The Impact of Surgeon Speciality Interest on Outcomes of Emergency Laparotomy in IBD.

INTRODUCTION: Emergency laparotomy may be required in patients with inflammatory bowel disease (IBD). NELA is the largest prospectively maintained database of adult emergency laparotomies in England and Wales and includes clinical urgency of the cases. The impact of surgeon subspeciality on outcomes after emergency laparotomy for IBD is unclear. We have investigated this association, according to the degree of urgency in IBD emergency laparotomy, including the effect of minimally invasive surgery (MIS). METHODS: Adults with IBD in the NELA database between 2013 and 2016 were included. Surgeon subspeciality was colorectal or non-colorectal. Urgencies are 'Immediate', '2-6 h', '6-18 h' and '18-24 h'. Logistic regression was used to investigate in-patient mortality and post-operative length of stay (LOS). RESULTS: There was significantly reduced mortality and LOS in IBD patients who were operated on by a colorectal surgeon in the least urgent category of emergency laparotomies; Mortality adjusted OR 2.99 (CI 1.2-7.8) P = 0.025, LOS IRR 1.18 (CI 1.02-1.4) P = 0.025. This association was not seen in more urgent categories. Colorectal surgeons were more likely to use MIS, P < 0.001, and MIS was associated with decreased LOS in the least urgent cohort, P < 0.001, but not in the other urgencies. CONCLUSIONS: We found improved outcomes in the least urgent cohort of IBD emergency laparotomies when operated on by a colorectal surgeon in comparison to a non-colorectal general surgeon. In the most urgent cases, there was no benefit in the operation being performed by a colorectal surgeon. Further work on characterising IBD emergencies by urgency would be of value.

Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit.

Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.

A systematic review of the impact of postoperative aerobic exercise training in patients undergoing surgery for intra-abdominal cancers.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programmes which advocate early mobility after surgery have improved immediate clinical outcomes for patients undergoing abdominal cancer resections with curative intent. However, the impact of continued physical activity on patient-related outcomes and functional recovery is not well defined. The aim of this review was to assess the impact of postoperative aerobic exercise training, either alone or in conjunction with another exercise modality, on patients who have had surgery for intra-abdominal cancer. METHODS: A literature search was performed of electronic journal databases. Eligible papers needed to report an outcome of aerobic capacity in patients older than 18 years of age, who underwent cancer surgery with curative intent and participated in an exercise programme (not solely ERAS) that included an aerobic exercise component starting at any point in the postoperative pathway up to 12 weeks. RESULTS: Eleven studies were deemed eligible for inclusion consisting of two inpatient, one mixed inpatient/outpatient and eight outpatient studies. Meta-analysis of four outpatient studies, each reporting change in 6-min walk test (6MWT), showed a significant improvement in 6MWT with exercise (MD 74.92 m, 95% CI 48.52-101.31 m). The impact on health-related quality of life was variable across studies. CONCLUSION: Postoperative exercise confers benefits in improving aerobic function post surgery and can be safely delivered in various formats (home-based or group/supervised).

Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit.

BACKGROUND: Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. METHODS: A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. RESULTS: Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85). CONCLUSIONS: Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.

CT-derived measures of muscle quantity and quality predict poorer outcomes from elective colorectal surgery: a UK multicentre retrospective cohort study.

PURPOSE: To assess whether preoperative radiologically defined lean muscle measures are associated with adverse clinical outcomes in patients undergoing elective surgery for colorectal cancer. METHODS: This retrospective UK-based multicentre data collection study identified patients having had colorectal cancer resection with curative intent between January 2013 to December 2016. Preoperative computed-tomography (CT) scans were used to measure psoas muscle characteristics. Clinical records provided postoperative morbidity and mortality data. RESULTS: This study included 1122 patients. The cohort was separated into a combined group (patients with both sarcopenia and myosteatosis) and others group (either sarcopenia or myosteatosis, or neither). For the combined group, anastomotic leak was predicted on univariate (OR 4.1, 95% CI 1.43-11.79; p = 0.009) and multivariate analysis (OR 4.37, 95% CI 1.41-13.53; p = 0.01). Also for the combined group, mortality (up to 5 years postoperatively) was predicted on univariate (HR 2.41, 95% CI 1.64-3.52; p < 0.001) and multivariate analysis (HR 1.93, 95% CI 1.28-2.89; p = 0.002). A strong correlation exists between freehand-drawn region of interest-derived psoas density measurement and using the ellipse tool (R2 = 81%; p < 0.001). CONCLUSION: Measures of lean muscle quality and quantity, which predict important clinical outcomes, can be quickly and easily taken from routine preoperative imaging in patients being considered for colorectal cancer surgery. As poor muscle mass and quality are again shown to predict poorer clinical outcomes, these should be proactively targeted within prehabilitation, perioperative and rehabilitation phases to minimise negative impact of these pathological states.

Perioperative mortality in bariatric surgery: meta-analysis.

BACKGROUND: Bariatric surgery is an established treatment for severe obesity; however, fewer than 1 per cent of eligible patients undergo surgery. The perceived risk of surgery may contribute to the low uptake. The aim of this study was to determine perioperative mortality associated with bariatric surgery, comparing different operation types and data sources. METHODS: A literature search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify studies published between 1 January 2014 and 31 July 2020. Inclusion criteria were studies of at least 1000 patients reporting short-term mortality after bariatric surgery. Data were collected on RCTs. Meta-analysis was performed to establish overall mortality rates across different study types. The primary outcome measure was perioperative mortality. Different operation types were compared, along with study type, in subgroup analyses. The study was registered at PROSPERO (2019: CRD 42019131632). RESULTS: Some 4356 articles were identified and 58 met the inclusion criteria. Data were available on over 3.6 million patients. There were 4707 deaths. Pooled analysis showed an overall mortality rate of 0.08 (95 per cent c.i. 0.06 to 0.10; 95 per cent prediction interval 0 to 0.21) per cent. In subgroup analysis, there was no statistically significant difference between overall, 30-day, 90-day or in-hospital mortality (P = 0.29). There was no significant difference in reported mortality for RCTs, large studies, national databases or registries (P = 0.60). The pooled mortality rates by procedure type in ascending order were: 0.03 per cent for gastric band, 0.05 per cent for sleeve gastrectomy, 0.09 per cent for one-anastomosis gastric bypass, 0.09 per cent for Roux-en-Y gastric bypass, and 0.41 per cent for duodenal switch (P < 0.001 between operations). CONCLUSION: Bariatric surgery is safe, with low reported perioperative mortality rates.

Weight loss surgery helps patients with severe obesity. This study looked at the risk of dying after weight loss surgery in over 3.6 million patients. The risk was less than 1 in 1000 (0.08 per cent). The risk was lowest for gastric band and sleeve gastrectomy, then for gastric bypasses and highest for the duodenal switch operation. This shows that weight loss surgery is safe, with a low risk of dying similar to that of other common operations.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BACKGROUND: Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS: A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS: A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION: This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

BACKGROUND: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Trainee-led emergency laparotomy operating.

BACKGROUND: To achieve completion of training in general surgery, trainees are required to demonstrate competency in common procedures performed at emergency laparotomy. The aim of this study was to describe the patterns of trainee-led emergency laparotomy operating and the association between postoperative outcomes. METHODS: Data on all patients who had an emergency laparotomy between December 2013 and November 2017 were extracted from the National Emergency Laparotomy Audit database. Patients were grouped by grade of operating surgeon: trainee (specialty registrar) or consultant (including post-Certificate of Completion of Training fellows). Trends in trainee operating by deanery, hospital size and time of day of surgery were investigated. Univariable and adjusted regression analyses were performed for the outcomes 90-day mortality and return to theatre, with analysis of patients in operative subgroups segmental colectomy, Hartmann's procedure, adhesiolysis and repair of perforated peptic ulcer disease. RESULTS: The study cohort included 87 367 patients. The 90-day mortality rate was 15·1 per cent in the consultant group compared with 11·0 per cent in the trainee group. There were no increased odds of death by 90 days or of return to theatre across any of the operative groups when the operation was performed with a trainee listed as the most senior surgeon in theatre. Trainees were more likely to operate independently in high-volume centres (highest- versus lowest-volume centres: odds ratio (OR) 2·11, 95 per cent c.i. 1·91 to 2·33) and at night (00.00 to 07.59 versus 08.00 to 11.59 hours; OR 3·20, 2·95 to 3·48). CONCLUSION: There is significant variation in trainee-led operating in emergency laparotomy by geographical area, hospital size and by time of day. However, this does not appear to influence mortality or return to theatre.

ANTECEDENTES: Para completar la formación en cirugía general, se requiere que los aspirantes demuestren solvencia en la práctica de los procedimientos comunes efectuados por laparotomía de urgencia. El objetivo de este estudio fue describir los esquemas de formación de los aspirantes en laparotomía de urgencia y su asociación con los resultados postoperatorios. MÉTODOS: Todos los pacientes a los que se realizó una laparotomía de urgencia entre diciembre del 2013 y noviembre del 2017 se obtuvieron a partir de la base de datos de la Auditoría Nacional de Laparotomía de Urgencia (National Emergency Laparotomy Audit, NELA). Los pacientes se agruparon según la experiencia del cirujano; cirujanos en periodo de formación (residentes, speciality registrar) o consultores (incluyendo los que habían completado la especialidad). Se investigaron las tendencias entre los residentes por universidad, tamaño del hospital y hora del día de la cirugía. Se realizaron análisis de regresión univariable y ajustados para la mortalidad a los 90 días y la reoperación, así como análisis de subgrupos para los procedimientos quirúrgicos de colectomía segmentaria, intervención de Hartmann, liberación de bridas y la sutura de una úlcera péptica perforada. RESULTADOS: La cohorte de estudio incluyó 87.367 pacientes. La mortalidad a los 90 días en el grupo de consultores fue del 15% en comparación con el 11% en el grupo de residentes. No hubo aumento del riesgo de mortalidad a los 90 días o de reoperación en ninguno de los subgrupos de las diferentes operaciones cuando la cirugía era efectuada por el residente considerado como el más senior en las listas de quirófano. Los residentes tenían más probabilidades de operar solos en centros de alto volumen (en comparación con centros de bajo volumen; razón de oportunidades, odds ratio (OR) 2,11, i.c. del 95% 1,91-2,33) o durante la noche (00:00-07:59 horas en comparación con 08:00-11:59; OR 3,20; i.c. del 95% 2,95-3,48). CONCLUSIÓN: Existen diferencias significativas en la formación que reciben los residentes en laparotomía de urgencia según el área geográfica, el tamaño del hospital y la hora del día. Sin embargo, estas diferencias no parecen afectar a la mortalidad ni a la tasa de reoperaciones.

Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study.

BACKGROUND: Delay to theatre for patients with intra-abdominal sepsis is cited as a particular risk factor for death. Our aim was to evaluate the potential relationship between hourly delay from admission to surgery and post-operative mortality in patients with perforated peptic ulcer (PPU). METHODS: All patients entered in the National Emergency Laparotomy Audit who had an emergency laparotomy for PPU within 24 h of admission from December 2013 to November 2017 were included. Time to theatre from admission was modelled as a continuous variable in hours. Outcome was 90-day mortality. Logistic regression adjusting for confounding factors was performed. RESULTS: 3809 patients were included, and 90-day mortality rate was 10.61%. Median time to theatre was 7.5 h (IQR 5-11.6 h). The odds of death increased with time to operation once adjustment for confounding variables was performed (per hour after admission adjusted OR 1.04 95% CI 1.02-1.07). In patients who were physiologically shocked (N = 334), there was an increase of 6% in risk-adjusted odds of mortality for every hour Em Lap was delayed after admission (OR 1.06 95% CI 1.01-1.11). CONCLUSION: Hourly delay to theatre in patients with PPU is independently associated with risk of death by 90 days. Therefore, we suggest that surgical source control should occur as soon as possible after admission regardless of time of day.

Association between surgeon special interest and mortality after emergency laparotomy.

BACKGROUND: Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy. METHODS: Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes. RESULTS: A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12). CONCLUSION: Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.

Quick and simple; psoas density measurement is an independent predictor of anastomotic leak and other complications after colorectal resection.

BACKGROUND: Radiologically defined sarcopenia has been shown to predict negative outcomes after cancer surgery, however radiological assessment of sarcopenia often requires additional software and standardisation against anthropomorphic data. Measuring psoas density using hospital Picture Archiving and Communication Systems (PACS), universally available in the UK, may have advantages over methods requiring the use of additional specialist and often costly software. The aim of this study was to assess the association between radiologically defined sarcopenia measured by psoas density and postoperative outcome in patients having a colorectal cancer resection. METHODS: All patients having a resection for colorectal cancer, discussed by the colorectal multi-disciplinary team in one institution between 1/1/15 and 31/12/15, were retrospectively identified. Mean psoas density at the level of the L3 vertebra was analysed from preoperative computed tomography (CT) scans to define sarcopenia using the Picture Archiving and Communication Systems (PACS). Postoperative complications and mortality were recorded. RESULTS: One hundred and sixty-nine patients had a colorectal resection for cancer and 140 of these had a primary anastomosis. Ninety-day mortality and 1-year mortality were 1.1% and 7.1%, respectively. Eighteen (10.7%) patients suffered a Clavien-Dindo grade 3 or 4 complication of which 6 (33%) were anastomotic leaks. In the whole cohort, sarcopenia was associated with an increased risk of Clavien-Dindo grade 3 or 4 complications [adjusted OR 6.33 (1.65-24.23) p = 0.007]. In those who had an anastomosis, sarcopenia was associated with an increased risk of anastomotic leak [adjusted OR 14.37 (1.37-150.04) p = 0.026]. CONCLUSIONS: A quick and easy radiological assessment of sarcopenia by measuring psoas density on preoperative CT scan using software universally available in the UK is highly predictive of postoperative morbidity in colorectal cancer patients.

Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment.

INTRODUCTION: Simulation-based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. We aimed to compare objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment. METHODS: HRV recordings were obtained from eight anesthetic trainees performing an uncomplicated rapid sequence induction at pre-determined procedural steps using a wireless Polar RS800CX monitor © in an emergency theatre setting. This was repeated in the simulated environment. Participants completed an STAI before and after the procedure. RESULTS: Eight trainees completed the study. The theatre environment caused an increase in objective stress vs baseline (p = .004). There was no significant difference between average objective stress levels across all time points (p = .20) between environments. However, there was a significant interaction between the variables of objective stress and environment (p = .045). There was no significant difference in subjective stress (p = .27) between environments. DISCUSSION: Simulation was unable to accurately replicate the stress of the technical procedure. This is the first study that compares the stress during SBT with the theatre environment and has implications for the assessment of simulated environments for use in examinations, rating of technical and non-technical skills, and stress management training.

Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation.

BACKGROUND: The aims of this study were to determine if patient ASA grade was associated with increased stress in anaesthetists with a subsequent effect on non-technical skills. METHODS: Stress was measured using a validated objective (heart rate variability or heart rate) and subjective tool. We studied eight consultant anaesthetists at baseline (rest) and during 16 episodes of intubation with an ASA 1 or 2 patient vs. an ASA 3 or 4 patient. The primary outcome for the study was objective and subjective stress between both patient groups. Secondary outcomes were non-technical skill ratings and the association between stress measurements. RESULTS: ASA 3 or 4 patients were associated with increases in objective stress when compared to baseline (mean 4.6 vs. 6.7; P = 0.004). However, ASA 1 or 2 patients were not associated with increases in stress when compared to baseline (mean 4.6 vs. 4.7; P = 1). There was no significant difference in subjective stress between the groups (P = 0.18). Objective stress negatively affected situational awareness (P = 0.03) and decision-making (P = 0.03); however, these did not decline to a clinically significant threshold. Heart rate variability (r = 0.60; P = 0.002) better correlated with subjective stress when compared to heart rate (r = 0.30; P = 0.15). Agreement between raters for Anaesthetic Non-Technical Skills (ANTS) scores was acceptable (ICC = 0.51; P = 0.003). CONCLUSION: This study suggests that higher patient ASA grade can increase stress in anaesthetists, which may impair non-technical skills.

Systematic review of pre-operative exercise in colorectal cancer patients.

The aim of this systematic review was to evaluate the evidence for exercise interventions prior to surgery for colorectal cancer resection. The evidence for use of exercise to improve physical fitness and surgical outcomes is as yet unknown. A systematic search was performed of MEDLINE, EMBASE, CINAHL, AMED and BNI databases for studies involving pre-operative exercise in colorectal cancer patients. Eight studies were included in the review. There is evidence that pre-operative exercise improves functional fitness, and to a lesser extent objectively measurable cardio-respiratory fitness prior to colorectal cancer resection. There is no clear evidence at present that this improvement in fitness translates into reduced peri-operative risk or improved post-operative outcomes. Current studies are limited by risk of bias. This review highlights the common difficulty in transferring promising results in a research setting, into significant improvements in the clinical arena. Future research should focus on which type of exercise is most likely to maximise patient adherence and improvements in cardio-respiratory fitness. Ultimately, adequately powered, randomised controlled trials are needed to investigate whether pre-operative exercise improves post-operative morbidity and mortality.

Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis.

Colorectal cancer is one of the most common cancers worldwide. However, it is unclear what influence body mass index (BMI) has on colorectal cancer prognosis. We conducted a systematic review and meta-analysis of observational studies to examine the association of BMI with colorectal cancer outcomes. We searched MEDLINE and EMBASE databases from inception to February 2015 and references of identified articles. We selected observational studies that reported all-cause mortality, colorectal cancer-specific mortality, recurrence and disease-free survival according to BMI category. Random-effects meta-analyses were conducted to combine estimates. We included 18 observational studies. Obese patients had an increased risk of all-cause mortality [relative risk (RR) 1.14; 95 % confidence interval (CI) 1.07-1.21], cancer-specific mortality (RR 1.14; 95 % CI 1.05-1.24), recurrence (RR 1.07; 95 % CI 1.02-1.13) and worse disease-free survival (RR 1.07; 95 % CI 1.01-1.13). Underweight patients also had an increased risk of all-cause mortality (RR 1.43; 95 % CI 1.26-1.62), cancer-specific mortality (RR 1.50; 95 % CI 1.20-1.87), recurrence (RR 1.13; 95 % CI 1.05-1.21) and worse disease-free survival (RR 1.27; 95 % CI 1.13-1.43). Overweight patients had no increased risk for any of the outcomes studied. Both obese and underweight patients with colorectal cancer have an increased risk of all-cause mortality, cancer-specific mortality, disease recurrence and worse disease-free survival compared to normal weight patients.

Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications.

AIM: Radiologically assessed muscle mass has been suggested as a surrogate marker of functional status and frailty and may predict patients at risk of postoperative complications. We hypothesize that sarcopenia negatively impacts on postoperative recovery and is predictive of complications. METHOD: One hundred patients undergoing elective resection for colorectal carcinoma were included in this study. Lean muscle mass was estimated by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra identified on a preoperative CT scan, normalizing for patient height. Perioperative morbidity was scored according to the Clavien-Dindo classification. All statistical data analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 20.0. RESULTS: Fifteen per cent of patients were identified as sarcopenic. There were no deaths in the study group. Sarcopenia was associated with a significantly increased risk of developing major complications (Grade 3 or greater, OR = 5.41, 95% CI: 1.45-20.15, P = 0.01). Sarcopenia did not predict length of stay, critical care dependency or time to mobilization. CONCLUSION: Sarcopenia, as a marker of frailty, is an important risk factor in surgical patients but difficult to estimate using bedside testing. CT scans, performed for preoperative staging, provide an opportunity to quantify lean muscle mass without additional cost or exposure to radiation and eliminate the inconvenience of further investigations.

A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips.

We systematically reviewed the observational associations of anaemia with outcomes and the effects of interventions to increase haemoglobin concentrations following hip fracture in older people. Anaemia on hospital admission was associated with increased mortality, relative risk 1.64 (95% CI 1.47-1.82), p < 0.0001. After adjustment for co-morbidities, the association of anaemia with increased mortality remained in four of eight observational studies. There was no association of postoperative transfusion with mortality after adjusting for covariates. Transfusion at 80 g.l(-1) vs 100 g.l(-1) increased acute myocardial infarction, relative risk 1.67 (95% CI 1.01-2.77), p = 0.05. Transfusion threshold was not associated with differences in other outcomes. There were insufficient high-quality studies to inform pre-operative blood transfusion or the use of peri-operative iron or erythropoietin. Studies for most interventions recruited too few participants to determine effects on infections, mortality or function.