Construct and criterion validity testing of the Non-Technical Skills for Surgeons (NOTSS) behaviour assessment tool using videos of simulated operations.

BACKGROUND: Surgeons' non-technical skills are an important part of surgical performance and surgical education. The most widely adopted assessment tool is the Non-Technical Skills for Surgeons (NOTSS) behaviour rating system. Psychometric analysis of this tool to date has focused on inter-rater reliability and feasibility rather than validation. METHODS: NOTSS assessments were collected from two groups of consultant/attending surgeons in the UK and USA, who rated behaviours of the lead surgeon during a video-based simulated crisis scenario after either online or classroom instruction. The process of validation consisted of assessing construct validity, scale reliability and concurrent criterion validity, and undertaking a sensitivity analysis. Central to this was confirmatory factor analysis to evaluate the structure of the NOTSS taxonomy. RESULTS: Some 255 consultant surgeons participated in the study. The four-category NOTSS model was found to have robust construct validity evidence, and a superior fit compared with alternative models. Logistic regression and sensitivity analysis revealed that, after adjusting for technical skills, for every 1-point increase in NOTSS score of the lead surgeon, the odds of having a higher versus lower patient safety score was 2·29 times. The same pattern of results was obtained for a broad mix of surgical specialties (UK) as well as a single discipline (cardiothoracic, USA). CONCLUSION: The NOTSS tool can be applied in research and education settings to measure non-technical skills in a valid and efficient manner.

High serum lactate as an adjunct in the early prediction of anastomotic leak following oesophagectomy.

BACKGROUND: Anastomotic leak (AL) following oesophagectomy carries a high mortality and morbidity. Early detection and intervention is required for a successful outcome. We have examined the role of a high postoperative serum lactate in predicting which patients are at risk of developing an anastomotic leak(AL). MATERIALS AND METHODS: All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database. Medical records were reviewed to identify the highest serum lactate recorded from blood gas analysis over each 24hr post-operative period. Patients who underwent transhiatal and left thoraco-abdominal oesophagectomies were excluded. Patients who developed a chyle leak were excluded. RESULTS: Of a total of 136 oesophagectomies included for analysis, 18 developed an AL (13.2%). Of these patients, 10 underwent thoracoscopic oesophageal mobilization with cervical anastomosis and the rest an Ivor Lewis procedure. Predictive factors for AL included neoadjuvant chemotherapy (15/18 83.3% vs 55/118 46.6% p = 0.0046) and number of positive lymph nodes (mean 4.2 vs control mean 2.3 p = 0.045). Overall net fluid balance was comparable between the 2 groups, although AL patients received slightly more fluid on Day 3. High lactate levels on days 1-3 were associated with an AL. Using a Day 2 lactate of 1.7 mmol/L, the sensitivity of predicting AL was 72% and specificity 88%. The mean lag time using existing diagnostic modalities was 7.9 days. CONCLUSION: A serum lactate of >1.7 mmol/l on day 2 should raise the possibility of a potential AL. Such patients should be selected for more intensive monitoring, optimization and selective gastroscopy.

The Surgical Management of Concomitant Gallbladder and Common Bile Duct Stones.

Background. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. Aim. To review 5-year results of bile duct exploration in an UGI unit. Methods. Common bile duct explorations (CBDEs) performed between January 2008 and January 2013 were identified from a prospectively collected clinical audit system and results reviewed retrospectively. Results. 216 CBDEs were performed, 119 (55%) as an emergency and 52 (24%) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16%) patients and attempted laparoscopically in 182 (84%). Fifty nine (32%) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41%) primary choledochotomies and 72 (59%) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68%) TC-CBDEs were considered successful and 23 (32%) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87%) patients and retained stones were identified in 20/123 (16%) LCBDEs. Complications occurred in 52/216 (24%) patients. There were 8/216 (4%) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15%) patients and 9/216 (4%) required relaparoscopy/laparotomy. No patient died. Conclusions. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise.

Quality of life after total and subtotal gastrectomy for gastric carcinoma.

BACKGROUND: There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer. METHOD: All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22). RESULTS: From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group. CONCLUSION: This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

Outcomes following Boerhaave's syndrome.

INTRODUCTION: Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit. METHODS: Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay. RESULTS: Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days. CONCLUSIONS: Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment.

BACKGROUND: A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM. METHODS: This was a single-centre retrospective study of patients who had undergone attempted curative resection for a pathological T3 oesophageal or OGJ cancer. Clinicopathological variables and distance from the tumour to the CRM, measured to ± 0.1 mm, were correlated with survival. RESULTS: A total of 226 patients were included. Sex (P = 0·018), tumour differentiation (P = 0·019), lymph node status (P < 0·001), number of positive nodes (P < 0·001), and CRM distance (P = 0·042) were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1-0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18·6 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables (P = 0·009). CONCLUSION: A positive CRM of 1 mm or less should be regarded as involved. Adjuvant radiotherapy confers a significant survival benefit in selected patients with an involved CRM.

Assessment of the mobility of mothers postpartum to identify those at greatest risk of venous thromboembolism.

Our aim was to directly assess the postnatal mobility of mothers and to relate and compare venous thromboembolism (VTE) risk with current guidelines on VTE thromboprophylaxis postpartum. VTE still remains one of the leading causes of direct maternal deaths in the western world and this risk is greatest in the postnatal period. Mode of delivery and postnatal mobility are key, however the effect of the former on the latter is unclear. A total of 200 antenatal women were recruited into the study. Each was given a pedometer and recorded the number of steps taken daily for 7 days postpartum. A total of 72 women completed the study. Those who underwent any form of vaginal delivery were mobile soonest. By day 7 postpartum, women following vaginal delivery were almost twice as mobile as those who underwent caesarean section (CS). Women who underwent emergency CS were more mobile than those who had elective CS, which is contrary to current assumptions.

mRNA profiling of the cancer degradome in oesophago-gastric adenocarcinoma.

BACKGROUND: Degradation of the extracellular matrix is fundamental to tumour development, invasion and metastasis. Several protease families have been implicated in the development of a broad range of tumour types, including oesophago-gastric (OG) adenocarcinoma. The aim of this study was to analyse the expression levels of all core members of the cancer degradome in OG adenocarcinoma and to investigate the relationship between expression levels and tumour/patient variables associated with poor prognosis. METHODS: Comprehensive expression profiling of the protease families (matrix metalloproteinases (MMPs), members of the ADAM metalloproteinase-disintegrin family (ADAMs)), their inhibitors (tissue inhibitors of metalloproteinase), and molecules involved in the c-Met signalling pathway, was performed using quantitative real-time reverse transcription polymerase chain reaction in a cohort of matched malignant and benign peri-tumoural OG tissue (n=25 patients). Data were analysed with respect to clinico-pathological variables (tumour stage and grade, age, sex and pre-operative plasma C-reactive protein level). RESULTS: Gene expression of MMP1, 3, 7, 9, 10, 11, 12, 16 and 24 was upregulated by factors >4-fold in OG adenocarcinoma samples compared with matched benign tissue (P<0.01). Expression of ADAM8 and ADAM15 correlated significantly with tumour stage (P=0.048 and P=0.044), and ADAM12 expression correlated with tumour grade (P=0.011). CONCLUSION: This study represents the first comprehensive quantitative analysis of the expression of proteases and their inhibitors in human OG adenocarcinoma. These findings implicate elevated ADAM8, 12 and 15 mRNA expression as potential prognostic molecular markers.

The evolution of laparoscopic antireflux surgery and its influence on postoperative stay.

Laparoscopic fundoplication is an established treatment for refractory gastro-oesophageal reflux disease. This study aims to compare the outcome of two laparoscopic antireflux techniques in a regional specialist unit. A sequential audit was carried out on patients undergoing laparoscopic Nissen (LN: performed May 1994 to November 2000) or laparoscopic anterior (LA: performed March 2001 to December 2004) fundoplication. Patient satisfaction was assessed by postal questionnaire. The cohorts undergoing each operation were also divided into two chronological groups of 51 patients, to study the effect of possible learning curve progression on the number of nights spent in the hospital postoperatively. In all, 142/204 (70%) questionnaires were returned from patients with follow-up ranging from 5 to 40 months postoperation. Overall, 102/142 (72%) reported a good or excellent outcome. Patients who underwent LA had a higher rate of antacid medication use (LN 17.4% versus LA 34.2%, P = 0.036) but there was a higher score for inability to belch following LN (LN 2.03 versus LA 1.53, P = 0.034). When comparing the chronologically divided cohorts, LN was associated with a significantly longer hospital stay than LA (P < 0.001, Mann-Whitney U test). There was a significant decrease in hospital stay from the first to second group of 51 LNs (P < 0.001, Mann-Whitney U test) and a further significant reduction in hospital stay from the first 51 to second 51 LAs (P < 0.001, Mann-Whitney U test). In conclusion, both procedures provide good symptom control. Increased requirement for acid suppression following LA and inability to belch following LN, may suggest more long-term durability of the LN wrap. The decrease in the number of nights spent in hospital may be related to the procedure performed but seems more likely to be an effect of increasing volume of surgical experience.

Changing trends in operative delivery performed at full dilatation over a 10-year period.

This study was a systematic anonymous audit of routinely collected data in a tertiary referral obstetric unit in London and included data from deliveries over a 10-year period (1992-2001). Data for all caesarean sections at full dilatation were collected, including maternal demographic information, the grade of operating clinician, and the place of delivery. Neonatal data collected included birth weight and umbilical arterial pH. No changes in the demographics of the population were observed. No increased rates of malposition were observed. Birth weight did not change. Increasing preference for the ventouse over forceps (ratio 0.2:1 to 1.9:1) over the decade (p = 0.002) was seen with an increased tendency to conduct the delivery in the operating theatre (p = 0.0025). Rate of caesarean section at full dilatation increased (2% by 2001). Increasing failures of operative vaginal delivery, especially using the ventouse (regression coefficient p = 0.025), and reduced attempts at instrumentation (regression coefficient p = 0.002) were seen.

Noninvasive fetal electrocardiography following intermittent umbilical cord occlusion in the preterm ovine fetus.

OBJECTIVE: To investigate whether a noninvasive fetal electrocardiography (fECG) system can identify cardiovascular responses to fetal hypoxaemia and validate the results using standard invasive fECG monitoring techniques. DESIGN: Prospective cohort study. SETTING: Biological research facilities at The University of Southampton. POPULATION OR SAMPLE: Late gestation ovine fetuses; n = 5. METHODS: Five fetal lambs underwent implantation of vascular catheters, umbilical cord occluder and invasive ECG chest electrodes under general anaesthesia (3% halothane/O(2)) at 119 days of gestation (term approximately 147 days of gestation). After 5 days of recovery blood pressure, blood gases, glucose and pH were monitored. At 124 and 125 days of gestation following a 10-minute baseline period a 90-second cord occlusion was applied. Noninvasive fetal ECG was recorded from maternal transabdominal electrodes using advanced signal-processing techniques, concurrently with invasive fECG recordings. MAIN OUTCOME MEASURES: Comparison of T:QRS ratios of the ECG waveform from noninvasive and invasive fECG monitoring systems. RESULTS: Our fECG monitoring system is able to demonstrate changes in waveforms during periods of hypoxaemia similar to those obtained invasively, which could indicate fetal distress. CONCLUSIONS: These findings may indicate a future use for noninvasive electrocardiography during human fetal monitoring both before and during labour in term and preterm pregnancies.

Variation of laparoscopic hernia repair in Scotland: a postcode lottery?

BACKGROUND AND PURPOSE: The laparoscopic approach is now recommended by NICE as the preferred technique for repair of bilateral and recurrent inguinal hernia and an accepted option for unilateral hernia. This study was set up to examine whether patients across Scotland had equal access to this method of treatment. METHODS: Information was collected on laparoscopic hernia repairs in adults at all acute general NHS hospitals in Scotland between the financial years 1997/8 and 2007/8. Private hospitals were excluded due to lack of data. The data were derived from SMR01 data of inpatient and daycase discharges from non-paediatric general acute NHS hospitals in Scotland as collected by the Information Services Division (ISD) of NHS National Services Scotland. FINDINGS: Of 6821 repairs in 2007/8, only 890 (13.0%) were performed laparoscopically, a small increase from 294 (4.5%) in 1997/8. The highest incidence of laparoscopic hernia repair in 2007/8 was in NHS Lothian, where 435 (41.1%) of all repairs were performed using the laparoscopic technique. Excluding NHS Lothian, the number of laparoscopic hernia repairs in the rest of Scotland showed a much smaller rise, from 184 (3.3%) to 455 (7.9%). NHS Lothian, (which has 20% of the Scottish population) performed 54.5% of laparoscopic repairs in Scotland between 1997/8 and 2007/8. In the most recent year available, 2007/8, 63.1% of bilateral primary, 53.7% of bilateral recurrent and 26.8% of unilateral recurrent hernia operations in Lothian were laparoscopic. This compares to only 9.9%, 7.0% and 7.1%, respectively, for other Scottish hospitals. CONCLUSIONS: Despite the fact that laparoscopic hernia repair has several proven advantages over open techniques, particularly in bilateral and recurrent hernias, activity remains at a low level in Scotland with the exception of NHS Lothian. In Scotland, laparoscopic techniques are not being used as recommended by NICE guidelines and there appears to be a "postcode lottery" in the provision of this method of treatment. Possible reasons are discussed and action plans are suggested.

Plasma MIC-1 correlates with systemic inflammation but is not an independent determinant of nutritional status or survival in oesophago-gastric cancer.

BACKGROUND: Macrophage inhibitory cytokine-1(MIC-1) is a potential modulator of systemic inflammation and nutritional depletion, both of which are adverse prognostic factors in oesophago-gastric cancer (OGC). METHODS: Plasma MIC-1, systemic inflammation (defined as plasma C-reactive protein (CRP) of > or =10 mg l(-1) or modified Glasgow prognostic score (mGPS) of > or =1), and nutritional status were assessed in newly diagnosed OGC patients (n=293). Healthy volunteers (n=35) served as controls. RESULTS: MIC-1 was elevated in patients (median=1371 pg ml(-1); range 141-39 053) when compared with controls (median=377 pg ml(-1); range 141-3786; P<0.001). Patients with gastric tumours (median=1592 pg ml(-1); range 141-12 643) showed higher MIC-1 concentrations than patients with junctional (median=1337 pg ml(-1); range 383-39 053) and oesophageal tumours (median=1180 pg ml(-1); range 258-31 184; P=0.015). Patients showed a median weight loss of 6.4% (range 0.0-33.4%), and 42% of patients had an mGPS of > or =1 or plasma CRP of > or =10 mg l(-1) (median=9 mg l(-1); range 1-200). MIC-1 correlated positively with disease stage (r(2)=0.217; P<0.001), age (r(2)=0.332; P<0.001), CRP (r(2)=0.314; P<0.001), and mGPS (r(2)=0.336; P<0.001), and negatively with Karnofsky Performance Score (r(2)=-0.269; P<0.001). However, although MIC-1 correlated weakly with dietary intake (r(2)=0.157; P=0.031), it did not correlate with weight loss, BMI, or anthropometry. Patients with MIC-1 levels in the upper quartile showed reduced survival (median=204 days; 95% CI 157-251) when compared with patients with MIC-1 levels in the lower three quartiles (median=316 days; 95% CI 259-373; P=0.036), but MIC-1 was not an independent prognostic indicator. CONCLUSIONS: There is no independent link between plasma MIC-1 levels and depleted nutritional status or survival in OGC.

The relationship between hospital volume and post-operative mortality rates for upper gastrointestinal cancer resections: Scotland 1982-2003.

BACKGROUND: Centralisation of surgical treatment of cancer has resulted in improved outcomes. We aimed to determine evidence of benefit for specialised management of upper gastrointestinal cancer in high-volume centres in Scotland. METHODS: Discharge records of patients undergoing oesophagectomy, gastrectomy, hepatectomy or pancreatectomy between 1982 and 2003 were identified. Hospital data were analysed on a year-by-year basis to derive 'hospital-years'. Hospital-years were divided into quartiles by volume, and were analysed with regard to in-hospital mortality during the operative admission [Chi-square test (chi(2)) and Chi-square test for trend (chi(2)(trend))]. RESULTS: 10,625 patients and 982 in-hospital deaths were included. In-hospital mortality rates declined during the study period: oesophagectomy 11.7-7.9%; gastrectomy 11.2-7.2%; hepatectomy 11.1-3.0%; and pancreatectomy 8.3-4.9%. For all resections except gastrectomy, mortality decreased as quartile of hospital-year volume increased (oesophagectomy: chi(2)p=0.006, chi(2)(trend)p=0.001; hepatectomy: chi(2)p=0.004, chi(2)(trend)p=0.003; pancreatectomy: chi(2)p=0.002, chi(2)(trend)p=0.001). ORs of death were lower for oesophagectomy (OR=0.58; 95%CI=0.39, 0.88; p=0.009) and pancreatectomy (OR=0.35; 95%CI=0.19, 0.64; p<0.001) in hospital-years within highest-volume quartiles compared with lowest. Scattergraphs of all resection types demonstrated inverse power relationships between number of resections per hospital-year and mortality. CONCLUSION: Concentration of cancer care has had major effects on health service delivery in Scotland. Centralisation should be supported in surgical management of upper gastrointestinal cancer.

The influence of systemic inflammation, dietary intake and stage of disease on rate of weight loss in patients with gastro-oesophageal cancer.

Although weight loss is often a dominant symptom in patients with upper gastrointestinal malignancy, there is a lack of objective evidence describing changes in nutritional status and potential associations between weight loss, food intake, markers of systemic inflammation and stage of disease in such patients. Two hundred and twenty patients diagnosed with gastric/oesophageal cancer were studied. Patients underwent nutritional assessment consisting of calculation of body mass index, measurement of weight loss, dysphagia scoring and estimation of dietary intake. Serum acute-phase protein concentrations were determined by enzyme-linked immunosorbent assay. In all, 182 (83%) patients had lost weight at diagnosis (median loss, 7% body weight). Weight loss was associated with poor performance status, advanced disease stage, dysphagia, reduced dietary intake and elevated serum C-reactive protein (CRP) concentrations. Multiple regression identified dietary intake (estimate of effect, 38%), serum CRP concentrations (estimate of effect, 34%) and stage of disease (estimate of effect, 28%) as independent variables in determining degree of weight loss. Mechanisms other than reduced dietary intake or mechanical obstruction by the tumour appear to be involved in the nutritional decline in patients with gastro-oesophageal malignancy. Recognition that systemic inflammation plays a role in nutritional depletion may inform the development of appropriate therapeutic strategies to ameliorate weight loss, making patients more tolerant of cancer-modifying treatments such as chemotherapy.

Work related aspects of inguinal hernia: a literature review.

INTRODUCTION: There is a traditional belief that that an inguinal hernia can be the result of increased intra-abdominal pressure (IAP) and therefore the development of a hernia may be attributed to single strenuous or recurrent strenuous events. As a result of this, litigation in this area is frequent. METHODS: Medline was searched for English language publications using the keywords of 'hernia' or 'hernia AND recurrence' combined with 'work related', 'physical activity' and 'intra abdominal pressure'. The reference lists of appropriate papers identified on the original search were also checked to identify all related publications. RESULTS: The search revealed 268 papers of which 59 were identified as appropriate to the subject of this review. Although publications in this area are scarce, from the literature available to date, there is no evidence to support the idea that single or recurrent strenuous events or early return to work related activity should result in the formation or recurrence of an inguinal hernia. CONCLUSION: Although immediate pain at the time of an intensive or recurrent activity followed by a new diagnosis of a hernia supports a link between the activity and the hernia occurrence, it is likely that a congenital or acquired weakness in the connective tissue or muscles of the patient meant that hernia occurrence was almost inevitable. This may have significant implications regarding 'work related' hernia and its associated litigation.

Fact or infection: do surgical trainees know enough about infection control?

INTRODUCTION: There exists a high level of non-compliance with basic infection control measures by medical staff. One explanation may be a lack of familiarity with contemporary infection control guidelines. As surgical trainees represent a key group of stakeholders responsible for the delivery of recommended infection control practice, we assessed knowledge of infection control guidelines amongst current UK surgical trainees. MATERIALS AND METHODS: Without warning, during the annual meeting of the UK Association of Surgeons in Training (ASiT), participating surgical trainees were asked to complete a questionnaire examining their basic knowledge of infection control and methicillin-resistant Staphylococcus aureus (MRSA) based on recently published guidelines. RESULTS: A total of 52 trainees (13 higher surgical trainees [HSTs]; 39 basic surgical trainees [BSTs]) returned completed questionnaires in the study. BSTs demonstrated a higher level of knowledge of infection control, outperforming the HSTs in 7 out of 11 questions. Of surgical trainees, 61.5% were misinformed regarding the prevalence of MRSA blood-stream infections and 69% were unaware of policies for transfer of MRSA-positive patients. Analysis revealed areas of concern in regards to an adequate general level of knowledge of infection control in surgical trainees, particularly in some key areas. CONCLUSIONS: To ensure patient safety and reduce hospital-acquired infections, it is vital that focused, co-ordinated programmes of education, in this rapidly changing field, are prioritised and formalised into surgical training, selection and assessment.

Improved management of acute gallstone disease after regional surgical subspecialization.

PURPOSE: Acute gallstone disease is a common indication for emergency hospital admission, and evidence now strongly supports early laparoscopic cholecystectomy as the treatment of choice. Recent data from the UK suggest that this is achieved in a minority of cases with a high proportion of patients managed by deferred elective surgery or emergency open cholecystectomy. We present results of a policy of definitive treatment during index admission after subspecialist reorganization of a regional emergency surgical service. METHODS: Data for all emergency gallstone admissions were retrieved from a prospectively collected regional surgical audit database and results were compared from 31 month periods before and after subspecialist service reorganization in August 2002. RESULTS: A total of 2442 patients were analyzed. Before subspecialization, 458 of 733 patients (62.4%) underwent cholecystectomy during index admission; after subspecialization, cholecystectomy during index admission for biliary colic/acute cholecystitis was achieved in 666 of 817 (81.5%) patients (90.2% laparoscopic, 6.5% conversion rate, and 3.3% primary open cholecystectomy) with a reduction in hospital stay from median 5 to 4 days. The rate of deferred surgery decreased from 37.5% to 18.4%. Early surgery reduced total hospital admission by more than 1 day per patient compared with deferred surgery. CONCLUSIONS: Early laparoscopic cholecystectomy during emergency admission is cost-effective and should be regarded as the standard of care. However, it requires appropriately trained surgeons and availability of a dedicated emergency room, which at present are not consistently provided in all regions of the UK.