Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon.

Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31 min; 95% CI - 4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.

Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study.

AIM: Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. METHODS: Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. RESULTS: A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. CONCLUSION: This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.

Robotic beyond total mesorectal excision (TME) for locally advanced or recurrent rectal cancer: a systematic review protocol.

INTRODUCTION: The surgical treatment for locally advanced or recurrent rectal cancer requires oncological clearance with a pelvic exenteration or a beyond total mesorectal excision (TME). The aim of this systematic review is to explore the safety and feasibility of robotic surgery in locally advanced and recurrent rectal cancer by evaluating perioperative outcomes, oncological clearance rates, and survival and recurrence rates postrobotic beyond TME surgery. METHODS: The systematic review will include studies published until the end of December 2023. The MEDLINE, EMBASE and Scopus databases will be searched. The screening process, study selection, data extraction, quality assessment and analysis will be performed by two independent reviewers. Discrepancies will be resolved by consensus with a third independent reviewer. The risk of bias will be assessed with validated scores. The primary outcomes will be oncological clearance, overall and disease-free survival, and local and systemic recurrence rates post robotic or robot-assisted beyond TME surgery for locally advanced or recurrent rectal cancer. Secondary outcomes will include perioperative outcomes. ETHICS AND DISSEMINATION: No ethical approval is required for this systematic review as no individual patient cases are studied requiring access to individual medical records. The results of the systematic review will be disseminated with conference presentations and peer-reviewed paper publications. PROSPERO REGISTRATION OF THE STUDY: CRD42023408098.

Effects of hippotherapy on motor function of children with cerebral palsy: a systematic review study.

Cerebral palsy includes a spectrum of neurodevelopmental disorders caused by brain damage, leading to impairment of movement, posture, and balance for a lifetime. There are many therapeutic interventions for cerebral palsy. One of them is hippotherapy, an alternative physical therapy. It is a type of equine-assisted activity and therapy where children with cerebral palsy and motor function skills interact with a horse. We aimed to study the effects of hippotherapy, as an alternative therapy, on the motor function of children with cerebral palsy. We performed a review of the latest literature on hippotherapy and cerebral palsy. The criteria we used were specific keywords, publication date, age of the subjects/studied population, and article type. The outcome of our research resulted in ten relevant studies. The findings demonstrate improvements in various aspects of motor function - more specifically in gross motor function skills, balance, coordination, gait parameters, and muscle strength. Two of ten studies used the Horse-Riding Simulator with significant improvements in postural control in sitting, motor function, and hip abduction range of motion. Hippotherapy can improve motor function skills of children between 2 and 14 years of age with cerebral palsy, affecting their well-being and overall quality of life. It can have a positive effect either as a standalone treatment or as a part of other traditional therapies. Extended research is needed to assess whether hippotherapy may present significant long-term changes in motor skills in children with cerebral palsy.

Postoperative chyle leak after major pancreatic resections in patients who receive enteral feed: risk factors and management options.

BACKGROUND: Chyle leak complicates 1.3-10.8 % of pancreatic resections. Universal use of parenteral nutrition following pancreatic resection may reduce the incidence of chyle leak. However, this denies the majority of patients who do not develop chyle leak the benefits of enteral nutrition (EN). The present study aimed to identify risk factors for chyle leak following pancreatic resection within a single institution where EN was used universally. METHODS: All patients who underwent pancreatic resection between January 2007 and December 2010 were identified retrospectively. The patients had been treated according to a common unit protocol of enteral feeding; those developing chyle leak were switched to a medium-chain triglyceride (MCT) regimen. Clinical progress and recovery after surgery was evaluated. Multivariate analysis was performed to identify factors associated with chyle leak. RESULTS: A total of 245 patients underwent major pancreatic resection (231 pancreatoduodenectomy, 14 total pancreatectomy). Chyle leak complicated 40 cases (16.3 %). After multivariate analysis, both extensive lymphadenectomy (P = 0.002) and postoperative portal/mesenteric venous thrombosis (PVT) (P = 0.009) were independently linked with a higher incidence of chyle leak. The development of chyle leak was not associated with poorer survival or prolonged duration of hospital stay. It was associated with a significantly increased duration of abdominal drainage and reduced likelihood of early hospital discharge (P = 0.026). CONCLUSIONS: Universal use of enteral feeding is associated with a high rate of chyle leak following pancreatic resection. Patients undergoing extensive lymphadenectomy or those who develop PVT postoperatively are at increased risk. Development of chyle leak was not associated with additional morbidity or mortality following implementation of an MCT regimen. The implication is that reactive management of chyle leak with conversion to a MCT predominant diet is safe.

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon.

BACKGROUND: Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes. METHODS: Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons. RESULTS: Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05). CONCLUSIONS: Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.

A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study.

CONTEXT: Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection. There is little evidence on the best route for delivery of enteral nutrition. Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy, or the nasojejunal route to deliver enteral nutrition, according to surgeon preference. OBJECTIVE: To compare morbidity, efficiency, and safety of these three routes for enteral nutrition following pancreaticoduodenectomy. PATIENTS: Data were obtained from a prospectively maintained database, for all patients undergoing pancreatic resection between January 2007 and June 2008. One-hundred pancreatic resected patients underwent enteral nutrition: 93 had Whipple's operations and 7 had total pancreatectomies. INTERVENTION: Enteral nutrition was delivered by agreed protocol, starting within 24 h of operation and increasing over 2-3 days to meet full nutritional requirement. RESULTS: Delivery route of enteral nutrition was: percutaneous transperitoneal jejunostomy in 25 (25%), percutaneous transperitoneal gastrojejunostomy in 32 (32%) and nasojejunal in 43 (43%). The incidence of catheter-related complications was higher in percutaneous techniques: 24% in percutaneous transperitoneal jejunostomy and 34% in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique (12%). Median time to complete establishment of oral intake was 14, 14 and 10 days in percutaneous transperitoneal jejunostomy, percutaneous transperitoneal gastrojejunostomy, and nasojejunal groups, respectively. Nasojejunal tubes were removed at median 11 days (mean 11.5 days) compared to 5-6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy. Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage (n=6; 10.5%), followed by pain after removal of feeding tube at 5-6 weeks (n=5; 8.8%), whereas in the nasojejunal group it was blockage (n=3; 7.0%), followed by displacement (n=2; 4.7%). Two patients died postoperatively in this cohort, however, there were no catheter-related mortalities. CONCLUSION: Enteral nutrition following pancreatic resection can be delivered in different ways. Nasojejunal feeding was associated with fewest and less serious complications. On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a randomized controlled trial is needed to address this issue.

Proctalgia and constipation secondary to hypertrophic polyglucosan inclusion body myopathy of the internal anal sphincter: a case report.

BACKGROUND: Hereditary polyglucosan inclusion body myopathy of the internal anal sphincter is a rare cause of proctalgia fugax and constipation. Treatment options are explored. CASE PRESENTATION: A 61 year-old Caucasian woman presented with an 18-year history of severe anal pain and constipation. She had no response to medical treatment which included amitriptyline and topically administered diltiazem. Endoscopy revealed no abnormalities, whereas endoanal ultrasound showed an abnormally thick internal anal sphincter (> 5 mm) and anal manometry showed intermittent episodes of very high resting pressures in excess of 200 mmHg that resolved spontaneously after 2 minutes. She had no relief of her symptoms after receiving an injection of botulinum toxin to the internal anal sphincter. She subsequently underwent a lateral internal anal sphincterotomy which led to complete resolution of her symptoms. CONCLUSIONS: Hereditary polyglucosan inclusion body myopathy of the internal anal sphincter should be considered in the differential diagnosis of a patient presenting with severe anal pain and constipation in the absence of an anal fissure or sepsis. If medical therapy with calcium antagonists fails to provide symptom relief, lateral internal sphincterotomy should be considered rather than botulinum toxin injection.

Neoadjuvant Long-Course Chemoradiotherapy for Rectal Cancer: Does Time to Surgery Matter?

The objective of this paper was to evaluate whether delaying surgery following long-course chemoradiotherapy for rectal cancer correlates with pathologic complete response. Pre-operative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer. Optimal timing of surgery following CRT is still not clearly defined. All patients with a diagnosis of rectal cancer who had undergone long-course CRT prior to surgery between January 2008 and December 2011 were included. Statistical analysis was performed using Stata 11. Fifty-nine patients received long-course CRT prior to surgery in the selected period. Twenty-seven percent (16/59) of patients showed a complete histopathologic response and 59.3% (35/59) of patients had tumor down-staging from radiologically-assessed node positive to histologically-proven node negative disease. There was no statistically significant delay to surgery after completion of CRT in the 16 patients with complete response (CR) compared with the rest of the group [IR: incomplete response; CR group median: 74.5 days (IQR: 70-87.5) and IR group median: 72 days (IQR: 57-83), P = 0.470]. Although no statistically significant predictors of either complete response or tumor nodal status down-staging were identified in logistic regression analyses, a trend toward complete response was seen with longer delay to surgery following completion of long-course CRT.

Early laparoscopic cholecystectomy in a district general hospital: is it safe and feasible?

BACKGROUND: Early laparoscopic cholecystectomy (ELC) is becoming the accepted treatment for the management of acute gallstone disease in specialist centres. It has also been achieved safely in the district general hospital (DGH) setting. We audited the management of acute gallstone disease in our DGH and set about to see if we could implement ELC safely and effectively. PATIENTS AND METHODS: A retrospective audit of 2 years of practice was performed using our hospital-computerised systems. Following this, departmental education regarding the benefits of early cholecystectomy was widely disseminated. Management guidelines were altered to promote and consider ELC for all suitable patients. A prospective audit of practice was then performed for 6 months. RESULTS: The first cycle revealed that only 10.42% of emergency patients admitted with gallstone-related disease had ELC. In the second cycle, 63 patients were admitted with acute gallstone disease. Three died from acute pancreatitis. Twenty-one (58%) of the 36, who were deemed suitable, had ELC. Fifteen (42%) had planned delayed laparoscopic cholecystectomy (DLC), with six (40%) being readmitted whilst waiting for their elective surgery (all undergoing ELC during their readmission). Conversion rates were similar between all groups. One of the patients having DLC had a bile leak, which settled following Endoscopic Retrograde Cholangiopancreatography and stent. CONCLUSION: We were able to increase ELC rates following the implementation of necessary changes. There did not appear to be any difference in conversion or morbidity rates between ELC and DLC. We conclude ELC is safe and feasible in the DGH setting.