The impact of hospital grade, hospital-volume, and surgeon-volume on outcomes for adults undergoing appendicectomy.

INTRODUCTION: Acute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy. AIM: To establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy. METHODS: Using the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed. RESULTS: During the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year). CONCLUSION: Patients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.

Audit of PPI Prescribing Practices: A Risk to Patient Safety?

Aim Proton pump inhibitors (PPIs) are frequently prescribed to surgical patients (50-60%) to prevent gastrointestinal bleeding. However, most surgical patients are at low risk of significant bleeds. The aim of this audit was to identify inappropriate PPI prescribing, if any, in a cohort of surgical inpatients. Methods This was a prospective analysis completed over a 4 month period. Data was collected via review of clinical notes and drug charts. The audit standard was the consensus guideline on indications for PPI use issued by Scarpignato et al (2016). Results In total 89 patients were included (n = 89). 73% were on PPI therapy. 30% had a documented indication for therapy which was concordant with recommendations. However, the majority of PPI prescriptions (70%) were inappropriate. Conclusion PPIs are frequently prescribed to surgical patients without an appropriate indication. Indiscriminate use of these drugs has implications in the form of costs and potential complications.

Changing trends in age and stage of colorectal cancer presentation in Ireland - From the nineties to noughties and beyond.

BACKGROUND: Recent studies report incidence of colorectal (CRC) in younger adults (<50 years old) is increasing, and these patients are more likely to present with advanced disease. We performed a population-based analysis of these trends in an Irish population. METHODS: A retrospective analysis was performed of all patients with histologically confirmed CRC in Ireland, using data from the National Cancer Registry of Ireland (NCRI) [1994-2012, inclusive]. Trends in age-adjusted CRC incidence and stage at presentation were tabulated. Total and average age-adjusted annual percentage change (APC) in CRC rates were calculated using regression analysis, with age adjusted to the European standard population for trend analysis. RESULTS: A total of 39,528 cases were included. Throughout the entire study period the most common age of presentation was 70-79 years (32.5%, n = 12 829) with Stage II (27.5%, n = 10 851) CRC. Overall, an increase in incidence of CRC of 2.1% was observed. A significantly increased incidence in patients aged 20-29 years (APC = 9.17%; total change = 4.2%; p = 0.003) was identified from 1994 to 2012. Overall, in patients <50 years, the incidence of stage I colorectal cancer at presentation significantly reduced from 23.5% to 11.6% (p = 0.01). This was associated with a significant parallel rise in stage IV disease (11%-23%, p = 0.02) in this age group. CONCLUSION: Increasing incidence of CRC in younger patient groups is observed in an Irish population, with an increase in advanced staged disease at presentation seen. Further studies should focus on identifying causality for this trend and identify potential targets for prevention going forward.

Surgical mortality - an analysis of all deaths within a general surgical department.

BACKGROUND: Post-operative mortality is one of the most universal and important outcomes that can be measured in surgical practice and is increasingly used to measure quality of care. The aim of this study was to evaluate overall mortality within a surgical department and to analyse factors associated with operative and non-operative death. METHODS: We analysed prospectively collected data detailing all surgical admissions, procedures and mortalities over a twelve year period (2000-2012) from a regional Irish hospital. We evaluated type of operation, patient factors and cause of death. RESULTS: A total of 62 085 patients were admitted under surgical care between the 1st of January 2000 and the 31st of December 2011. There were a total of 578 deaths during this period (0.93% overall mortality rate). 415 deaths (71.8%) occurred in non-operative patients in which advanced cancer (36.5%), sepsis (14.9%), cardiorespiratory failure (13.2%) and trauma (11%) were the primary causes. A total of 22 788 surgical procedures were performed with an operative mortality rate of 0.71%. Mortality rate following elective surgery was 0.17% and following emergency surgery was 10-fold higher (1.7%). The main cause of post-operative death was sepsis (30.02%). Emergency operations, increasing age and major procedures significantly increased mortality risk (p < 0.001). CONCLUSION: Post-operative deaths comprise a small proportion of overall deaths within a surgical service. Mortality figures alone are not an accurate representation of surgical performance but in the absence of other easily available quality outcome measures they can be used as a surrogate marker when all confounding factors are accounted for.

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.

Managing ureteric colic in a smaller hospital without urological support.

No official guidelines exist on managing ureteric colic in small hospitals without urological support. We reviewed the logistics of managing this condition by examining all cases of ureteric colic over two years. Seventy nine of 118 cases had hydronephrosis; a criteria for urology referral. Thirty nine patients passed their stone spontaneously but 40 of these cases could not and required transfer. Twenty two (55%) patients were transferred (mean time to transfer: 3.29 days). The other 18 (45%) were discharged to await a urology outpatients clinic (mean time to discharge: 3.00 days). Patients that passed their stone spontaneously generally had stones under 5mm (mean stay: 2.09 days). We would recommend that patients with stones over 5mm or with hydronephrosis be referred immediately to prevent urological sepsis and or renal impairment.

What is the future for General Surgery in Model 3 Hospitals?

BACKGROUND: General Surgery consultant recruitment poses considerable challenges in Model 3 Hospitals in Ireland. AIM: The aim of this paper is to examine General Surgery activity and consultant staffing in order to inform future manpower and service planning. METHODS: General surgical activity in Model 3 Hospitals was examined using the validated 2014 Hospital Inpatient Enquiry (HIPE) dataset. Current consultant staffing was ascertained from hospital personnel departments and all trainees on the National Surgical Training Programme were asked to complete a questionnaire on their career intentions. RESULTS: Model 3 Hospitals accounted for 50% of all General Surgery discharges. In the elective setting, 51.5% of all procedures were endoscopic investigations and in the acute setting only 22% of patients underwent an operation. Most surgical procedures were of low acuity and included excision of minor lesions, appendicectomy, cholecystectomy and hernia repair. Of 76 General Surgeons who work in Model 3 Hospitals 25% were locums and 54% had not undergone formal training in Ireland. A further 22% of these surgeons will retire in the next five years. General Surgical trainees surveyed indicated an unwillingness to take up posts in Model 3 Hospitals, while 83% indicated that a post in a Model 4 Hospital is 'most desirable'. Lack of attractiveness related to issues regarding rotas, lack of ongoing skill enhancement, poor experience in the management of complex surgical conditions, limited research and academic opportunity, isolation from colleagues and poor trainee support. CONCLUSIONS: These data indicated that an impending General Surgery consultant manpower crisis can only be averted in Model 3 Hospitals by either major change in the emphasis of surgical training or a significant reorganisation of surgical services.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

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.

Low incidence of retained common bile duct stones using a selective policy of biliary imaging.

AIM: Biliary imaging has decreased since the advent of laparoscopic cholecystectomy. This study aimed to examine the incidence of retained common bile duct (CBD) stones, using a selective policy of biliary imaging. METHODS: A prospective computerised database was used to study patients who underwent laparoscopic cholecystectomy by one surgeon over 36 months. Two hundred and thirty-five patients (191 female, 44 male) were operated on. Ages ranged from 15 to 82 years (mean 47 years). Follow-up periods ranged from six to 39 months (mean 23.3 months). Selection for pre-operative endoscopic retrograde cholangiopacreatogram (ERCP), intraoperative cholangiography (IOC) or neither depended on liver function tests (LFTs) and CBD diameter on ultrasound prior to surgery. If LFTs were persistently raised and/or the CBD was dilated on ultrasound, patients underwent pre-operative ERCP. If LFTs were raised, and returned to normal promptly, IOC was performed. RESULTS: Of 235 patients, 26 had pre-operative ERCP, 62 had IOC and 157 had neither. Ten patients had both ERCP and IOC. To date, one patient (0.43%) has radiologically-proven unsuspected retained CBD stones; these were successfully treated with ERCP. CONCLUSION: Selective biliary imaging in patients undergoing laparoscopic cholecystectomy is safe. This process identifies the majority of patients with ductal calculi and minimises the need for unnecessary ERCP and peroperative cholangiography.

The effect of insulin-induced hypoglycemia on gene expression in the hypothalamic-pituitary-adrenal axis of the rat.

This study has examined the effects of insulin-induced hypoglycemia on expression of the CRH, arginine vasopressin, and POMC genes and corresponding peptides in freely moving, unanesthetized, male Sprague-Dawley rats. Animals were infused with 150 mM NaCl for 3 days before the experimental day and were then administered insulin (4 U/kg) or saline iv. In one experiment animals were killed 0, 30, 60, or 90 min after insulin or saline, and RNA was isolated from anterior pituitary, cerebral cortex, and punches of the hypothalamic paraventricular and supraoptic nuclei. In a second experiment, animals were killed 90 min after insulin or saline treatment, and RNA was isolated from whole hypothalami. RNA was analyzed by Northern blot. Plasma glucose fell from 106 +/- 5 to 38 +/- 2 mg/dl after insulin administration and remained low for the duration of the experiment. Plasma levels of ACTH, corticosterone, and vasopressin were 10-, 6-, and 4-fold higher, respectively, in the insulin-treated vs. control animals (by analysis of variance, P less than 0.0001 in all cases), while plasma CRH was unchanged. During hypoglycemia POMC mRNA levels were 1.8-fold higher in the insulin-treated group (by analysis of variance, P less than 0.025). In contrast, paraventricular nucleus, whole hypothalamic, and parietal cortex CRH mRNA and vasopressin mRNA were unchanged. These data support previous studies which indicated that POMC gene expression is increased by hypoglycemia. However, we found no evidence for an increase in paraventricular nucleus or cerebral cortex CRH mRNA expression during hypoglycemia-associated stimulation of the hypothalamic-pituitary-adrenal axis, suggesting that another factor(s) may mediate the observed increase in POMC gene expression.

Combined effects of glutamine and epidermal growth factor on the rat intestine.

Glutamine (GLN) is an important fuel and epidermal growth factor (EGF) is a potent mitogen for intestinal mucosa cells. GLN-enriched parenteral nutrition was administered to male Wistar rats, and subcutaneous injections of EGF were given for 3, 6, and 7 days. Control animals were fed a non-GLN-containing solution. Other groups of animals received GLN or EGF alone. Mucosal samples were obtained from the jejunum, ileum, and colon for measurement of weight, DNA, protein, and mucosal thickness. Disaccharidase activity was measured in the jejunum. After 3 days, only animals that received both GLN and EGF had a significant increase in small-bowel mucosal protein and thickness relative to controls. A similar pattern was observed in the colon, where animals that received both agents had a greater mucosal thickness, DNA, and protein content than controls. At 7 days, animals that received EGF or GLN had greater nitrogen retention. In addition, animals that were treated with EGF had elevated sucrase and maltase activity compared with GLN-fed animals at this time. Animals treated with GLN and EGF tended to have increased sucrase activity relative to controls. GLN feeding was associated with increased mucosal DNA and protein contents throughout the intestine for the combined series. EGF increased mucosal DNA and protein in the small intestine but not in the colon. The effect of EGF on the protein content of the small-bowel mucosa was dose dependent. The effects of GLN and EGF on the small bowel and colonic mucosa were additive. These studies suggest that specific nutrients and hormones may be used in combination to decrease the mucosal atrophy that commonly occurs after gut disuse or disease.

Effects of human recombinant growth hormone (rhGH) on inflammatory responses in patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Human recombinant growth hormone (rhGH) has been shown to increase skeletal muscle protein synthesis and improve nitrogen balance in critically ill patients and those undergoing surgery. rhGH effects on hepatic protein turnover in critically ill patients are less clearly understood. OBJECTIVE: To examine rhGH effects on hepatic acute phase protein responses and inflammatory cytokine release in patients undergoing major surgery. DESIGN: Prospective double blind randomised trial. SETTING: Tertiary referral university teaching hospital. PATIENTS: Patients undergoing elective abdominal aortic aneurysm repair. INTERVENTION: Patients received rhGH (Genotropin, 0.3 IU/kg per day, n = 8) or placebo (n = 10) for 6 days prior to surgery. RESULTS: Blood levels of growth hormone (GH) and insulin-like growth factor (IGF-1) were measured following rhGH treatment and C-reactive protein (CRP), serum amyloid A (SAA) and the cytokines interleukin-6 (IL-6) and the IL-1 receptor antagonist (IL-1ra) were measured for up to 24 h following surgery. Significant increases in plasma rhGH (0.84 +/- 0.3, mean (sem) versus 52 +/- 20 mU/l, p < 0.0008) and IGF-1 levels (119 +/- 13 versus 644 +/- 110 ng/ml, p < 0.0001) were seen prior to surgery following rhGH administration. No differences in acute phase protein or cytokine levels were seen following surgery in patients receiving rhGH. CONCLUSIONS: These results indicate that pre-operative administration of rhGH does not alter acute phase protein or inflammatory cytokine release in response to major surgery.

Tumor necrosis factor induces adult respiratory distress syndrome in rats.

To evaluate the effect of tumor necrosis factor (TNF), a major mediator of sepsis, on lung structure and function, we infused 200-g male Wistar rats with TNF (0, 2 x 10(5), or 4 x 10(5) U/kg of TNF) for 24 hours. Volume-pressure measurements were determined in the excised lungs using both air and saline, which eliminated surface tension forces. Total lung wet and dry weight, nitrogen level, and DNA and protein content were measured. Lungs of the rats that received TNF accepted significantly smaller volumes of air and saline at all pressures compared with the control group. Both the lung wet and dry weights increased with TNF. Lung DNA and protein content also increased, suggesting increased cellularity in the TNF-infused lungs. Thus, the lungs of the TNF-treated rats were stiffer, with reduced compliance values, and heavier due to increased water content and increased cellularity. These data indicate that sublethal administration of TNF in this rat model induces the adult respiratory distress syndrome and increases the work potential of respiration.

Are the catabolic effects of tumor necrosis factor mediated by glucocorticoids?

The effect of tumor necrosis factor (TNF) on the hypothalamic-adrenal stress response was determined by infusion of TNF, 0, 2 x 10(5), and 4 x 10(5) U/kg per 24 hours, in parenterally fed male Wistar rats. Following infusions over 1 to 6 days, adrenal weight was increased with increasing dosage of TNF. Tumor necrosis factor at a dosage of 4 x 10(5) U/kg per 24 hours increased the plasma corticotropin level over the same period. In a further series of experiments the metabolic effects of TNF were compared with the effects of corticosterone, the predominant glucocorticoid in the rat. In comparison with controls, rats given corticosterone (75 mg subcutaneously) or TNF (2 x 10(5) U/kg per 24 hours) demonstrated decreased nitrogen balance and diminished carcass nitrogen content over a 6-day period. Tumor necrosis factor alone, however, induced a significant increase in liver nitrogen content and diminished jejunal mucosa DNA and protein levels in comparison with the control and corticosterone groups. Finally, adrenalectomized animals receiving basal corticosterone replacement were infused with TNF. Urinary nitrogen loss was significantly diminished in these animals compared with sham adrenalectomized controls, indicating that an intact adrenal stress response is necessary for the increased nitrogen loss following TNF infusion. Tumor necrosis factor may exert an important regulatory influence on the interorgan substrate flux that occurs during critical illness. The effects of TNF on skeletal muscle proteolysis can be simulated by adrenal glucocorticoid administration. The effects of this cytokine on visceral organs appear to be unique to TNF and cannot be reproduced by the administration of glucocorticoids alone.

Tumour marker detection in oesophageal carcinoma.

Levels of the tumour markers CEA, CA 19-9, CA 125 and SCC were measured in 58 patients presenting with oesophageal carcinoma and compared with levels in patients with benign oesophageal disease and levels in normal volunteers. CEA and CA 19-9 were significantly increased in the patients with oesophageal cancer, however, individual sensitivity for CEA, CA 19-9, CA 125 and SCC was only 28, 34, 10, and 32%, respectively. The combined sensitivity of all markers was 64% and specificity was 80%. There was no difference in combined tumour marker sensitivity between squamous or adenocarcinomas of the oesophagus. No consistent change in marker levels occurred with treatment, and tumour marker levels could not be significantly correlated with stage of disease or short-term survival. These results indicate that tumour marker sensitivity is too low for oesophageal cancer screening and has poor prognostic significance in those undergoing treatment.

Nutritional, respiratory, and psychological effects of recombinant human growth hormone in patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Recombinant human growth hormone (rhGH) has been shown to have powerful anabolic effects and to reduce or even prevent nitrogen catabolism in stressed patients. The effects of rhGH on functional parameters are less clearly defined. The aim of this study was to assess the effects of perioperative rhGH on nutritional markers, skeletal muscle function, and psychological well-being in patients undergoing infrarenal, abdominal aortic aneurysm repair. METHODS: Thirty-three patients undergoing elective infrarenal abdominal aortic aneurysm repair were randomized to one of three groups: (1) control (n = 12): placebo for 6 days before and after surgery; (2) preop + postop (n = 10): rhGH (Genotropin; Pharmacia Ltd, Uppsala, Sweden) 0.3 IU/kg/d for 6 days before and after surgery; and (3) postop (n = 11): placebo for 6 days before and rhGH 0.3 IU/kg/d for 6 days after surgery. Patients were assessed on days -7 and -1 before surgery and days 7, 14, and 60 after surgery. RESULTS: Administration of rhGH resulted in increased insulin-like growth factor 1 levels, the increase being significantly more marked in the group given rhGH preoperatively. Preoperative and postoperative rhGH reduced the postoperative decrease in both serum transferrin and grip strength at day 7 by 30% and 70%, respectively. Postoperative respiratory function and arterial oxygenation also were improved, with significant differences in arterial oxygenation between rhGH-treated and untreated groups. No difference in mood was seen between groups after surgery, nor was there any difference between subjective assessment of fatigue scores between groups. CONCLUSIONS: This pilot study indicates that rhGH administered preoperatively has beneficial effects on skeletal muscle and respiratory function and may be more useful than postoperative rhGH administration alone.

A prospective comparison of laparoscopic versus open cholecystectomy.

In one surgical unit, 115 patients undergoing cholecystectomy were studied to compare patient recovery, subjective and objective pain experienced and complications after laparoscopic and open cholecystectomy. The data were collected prospectively where allocation to open or laparoscopic cholecystectomy was by consecutive attendance. Laparoscopic cholecystectomy was feasible in 90% of patients presenting with symptomatic gallstones. Compared with the open operation, laparoscopic cholecystectomy was safe with less peroperative and postoperative morbidity, was more cost-effective and was associated with faster patient recovery as documented by less postoperative pain, earlier return to diet, earlier full mobilisation and discharge home. Laparoscopic cholecystectomy is superior to open cholecystectomy and should be available to all patients requiring elective cholecystectomy.

The role of the defunctioning ileostomy in restorative proctocolectomy.

Restorative proctocolectomy is now the treatment of choice for most patients with ulcerative colitis and familial polyposis coli. Temporary defunctioning ileostomy has been advocated during the period of anastomotic healing to prevent pelvic sepsis. However, the ileostomy itself may be a source of significant complications. To examine ileostomy function we reviewed thirty five patients (mean age 34.5 +/- 1.95 years) who underwent restorative proctocolectomy. Thirty four patients had a defunctioning ileostomy established at the time of pouch anal anastomosis. Closure of the ileostomy has been carried out in 33 patients (mean closure time 3.1 +/- 0.29 months). One patient underwent early pouch excision. Thirteen of the 35 patients developed post-operative complications (37%), two directly related to the defunctioning ileostomy. Both occurred following closure of the stoma and required laparotomy. Serious complications associated with defunctioning ileostomy as demonstrated in this study are uncommon (8.5%). Given the potentially disastrous consequences of a pouch-anal anastomotic leak we feel that the relatively low morbidity associated with a defunctioning ileostomy justifies its continued routine usage in the operation of restorative proctocolectomy.

The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience.

BACKGROUND: Concerns have been voiced regarding the impact of the European Working Time Directive (EWTD) on surgical training. Following its introduction (August 2009) in Wexford General Hospital, Ireland Surgical Senior House Officers (SSHOs) are required to leave the hospital at 10 a.m. the morning after on-call duty. This study investigates the consequences of this practice on operative experience gained by six SSHOs in comparison to their predecessors. METHODS: A prospectively maintained database of surgical procedures was interrogated. Operative experience of SSHOs over a 5-month period (August-December 2009) was compared with that of colleagues 1 year earlier. The primary endpoint was overall operative volume of SSHOs. Subgroup analysis was performed of cases by primary operator versus assistant, intermediate versus minor procedures and by team. Comparison was made of operative volume between Group 1 (pre-EWTD) and Group 2 (post-EWTD). RESULTS: Operative volume for Group 1 (pre-EWTD) was 461 cases. Group 2 (post-EWTD) was involved in a total of 349 operations, showing a decrease of 24% (P=0.006). SSHOs in Group 1 (pre-EWTD) had been the primary operator in 109 cases compared to 87 in Group 2 (post-EWTD), demonstrating a reduction of 20% (P=0.06). Most worryingly, there was a reduction of 63% (P=0.04) in the intermediate cases performed as operating surgeon in Group 2 (post-EWTD). CONCLUSIONS: The present data set demonstrates a significant reduction in operative experience gained by SSHOs after local implementation of the EWTD. A major challenge facing Irish surgical training over the next decade is reduced operative exposure in the clinical setting.