Impact of surgical complications on the operating surgeon.

AIM: The involvement of surgeons in major adverse outcomes can have a negative impact on their personal and professional lives, as well as on patient outcomes. Healthcare professionals involved in such incidents have been referred to as 'second victims'. We designed an online survey to study the impact of operative complications on surgeons' professional and personal lives. METHOD: An online survey of general, gastrointestinal, hepato-pancreato-biliary and vascular surgeons was conducted using the Twitter feed of the Association of Coloproctology of Great Britain and Ireland, the Association of Surgeons of Great Britain and Ireland and the European Society of Coloproctology over an 8-week period. RESULTS: Questionnaires were completed by 82 participants. Ninety-one per cent of respondents were consultant surgeons, 37% with more than 15 years' experience. Eighty-three per cent were colorectal surgeons. The majority of surgeons (95%) reported that their practice had been affected as a result of serious complications and 54% suggested that it had had a negative impact on their family life. Fifty-five per cent of respondents mentioned lack of support in their institution for healthcare professionals involved in adverse outcomes and an existing blame culture. Suggestions for improvement included mentoring (41%), counselling (38%), openness (66%), peer support groups (52%) and human factors training (32%). CONCLUSION: This survey highlights that the majority of surgeons involved in serious complications are adversely affected. Those involved in the running of surgical services need to improve support for surgeons in the aftermath of such events.

Clinical endodontic management during the COVID-19 pandemic: a literature review and clinical recommendations.

The spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in millions of confirmed cases and hundreds of thousands of deaths. Despite all efforts to contain the spread of the disease, the number of infections and deaths continue to rise, particularly in some regions. Given its presence in the salivary secretions of affected patients, and the presence of many reported asymptomatic cases that have tested positive for COVID-19, dental professionals, including Endodontists, are at high risk of becoming infected if they do not take appropriate precautions. As of today, there are no predictable treatments or approved vaccines that can protect the public and healthcare professionals from the virus; however, there is speculation that a vaccine might be available sometime in 2021. Until then, general dentists and Endodontist will need to be able to treat emergency patients in order to relieve pressure on emergency clinics in hospitals or local community hubs. In addition, as the pandemic continues, strategies to manage patients will need to evolve from a palliative to a more permanent/definitive treatment approach. In this article, an update on the treatment considerations for dental care in general is provided, as well as a discussion on the available endodontic guidelines reported in the literature. Recommendations on clinical management of endodontic emergencies are proposed.

Ileorectal anastomosis in ulcerative colitis: what do surgeons and patients need to know? A systematic literature review.

INTRODUCTION: Ileal pouch-anal anastomosis (IPAA) is currently the gold standard for restoration of gastrointestinal continuity after colectomy for ulcerative colitis in the UK. However, with further experience of the risks relating to IPAA, the use of ileorectal anastomosis (IRA) is being revisited. Decisions regarding restorative surgery after colectomy are individual to every patient's circumstances, and this paper aims to provide a comprehensive review of the literature to guide a full discussion of the risks and benefits of IRA. METHODS: A systematic literature review was conducted of papers published from 2000 onwards relating to IRA and ulcerative colitis, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The papers were reviewed by two independent surgeons for information it was felt that patients and surgeons would want to know about the operation (cancer risk, bowel function, sexual and urinary function, fecundity/fertility and postoperative complications). RESULTS: Seventeen papers were identified for inclusion as they reported original data on one or more of the categories identified for discussion. The median ten-year cancer risk after IRA was 2.8% and the median failure rate at ten years was 21%. IRA was generally found to have lower postoperative complication rates and better bowel function than IPAA, with sexual function similar and fecundity not commented on in any paper. CONCLUSIONS: For some patients, IRA can offer restorative surgery in the short or long term, with acceptable cancer risk, failure rate and postoperative complications, while avoiding the higher risks associated with IPAA.

A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation.

AIM: Despite advances in surgical technique, parastomal herniation is common. This systematic review aims to assess the efficacy of prophylactic mesh at primary operation in reducing the incidence of parastomal hernia. METHOD: Medline, EMBASE and CENTRAL were searched for relevant publications between January 1980 and January 2010. The search strategy included text terms and MESH headings for parastomal hernia, mesh and prevention and/or prophylaxis of hernia. No language restrictions were applied. Bibliographies from the papers requested in full were manually checked. All randomized controlled trials were included regardless of the language of publication. Results were extracted from the papers by two observers independently on a predefined data sheet. Disagreements were resolved by discussion. REVMAN 5 was used for statistical analysis. RESULTS: Of 27 possible studies three randomized controlled trials fulfilled the criteria for systematic review, with a total of 128 patients (mesh 64, no mesh 64). The two study groups were well matched demographically. The incidence of parastomal hernia in the mesh group was 12.5% (8/64) compared with 53% (34/64) in the control group (P < 0.0001). There was no difference in mesh related morbidity in the two groups. CONCLUSION: Although only three trials with 128 patients fulfilled the criteria for this systematic review, the data suggest that the use of prophylactic prosthetic mesh at the time of primary stoma formation reduces the incidence of parastomal hernia.

Short-term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians.

AIM: The 30-day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied. METHOD: An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded. RESULTS: In all, 173 patients (80 men) of median age 84 (80-93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14-45) kg/m(2). Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty-three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1-37) days. Three (1.7%) patients died within 30 days of surgery. CONCLUSION: This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.

Surgical site infection prevention bundle in elective colorectal surgery.

OBJECTIVE: Surgical Site Infections (SSIs) are responsible for a significant economic burden as well as intangible costs suffered by the patient, with up to 60% deemed preventable. Colorectal patients are disproportionally affected by SSI due the risk of wound contamination with bowel content. We aimed to reduce the rate of superficial SSI after elective colorectal surgery using a bundle of evidence-based interventions. METHODS: An SSI prevention bundle was implemented in elective colorectal surgery, comprised of triclosan-coated sutures, 2% chlorhexidine skin preparation and use of warmed carbon dioxide (CO2) during laparoscopic procedures. The SSI reduction strategy was prospectively implemented and compared with historical controls. Our primary outcome measure was the overall rate of superficial SSI. Centres for Disease Control and Prevention criteria, which use microbiological evidence in conjunction with clinical features were used as the definition of SSI. RESULTS: The overall SSI rate was 27.4% in the pre-bundle group (N = 208) and 12.5% in the patients who received the SSI prevention bundle (N = 184) (adjusted odds ratio 0.38; confidence interval 0.21-0.67; P<0.001). The median time to SSI diagnosis was postoperative day 8. Overall patient length of stay (LOS) was unchanged from six days at baseline following implementation of the bundle. CONCLUSIONS: We have shown successful implementation of an SSI prevention bundle which has reduced superficial SSI rate. We recommend this SSI prevention bundle becomes standard practice in elective colorectal surgery and plan to extend the bundle to emergency general surgery.

Colorectal cancer in the young - outcomes following surgical management?

INTRODUCTION: Colorectal cancer (CRC) is the third most common cancer, accounting for approximately 10% of all cancer deaths. The incidence of CRC in young adults and the adolescent population is increasing. This study aims to highlight short-term outcomes for young patients with CRC. METHODS: Data were collected retrospectively for all patients aged less than 50 years diagnosed with CRC at a university teaching hospital between October 2012 and June 2018. The primary endpoints were disease-free survival (DFS) and overall survival (OS). RESULTS: A total of 120 patients (65 males, 55 females) with CRC aged under 50 years were initially included; 20 did not receive surgical treatment (12 metastatic adenocarcinoma, 5 metastatic squamous cell cancer (SCC), 3 neuroendocrine tumours (NET)), and 13 patients had insufficient data for analysis and were excluded. A total of 87 patients underwent surgical intervention and 66 with diagnosis of adenocarcinoma were included in survival analysis. Median age of patients was 42 years (19-49 years). Cancer recurrence was seen in 14 patients, 10 showing local, 3 liver and 1 lung metastasis. The median OS was 28 months (3-156 months). The median DFS was 13 months (3-85 months). Overall 5-year survival and DFS were 72% and 59%, respectively. Median survival in the group who did not undergo surgery was 4.5 months (1-15 months). CONCLUSIONS: CRC is often more advanced and aggressive in younger patients. Current guidelines can result in young patients being investigated/treated for other gastrointestinal conditions before referral for CRC investigation.

Stoma complications: a literature overview.

Stoma formation is a commonly performed procedure in colorectal surgery as a part of operations performed for malignant- and inflammatory bowel disease. Stoma formation is a simple, but not trivial, undertaking. When performed badly, it can leave the patients with a legacy of complications such as leakage, prolapse, parastomal hernia and retraction. Various studies have reported a complication rate of 21-70%. We performed a literature search using the Medline, Ovid and Google scholar database for all the articles published between January 1980 and December 2008. The search terms used were colostomy, ileostomy, stoma, parastomal hernia, stenosis, prolapse, necrosis and complications. The following article summarizes the common complications associated with stomas.

Management of sigmoid volvulus using percutaneous endoscopic colostomy.

INTRODUCTION: The aim of this systematic review was to appraise the current literature on the use of percutaneous endoscopic colostomy (PEC) as an alternative to major surgery and endoscopic decompression alone for treating sigmoid volvulus in frail, comorbid patients. METHODS: A systematic literature search of literature published between April 2000 and January 2017 was carried out using the MEDLINE®, Embase™ and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases. The search terms were "percutaneous endoscopic colostomy", "PEC", "sigmoidopexy", "sigmoidostomy" and "sigmoid volvulus". The studies identified were screened and those that did not fulfil the inclusion criteria were excluded. FINDINGS: Seven observational studies and seven case reports (comprising eighty-one patients) were found to match our inclusion criteria. All patients had recurrent sigmoid volvulus and were treated with PEC either with a single PEC tube or with two PEC tubes inserted. Sigmoid volvulus recurred in 10 of the 81 patients; 3 of these individuals developed recurrence with PEC tubes in situ and 7 following tube removal. There were seven deaths after the procedure. The most frequent morbidity associated with PEC tube insertion was site infection (n=6). CONCLUSIONS: Our systematic review highlights the use of PEC as an alternative in managing recurrent sigmoid volvulus in frail, comorbid patients unfit for or refusing surgery, with the best outcomes seen in those patients where two PEC tubes were inserted and remained in situ indefinitely. Further studies are needed to improve the safety and efficacy of the procedure as well as post-procedure care.

Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis.

OBJECTIVE: Despite the high prevalence of hospitalization for left iliac fossa tenderness, there is a striking lack of randomized data available to guide therapy. The authors hypothesize that an oral antibiotic and fluids are not inferior to intravenous (IV) antibiotics and 'bowel rest' in clinically diagnosed acute uncomplicated diverticulitis. METHOD: A randomized controlled trial was constructed in two District General Hospitals. All clinically diagnosed patients presenting with acute uncomplicated diverticulitis were eligible for the study. Oral and IV regimens utilizing ciprofloxacin and metronidazole were compared. The primary outcomes studied were surrogates for resolution of symptoms (including tenderness on day 3 and length of stay) and failure of oral therapy. Secondary endpoints studied were serial constitutional and biomarker trends. RESULTS: There were 41 patients in the oral arm and 38 in the IV arm (n = 79). No patient had to be converted to IV antibiotics from the oral group. There was a complete resolution of symptoms in both groups. Tenderness was equivalent in both groups on day 3. Among secondary endpoints, a serial decrease in C reactive protein was the best serological predictor of resolution for both groups. CONCLUSION: Oral antibiotics are not inferior to intravenous antibiotics in achieving resolution of clinically diagnosed diverticulitis.

Two week rule referral for patients with colorectal cancer below the age of 50; are we being ageist?

OBJECTIVES: The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment. METHODS: The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years. RESULTS: There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria. CONCLUSION: Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Influence of prostate size on the outcome of holmium laser enucleation of the prostate.

OBJECTIVE: To analyse the effect of prostate size on the outcome of holmium laser enucleation of prostate (HoLEP, an established procedure for treating symptomatic benign prostatic hypertrophy, BPH), in the initial 354 patients at 1 year of follow-up. PATIENTS AND METHODS: We retrospectively reviewed the records of 354 patients who had HoLEP at our institution from April 2003 to March 2007. In 235 patients the prostate weighed <60 g (group 1), in 77 it weighed 60-100 g (group 2) and in 42 >100 g (group 3). Demographic data and perioperative variables were recorded and compared among the three groups. RESULTS: The mean prostate size was 38.1, 76.4 and 133.5 g for groups 1, 2 and 3, respectively (P < 0.001), and the respective mean weight of resected prostate was 18.47, 40.8 and 82.76 g, respectively (P < 0.001). The mean procedure efficiency increased from 0.36 g/min in group 1 to 0.49 g/min in group 2 and 0.58 g/min in group 3 (P < 0.001). The decrease in haemoglobin level after HoLEP was greater in group 3 than in the other groups. Overall, HoLEP resulted in a 75% reduction in American Urologic Association symptom score, a 225% increase in peak urinary flow rate and an 86% decrease in postvoid residual urine volume at 1 year of follow-up. Perioperative complications were evenly distributed among the three groups, except for a higher incidence of superficial bladder mucosal injury and stenotic complications in group 3. CONCLUSIONS: HoLEP is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and is associated with low morbidity. The efficiency of HoLEP increases with increasing prostate size.

Preoperative axillary staging in breast cancer-saving time and resources.

This study was performed to assess the feasibility and accuracy of ultrasound guided fine needle aspiration biopsy for axillary staging in invasive breast cancer. Data were collected prospectively from June 2005 to June 2006. In all, 197 patients with invasive breast cancer and clinically nonsuspicious axillary lymph nodes were included. Patients with suspicious nodes on ultrasound had fine needle aspiration biopsy. Those with fine needle aspiration biopsy positive for malignancy were planned for axillary nodes clearance otherwise they had sentinel node biopsy. Patients (41) had ultrasound guided fine needle aspiration biopsy. Three cases were excluded for being nonconclusive. Postoperative histology showed 18/38 cases (47.4%) axillary lymph nodes positive and 20/38 cases (52.6%) axillary nodes negative. Ultrasound guided fine needle aspiration biopsy was positive in 8/38 cases (21.1%), negative in 30/38 cases (78.9%). The sensitivity of ultrasound guided fine needle aspiration biopsy was found to be 47.1%, specificity 100%, positive predictability 100%, negative predictability 70%, and overall accuracy 76.3%. Ultrasound guided fine needle aspiration biopsy was found to be more accurate and sensitive when two or more nodes were involved, raising the sensitivity to 80% and negative predictability to 93.3%. Preoperative axillary staging with ultrasound guided fine needle aspiration biopsy in invasive breast cancer patients is very beneficial in diagnosing nodes positive cases. These cases can be planned for axillary lymph nodes clearance straightaway therefore saving patients from undergoing further surgery as well as time and resources.

Compliance with enhanced recovery protocols in elderly patients undergoing colorectal resection.

Introduction Enhanced recovery after surgery (ERAS) is associated with reduced length of stay (LOS) and improved outcomes in colorectal surgery. It is unclear whether ERAS can be safely implemented in elderly patients undergoing complex colorectal resections. The aim of this study was to evaluate the feasibility of ERAS in patients of all ages undergoing colorectal surgery. Methods A prospective database of a consecutive series of patients undergoing colorectal resections with ERAS between August 2012 and December 2014 was evaluated. Patients were divided into four age groups. Outcomes studied were compliance with ERAS elements, LOS, morbidity and mortality. Results Of the 294 patients in the study cohort, 79 were <60 years, 81 were 60-69 years, 86 were 70-79 years and 48 were ≥80 years of age. There was no significant difference between age groups in compliance with ERAS elements. Age was not predictive of delayed discharge (LOS >6 days) or morbidity. Factors that were predictive of delayed discharge on multivariate analysis were open surgery (odds ratio [OR]: 2.23, p=0.003), conversion to open surgery (OR: 3.23, p=0.017), stoma formation (OR: 2.10, p=0.019) and chronic obstructive pulmonary disease (OR: 4.12, p=0.038). Factors predictive of morbidity on multivariate analysis comprised conversion to open surgery (OR: 7.72, p=0.004), high creatinine (OR: 1.03 per unit increase in creatinine, p=0.008) and stoma education (OR: 0.31, p=0.030). Conclusions ERAS can be successfully implemented in older patients. There was equal compliance with the ERAS programme across the four age groups and no significant effect of age on LOS or morbidity.

Low molecular weight heparin prophylaxis in day case surgery.

BACKGROUND: The role of Low molecular weight heparins (LMWH) in day case/short-stay surgery is unknown. AIM: To characterise the current national use of LMWH prophylaxis in specific day and short stay surgeries. METHODS: A standardised anonymous postal questionnaire was sent to all consultant general surgeons in Ireland. The operations selected were herniorraphy, anorectal, varicose vein and laparoscopic cholecystectomy. RESULTS: Questionnaires were sent to 82 surgeons in 2003. There was a response rate of 68.3% (56). Fifty-four per cent of respondents said there was a protocol in place for administration of LMWH in day case surgery. Of these 41% were not confident that their protocols were being adhered. Fifty-nine per cent of all respondents said they stratified patients according to individual risk. Thirteen per cent reported occurrence of VTE post day case surgery CONCLUSION: This study demonstrates a heterogeneous pattern of administration of LMWH. In the absence of published validated protocols, the authors suggest a consensus day case protocol.

An audit of ultrasound-assisted catheter insertion in patients receiving chemotherapy.

BACKGROUND AND AIMS: Hickman catheters have been shown to provide safe long-term venous access for patients with malignant diseases. In many centres, catheters are placed using fluoroscopic guidance. We hypothesised that ultrasound-assisted catheter placement by surgeons in the operating theatre would be a simple, safe and effective alternative technique with reduced infective complication rates. METHODS: Hickman catheter insertions between May 1998 and March 2002 were studied. The data were collected from the Hospital Inpatient Enquiry database and the case notes of all patients were reviewed. Percutaneous catheter placement with tunnelling was performed in the operating theatre after scanning the internal jugular vein (IJV) for position, size and patency, using a Pie 100LC Scanner (Pie Medical, Maastricht). A standard chest radiograph confirmed catheter position at the end of the procedure. RESULTS: Fifty-eight patients (30 males and 28 females) had 65 Hickman catheters inserted. The median age was 60 years (range 32-82 years). Catheter placement was achieved in all patients, 59 in the right IJV and six in the left. Ultrasound scanning demonstrated that the right IJV was thrombosed in six patients (10%), thus avoiding unnecessary attempts at cannulation. The Hickman catheters remained in situ for a combined total of 5857 days (median, 89 days, range 4-485 days). Immediate complications occurred in two patients (pneumothorax in both). One patient required a chest drain. The overall sepsis rate was 3.92 per 1000 catheter days. Systemic sepsis was slightly higher (2.21 per 1000 catheter days) than superficial sepsis (1.71 per 1000 catheter days). In all the patients who developed systemic sepsis the catheter had to be removed (n = 13). All the superficial infections were treated successfully with antibiotics (n = 10 patients). Two catheters developed thrombosis. CONCLUSION: We conclude that ultrasound-assisted percutaneous placement of Hickman catheters in the operating suite is a simple, safe and effective technique and may help to reduce infective complications.

Non-orthopaedic paediatric trauma in a regional hospital.

BACKGROUND: In the Republic of Ireland there are no paediatric surgeons outside Dublin. Most paediatric trauma is managed in general hospitals by general or orthopaedic surgeons. AIM: In this study we audited our experience with paediatric trauma in a regional setting. METHODS: We carried out a retrospective review of all non-orthopaedic paediatric trauma patients admitted to our institution over a two-year period.The method of injury, management and outcome were recorded and the TRISS (revised trauma injury severity score) method was used to calculate the probability of survival. RESULTS: One hundred and fifty four paediatric patients were admitted following trauma. Falls, RTAs and burns were the commonest reasons for admission. Twenty nine of these patients (19%) required surgical procedures. There were no unexpected deaths. CONCLUSION: The majority of paediatric trauma admissions were for minor injuries. A number of seriously injured children were successfully treated with no unexpected deaths.

Ileostomy obstruction by ingested apricot stone with clinical-radiological-pathological correlation.

Patients with stomas often present with bowel obstruction, often secondary to adhesions. This case describes the presentation, investigation and management of a 62-year-old woman with an end ileostomy, who presented to hospital with acute abdominal pain and subacute bowel obstruction. Further questioning revealed the recent ingestion of an apricot stone and this was identified by multimodality imaging as the cause of the luminal obstruction in the distal ileum, just proximal to the stoma. After a failed period of conservative management, examination under anaesthesia was performed and digital extraction attempted, but this was unsuccessful. Rather than surgical stoma revision, endoscopic removal was achieved. The patient improved and was discharged the following day. However, her small bowel obstruction relapsed within 48 h. She was readmitted and underwent stoma revision with no further problems.

Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia.

BACKGROUND: Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The patency rate of processus vaginalis is highest in infants but there are few data on the subsequent risk of contralateral hernia development in infants. In this retrospective study, we aimed to find out the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infants aged less than one year. METHODS: All infants who underwent a unilateral Inguinal herniotomy between January 1990 and December 1998 were studied retrospectively. Infants with bilateral hernia (n = 7) were excluded from the study. RESULTS: One hundred and one infants (93 boys and 8 girls) were studied. Median age at operation was 23 (range 2-52) weeks. The herniotomy was right-sided in 75% of the infants. Follow-up ranged from three and a half years to 11 years. A contralateral hernia developed in nine infants (9.0%). One of the initial hernias was incarcerated. Median time from operation to occurrence of contralateral hernia was 18 (range 2-60) months. None of the contralateral hernia was incarcerated. Age, sex, incarceration and side of initial hernia did not influence the development of contralateral hernia. CONCLUSION: The low incidence and benign nature of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.