The Myles Gibson military lecture: surgery in the Napoleonic Wars.

Throughout the twenty-two year period of the Napoleonic Wars, campaigns under extremes of climate cost the Allies much in terms of mortality and morbidity. Although Bonaparte brought about many sound political and national improvements, when France had been brought to its knees by the bloody Revolution, his ambitions became excessive and his military forays difficult to support. Following early successes in the field, he underestimated the determination, persistence and the ability of some opposing commanders. The French medical services profited greatly from the innovations of the post-revolutionary period, and the efforts of men such as Larrey and Percy. The British Army medical support was scanty, and, initially lacked experience. To some extent, this latter defect was corrected by Sir James McGrigor during the Peninsular War. Each campaign brought it's own perils and most men died of deprivation, disease and effects of climate, rather than battle injury. There were technically able surgeons who were inevitably hampered by lack of antiseptic technique, anaesthesia and the lack of understanding of the fundamental aspects of hygiene, adequate diet and good nursing care.

One-year survey of carcinoma of the oesophagus and stomach in Wales.

BACKGROUND: The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales. METHODS: Patients were identified from hospital records. Details were recorded in structured format for analysis. RESULTS: Analysable data were obtained for 910 of 916 patients. The overall incidence was 31.4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0.001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. 'Open and close' operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0.05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0.01) irrespective of case volume. CONCLUSION: Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.

Patients' perception of surgical services in a district general hospital.

BACKGROUND: In addition to studying the outcomes of surgery in terms of mortality and morbidity rates and performance, it is also important to consider how patients perceive the delivery of the service given to them. METHODS: A patient satisfaction survey was carried out by the Surgical Epidemiology and Audit Unit of the Royal College of Surgeons of England, on patients undergoing surgical procedures by the Department of Surgery at Wrexham Maelor Hospital. No day cases were included in the study. Two hospitals in southern England (undergoing the same survey) designated X and Y were used for comparison. RESULTS: Some 2000 questionnaires were sent out twice; 1666 subjects (83 per cent) responded to the first questionnaire and 1445 (87 per cent) of these responded to a second questionnaire 6 weeks later (overall response 72 per cent). A total of 35 per cent of patients were older than 65 years of age. Some 76 per cent of patients with a malignant condition were seen within 4 weeks of referral compared with 38 per cent of those with a benign condition (P < 0.0001). A total of 78 per cent of patients with cancer were admitted within 4 weeks compared with 84 and 88 per cent in hospitals X and Y. Some 23 per cent of patients were admitted as an emergency. Eighteen per cent of patients did not know who presented a consent form to them before surgery compared with 13 and 17 per cent in hospitals X and Y (P < 0.0001). Some 26 per cent of patients perceived that they had complications after surgery compared with 27 and 25 per cent for hospitals X and Y. A total of 35 per cent of patients did not receive a follow-up appointment and 20 per cent of these patients were unhappy about this. Two areas of major concern revealed by the responses were the lack of written information and the overall poor scores generally attained by the emergency admission ward. However, 94 per cent of patients said that they would return to the same consultant. CONCLUSION: Patients were generally happy with their surgical care and there was little difference between the three hospitals studied. Lower scores were given when patients were admitted to emergency admission wards. Higher scores were given when patients received printed information.

A 5-year survival study of general surgical patients aged 65 years and over.

A prospective 5-year survival study of 900 patients, aged 65 years and over, undergoing a general surgical procedure, demonstrated that following an initial high mortality rate the survival of the group as a whole approached that of an age-matched population. Non-elective admissions, age 75 years and over, ASA grade 4-5 and major surgery were associated with a high early mortality. Mortality associated with malignancy extended over 1 year. The study reinforces the conclusion that age alone should be no bar to surgery and anaesthesia, endorses the findings of the National Confidential Enquiry into Peri-operative deaths and emphasises the need to re-examine the provision of anaesthetic and surgical services in District General Hospitals. The benefits of elective admission in the very old are highlighted, along with the potential for extension of day case surgery.

The use and impact of a daily general surgical emergency operating list in a district general hospital: a prospective study.

Daytime emergency operating lists (EOL) have been shown to reduce out-of-hours operating but problems with their introduction have been reported. A six-month prospective study of EOL and unscheduled operations (USO) was undertaken. Two firms use their EOL differently--one including mostly emergencies, the other including a number of urgent elective cases. After the introduction of EOL only 9 per cent of emergency operations were performed after midnight. Including urgent elective cases on the EOL allowed full use of available theatre time but meant that proportionately more emergency operations were unscheduled. A senior surgeon was involved with 75 per cent of EOL and 36 per cent of USO operations, and a senior anaesthetist with 52 per cent of EOL and 14 per cent of USO. Senior anaesthetic involvement would have been greater if there were more senior staff. There had been a marked increase in the number of USO over the four years previous to this study. EOL do reduce out-of-hours operating and allow excellent supervision and therefore training opportunities. Care must be taken with the case mix to balance full use of theatre time with reduction in out-of-hours operating.

Evolving role of intensive and high-dependency care.

As stratified patient care evolves, and with an increasing population of elderly patients undergoing major surgery there is a growing demand for critical and high-dependency care beds. Results of an audit comparing the activity of a combined Intensive Care and High-Dependency Unit (ITU/HDU) in 1981 with 1991 has shown an increase in the number of patients admitted, particularly for high-dependency care. The overall mortality in 1981 was 12% compared with 9.5% in 1991. The greatest improvement was seen in ventilated patients, where the mortality was reduced from 54% in 1981 to 30% in 1991. An attempt is made to predict the demand for critical care and high-dependency beds for the future in a population of approximately 250,000 based on current trends. It is perceived that it will be necessary to establish a six-bed ITU and eight high-dependency surgical beds in two separate but adjacent units, where there will be a free interchange of skills at the different levels of care.

The efficiency of management of emergency surgery in a district general hospital--a prospective study.

In a 6-month prospective study of management of surgical emergencies in a district general hospital, we have tried firstly to determine the degree to which non-life-threatening emergencies could be managed within 'social hours' (0800-1800), and secondly to identify examples of and reasons for potentially hazardous delay in the performance of urgent procedures. Emergency referrals undergoing surgery were categorised into three groups: Group A--patients requiring surgery either immediately or at the earliest possible time (maximum 3 h after diagnosis). Group B--patients requiring urgent but not immediate surgery (within 6 h of diagnosis). Group C--patients whose operations could be delayed until social hours without detriment. The reason for delay--shortage of theatre nursing, anaesthetic or surgical staff--was recorded in each case. Of the 95 patients in Group C (elective management) 63 (65%) underwent surgery within social hours, 15 (16%) between 1800 and 2100 and 17 (18%) at night. Unacceptable delays occurred in 37 (14%) of the 260 cases and were most likely to affect patients in Group A who most needed urgent care. We conclude that our current staffing levels in theatre nursing should be increased to consistently provide two (rather than one) staffed theatres for emergencies, in addition to a theatre team dedicated exclusively to obstetrics. Anaesthetic manpower should be increased to provide four duty anaesthetists with no more than one at SHO level as obstetric and intensive care duties can be complex. General surgical staffing requires expansion in order that on-call staff have no fixed commitments during and in the session immediately after their duty periods.

Surgery in a geriatric population.

A prospective audit of 1111 general surgical procedures undertaken on 1040 elderly patients (over 64 years) revealed a mortality of 3.5% in potentially viable patients. Aged patients (over 74 years) had twice the mortality of old patients (65-74 years). Emergency surgery carried a sevenfold risk factor which is greater than is usually described. Of those patients who died (n = 56) 20 had a laparotomy for surgically incurable disease. Although the four grades of surgeon achieved similar mortality rates (range 4-5.8%), senior surgeons performed more major procedures (Consultants, 40%; SHOs, 19%). There was a low supervision rate of SHOs (37/100 overall, and 9/19 major cases). Of the 26 patients dying from medical disorders 17 had a previous history of that disorder, and only nine of these patients were admitted to our high dependency care unit. We conclude that mortality rates in the elderly could be improved by encouraging elective surgery and avoiding diagnostic laparatomy in patients with incurable surgical disease. We also suggest that no inexperienced surgeon should operate unsupervised on any elderly patient who is in ASA category 4 or 5, or who undergoes major or intermediate surgery. Further, all elderly patients in ASA category 4 or 5, or those with previous medical problems who have major emergency procedures should be managed postoperatively in a high dependency care unit.