Acquisition of microvascular suturing techniques is feasible using objective measures of performance outside of the operating room.

The aim of this study was to determine the effectiveness of a microsurgical simulation course on a group of novice surgeons. The study also aimed to see whether a device to measure manual dexterity (Imperial College Surgical Assessment Device, ICSAD), a global rating scale and an end product assessment tool could be used to objectively measure performance. Thirty surgeons were recruited to take part and were evenly split into novice, intermediate, and expert groups. The novice group took part in a one-week microsurgical course. The assessment of performance was done with the surgeon anastomosing a harvested rat aorta. They were assessed using ICSAD, which records number of hand movements, distance moved by hands and time. The assessment was also video recorded and later watched by two assessors. The procedure performance was scored using a global rating scale and the final anastomosis was scored using an end product assessment tool. The novice surgeons took the assessment at the beginning and at the end of the course. The intermediate and expert group performed the assessment once to use as a comparison to the novice group. By the end of the course the novices performed significantly better in all parameters in comparison to their pre course assessment. The novice group performed similarly to the expert group in their end of course assessment in four out of the five assessment parameters. Simulation using objective measures of performance can be used to effectively to train a group of novice microsurgeons.

Hierarchical multilevel analysis of increased caseload volume and postoperative outcome after elective colorectal surgery.

BACKGROUND: The study aimed to explore the impact of surgeon and institution volume on outcome following colorectal surgery in England using multilevel hierarchical analysis. METHODS: An observational study design was used. All patients undergoing primary elective colorectal resection between 2000 and 2008 were included from the Hospital Episode Statistics database. Consultant surgeons and hospitals were divided into tertiles (low, medium and high volume) according to their mean annual colorectal cancer resection caseload. Outcome measures examined were postoperative 30-day mortality, 28-day readmission and reoperation, and length of stay. Hierarchical multiple regression analysis adjusted for age, sex, co-morbidity, social deprivation, year of surgery, operation type and surgical approach. RESULTS: A total of 109 261 elective cancer colorectal resections were included. High-volume consultant surgeons and hospitals were defined as performing more than 20·7 and 103·5 elective colorectal cancer procedures per year respectively. Consultant and hospital operative volumes increased throughout the study period. In hierarchical regression models, greater surgeon and institutional volume independently predicted only shorter length of hospital stay. No statistical association was observed between higher provider volume and postoperative mortality, 28-day reoperation or readmission rates. CONCLUSION: Increasing elective colorectal cancer caseload alone may have marginal postoperative benefit.

Mortality in high-risk emergency general surgical admissions.

BACKGROUND: There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts. METHODS: The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions. RESULTS: Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2-18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P < 0·001). Low-mortality outlying Trusts had significantly more intensive care beds per 1000 hospital beds (20·8 versus 14·0; P = 0·017) and made significantly greater use of CT (24·6 versus 17·2 scans per bed per year; P < 0·001) and ultrasonography (42·5 versus 30·2 scans per bed per year; P < 0·001). CONCLUSION: There is significant variability in mortality risk between hospital Trusts treating high-risk emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes.

Dynamic Magnetic Resonance Imaging Demonstrates the Integrity of Perineal Reconstruction following Cylindrical Abdominoperineal Excision with Reconstruction of the Pelvic Floor Using Porcine Collagen.

A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T(3)N(2) rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.

Is 30-day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

AIM: The study aimed to define mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients. METHOD: A systematic review was undertaken to identify studies that reported on mortality in the elderly following elective colorectal resection. Searches of MEDLINE, Embase and PubMed databases were carried out by two independent reviewers and the results were collated. Two reviewers conducted literature searches independently and the third reviewer acted as an arbiter in case of discordance. RESULTS: Two-hundred and thirty-six studies published in 2000 or later were identified in the search. Studies were excluded if they included emergency surgery, included patients receiving surgery before 1995, or did not comment on mortality in an elderly age group. Seventeen studies were finally included in the review. Thirty-day or postoperative mortality rates varied from 0 to 13.3%. Short-term mortality was low in elderly patients selected for minimal access surgery. National population and registry observational audits reported higher short-term mortality rates than most small case series or cohort studies. One national audit demonstrated that a significant mortality risk persists for up to 1 year after surgery. CONCLUSION: Historical case series suggest that 30-day mortality following colorectal resection in the elderly is low. The reliability of 30-day mortality measures to reflect surgical success in this cohort is, however, questionable as a significant proportion of patients die in the months following surgery.

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection.

BACKGROUND: Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure-to-rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England. METHODS: The Hospital Episode Statistics (HES) database was used to identify patients undergoing primary resection for colorectal cancer between 2000 and 2008 in English National Health Service (NHS) trusts. Units were ranked into quintiles according to overall risk-adjusted mortality. Highest and lowest mortality quintiles were compared with respect to reoperation rates and FTR-surgical (FTR-S) rates. FTR-S was defined as the proportion of patients with an unplanned reoperation who died within the same admission. RESULTS: Some 144 542 patients undergoing resection for colorectal cancer in 150 English NHS trusts were included. On ranking according to risk-adjusted mortality, rates varied significantly between lowest and highest mortality quintiles (5·4 and 9·3 per cent respectively; P = 0·029). Lowest and highest mortality quintiles had equivalent adjusted reoperation rates (both 4·8 per cent; P = 0·211). FTR-S rates were significantly higher at units within the worst mortality quintile (16·8 versus 11·1 per cent; P = 0·002). CONCLUSION: FTR-S rates differed significantly between English colorectal units, highlighting variability in ability to prevent death in this high-risk group. This variability may represent differences in serious surgical complication management. FTR-S represents a readily collectable marker of surgical complication management that is likely to be applicable to other surgical specialties.

A colorectal perspective on voluntary submission of outcome data to clinical registries.

BACKGROUND: The aim of the study was to identify outcome differences amongst patients undergoing resection of colorectal cancer at English National Health Service trusts using Hospital Episode Statistics (HES). A comparison was undertaken of trusts that submitted and those that did not submit, or submitted only poorly, voluntarily to a colorectal clinical registry, the National Bowel Cancer Audit Programme (NBOCAP). METHODS: The NBOCAP data set was used to classify trusts according to submitter status. HES data were used for outcome analysis. Data for major resections of colorectal cancer performed between 1 August 2007 and 31 July 2008 were obtained from HES. Trusts not submitting data to NBOCAP and those submitting less than 10 per cent of their total workload were termed 'non-submitters'. HES data for 30-day mortality, length of stay and readmission rates were compared according to submitter and non-submitter status in multifactorial analyses. RESULTS: A total of 17,722 patients were identified from HES for inclusion. Unadjusted 30-day in-hospital mortality rates were higher in non-submitting than in submitting trusts (5·2 versus 4·0 per cent; P = 0·005). Submitter status was independently associated with reduced 30-day mortality (odds ratio 0·76, 95 per cent confidence interval 0·61 to 0·96; P = 0·021) in regression analysis. CONCLUSION: A higher postoperative mortality rate following resection of colorectal cancer was found in trusts that do not voluntarily report data to NBOCAP. Implications regarding the voluntary nature of submission to such registries should be reviewed if they are to be used for outcome benchmarking.

Establishing quality in colorectal surgery.

AIM: The review aimed to offer a contemporary perspective of the quality of current colorectal surgery. METHOD: A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language. RESULTS: Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework. CONCLUSION: A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.