Patient-reported impact of emergency laparotomy on employment and health status 1 year after surgery.

BACKGROUND: Whilst there has been significant improvement in mortality outcomes after emergency laparotomy, there is little information on longer term outcomes in the year after discharge. The main aim of the study was to assess the impact that an emergency laparotomy has on patients' and employment and health status 1 year after surgery. METHODS: This study was a questionnaire study conducted in a single centre district general hospital of patients who had undergone an emergency laparotomy between October 2015 and December 2016. Patients were included according to the National Emergency Laparotomy Audit criteria. At screening, patients who were alive at 1 year and had the capacity to consent were approached between January and December 2017. Patients underwent a researcher-led telephone interview using a semi-structured questionnaire to assess the impact of emergency laparotomy on overall, general and physical health (Glasgow Benefit Inventory) as well as employment status. The symptoms that patients experienced and their impact were also recorded. RESULTS: Forty-two patients responded to and completed the questionnaire. Just over one-third of patients experienced a deterioration in their general or physical health and 21% of patients experienced a change in employment. Factors which significantly impacted on health status were stoma issues, postoperative morbidity and a change in employment (p < 0.05). The main symptoms which patients identified as being troublesome were altered bowel habit and stoma issues with a resultant social and psychological impact. CONCLUSIONS: One-third of patients experienced a deterioration in their psychosocial and physical health status as well as a change in employment during the first-year postsurgery. Larger research studies are required to define the impact of emergency laparotomy on patients in the longer term and more research is needed to improve perioperative rehabilitation in the postoperative period to ensure optimal functional gain after technically successful surgery.

Scotland's "Incentivised Laparoscopy Practice" programme: Engaging trainees with take-home laparoscopy simulation.

BACKGROUND: The transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement worldwide, as for example in our 2014-15 study of an Incentivised Laparoscopy Practice programme (ILPv1). Drawing on learning from our subsequent multi-centre study examining barriers and facilitators, we revised the programme for 2018 onwards. We now report on engagement with the 2018-2022 versions of this home-based simulation programme (ILP v2.1-2.3). METHODS: In ILP v2.1-2.3, three consecutive year-groups of new-start Core Surgical Trainees (n = 48, 46 and 53) were loaned portable simulators. The 6-month education programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review (but not mandatory for progression). ILP was set within a wider reform, "Improving Surgical Training". RESULTS: ILP v2.1-2.3 saw pass rates of 94%, 76% and 70% respectively (45/48, 35/46 and 37/53 trainees), compared with only 26% (7/27) in ILP v1, despite now including some trainees not intending careers in laparoscopic specialties. The ILP v2.2 group all reported their engagement with the whole simulation strategy was hampered by the COVID19 pandemic. CONCLUSIONS: Simply providing take-home simulators, no matter how good, is not enough. To achieve trainee engagement, a whole programme is required, with motivated learners, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a "reform within a reform, within a context."

Peritoneal fluid biomarkers in the detection of colorectal anastomotic leaks: a systematic review.

PURPOSE: Anastomotic leak (AL) in colorectal surgery leads to significant morbidity, mortality and poorer oncological outcomes. Diagnosis of AL is frequently delayed as current methods of detection are not 100% sensitive or specific. 'Biomarkers', such as cytokines and markers of ischaemia, from the milieu of the anastomosis may aid early detection. This paper aims to review the evidence for their role in AL detection, allowing identification of targets for future research. METHODS: A systematic review was performed using PubMed, MEDLINE and Cochrane Library databases. Papers concerning detection or prediction of AL with biomarkers were identified. References within the papers were used to identify further relevant articles. RESULTS: Research has taken place in small cohorts with varying definitions of AL. Lactate has consistently been shown to be elevated in patients with intra-abdominal complications and ALs. pH on post-operative day 3 showed excellent specificity. Despite mixed results, a meta-analysis found that the cytokines tumour necrosis factor-α and interleukin-6 were elevated early in AL. Detection of bacteria in drain fluid by RT-PCR has good specificity but a high rate of false positives. CONCLUSIONS: Peritoneal cytokines, lactate and pH have the potential to identify AL early. The consistency of the results for lactate and pH, alongside the fact that they are easy, quick and inexpensive to test, makes them the most attractive targets. Studies in larger cohorts with standardized definitions of AL are required to clarify their usefulness. Emerging biosensor technology may facilitate the development of small, low-cost and degradable intra-abdominal devices to measure peritoneal fluid biomarkers.

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study.

BACKGROUND: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors. METHODS: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012-2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded. RESULTS: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20-0.60 95% CI and 0.47; 0.25-0.88, respectively). CONCLUSION: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

Improving surgical training: Establishing a surgical anatomy programme in Scotland.

BACKGROUND: It is well recognized that a sound foundation in surgical anatomy is a cornerstone of safe surgical practice, yet many trainees struggle with the upskilling in anatomy that is required to support their day-to-day practice. In the context of the UK-wide Improving Surgical Training pilot, we set out to establish a surgical anatomy programme for core surgical trainees in the Scotland Deanery. The aim was to enable all trainees to review the surgical anatomy of the whole body to MRCS level at least once during core surgical training. MATERIALS AND METHODS: Teaching was delivered in Edinburgh, with trainees commuting from all parts of the Scotland Deanery. Individual teaching days focused on the surgical anatomy of the head and neck, trunk and limbs, using a combination of lectures (principles and cases) and interactive demonstrations on prosected specimens. Faculty comprised a balance of surgical demonstrators and senior academic staff, including MRCS examiners. RESULTS: In total, 16 individual teaching sessions were attended by over 300 trainees across the first 2 years of the programme. Evaluation form response rate was nearly 80%. The programme was highly rated by trainees in relation to the method of delivery, level of teaching and surgical focus. CONCLUSION: Surgical anatomy remains an integral part of surgical training. Our experience in developing a deanery-wide surgical anatomy programme highlights the crucial links between medical school, training deanery and surgical college. This collaborative approach can be extended to higher surgical training and continuing professional development, and the methods can be adapted to meet the needs of trainees in different parts of the globe.

Early experience of a virtual journal club.

BACKGROUND: Traditional journal club models based on didactic presentation sessions followed by group discussion have many limitations. To overcome some of these shortcomings, a virtual journal club (VJC) using social media and e-mail was developed. The aim of this study was to report the initial experience of this novel multimodal e-learning platform to facilitate journal club discussion and promote the development of critical appraisal skills. METHODS: Journal articles were discussed monthly via e-mail and social media. After a 3-week period of discussion, all comments were collated and group-generated critical appraisal summaries were fed back to participants. In addition, letters to the journal editors based on the group appraisal were submitted. A questionnaire survey to evaluate the VJC concept was also conducted. FINDINGS: After eight cycles of the VJC, the mean trainee participation rate was 29.6 per cent (range 21.1-42.1%). Senior trainees (≥4 years of postgraduate experience) were more likely to participate than more junior trainees (75.0 versus 21.1%; p = 0.005). The majority of participants thought that the VJC was educationally valuable, easy to participate in, helpful in keeping up to date with recent papers and useful in developing critical appraisal skills. Barriers to participation were lack of time, motivation and lack of experience in critical appraisal. In addition, the group-generated critical appraisal summaries derived from VJC discussions led to eight published 'letters to the editor'. Traditional journal club models based on didactic presentation sessions followed by group discussion have many limitations CONCLUSION: This novel VJC model is a feasible and popular method of delivering a journal club in the postgraduate setting.

Laparoscopic adjustable gastric banding for severe obesity.

BACKGROUND: Morbid obesity is an increasingly common condition with serious associated morbidity and decreased life expectancy. The only treatment with long-term efficacy for this condition is surgical intervention. Laparoscopic adjustable gastric banding (LAGB) is a procedure increasingly performed in European centres and recently approved by the FDA in USA. This article reviews its effectiveness and complications. METHODS: A literature search identified relevant articles. RESULTS: LAGB results in approximately 60% (43-78%) excess weight loss at 3 years with improvement in co-morbidities, with perioperative mortality <0.5%. Potential complications include prolapse or pouch dilatation, and port-related complications. Less common complications are intra-operative gastric perforation and band erosion. Rate of reoperation varies greatly between series, and is usually needed for band repositioning or port-related procedures, many of the latter performed under local anesthesia. CONCLUSION: The available data demonstrate that LAGB is a safe bariatric procedure, and is effective in the short- and medium-term. Results of long-term follow-up are awaited.

Salmonellosis as a differential diagnosis.

With a low incidence of Salmonella infection, salmonellosis is an uncommon problem in Scotland. It occurs in both immune-compromised and immune-competent patients. We present two cases of salmonellosis in immune-competent patients who had had a history of gastroenteritis. Diagnosis was delayed in one patient; however, both patients received appropriate treatment and made good recovery following their respective illnesses. Apart from acting as a reminder to consider salmonellosis as a differential diagnosis when managing patients with infective process, the cases also highlight the importance of concise history taking, and the importance of cultures-and-sensitivities in managing infectious cases.

Timely computed tomography scan diagnoses spigelian hernia: a case study.

A spigelian hernia is a rare cause of acute abdominal pain and its diagnosis is often difficult to make. A CT scan of the patient demonstrated an incarcerated spigelian hernia containing small bowel which had subsequently reduced spontaneously. The patient underwent laparoscopic repair of her spigelian hernia the following day and made a fast and uneventful recovery. This case illustrates the importance of imaging a patient whilst symptomatic if the diagnosis of a spigelian hernia is entertained.