of a bring your own device (BYOD) scheme.

The 2-week wait service: a UK tertiary colorectal centre's experience in the early identification of colorectal cancer.

OBJECTIVES: National Institute for Health and Clinical Excellence (NICE) guidelines were introduced in the UK to ensure that patients with high-risk symptoms of colorectal cancer were reviewed promptly. We assessed the proportion of patients referred to our department's nurse-led 2-week wait (2WW) clinic with high-risk symptoms or signs that met these guidelines and the rate of colorectal cancer pickup. PATIENTS AND METHODS: Patients were identified from a prospectively maintained logbook of 2WW referrals over a 1-year period (1 January 2008-31 December 2008). Computerized notes were reviewed to obtain the following information: referral symptoms or signs and the proportion of patients diagnosed with colorectal cancer. RESULTS: A total of 720 patients were seen in the 2WW clinic over this period. Only 356/720 (49.4%) met the referral criteria. The overall pickup rate of colorectal cancer was 52/720 (7.2%) and was not found to be significantly higher in patients meeting guidelines compared with those who did not exhibit these features (7.6 vs. 6.9%; P=0.771). Over the 5-year follow-up period, no patients discharged from the 2WW pathway subsequently re-presented with colorectal cancer. CONCLUSION: Over half of the referrals did not meet the NICE criteria, suggesting that the system is being used as a rapid access route to investigation. Despite this, there is no significant difference in the pickup rate of colorectal cancer in patients with or without high-risk features. Nurse-led 2WW clinics with subsequent investigation appear to be effective in both the identification and exclusion of colorectal cancer.

A survey to determine the potential impact of foundation year career aims on surgical specialty training.

INTRODUCTION: The competition for Core Surgical Training (CST) positions and subsequent Surgical Specialty Training (ST3) posts throughout the UK is fierce. Our aim was to conduct a pilot study to assess whether current foundation year doctors were considering pursuing a career in surgery and the reasons guiding their decisions. METHODS: A ten-item questionnaire was voluntarily completed by foundation doctors at a large acute teaching trust. Factors evaluated included: experience working within a surgical rotation; previous consideration of a career in surgery; whether they found a career in surgery appealing; reasons guiding their decision and would they be applying to CST. RESULTS: All 67 foundation doctors approached agreed to participate: of which 56 (83.6%) had experience working within a surgical rotation. Males were significantly more likely to find a career in surgery appealing (p < 0.001). Although 20 (29.9%) had previously considered a surgical career, only 11 (16.4%) would be applying to CST. Reasons for finding a career in surgery appealing included: job satisfaction (84.2%), diversity of work (79.0%) and working environment/colleagues (47.4%). Of those that did not consider a career in surgery to be appealing, reasons included: working hours (75.0%), work/life balance (62.5%), working environment/colleagues (50%). DISCUSSION AND CONCLUSION: Although only a small proportion of current foundation doctors were surveyed in our study, only 16.4% were considering applying for CST. These figures are lower than previously suggested and would indicate that there will be fewer applicants for CST in future years, which may potentially reduce the current bottleneck of applicants at ST3.

The role of endorectal ultrasound and magnetic resonance imaging in the management of early rectal lesions in a tertiary center.

BACKGROUND: In early rectal cancer, ERUS has a vital role in determining radical or local excision based on identification of T-stage. Transanal endoscopic microsurgery (TEMs) has a reduced morbidity and mortality compared with radical surgery. Correct identification of lesions that can be managed with TEMs is therefore imperative. Our aim was to assess the accuracy of ERUS in identifying mucosal/submucosal lesions and thus their suitability for TEMs. PATIENTS AND METHODS: A retrospective analysis of a prospectively maintained database of patients who underwent ERUS was carried out over an initial 25-month period at a tertiary colorectal center. Our main outcome measures were T-stage measured using ERUS or magnetic resonance imaging (MRI) (indicating suitability for local excision, ie, ≤ T1) with correlation with that of the subsequent surgical specimen and improvement in accuracy over time. After data analysis and review, the study was repeated over the subsequent 12 months to establish whether there was a learning curve with the use of ERUS. RESULTS: Over the initial period, 52 patients who met the inclusion criteria underwent ERUS. T-staging was accurate in 73.1% (38/52) with identification of ≤ T1 lesions having a sensitivity of 70.8% and a specificity 100%. The accuracy, sensitivity, and specificity of MRI was similar to that of ERUS (72.7%, 70.0%, and 100% respectively). Over the subsequent period, 23 patients underwent ERUS with T-staging accuracy improving to 78.3% (18/23) (P = .777). CONCLUSION: In our experience, ERUS is a useful adjunct to clinical assessment and pelvic MRI in determining suitability for local excision. Its 100% specificity in determining that a lesion is limited to the mucosa or submucosa aids in the assessment of lesions that are being considered for submucosal resection. Over the time periods assessed, improvement in T-staging accuracy was demonstrated, which might be due to the presence of a learning curve.

Management of a complex recurrent perineal hernia.

Symptomatic perineal hernias following abdomino-perineal excision of rectum have been reported to occur uncommonly. We present the case of a 79-year-old gentleman who developed a perineal hernia after laparoscopic-assisted extralevator abdomino-perineal excision (ELAPE) of the rectum. Despite initial myocutaneous flap repair, there was further symptomatic recurrence. Magnetic resonance imaging demonstrated non-compromised bowel extending beneath the gracilis flap with extension into the adductor compartment of the left thigh. Given the recurrent nature, a rectus flap repair was performed and after 15 months, he remains hernia free. There is currently no consensus as to the optimal operative technique in the prevention and management of these hernias; however, primary reconstruction at the time of ELAPE may be preferable. Symptomatic perineal hernias can be severely debilitating and require operative repair. We suggest that surgical options should be discussed and carried out with the input of a Plastic surgeon.

A Prospective Randomized Control Study on Patient's Recall of Consent after Hand Surgery: How Much They Want to Know?

Informed consent implies that the person undergoing an intervention thoroughly understands its pros and cons. We conducted a randomized control trial to evaluate patients' recall of complications after day case hand surgery and how this can be influenced by age and/or socioeconomic factors. Patients' wishes on the extent and type of provided information were also evaluated. A total of 124 cases were recruited. Ten cases were excluded because they presented for follow up more than 2 weeks after surgery. The other patients were randomized into 2 groups: the first one (48) received only verbal information, while the second one (66) also received written information sheets. No statistically significant difference was noted in the recall between the two groups. No difference among gender, age or socioeconomic status was noted. Most patients preferred both written and verbal information. Preference for knowledge of rates of complications increased when surgery was dangerous. Our results don't show any significant difference in patients' recall depending on the type of consenting method. Nevertheless, we still propose that patients should receive as much information as possible before undergoing any intervention.