Enhanced recovery programme after colorectal surgery in high-income and low-middle income countries: a systematic review and meta-analysis.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols strive to optimise outcomes following elective surgery; however, there is a dearth of evidence to support its equitable application and efficacy internationally. MATERIALS AND METHODS: The authors performed a systematic review and meta-analysis of studies on the uptake and impact of ERAS with the aim of highlighting differences in implementation and outcomes across high-income countries (HICs) and low-middle income countries (LMICs). The primary outcome was characterisation of global ERAS uptake. Secondary outcomes included length of hospital stay (LOS), 30-day readmission, 30-day mortality and postoperative complications. RESULTS: Three hundred thirty-seven studies with considerable heterogeneity were included in the analysis (291 from HICs, and 46 from LMICs) with a total of 110 190 patients. The weighted median number of implemented elements were similar between HICs and LMICs ( P =0·94), but there was a trend towards greater uptake of less affordable elements across all aspects of the ERAS pathway in HICs. The mean LOS was significantly shorter in patient cohorts in HICs (5·85 days versus 7·17 days in LMICs, P <0·001). The 30-day readmission rate was higher in HICs (8·5 vs. 4·25% in LMICs, P <0·001, but no overall world-wide effect when ERAS compared to controls (OR 1·00, 95% CI: 0·88-1·13). There were no reported differences in complications ( P =0·229) or 30-day mortality ( P =0·949). CONCLUSION: Considerable variation in the structure, the implementation and outcomes of ERAS exists between HICs and LMICs, where affordable elements are implemented, contributing towards longer LOS in LMICs. Global efforts are required to ensure equitable access, effective ERAS implementation and a higher standard of perioperative care world-wide.

Achalasia: investigation and management.

Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.

Evaluation of a Microsurgery Training Curriculum.

BACKGROUND: Microsurgery is one of the most challenging areas of surgery with a steep learning curve. To address this educational need, microsurgery curricula have been developed and validated, with the majority focus on technical skills only. The aim of this study was to report on the evaluation of a well-established curriculum using the Kirkpatrick model. METHODS: A training curriculum was delivered over 5 days between 2017 and 2020 focusing on (1) microscopic field manipulation, (2) knot tying, nondominant hand usage, (3) 3-D models/anastomosis, and (4) tissue experience. The Kirkpatrick model was applied to evaluate the curriculum at four levels: (1) participants' feedback (2) skills development using a validated, objective assessment tool (Global Assessment Score form) and CUSUM charts were constructed to model proficiency gain (3) and (4) assessing skill retention/long-term impact. RESULTS: In total, 155 participants undertook the curriculum, totaling 5,425 hours of training. More than 75% of students reported the course as excellent, with the remaining voting for "good." All participants agreed that the curriculum met expectations and would recommend it. Significant improvement in anastomosis attainment scores between days 1 and 3 (median score 4) and days 4 and 5 (median score 5) (W = 494.5, p = 0.00170). The frequency of errors reduced with successive attempts (chi square = 9.81, p = 0.00174). The steepest learning curve was in anastomosis and patency domains, requiring 11 attempts on average to reach proficiency. In total, 88.5% survey respondents could apply the skills learnt and 76.9% applied the skills learnt within 6 months. Key areas of improvement were identified from this evaluation, and actions to address them were implemented in the following programs. CONCLUSION: Robust evaluation of curriculum can be applied to microsurgery training demonstrating its efficacy in reducing surgical errors with an improvement in overall technical skills that can extend to impact clinical practice. It allows the identification of areas of improvement, driving the refinement of training programs.

Safety and effectiveness of live broadcast of surgical procedures: systematic review.

INTRODUCTION: Live Broadcast of Surgical Procedures (LBSP) has gained popularity in conferences and educational meetings in the past few decades. This is due to rapid advancement in both Minimally Invasive Surgery (MIS) that enable transmission of the entire operative field and transmission ease and technology to help broadcast the operation to a live audience. The aim of this study was to update the evidence with specific emphasis on the patient safety issues related to LBSP in MIS. METHODS: A systematic review of the literature was performed using Medline, Embase and Pubmed using defined search terms related to LBSP in educational events across all surgical specialities, in accordance with the PRISMA guidelines. We also consolidated the prior guidelines and position statements on this topic. Outcomes included reports on the educational value of LBSP as well as patient safety outcomes and ethical issues that were captured by clinical outcomes. RESULTS: A total 1230 abstracts were identified with 27 papers meeting the inclusion criteria (13 original articles and 14 position statements/guidelines). All studies highlighted the educational benefits of LBSP but without clear measure of these benefits. Clinical outcomes were not compromised in 9 studies but were inferior in the remaining 4, including lower completion rate of endoscopic surgery and higher rate of re-operation. Only nine studies complied with dedicated consent forms for LBSP with no consistent approach of reporting on maintaining patient confidentiality during LBSP. There was a lack of recommendation on standardised approach of reporting on LBSP including the outcomes across the 14 published guidelines and positions statements. CONCLUSIONS: Live Broadcast of Surgical Procedures can be of educational value but patient safety may be compromised. A standardised framework of reporting on LBSP and its outcomes is required from an ethical and patient safety perspective. PROSPERO REGISTRATION: CRD42021256901.

The REBOA window: a cadaveric study delineating the optimum site for austere cannulation of the femoral artery for resuscitative endovascular balloon occlusion of the aorta.

INTRODUCTION: Haemorrhage is the major cause of early mortality following traumatic injury. Patients suffering from non-compressible torso haemorrhage are more likely to suffer early death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can be effective in initial resuscitation; however, establishing swift arterial access is challenging, particularly in a severe shock. This is made more difficult by anatomical variability of the femoral vessels. METHODS: The femoral vessels were characterised in 81 cadaveric lower limbs, measuring specifically the distance from the inferior border of the inguinal ligament to the distal part of the origin of the profunda femoris artery (PFA), and from the distal part of the origin of the PFA to where the femoral vein lies posterior to and is completely overlapped by the femoral artery. RESULTS: The femoral vein lay deep to the femoral artery at a mean distance of 105 mm from the inferior border of the inguinal ligament. The PFA arose from the femoral artery at a mean distance of 51.1 mm from the inguinal ligament. From the results, it is predicted that the PFA originates from the common femoral artery approximately 24 mm from the inguinal ligament, and the femoral vein is completely overlapped by the femoral artery by 67.7 mm distal from the inguinal ligament, in 95% of subjects. CONCLUSIONS: Based on the results, proposed is an 'optimal access window' of up to 24 mm inferior to the inguinal ligament for common femoral arterial catheterisation for pre-hospital REBOA, or more simply within one finger breadth.

Are textbook lungs really normal? A cadaveric study on the anatomical and clinical importance of variations in the major lung fissures, and the incomplete right horizontal fissure.

INTRODUCTION: The lungs have three main fissures: the right oblique fissure (ROF), right horizontal fissure (RHF), and left oblique fissure (LOF). These can be complete, incomplete or absent; quantifying the degree of completeness of these fissures is novel. Standard textbooks often refer to the fissures as complete, but awareness of variation is essential in thoracic surgery. MATERIALS AND METHODS: Fissures in 81 pairs of cadaveric lungs were classified. Oblique fissures were measured from lung hila posteriorly to the lung hila anteriorly; and the RHF measured from the ROF to the anteromedial lung edge. The degree of completeness of fissures was expressed as a percentage of the total projected length were they to be complete. The frequency and location of accessory fissures was noted. RESULTS: LOF were complete in 66/81 (81.5%), incomplete in 13/81 (16.0%) and absent in 2/81 (2.47%); ROF were complete in 52/81 (64.2%), incomplete in 29/81 (35.8%) and never absent; RHF were more variable, complete in 18/81 (22.2%), incomplete in 54/81 (66.7%) and absent in 9/81 (11.1%). LOF and ROF were on average 97.1% and 91.6% complete, respectively, being deficient posteriorly at the lung hila. The RHF on average 69.4% complete, being deficient anteromedially. There were accessory fissures in 10 left and 19 right lungs. CONCLUSIONS: This study provides a projection of the anatomy thoracic surgeons may encounter at operation, in particular the variable RHF. This knowledge is essential for optimal outcomes in both benign and oncological procedures influenced by the fissures.

Configuration of the extra-renal venous system in relation to the left renal vein: A cadaveric study and new proposed classification.

The advent of laparoscopic live-donor nephrectomy for renal transplantation has prompted the need to define the precise anatomical relations of the left renal vein (LRV) and its tributaries. The left kidney is preferred as the greater length of the LRV facilitates implantation in the recipient. While previous studies have described variations in the LRV system, the connections between the left ascending lumbar vein (LALV) and LRV tributaries have been less well-defined. This study aims to further characterise the LALV and proposes a novel classification for its relation to other veins. Dissection of the LRV system, including the left suprarenal vein (LSV), left gonadal vein (LGV) and LALV, was performed in 38 cadavers. Their drainage points into the LRV were recorded, and measurements taken of the distances from these points to the junction of the LRV and inferior vena cava (IVC). The position of the LRV in relation to the aorta was anterior in 35 cases (92%), entirely posterior in 1 case (3%), and circumaortic in 2 cases (5%). Duplication of the LSV and LGV occurred in 6 (16%) and 10 (27%) cases respectively. A direct posterior connection between the LALV and LRV was identified in 32 (86%) cases. The drainage point of the LALV into the LRV lay between the IVC and LGV in 8 (25%) cases. In 20 cases (63%), the drainage points of the LALV and LGV were equidistant from the IVC; and in 5 cases (16%), those of the LALV and posterior branch of the LRV were equidistant from the IVC. In these two groups, the vessels shared a confluent trunk in 10 and 4 cases respectively. In 3 cases, connections were observed between all three vessels (LALV, LGV and posterior branch of LRV). No confluence trunk was shared by the LALV and LSV. These results confirm the high incidence of communicating LALVs, which represent a potentially troublesome source of operative bleeding if unrecognised. Confluent venous trunks may also present difficulties during vessel ligation prior to nephrectomy. It is suggested that a novel classification of the relation of the LALV based on these findings may assist in surgical planning and reduce complications.