Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer.

BACKGROUND: The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS: This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS: A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION: In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient.

BACKGROUND: Failure to rescue (FTR) denotes mortality from post-operative complications after surgery with curative intent. High-volume, low-mortality units have similar complication rates to others, but have lower FTR rates. Effective response to the deteriorating post-operative patient is therefore critical to reducing surgical mortality. Resilience Engineering might afford a useful perspective for studying how the management of deterioration usually succeeds and how resilience can be strengthened. METHODS: We studied the response to the deteriorating patient following emergency abdominal surgery in a large surgical emergency unit, using the Functional Resonance Analysis Method (FRAM). FRAM focuses on the conflicts and trade-offs inherent in the process of response, and how staff adapt to them, rather than on identifying and eliminating error. 31 semi-structured interviews and two workshops were used to construct a model of the response system from which conclusions could be drawn about possible ways to strengthen system resilience. RESULTS: The model identified 23 functions, grouped into five clusters, and their respective variability. The FRAM analysis highlighted trade-offs and conflicts which affected decisions over timing, as well as strategies used by staff to cope with these underlying tensions. Suggestions for improving system resilience centred on improving team communication, organisational learning and relationships, rather than identifying and fixing specific system faults. CONCLUSION: FRAM can be used for analysing surgical work systems in order to identify recommendations focused on strengthening organisational resilience. Its potential value should be explored by empirical evaluation of its use in systems improvement.

Treatment of left-sided colonic emergencies: a comparison of US and UK surgical practices.

BACKGROUND: Surgeons are increasingly considering resection and primary anastomosis when treating left-sided colonic obstruction or perforation in preference to the more traditional staged procedures. Previous studies in the United Kingdom (UK) and United States of America (USA) have suggested a greater interest in single-staged procedures amongst UK surgeons. This study was aimed to directly compare the treatment preferences between UK and US surgeons. METHOD: A questionnaire, designed to determine the procedure of choice when faced with left-sided colonic emergencies in patients with good and poor anaesthetic risk, was sent to 500 surgeons in the UK and 500 surgeons in the USA. RESULTS: UK surgeons were more likely to perform resection, primary anastomosis and on-table colonic lavage in patients with sigmoid obstruction (good anaesthetic risk: P < 0.0001; poor risk: P < 0.01) and sigmoid perforation (good risk: P < 0.0001). In good-risk patients with sigmoid obstruction, US surgeons were more likely than UK to choose Hartmann's procedure (P < 0.0001). US surgeons performing primary anastomosis were less likely to perform on-table lavage. CONCLUSION: Single-stage procedures are widely accepted as viable treatment options in both the UK and the USA when dealing with left-sided colonic emergencies. British surgeons are more likely to favour single-staged procedures, particularly with on-table colonic lavage, when compared with US surgeons.

Meta-analysis of peritoneal lavage in appendicectomy.

Background: The use of peritoneal lavage to prevent postoperative intra-abdominal abscess (IAA) after appendicectomy has been debated widely. Methods: A systematic review and meta-analysis of suction alone versus lavage for appendicitis was performed to determine the relative benefit of lavage. Primary outcomes were postoperative IAA and wound infection (WI). Inclusion criteria were human studies reporting a comparison of appendicectomy with or without peritoneal lavage. Results: Eight studies met the inclusion criteria, the majority of which were retrospective. Only three were RCTs. Four studies included analysis only of the paediatric population. The rate of IAA was 1·0-19·5 per cent in patients receiving suction alone and 1·5-18·6 per cent in those having lavage. WI rates were 1·0-29·2 per cent for suction alone and 0·8-20·5 per cent for lavage. The pooled risk difference for IAA was 0·01 (95 per cent c.i. -0·03 to 0·06; P = 0·50) and that for WI was 0·00 (-0·05 to 0·05; P = 0·98). Analyses of both outcomes indicated a medium degree of heterogeneity between effect estimates with I 2 values of 71 per cent (P = 0·001) and 70 per cent (P = 0·010) for IAA and WI respectively. Conclusion: There is no evidence of benefit of lavage over suction for postoperative infective complications, and no individual study demonstrated a significant benefit in patients receiving lavage.

The role of antimicrobial sutures in preventing surgical site infection.

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group.

BACKGROUND: Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas. METHODS: This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS). RESULTS: 1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality. CONCLUSION: This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy.

INTRODUCTION: The aim of this study was to review changes in the management of acute appendicitis in a ten-year period at a large university teaching hospital in London. METHODS: This was a retrospective cohort study reviewing the medical records of patients who underwent an appendicectomy over a period of 12 months either in 1999 or 2009. Data collected included use of radiological investigations (ultrasonography, computed tomography [CT]), technique of appendicectomy (open [OA] or laparoscopic [LA]), operative time, histopathology and post-operative complications. Univariate and multivariate analysis was performed to assess the influence of variables on the incidence of negative appendicectomy, appendiceal perforation and post-operative complications. RESULTS: All of the patients operated on in 1999 (n=109) had OA. Of the patients operated on in 2009 (n=164), 67 had OA, 91 had LA and 6 had LA converted to OA. None of the patients in 1999 had CT whereas in 2009 26% of patients had CT (sensitivity 94.7%, specificity 75.0%). This increased use of pre-operative imaging had no effect on negative appendicectomy (25.7% vs 12.8%, p=0.445), perforation (30.0% vs 21.3%, p=0.308) or complication rates (9.2% vs 10.4%). The complication rate was also similar regardless of whether patients had OA or LA (11.9% vs 9.9%). Multivariate analysis revealed that age was the only predictor of negative appendicectomy (p=0.029) or perforation (p=0.014). CONCLUSIONS: This study shows that significant increase in the use of pre-operative imaging and laparoscopy in the management of patients with acute appendicitis failed to reduce negative appendicectomy, perforation and complications rates. The patient's age was the only predictor of negative appendicectomy and perforation.

The incremental value of dual modality PET/CT imaging over PET imaging alone in advanced colorectal cancer.

BACKGROUND: (18)Fluoro-2-Deoxy Glucose (18 FDG) positron emission tomography (PET) impacts upon the management of recurrent colorectal cancer (CRC) but is limited by anatomical localisation. The development of integrated positron emission and computerised tomography (PET/CT) yields high anatomical resolution combined with the PET data. We evaluate the added value of PET/CT over PET alone. METHOD: Thirty-one consecutive patients had PET/CT for suspected recurrent CRC. Two blinded observers (A and B) reported images from PET alone and from integrated PET/CT. Lesion detection, lesion localisation, diagnostic certainty and impact on surgical management was assessed for each data set and then compared. The minimum clinical follow up was for 8 months (median 9.6 months) and 7 patients had histological confirmation of diagnosis. RESULTS: Compared to PET alone, PET/CT the percentage of lesions accurately localised increased from 96% to 99% for observer A and 86% to 99% for Observer B. PET/CT increased the number of lesions reported as definitely abnormal or normal from 78% to 95% for Observer A and from 72% to 94% for Observer B. Surgical management was changed in 6 patients (19%). Inter-observer variability was reduced with PET/CT. CONCLUSION: PET/CT improves the accuracy of reporting in recurrent colorectal cancer and influences surgical management in a significant proportion of patients when compared to PET only imaging.