The role of teamwork and non-technical skills for improving emergency surgical outcomes: an international perspective.

The assurance of patient safety in emergency general surgery remains challenging due to the patients' high-risk underlying conditions and the wide variability in emergency surgical care provided around the globe. The authors of this article convened as an expert panel on patient safety in surgery at the 8th International Conference of the World Society of Emergency Surgery (WSES) in Edinburgh, Scotland, on September 7-10, 2021. This review article represents the proceedings from the expert panel discussions at the WSES congress and was designed to provide an international perspective on optimizing teamwork and non-technical skills in emergency general surgery.

Emergency general surgery 'Hot Clinic': Efficiency, prevention of hospital admissions and factors influencing patient experience.

OBJECTIVE: The constant pressure facing hospitals to reduce emergency inpatient admissions has led towards more consultant-led 'Hot Clinics' (HC). The patient experience in these settings remains poorly understood. This study evaluates the efficiency and ability of the HC to prevent unnecessary emergency surgical admissions and factors influencing the patient experience. METHODS: Patients were referred to the HC from the Emergency Department, General Practice or Out-of-Hours service over the initial six-week period. A questionnaire collected the reason for referral, management without a HC, final diagnosis and management. Appropriateness of referrals were evaluated by the HC consultant and retrospectively by a blinded consultant. A second questionnaire collected information on patient satisfaction in a subsequent study period. RESULTS: 119/126 referrals (94%) were judged appropriate in the HC analysis with 97/126 (77%) considered appropriate in the retrospective analysis. The HC reduced the amount of potential emergency surgical admissions from 114 to 14 (p < 0.001). In the second period, 114/121 patients (94%) rated the HC as very good or good; with privacy (p < 0.05) and decision-making (p < 0.001) linked to patient satisfaction. Comfort (p < 0.05) and decision-making (p < 0.001) were linked to patients recommending the service. 103 patients (85%) would be extremely, or very likely to recommend the HC service with 93 patients (77%) preferring HC treatment over a hospital admission. CONCLUSIONS: Most referrals to the HC were appropriate and it continues to prevent unnecessary emergency surgical admissions. The HC service is valued by NHS patients, who prefer HC treatment over admission. Various factors to improve the patient experience in HC have been identified.

Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis.

OBJECTIVES: The aim of this study was to identify current problems and potential solutions to improve the working environment for the delivery of safe surgical care in the UK. DESIGN: Prospective, questionnaire-based cross-sectional study. SETTING/PARTICIPANTS: Following validation, an electronic questionnaire was distributed to postgraduate local education and training board distribution lists, the Royal College of Surgeons of Edinburgh (RCSEd) mailing lists and trainee organisations. This consisted of a single open-ended question inviting five open-ended responses. Throughout the 13-week study period, the survey was also published on a number of social media platforms. RESULTS: A total of 505 responders completed the survey, of which 35% were consultants, 30% foundation doctors, 17% specialty trainees, 11% specialty doctors, 5% core trainees and <1% surgical nurse practitioners. A total of 2238 free-text answers detailed specific actions to improve the working environment. These responses were individually coded and then grouped into nine categories (staff resources, non-staff resources, support, working conditions, communication and team work, systems improvement, patient centred, training and education, and miscellaneous). CONCLUSIONS: The results of this study have identified a number of key areas that, if addressed, may improve the environment for the delivery of safer surgical care. Common themes that emerged across all grades included: increased front-line staff; a return to a 'firm' structure to improve team continuity; greater senior support; and improved hospital facilities to help staff rest and recuperate. While unlimited funding remains unrealistic, many of the suggestions could be implemented in a cost-neutral fashion and include insightful ideas for remodelling or restructuring the workforce to improve the efficiency of the surgical team. The findings of this study formed the basis of a set of recommendations published by the RCSEd as a discussion paper.

Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia.

INTRODUCTION: There are limited data regarding long-term outcomes after surgical repair of giant paraoesophageal hiatus hernia (GPHH). The aim of this study was to assess symptomatic recurrence and patient-reported outcomes following GPHH repair. METHODS: 178 patients undergoing elective (127) and emergency (51) GPHH repair between 1994 and 2015 were identified from the prospectively collected Lothian Surgical Audit database. Electronic patient records were used to determine rate of clinical recurrence. A postal questionnaire was used to assess modified DeMeester, 'Gastrointestinal Symptom Rating Scale' symptom scores, breathing and exercise tolerance, and patient satisfaction. RESULTS: Median follow-up was 35 months (range 12-238). 15 (8.4%) patients developed a clinical recurrence and 13 (7.3%) underwent a further operation. The clinical recurrence rates were similar in patients followed-up less than 5 years and beyond 5 years [10/128 (7.8%) vs 5/50 (10%)]. Mortality rate was 1.6% for elective compared with 16.7% for emergency procedures (P < 0.001). Completed questionnaires were received from 95 (78.5%) of 121 eligible patients. Mean symptom scores were low (Modified DeMeester 2.6). 83.7% of patients reported a good or excellent outcome, and 97.8% believed they had made the correct decision to undergo surgery. CONCLUSIONS: Surgical repair of GPHH is associated with high levels of patient satisfaction and good overall symptom outcome. There is a clinical recurrence rate of 8.4%, which does not significantly increase with long-term follow-up.

Patients unfit for neoadjuvant therapy may still undergo resection of locally advanced esophageal or esophagogastric junctional cancer with acceptable oncological results.

Neoadjuvant chemotherapy (NA) is routinely offered to patients undergoing resection for locally advanced (≥cT3Nx or cTxN+) esophageal or esophagogastric junctional (EGJ) cancer in the United Kingdom. Patients with comorbidity precluding the use of NA can be considered for resection yet the effect of omitting NA on survival is unclear. METHODS: Retrospective review of prospectively collected clinical data from patients undergoing attempted curative therapy for ≥cT3Nx or cTxN+ esophageal or EGJ (Siewert type I-III) cancer between 2001 and 2013. RESULTS: NA was commenced in 289 patients and primarily comprised 2 cycles of cisplatin and 5-fluorouracil (264 patients, 91%). Surgery alone was planned for 82 patients with NA omitted due to comorbidity. Patients undergoing surgery alone were matched for clinical variables and stage with those undergoing NA but were significantly older (mean=8 y, P<0.001). NA was associated with an improved median overall survival of 28.7 months, compared with 20.9 months for patients undergoing surgery alone (P=0.008). Patients undergoing surgery alone had a 90-day postoperative mortality rate of 10% compared with 3% for those undergoing NA (P=0.011). In patients discharged postoperatively, the median overall survival benefit of NA was 2.7 months (P=0.048). Those 19% of patients experiencing a significant histologic response to NA demonstrated further improved survival. CONCLUSIONS: NA improves survival in patients undergoing resection for locally advanced esophageal or EGJ cancer; however, the median benefit is <3 months in patients discharged postoperatively. Patients precluded from NA achieve acceptable oncological results but experience a higher risk of perioperative mortality.

Multidetector Computed Tomography Versus Staging Laparoscopy for the Detection of Peritoneal Metastases in Esophagogastric Junctional and Gastric Cancer.

OBJECTIVE: Staging laparoscopy (SL) is the gold standard investigation for detecting peritoneal metastases (PM) in patients with esophagogastric cancer but computed tomography (CT) has undergone significant improvements in recent years. The aim of this study was to investigate whether CT can replace SL in the detection of PM. MATERIALS AND METHODS: Patients undergoing SL between January 2008 and December 2009 were identified from a prospectively collected database, operation notes were reviewed for the detection of PM. Corresponding CTs were reassessed by 2 experienced gastrointestinal radiologists, blinded to the SL results. RESULTS: In total, 74 patients undergoing SL were included. Sensitivity and specificity of SL for PM were 94.1% (95% confidence interval, 69.2-99.7) and 100% (90.7-100). Sensitivity and specificity of CT were 58.8% (33.5-80.6) and 89.6% (76.6-96.1), respectively. Area under the curve of receiver operating characteristic curves for SL and CT were 0.971 (SE, 0.033) and 0.742 (SE, 0.78), respectively. CONCLUSIONS: CT cannot replace SL for the detection of PM in lower esophageal and gastric cancer.

Emergency general surgery 'Hot Clinics' reduce admission rates and duration of inpatient stay.

OBJECTIVE: To determine the impact of a 'Hot Clinic' (HC) on emergency general surgery patient flow-through. DESIGN: Prospective service evaluation study. SETTING: HC is a four-bedded area coordinated by a specialist nurse. The HC consultant sees emergency patients referred from the emergency department, general practitioners or those in preceding 24 h considered suitable for interim discharge while awaiting investigations and HC reassessment. PATIENTS: All patients with acute abdominal pain were evaluated in three 4 week groups: before (group 1), 1 month (group 2) and 6 months after the HC was introduced (group 3). Interhospital transfers, intrahospital ward referrals and trauma patients were excluded. INTERVENTION: Introduction of consultant-led surgical HC every weekday afternoon. MAIN OUTCOME MEASURES: Proportion of patients admitted under general surgeons, length of inpatient stay and the proportion of patients referred again within 3 months were investigated. RESULTS: 1409 patients were referred, of which 1061 met the inclusion criteria: 307 in group 1, 326 in group 2 and 428 in group 3. There was no difference in gender distribution (p=0.759). Inpatient admissions were significantly reduced (85.0% vs 78.2% vs 54.4%; p<0.001) and the inpatient duration of stay was significantly shorter after HC introduction (median (IQR) (95% CI) 63.8 (29.0-111.6) (51.8 to 72.8) hours vs 48.8 (21.7-101.2) (42.0 to 55.6) hours vs 47.7 (20.9-92.7) (42.8 to 56.9) hours; p=0.011). CONCLUSIONS: Emergency general surgery HCs are associated with significant reductions in admission rates and inpatient bed occupancy. This service redesign has the potential to dramatically relieve pressure on acute surgical services.

Argon plasma coagulation compared with stent placement in the palliative treatment of inoperable oesophageal cancer.

BACKGROUND: Self-expandable metal stents (SEMSs) are the main palliative modality used in inoperable oesophageal cancer. Other palliative modalities, including argon plasma coagulation (APC), have also been used. OBJECTIVE: The purpose of this study was to assess the relative efficacy of SEMS and APC regarding the survival of patients with inoperable oesophageal cancer, not receiving chemo/radiotherapy. METHODS: Single centre, retrospective analysis of all patients (n = 228) with inoperable oesophageal cancer between January 2000 and July 2014, not receiving chemo-radiotherapy, treated with SEMS (n = 160) or APC (n = 68) as primary palliation modalities. Cox regression analysis was performed to identify individual factors affecting survival and Kaplan-Meier curves were created for patients treated with APC and SEMS for stage III and IV disease. Survival intervals were compared by the log-rank test. RESULTS: Type of treatment was the only statistically significant factor affecting survival, after disease stage stratification (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.13-1.65 of SEMS over APC, p: 0.002). Median survival for patients treated with APC and SEMS was 257 (interquartile range (IQR): 414, 124) and 151 (IQR: 241, 61) days respectively in stage III disease. It was 135 (IQR: 238, 43) and 70 (IQR: 148, 32) days respectively in stage IV disease. Both differences were statistically significant (p = 0.02 and 0.05 respectively). CONCLUSIONS: APC is a promising palliation modality in inoperable oesophageal cancer, when patients are not candidates for chemo-radiotherapy. A randomized controlled trial will be needed to confirm those results.

Quantitative Shotgun Proteomics Unveils Candidate Novel Esophageal Adenocarcinoma (EAC)-specific Proteins.

Esophageal cancer is the eighth most common cancer worldwide and the majority of patients have systemic disease at presentation. Esophageal adenocarcinoma (OAC), the predominant subtype in western countries, is largely resistant to current chemotherapy regimens. Selective markers are needed to enhance clinical staging and to allow targeted therapies yet there are minimal proteomic data on this cancer type. After histological review, lysates from OAC and matched normal esophageal and gastric samples from seven patients were subjected to LC MS/MS after tandem mass tag labeling and OFFGEL fractionation. Patient matched samples of OAC, normal esophagus, normal stomach, lymph node metastases and uninvolved lymph nodes were used from an additional 115 patients for verification of expression by immunohistochemistry (IHC).Over six thousand proteins were identified and quantified across samples. Quantitative reproducibility was excellent between technical replicates and a moderate correlation was seen across samples with the same histology. The quantitative accuracy was verified across the dynamic range for seven proteins by immunohistochemistry (IHC) on the originating tissues. Multiple novel tumor-specific candidates are proposed and EPCAM was verified by IHC.This shotgun proteomic study of OAC used a comparative quantitative approach to reveal proteins highly expressed in specific tissue types. Novel tumor-specific proteins are proposed and EPCAM was demonstrated to be specifically overexpressed in primary tumors and lymph node metastases compared with surrounding normal tissues. This candidate and others proposed in this study could be developed as tumor-specific targets for novel clinical staging and therapeutic approaches.

Long-term outcomes following laparoscopic anterior and Nissen fundoplication.

BACKGROUND: Limited evidence exists to which operation gives best long-term outcomes for gastro-oesophageal reflux disease. This study aimed to assess long-term symptomatic outcome and satisfaction following laparoscopic anterior (LA) or Nissen fundoplication in a specialist upper gastrointestinal unit. METHODS: Patients who underwent primary LA or Nissen (LN) fundoplication between May 1994 and June 2010 were identified from a prospectively collected database. DeMeester, modified DeMeester, 'Gastrointestinal Symptom Rating Scale' scores and patient satisfaction were assessed by questionnaire. RESULTS: A total of 387 patients underwent surgery and 246 patients (65%) completed questionnaires, with 181 LA patients and 65 LN patients. Median follow-up was 83 months for LA and 179 months for LN (P < 0.001). A total of 218/245 (89%) reported major improvement in symptoms and 27 (11%) reported poor outcomes. There was no differences between LA and LN for symptom scores at short (<5 years) or long-term follow-up (>5 years). Women reported significantly higher DeMeester scores and lower satisfaction (P = 0.012). One hundred and eighteen (48%) patients were taking proton pump inhibitors (PPI) at follow-up despite high satisfaction rates. CONCLUSION: LA and LN have similar long-term results with patients reporting high satisfaction levels. Women reported more symptoms and less satisfaction than men. Despite high satisfaction rates a high percentage of patients take PPIs.

Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents.

BACKGROUND: The importance of non-technical skills in improving surgical safety and performance is now well recognised. Better understanding is needed of the impact that non-technical skills of the multi-disciplinary theatre team have on intra-operative incidents in the operating room (OR) using structured theatre-based assessment. The interaction of non-technical skills that influence surgical safety of the OR team will be explored and made more transparent. METHODS: Between May-August 2013, a range of procedures in general and vascular surgery in the Royal Infirmary of Edinburgh were performed. Non-technical skills behavioural markers and associated intra-operative incidents were recorded using established behavioural marking systems (NOTSS, ANTS and SPLINTS). Adherence to the surgical safety checklist was also observed. RESULTS: A total of 51 procedures were observed, with 90 recorded incidents - 57 of which were considered avoidable. Poor situational awareness was a common area for surgeons and anaesthetists leading to most intra-operative incidents. Poor communication and teamwork across the whole OR team had a generally large impact on intra-operative incidents. Leadership was shown to be an essential set of skills for the surgeons as demonstrated by the high correlation of poor leadership with intra-operative incidents. Team-working and management skills appeared to be especially important for anaesthetists in the recovery from an intra-operative incident. CONCLUSION: A significant number of avoidable incidents occur during operative procedures. These can all be linked to failures in non-technical skills. Better training of both individual and team in non-technical skills is needed in order to improve patient safety in the operating room.

Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma.

BACKGROUND: The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. METHODS: A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. RESULTS: 83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. CONCLUSION: A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.

Undergraduate medical textbooks do not provide adequate information on intravenous fluid therapy: a systematic survey and suggestions for improvement.

BACKGROUND: Inappropriate prescribing of intravenous (IV) fluid, particularly 0.9% sodium chloride, causes post-operative complications. Fluid prescription is often left to junior medical staff and is frequently poorly managed. One reason for poor intravenous fluid prescribing practices could be inadequate coverage of this topic in the textbooks that are used. METHODS: We formulated a comprehensive set of topics, related to important common clinical situations involving IV fluid therapy, (routine fluid replacement, fluid loss, fluids overload) to assess the adequacy of textbooks in common use. We assessed 29 medical textbooks widely available to students in the UK, scoring the presence of information provided by each book on each of the topics. The scores indicated how fully the topics were considered: not at all, partly, and adequately. No attempt was made to judge the quality of the information, because there is no consensus on these topics. RESULTS: The maximum score that a book could achieve was 52. Three of the topics we chose were not considered by any of the books. Discounting these topics as "too esoteric", the maximum possible score became 46. One textbook gained a score of 45, but the general score was poor (median 11, quartiles 4, 21). In particular, coverage of routine postoperative management was inadequate. CONCLUSIONS: Textbooks for undergraduates cover the topic of intravenous therapy badly, which may partly explain the poor knowledge and performance of junior doctors in this important field. Systematic revision of current textbooks might improve knowledge and practice by junior doctors. Careful definition of the remit and content of textbooks should be applied more widely to ensure quality and "fitness for purpose", and avoid omission of vital knowledge.

The management of perforated gastric ulcers.

INTRODUCTION: Perforated gastric ulcers are potentially complicated surgical emergencies and appropriate early management is essential in order to avoid subsequent problems including unnecessary gastrectomy. The aim of this study was to examine the management and outcome of patients with gastric ulcer perforation undergoing emergency laparotomy for peritonitis. METHODS: Patients undergoing laparotomy at the Royal Infirmary of Edinburgh for perforated gastric ulcers were identified from the prospectively maintained Lothian Surgical Audit (LSA) database over the five-year period 2007-2011. Additional data were obtained by review of electronic records and review of case notes. RESULTS: Forty-four patients (25 male, 19 female) were identified. Procedures performed were: 41 omental patch repairs (91%), 2 simple closures (4.5%) and 2 distal gastrectomies (4.5%; both for large perforations). Four perforated gastric tumours were identified (8.8%), 2 of which were suspected intra-operatively and confirmed histologically, 1 had unexpected positive histology and 1 had negative intra-operative histology, but follow-up endoscopy confirmed the presence of carcinoma (1 positive biopsy in 21 follow-up endoscopies); all 4 were managed without initial resection. Median length of stay was 10 days (range 4-68). Overall 7 patients died in hospital (15.9%) and there were 21 morbidities (54.5%). Registrars performed the majority of the procedures (16 alone, 21 supervised) with no significant difference in post-operative morbidity (P = 0.098) or mortality (P = 0.855), compared to consultants. CONCLUSION: Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Initial biopsy and follow-up endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy.

Post-operative antibiotics after appendectomy and post-operative abscess development: a retrospective analysis.

BACKGROUND: Appendectomy is one of the most common emergency operations. Prophylaxis against infective complications involves post-operative antibiotics. There is no consensus as to the optimum antibiotic regimen. This study aimed to assess the relation between the duration of the post-operative antibiotic administration and intra-abdominal infections (IAIs). PATIENTS AND METHODS: All patients who underwent appendectomy between September 1, 2009, and August 31, 2010, were identified. The appearance of the appendix at operation, post-operative antibiotics, white blood cell count, and temperature at the time of conversion of intravenous (IV) to oral antibiotics were compiled. IAIs were assessed as the final outcome. RESULTS: Two hundred sixty six patients underwent appendectomy-188 for simple appendicitis and 78 for complicated appendicitis. There were 18 IAIs (6.8%) overall, 10 (12.8%) after complicated appendicitis and eight (4.2%) after simple appendicitis. Prolonging antibiotics beyond the operation in the simple appendicitis group did not alter the incidence of IAI. Similarly, in the complicated appendicitis group, prolonging antibiotics beyond five days did not alter the incidence of IAI. Furthermore, in patients with complicated appendicitis, the presence of leukocytosis, fever, or both when IV antibiotics were converted to oral drugs was associated with the development of IAI (p=0.013). CONCLUSION: In simple appendicitis, post-operative antibiotics may not be beneficial at all. In complicated appendicitis, prolonging the course of antibiotics was not associated with a reduced IAI rate. However, cessation of IV antibiotics when fever or leukocytosis was present was associated with IAI development.

Surgical management of emergency and elective giant paraesophageal hiatus hernias.

BACKGROUND: Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting. SUBJECTS AND METHODS: Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed. RESULTS: Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184). CONCLUSIONS: This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.