International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research.

Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.

Surgeon perceptions of personality as an influencing factor on anastomotic decision-making: A qualitative analysis.

AIM: Surgeon personality is a factor influencing rectal anastomotic decision-making. However, it is unclear how or why this may be the case, or what aspects of personality are involved. The aim of this study was to investigate the views of colorectal surgeons on how their individual personality may influence variation in anastomotic decision-making. METHOD: Purposive sampling was used to invite certified UK-based colorectal surgeons to participate, with individual interviews used for data collection. Participants were recruited until ongoing data review indicated no new codes were generated (i.e. data sufficiency). Data were analysed thematically following Braun and Clarke's six-step framework. RESULTS: Seventeen colorectal surgeons (eight female, nine male) participated. Two key themes relating to personality and decision-making were identified: (1) surgeon development and training and (2) patient-surgeon interactions, each with relevant subthemes. Surgeons described how their personality may influence patients' postoperative outcomes (e.g. decision-making, team working and communication) and potential mechanisms for how their personality may influence operative risk-taking. Following anastomotic leakage, surgeons described a disproportionate sense of guilt and responsibility. There appears to be a significant transition in responsibility from trainee to newly appointed consultant, which may be part of the 'hidden curriculum' of surgical training. CONCLUSION: Colorectal surgeons have described their perceptions of how personality traits may impact variation in decision-making and patient outcomes for the first time. Early career surgeons felt ill-prepared for the level of guilt experienced when managing complications. Surgeons appear open to personality assessment if this was through an educational lens, with the aim of improving decision-making following complications and overall performance.

Influencing factors in surgical decision-making: a qualitative analysis of colorectal surgeons' experiences of postoperative complications.

AIM: When making anastomotic decisions in rectal cancer surgery, surgeons must consider the risk of anastomotic leakage, which bears implications for the patient's quality of life, cancer recurrence and, potentially, death. The aim of this study was to investigate the views of colorectal surgeons on how their individual attributes (e.g. experience, personality traits) may influence their decision-making and experience of complications. METHOD: This qualitative study used individual interviews for data collection. Purposive sampling was used to invite certified UK-based colorectal surgeons to participate. Participants were recruited until ongoing data review indicated no new codes were generated, suggesting data sufficiency. Data were analysed thematically following Braun and Clarke's six-step framework. RESULTS: Seventeen colorectal surgeons (eight female, nine male) participated. Two key themes with relevant subthemes were identified: (1) personal attributes influencing variation in decision-making (e.g. demographics, personality) and (2) the influence of complications on decision-making. Surgeons described variation in the management of complications based upon their personal attributes, which included factors such as gender, experience and subspeciality interests. Surgeons described the detrimental impact of anastomotic leakage on their mental and physical health. Experience of anastomotic leakage influences future decision-making and is associated with changes in practice even when a technical error is not identified. CONCLUSION: Colorectal surgeons consider anastomotic leaks to be personal 'failures', which has a negative impact on surgeon welfare. Better understanding of how surgeons make difficult decisions, and how surgeons respond to and learn from complications, is necessary to identify 'personalized' methods of supporting surgeons at all career stages, which may improve patient outcomes.

Postoperative outcomes and identification of risk factors for complications after emergency intestinal stoma surgery - a multicentre retrospective study.

AIM: Approximately 4000 patients in the UK have an emergency intestinal stoma formed each year. Stoma-related complications (SRCs) are heterogeneous but have previously been subcategorized into early or late SRCs, with early SRCs generally occurring within 30 days postoperatively. Early SRCs include skin excoriation, stoma necrosis and high output, while late SRCs include parastomal hernia, retraction and prolapse. There is a paucity of research on specific risk factors within the emergency cohort for development of SRCs. This paper aims to describe the incidence of SRCs after emergency intestinal surgery and to identify potential risk factors for SRCs within this cohort. METHOD: Consecutive patients undergoing emergency formation of an intestinal stoma (colostomy, ileostomy or jejunostomy) were identified prospectively from across three acute hospital sites over a 3-year period from the ELLSA (Emergency Laparotomy and Laparoscopic Scottish Audit) database. All patients were followed up for a minimum of 1 year. A multivariate logistic regression model was used to identify risk factors for early and late SRCs. RESULTS: A total of 455 patients were included (median follow-up 19 months, median age 64 years, male:female 0.52, 56.7% ileostomies). Early SRCs were experienced by 54.1% of patients, while 51% experienced late SRCs. A total of 219 patients (48.1%) had their stoma sited preoperatively. Risk factors for early SRCs included end ileostomy formation [OR 3.51 (2.24-5.49), p < 0.001], while preoperative stoma siting was found to be protective [OR 0.53 (0.35-0.83), p = 0.005]. Patient obesity [OR 3.11 (1.92-5.03), p < 0.001] and reoperation for complications following elective surgery [OR 4.18 (2.01-8.69), p < 0.001] were risk factors for late SRCs. CONCLUSION: Stoma-related complications after emergency surgery are common. Preoperative stoma siting is the only truly modifiable risk factor to reduce SRCs, and further research should be aimed at methods of improving the frequency and accuracy of this in the emergency setting.

Appendectomy versus antibiotic treatment for acute appendicitis.

BACKGROUND: Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery. OBJECTIVES: To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication. SELECTION CRITERIA: We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic). DATA COLLECTION AND ANALYSIS: We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group. MAIN RESULTS: We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS: Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.

Poor outcomes in patients with sepsis undergoing emergency laparotomy and laparoscopy are attenuated by faster time to care measures.

AIM: Emergency laparotomy and laparoscopy (EmLap) are amongst the commonest surgical procedures, with high prevalence of sepsis and hence poorer outcomes. However, whether time taken to receive care influences outcomes in patients requiring antibiotics for suspected infection remains largely unexplored. The aim of this work was to determine whether (1) time to care contributes to outcome differences between patients with and without suspected infection and (2) its impact on outcomes only amongst those with suspected infection. METHOD: Clinical information was retrospectively obtained from the 2017-2018 Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA). Time to care referred to six temporal variables describing radiological investigation, anaesthetic triage and surgical management. Outcome measures [mortality, readmission, hospital death, postoperative destination and length of stay (LoS)] were compared using adjusted and unadjusted regression analyses to determine whether the outcome differences could be explained by faster or slower time to care. RESULTS: Amongst 2243 EmLap patients [median age 65 years (interquartile range 51-75 years), 51.1% female], 892 (39.77%) received antibiotics for suspected infection. Although patients with suspected infection had faster time to care (all p ≤ 0.001) and worse outcomes compared with those who did not, outcome differences were not statistically significant when accounted for time (all p > 0.050). Amongst those who received antibiotics, faster time to care was also associated with decreased risk of postoperative intensive care unit (ICU) stay and shorter LoS (all p < 0.050). CONCLUSION: Worse outcomes associated with infection in EmLap patients were attenuated by faster time to care, which additionally reduced the LoS and ICU stay risk amongst those with suspected infection.

The impact of intestinal stoma formation on patient quality of life after emergency surgery-A systematic review.

AIM: Elective stoma formation has a negative effect on patient quality of life (QoL), with a potential detrimental impact on body image, confidence and social functioning being shown previously. However, the impact of emergency stoma formation on QoL has been explored less frequently. This systematic review aims to synthesize all available literature exploring QoL via patient-reported outcome measures. METHODS: A search strategy was implemented on 24 November 2022 across Embase, MEDLINE, PsycInfo and the Cochrane Library database after registration on PROSPERO (CRD42022370606). Studies were included if they used a standardized patient-reported outcome measure, had more than five emergency stoma patients, age > 18 years and were fully published in English. Two of three independent researchers screened articles, extracted data and performed quality assessment using the Newcastle-Ottawa Scale and the Cochrane risk of bias tool. RESULTS: In all, 1775 articles were screened, with 16 included in the systematic review. This included 1868 emergency stoma patients (men:women 0.53; median age 64.6 years) followed up for a median of 12 months. Patients who had a Hartmann's procedure for perforated diverticulitis had poorer QoL than those who underwent primary anastomosis. There was a negligible difference in QoL between those who had a colonic stent for obstructing colorectal cancer compared with those who underwent emergency stoma formation. Female sex, end stoma formation and ileostomy formation were all identified as risk factors for poorer QoL. CONCLUSION: Patients undergoing emergency stoma surgery have marginally poorer QoL compared with those undergoing similar procedures without stoma formation. Further work is required to identify risk factors associated with this and also to compare QoL after stoma reversal.

Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology.

AIM: Variation in major gastrointestinal surgery rates in the older population suggests heterogeneity in surgical management. A higher prevalence of comorbidities, frailty and cognitive impairments in the older population may account for some variation. The aim of this study was to determine surgeon preference for major surgery versus conservative management in hypothetical patient scenarios based on key attributes. METHOD: A survey was designed according to the discrete choice methodology guided by a separate qualitative study. Questions were designed to test for associations between key attributes (age, comorbidity, urgency of presentation, pathology, functional and cognitive status) and treatment preference for major gastrointestinal surgery versus conservative management. The survey consisting of 18 hypothetical scenarios was disseminated electronically to UK gastrointestinal surgeons. Binomial logistic regression was used to identify associations between the attributes and treatment preference. RESULTS: In total, 103 responses were received after 256 visits to the questionnaire site (response rate 40.2%). Participants answered 1847 out of the 1854 scenarios (99.6%). There was a preference for major surgery in 1112/1847 (60.2%) of all scenarios. Severe comorbidities (OR 0.001, 95% CI 0.000-0.030; P = 0.000), severe cognitive impairment (OR 0.001, 95% CI 0.000-0.033; P = 0.000) and age 85 years and above (OR 0.028, 95% CI 0.005-0.168; P = 0.000) were all significant in the decision not to offer major gastrointestinal surgery. CONCLUSION: This study has demonstrated variation in surgical treatment preference according to key attributes in hypothetical scenarios. The development of fitness-stratified guidelines may help to reduce variation in surgical practice in the older population.

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.

Adapting Patient and Public Involvement processes in response to the Covid-19 pandemic.

BACKGROUND: The COVID-19 pandemic brought rapid and major changes to research, and those wishing to carry out Patient and Public Involvement (PPI) activities faced challenges, such as restrictions on movement and contact, illness, bereavement and risks to potential participants. Some researchers moved PPI to online settings during this time but remote consultations raise, as well as address, a number of challenges. It is important to learn from PPI undertaken in this period as face-to-face consultation may no longer be the dominant method for PPI. METHODS: UK stay-at-home measures announced in March 2020 necessitated immediate revisions to the intended face-to-face methods of PPI consultation for the ESORT Study, which evaluated emergency surgery for patients with common acute conditions. PPI plans and methods were modified to all components being online. We describe and reflect on: initial plans and adaptation; recruitment; training and preparation; implementation, contextualisation and interpretation. Through first-hand accounts we show how the PPI processes were developed, experienced and viewed by different partners in the process. DISCUSSION AND CONCLUSIONS: While concerns have been expressed about the possible limiting effects of forgoing face-to-face contact with PPI partners, we found important benefits from the altered dynamic of the online PPI environment. There were increased opportunities for participation which might encourage the involvement of a broader demographic, and unexpected benefits in that the online platform seemed to have a 'democratising' effect on the meetings, to the benefit of the PPI processes and outcomes. Other studies may however find that their particular research context raises particular challenges for the use of online methods, especially in relation to representation and inclusion, as new barriers to participation may be raised. It is important that methodological challenges are addressed, and researchers provide detailed examples of novel methods for discussion and empirical study. PATIENT AND PUBLIC CONTRIBUTION: We report a process which involved people with lived experience of emergency conditions and members of the public. A patient member was involved in the design and implementation, and two patients with lived experience contributed to the manuscript.

An evaluation of the feasibility of implementing the BeWEL lifestyle intervention programme for people at increased risk of colorectal cancer - from research to real life.

BACKGROUND: The BeWEL randomised controlled trial (RCT) of weight loss in people with colorectal adenomas demonstrated that a significant proportion of people are interested in lifestyle interventions (49%) and clinically relevant changes in body weight were achieved at 12-month follow-up. The current work aimed to assess the feasibility of the BeWEL programme invitation and delivery in a nonresearch setting to assess whether the original results could be replicated. METHODS: The original BeWel programme was modified through the provision of verbal introductions (vs. letter), requirement for people to contact BeWEL team (vs. BeWEL team contacting them), community delivery (vs. home), duration (12 weeks vs. 12 months) and two intervention visits (vs. 3) and inclusion of people with predisposition to colorectal cancer. Eligible people were informed about the BeWel programme from National Health Service (NHS) staff after colonoscopy procedures and invited to contact a dedicated Bowel Cancer UK lifestyle team. RESULTS: Findings demonstrated that programme uptake (10.6% vs. 33%) and retention (71% vs. 93%) was significantly lower than that obtained from the BeWEL RCT. For people who participated in the 3-month programme (n = 21), self-reported weight loss (mean: -7% body weight) was successful, and the programme was well received. CONCLUSIONS: The current approach to engaging clients with the BeWEL programme is unsustainable. Reliance on busy NHS staff to deliver invitations and the need for people to contact the delivery team (due to data protection) may have impacted on uptake. Alternative approaches to supporting weight management in this population should be explored further.

Investigation of frailty markers including a novel biomarker panel in emergency laparotomy: protocol of a prospective cohort study.

BACKGROUND: Emergency laparotomy (EmLAP) is one of the commonest emergency operations performed in the United Kingdom (approximately 30, 000 laparotomies annually). These potentially high-risk procedures can be life changing with frail patients and/ or older adults (≥ 65 years) having the poorest outcomes, including mortality. There is no gold standard of frailty assessment and no clinical chemical biomarkers existing in practice. Early detection of subclinical changes or deficits at the molecular level are essential in improving our understanding of the biology of frailty and ultimately improving patient outcomes. This study aims primarily to compare preoperative frailty markers, including a blood-based biomarker panel, in their ability to predict 30 and 90-day mortality post-EmLAP. The secondary aim is to analyse the influence of perioperative frailty on morbidity and quality of life post-EmLAP. METHODS: A prospective single centred observational study will be conducted on 150 patients ≥ 40 years of age that undergo EmLAP. Patients will be included according to the established NELA (National Emergency Laparotomy Audit) criteria. The variables collected include demographics, co-morbidities, polypharmacy, place of residence, indication and type of surgery (as per NELA criteria) and prognostic NELA score. Frailty will be assessed using: a blood sample for ultra-high performance liquid chromatography mass spectrometry analysis; preoperative CT abdomen pelvis (sarcopenia) and Rockwood Clinical Frailty Scale (CFS). Patients will be followed up for 90 days. Variables collected include blood samples (at post operative day 1, 7, 30 and 90), place of residence on discharge, morbidity, mortality and quality of life (EQ-5D-5 L). The frailty markers will be compared between groups of frail (CFS ≥ 4) and non-frail using statistical methods such as regression model and adjusted for appropriate confounding factors. DISCUSSION: This study hypothesises that frailty level changes following EmLAP in frail and non- frail patients, irrespective of age. We propose that non- frail patients will have better survival rates and report better quality of life compared to the frail. By studying the changes in metabolites/ biomarkers in these patients and correlate them to frailty status pre-surgery, this highly novel approach will develop new knowledge of frailty and define a new area of clinical biomolecular research. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05416047. Registered on 13/06/2022 (retrospectively registered).

Impact of the first wave of COVID-19 on outcomes following emergency admissions for common acute surgical conditions: analysis of a national database in England.

BACKGROUND: This study assessed the impact of the first COVID-19 wave in England on outcomes for acute appendicitis, gallstone disease, intestinal obstruction, diverticular disease, and abdominal wall hernia. METHODS: Emergency surgical admissions for patients aged 18 years and older to 124 NHS Trust hospitals between January and June in 2019 and 2020 were extracted from Hospital Episode Statistics. The risk of 90-day mortality after admission during weeks 11-19 in 2020 (national lockdown) and 2019 (pre-COVID-19) was estimated using multilevel logistic regression with case-mix adjustment. The primary outcome was all-cause mortality at 90 days. RESULTS: There were 12 231 emergency admissions and 564 deaths within 90 days during weeks 11-19 in 2020, compared with 18 428 admissions and 542 deaths in the same interval in 2019. Overall, 90-day mortality was higher in 2020 versus 2019, with an adjusted OR of 1.95 (95 per cent c.i. 0.78 to 4.89) for appendicitis, 2.66 (1.81 to 3.92) for gallstone disease, 1.99 (1.44 to 2.74) for diverticular disease, 1.70 (1.13 to 2.55) for hernia, and 1.22 (1.01 to 1.47) for intestinal obstruction. After emergency surgery, 90-day mortality was higher in 2020 versus 2019 for gallstone disease (OR 3.37, 1.26 to 9.02), diverticular disease (OR 2.35, 1.16 to 4.73), and hernia (OR 2.34, 1.23 to 4.45). For intestinal obstruction, the corresponding OR was 0.91 (0.59 to 1.41). For admissions not leading to emergency surgery, mortality was higher in 2020 versus 2019 for gallstone disease (OR 2.55, 1.67 to 3.88), diverticular disease (1.90, 1.32 to 2.73), and intestinal obstruction (OR 1.30, 1.06 to 1.60). CONCLUSION: Emergency admission was reduced during the first lockdown in England and this was associated with higher 90-day mortality.

Exploring variation in surgical practice: does surgeon personality influence anastomotic decision-making?

BACKGROUND: Decision-making under uncertainty may be influenced by an individual's personality. The primary aim was to explore associations between surgeon personality traits and colorectal anastomotic decision-making. METHODS: Colorectal surgeons worldwide participated in a two-part online survey. Part 1 evaluated surgeon characteristics using the Big Five Inventory to measure personality (five domains: agreeableness; conscientiousness; extraversion; emotional stability; openness) in response to scenarios presented in Part 2 involving anastomotic decisions (i.e. rejoining the bowel with/without temporary stomas, or permanent diversion with end colostomy). Anastomotic decisions were compared using repeated-measure ANOVA. Mean scores of traits domains were compared with normative data using two-tailed t tests. RESULTS: In total, 186 surgeons participated, with 127 surgeons completing both parts of the survey (68.3 per cent). One hundred and thirty-one surgeons were male (70.4 per cent) and 144 were based in Europe (77.4 per cent). Forty-one per cent (77 surgeons) had begun independent practice within the last 5 years. Surgeon personality differed from the general population, with statistically significantly higher levels of emotional stability (3.25 versus 2.97 respectively), lower levels of agreeableness (3.03 versus 3.74), extraversion (2.81 versus 3.38) and openness (3.19 versus 3.67), and similar levels of conscientiousness (3.42 versus 3.40 (all P <0.001)). Female surgeons had significantly lower levels of openness (P <0.001) than males (3.06 versus 3.25). Personality was associated with anastomotic decision-making in specific scenarios. CONCLUSION: Colorectal surgeons have different personality traits from the general population. Certain traits seem to be associated with anastomotic decision-making but only in specific scenarios. Further exploration of the association of personality, risk-taking, and decision-making in surgery is necessary.

Comparison of the clinical frailty score (CFS) to the National Emergency Laparotomy Audit (NELA) risk calculator in all patients undergoing emergency laparotomy.

AIM: There is evolving evidence that preoperative frailty predicts outcomes of older adults undergoing emergency laparotomy (EmLap). We assessed frailty scoring in an emergency surgical population that included patients of all ages and then compared this to an established perioperative prognostic score. METHOD: Data from the prospective Emergency Laparoscopic and Laparotomy Scottish Audit (ELLSA; November 2017-October 2018) was used. All adults over 18 were included. Frailty was measured using 7-point clinical frailty score (CFS). OUTCOME MEASURES: 30-day mortality, hospital length of stay (LOS), 30-day readmission. Areas under the receiver-operating characteristic (ROC) curves were calculated for CFS (1-7) and compared to the National Emergency Laparotomy Audit (NELA) score with Forest plots used to compare 30-day mortality across CFS and NELA categories. RESULTS: A total of 2246 patients (median age 65 years [IQR 51-75]; female 51%) underwent EmLap (60% for colorectal pathology). A total of 10.6% were frail preoperatively (≥CFS 5). As CFS increased so did 30-day mortality (2.1% CFS1 to 25.3% CFS6 and 7; ꭓ2 78.2, p < 0.001) and median LOS (10 days CFS1 to 20 days CFS6 and 7; p < 0.001). Readmission rates did not differ significantly across CFS. ROC (95% CI) for mortality was 0.71 (0.65-0.77) for CFS and 0.84 (0.78-0.89) for NELA. Addition of CFS to NELA did not increase ROC value. CONCLUSION: This study supports the prognostic role of frailty in the emergency surgical setting, finding increasing frailty to be associated with increased mortality and longer LOS in adults of all ages. Although NELA performed better, CFS remained predictive and has the advantage of being calculated preoperatively to aid decision-making and treatment planning.

Multiple house occupancy is associated with mortality in hospitalized patients with COVID-19.

BACKGROUND: In response to the COVID-19 pandemic, many countries mandated staying at home to reduce transmission. This study examined the association between living arrangements (house occupancy numbers) and outcomes in COVID-19. METHODS: Study population was drawn from the COPE study, a multicentre cohort study. House occupancy was defined as: living alone; living with one other person; living with multiple other people; or living in a nursing/residential home. Outcomes were time from admission to mortality and discharge (Cox regression), and Day 28 mortality (logistic regression) analyses were adjusted for key comorbidities and covariates including admission: age, sex, smoking, heart failure, admission C-reactive protein (CRP), chronic obstructive pulmonary disease, estimated glomerular filtration rate, frailty and others. RESULTS: A total of 1584 patients were included from 13 hospitals across UK and Italy: 676 (42.7%) were female, 907 (57.3%) were male, median age was 74 years (range: 19-101). At 28 days, 502 (31.7%) had died. Median admission CRP was 67, 82, 79.5 and 83 mg/l for those living alone, with someone else, in a house of multiple occupancy and in a nursing/residential home, respectively. Compared to living alone, living with anyone was associated with increased mortality: within a couple [adjusted hazard ratios (aHR) = 1.39, 95% confidence intervals (CI) 1.09-1.77, P = 0.007]; living in a house of multiple occupancy (aHR = 1.67, 95% CI 1.17-2.38, P = 0.005); and living in a residential home (aHR = 1.36, 95% CI 1.03-1.80, P = 0.031). CONCLUSION: For patients hospitalized with COVID-19, those living with one or more people had an increased association with mortality, they also exhibited higher CRP indicating increased disease severity suggesting they delayed seeking care.

Prehabilitation services for people diagnosed with cancer in Scotland - Current practice, barriers and challenges to implementation.

BACKGROUND: Prehabilitation is the practice of enhancing a patient's functional and psychological capacity before treatment commences. It is of interest in the cancer context because of the impact of treatments on quality of life and cancer survivorship. This work aims to document current practice, barriers and challenges to implementing prehabilitation to inform the development of a national framework. METHODS: A mixed-methods approach was applied: an on-line survey was sent to stakeholders in cancer care across Scotland, supplemented by in-depth interviews. Key domains explored were the perceived importance of prehabilitation, availability, delivery and content of services, outcome measures, referral processes and funding. FINDINGS: A total of 295 survey responses were obtained and 11 interviews completed. Perceived importance of prehabilitation was rated highly. There was uncertainty over the definition of prehabilitation and most respondents did not know if local services were available. Where services were described, a range of health professionals were involved, different outcome measures were utilised and frequency of referrals varied. Respondents highlighted short time frames between referral and treatment, concerns about patient engagement, the evidence base for action and funding priorities. Respondents also commented on which context a referral should be made and to whom, and the need for equity of service across the country. CONCLUSIONS: The current work found clear evidence of the perceived importance of prehabilitation in cancer patients. However, issues and key gaps were identified within current services (including issues arising from COVID-19) which must be addressed to enable wide-spread development and implementation of equitable programmes.

Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study.

OBJECTIVE: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. SUMMARY BACKGROUND DATA: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. METHODS: An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. RESULTS: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. CONCLUSIONS: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Healthcare professional preferences in the health and fitness assessment and optimization of older patients facing colorectal cancer surgery.

AIM: There are few age- and fitness-specific, evidence-based guidelines for colorectal cancer surgery. The uptake of different assessment and optimization strategies is variable. The aim of this study was to explore healthcare professional opinion about these issues using a mixed methods design. METHODS: Semi-structured qualitative interviews were undertaken with healthcare professionals from a single UK region involved in the treatment, assessment and optimization of colorectal surgery patients. Interviews were analysed using the framework approach. An online questionnaire survey was subsequently designed and disseminated to UK surgeons to quantitatively assess the importance of interview themes. Descriptive statistics were used to analyse questionnaire data. RESULTS: Thirty-seven healthcare professionals out of 42 approached (response rate 88%) were interviewed across five hospitals in the south Yorkshire region. Three broad themes were developed: attitudes towards treatment of the older patient, methods of assessment of suitability and optimization strategies. The questionnaire was completed by 103 out of an estimated 256 surgeons (estimated response rate 40.2%). There was a difference in opinion regarding the role of major surgery in older patients, particularly when there is coexisting dementia. Assessment was not standardized. Access to optimization strategies was limited, particularly in the emergency setting. CONCLUSION: There is wide variation in the process of assessment and provision of optimization strategies in UK practice. Lack of evidence-based guidelines, cost and time constraints restrict the development of services and pathways. Differences in opinion between surgeons towards patients with frailty or dementia may account for some of the variation in colorectal cancer outcomes.

Protocol for a multi-centre observational and mixed methods pilot study to identify factors predictive of poor functional recovery after major gastrointestinal surgery and strategies to enhance uptake of perioperative optimization: Optimizing the care and treatment pathways for older patients facing major gastrointestinal surgery (OCTAGON).

INTRODUCTION: National datasets report large variations in outcomes from older people (≥65 years) between different UK surgical units. This implies that not all patients receive the same level of care or access to resources, such as rehabilitation or allied health professional input. This might impact functional decline. AIMS: Our aim is to evaluate the baseline status of older patients facing major gastrointestinal surgery and the impact of variation in perioperative assessment and provision of perioperative support on functional outcomes. Patients' experiences and views of assessment and optimization will be explored via integrated qualitative semi-structured interviews. METHODS AND ANALYSIS: This multi-centre, pilot cohort study will include patients ≥65 years presenting via both elective and emergency pathways at three to five South Yorkshire NHS hospitals (Clinical Trials registration NCT04545125). The primary outcome is functional recovery measured using the World Health Organization Disability Assessment Schedule 2.0 at 6 weeks post-operation. Secondary outcomes include feasibility, quality of life, length of stay and complication rate. An opportunistic sample size of 120 has been estimated and will inform the design of a future, adequately powered study. For the qualitative study, 20-30 semi-structured patient interviews will be undertaken with patients from the cohort study to explore experiences of assessment and optimization. Interviews will be digitally recorded, transcribed verbatim and analysed according to the framework approach. ETHICS AND DISSEMINATION: This study has been approved by the National Health Service Research Ethics Committee and is registered centrally with Health Research Authority. It has been adopted by the National Institute for Health Research Portfolio scheme. Dissemination will be via international and national surgical and geriatric conferences.