Characterisation of older patients that require, but do not undergo, emergency laparotomy: a multicentre cohort study.

BACKGROUND: Older adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps). METHODS: A multicentre cohort study (n=64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap). RESULTS: NoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0-88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were >80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements. CONCLUSIONS: This study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process. CLINICAL TRIAL REGISTRATION: ISRCTN14556210.

Innovations towards achieving environmentally sustainable operating theatres: A systematic review.

INTRODUCTION: The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions. METHODS: A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included. RESULTS: 675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability. DISCUSSION: This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Volatile Organic Compounds in the Early Diagnosis of Non-healing Surgical Wounds: A Systematic Review.

BACKGROUND: The normal healing of surgical wounds can be disrupted by infection and/or dehiscence, leading to development of chronic, non-healing wounds (NHW). Diagnosis of NHWs is via clinical acumen and analysis of microbiology wound swabs. Volatile organic compounds (VOCs) are emitted generally by human subjects and specifically as products of bacterial metabolism and are detected in the wound area. This systematic review will assess the potential use of VOCs released by surgical wounds as a non-invasive method for identifying bacterial species and the progression to NHW. METHOD: A systematic search of studies, via PRISMA guidelines, was conducted. Of 220 papers screened, seven studies were included. Outcome data were extracted on methods for VOC analysis and wound/bacterial VOC profiles. RESULTS: The studies have shown that VOC profiles are identified by two methods: gas chromatography-mass spectrometry and electronic nose. There are VOC profiles associated with causative bacterial species, with early indications that they could be anatomically specific or could monitor treatment effects. CONCLUSION: VOC profiling of bacterial species within wounds is possible and could become a point of care test. More research is needed on specific VOC profiles to wound location and whether these profiles may predict progression to NHW.

Peritoneal cytokines as a predictor of colorectal anastomotic leaks on postoperative day 1: a systematic review and meta-analysis.

BACKGROUND: Anastomotic leakage (AL) is a major complication of colorectal surgery resulting in morbidity, mortality and poorer quality of life. The early diagnosis of AL is challenging due to the poor positive predictive value of tests available and reliance on clinical presentation which may be delayed. The aim of this systematic review was to assess the applicability of peritoneal cytokine levels as an early predictive test of AL in postoperative colorectal cancer patients. METHODS: A comprehensive literature search was performed from inception to January 2021, in MEDLINE and EMBASE databases using MeSH and non-MeSH terms in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies evaluating peritoneal cytokines in the context of AL were included in this review. RESULTS: Two hundred ninety-two abstracts were screened, 30 full manuscripts evaluated, and 12 prospective studies were included. There were 8 peritoneal cytokines evaluated (interleukin [IL]-1ß, IL-6, IL-8, IL-10, vascular endothelial growth factor [VEGF], tumour necrosis factor alpha [TNF alpha] and matrix metalloproteinase [MMP]2 and MMP9) between AL and non-AL groups on postoperative day 1. Those that included IL-6 (7 studies), IL-10 (4 studies), TNF alpha (6 studies) and MMP9 (2 studies) were included in the meta-analysis. IL-10 was the only cytokine in the meta-analysis that was significantly (p < 0.05) raised in drain fluid on postoperative day 1 in AL patients. CONCLUSIONS: Peritoneal IL-10 was significantly raised on postoperative day 1 in patients who subsequently developed AL. This may be a useful early predictor of AL and aid in an earlier diagnosis for postoperative colorectal patients. The range of cytokines investigated within the literature is limited and from heterogeneous studies which suggests more research is needed.

Warmed and humidified insufflation to prevent perioperative hypothermia and improve the quality of recovery in elective laparoscopic colorectal resection patients: a feasibility study for a triple-blind randomized controlled trial.

AIM: The use of standard CO2 for insufflation during laparoscopic colorectal surgery may be associated with cooling and drying of the peritoneal cavity, contributing to perioperative hypothermia. The aim of this work was the assess the feasibility of a study to compare insufflation of warmed, humidified CO2 (WHCO2) (using HumiGard, Fisher and Paykel Healthcare) with standard measures and its impact on the quality of recovery of surgical patients. METHOD: A single-centre, triple-blind, feasibility, randomized controlled trial (RCT) of adults scheduled for planned laparoscopic colorectal surgery. The primary outcome was recruitment. Secondary outcomes included feasibility of blinding, acceptability to patients and suitability of objective measures: patient-reported quality of recovery using a validated questionnaire (QoR-40), patient pain scores and semi-continuous core temperature measurements. RESULTS: Thirty-nine participants were randomized to either the WHCO2 group (n = 19) or standard care alone (n = 20). Recruitment to the study was successful and acceptable to patients. Blinding of the surgeons, patients and assessors was effective. Response rates to QoR-40 were high but ceiling effects were observed, indicating that the tool was unsuitable in this population. Fewer patients in the WHCO2 group reported postoperative nausea and vomiting (PONV) at days 1 (53% vs. 65%) and 3 (37% vs. 60%). The median hospital length of stay was 5.5 days in the standard care group and 4 days in the WHCO2 group. CONCLUSION: A study of WHCO2 for insufflation in laparoscopic colorectal surgery would be highly acceptable to both patients and researchers. Potential reductions in PONV and hospital length of stay in patients treated with WHCO2 merit further investigation. The design of the full-scale RCT will benefit from this feasibility study.

Diagnosis of colorectal and emergency surgical site infections in the era of enhanced recovery: an all-Wales prospective study.

AIM: Surgical site infections (SSIs) are associated with increased morbidity, hospital stay and cost. The literature reports that 25% of patients who undergo colorectal surgical procedures develop a SSI. Due to the enhanced recovery programme, patients are being discharged earlier with some SSIs presenting in primary care, making accurate recording of SSIs difficult. The aim of this study was to accurately record the 30-day SSI rate after surgery performed by colorectal surgeons nationally within Wales. METHOD: During March 2019, a national prospective snapshot study of all patients undergoing elective or emergency colorectal and general surgical procedures under the care of a colorectal consultant at 12 Welsh hospitals was completed. There was a multimodal 30-day follow-up using electronic records, clinic visits and/or telephone calls. Diagnosis of SSI was based on Centers for Disease Control and Prevention diagnostic criteria. RESULTS: Within Wales, of the 545 patients included, 13% developed a SSI within 30 days, with SSI rates of 14.3% for elective surgery and 11.7% for emergency surgery. Of these SSIs, 49.3% were diagnosed in primary care, with 28.2% of patients being managed exclusively in the community. There were two peaks of diagnosis at days 5-7 and days 22-28. SSI rates between laparoscopic (8.6%) and open (16.2%) surgeries were significantly different (p = 0.028), and there was also a significantly different rate of SSI between procedure groups (p = 0.001), with high SSI rates for colon (22%) and rectal (18.9%) surgery compared with general surgical procedures. CONCLUSION: This first all-Wales prospective study demonstrated an overall SSI rate of 13%. By incorporating accurate primary care follow-up it was found that 49.3% of these SSIs were diagnosed in primary care.

COVID-19 and the emergency presentation of colorectal cancer.

AIM: The COVID-19 pandemic led to widespread disruption of colorectal cancer services during 2020. Established cancer referral pathways were modified in response to reduced diagnostic availability. The aim of this paper is to assess the impact of COVID-19 on colorectal cancer referral, presentation and stage. METHODS: This was a single centre, retrospective cohort study performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January and December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging. RESULTS: In all, 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender and tumour location (P > 0.05). There was a significant decrease in urgent suspected cancer referrals, diagnostic colonoscopy and radiological imaging performed between March and June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018-2019 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018-2019 (P = 0.03). CONCLUSION: This study demonstrates that a relatively short-term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is therefore critical that efforts are made to make this pathway more robust to minimize the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment.

Association of Postoperative Clinical Outcomes With Sarcopenia, Frailty, and Nutritional Status in Older Patients With Colorectal Cancer: Protocol for a Prospective Cohort Study.

BACKGROUND: Older patients account for a significant proportion of patients undergoing colorectal cancer surgery and are vulnerable to a number of preoperative risk factors that are not often present in younger patients. Further, three preoperative risk factors that are more prevalent in older adults include frailty, sarcopenia, and malnutrition. Although each of these has been studied in isolation, there is little information on the interplay between them in older surgical patients. A particular area of increasing interest is the use of urine metabolomics for the objective evaluation of dietary profiles and malnutrition. OBJECTIVE: Herein, we describe the design, cohort, and standard operating procedures of a planned prospective study of older surgical patients undergoing colorectal cancer resection across multiple institutions in the United Kingdom. The objectives are to determine the association between clinical outcomes and frailty, nutritional status, and sarcopenia. METHODS: The procedures will include serial frailty evaluations (Clinical Frailty Scale and Groningen Frailty Indicator), functional assessments (hand grip strength and 4-meter walk test), muscle mass evaluations via computerized tomography morphometric analysis, and the evaluation of nutritional status via the analysis of urinary dietary biomarkers. The primary feasibility outcome is the estimation of the incidence rate of postoperative complications, and the primary clinical outcome is the association between the presence of postoperative complications and frailty, sarcopenia, and nutritional status. The secondary outcome measures are the length of hospital stay, 30-day hospital readmission rate, and mortality rate at days 30 and 90. RESULTS: Our study was approved by the National Health Service Research Ethics Committee (reference number: 19/WA/0190) via the Integrated Research Application System (project ID: 231694) prior to subject recruitment. Cardiff University is acting as the study sponsor. Our study is financially supported through an external, peer-reviewed grant from the British Geriatrics Society and internal funding resources from Cardiff University. The results will be disseminated through peer-review publications, social media, and conference proceedings. CONCLUSIONS: As frailty, sarcopenia, and malnutrition are all areas of common derangement in the older surgical population, prospectively studying these risk factors in concert will allow for the analysis of their interplay as well as the development of predictive models for those at risk of commonly tracked surgical complications and outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16846.

Normothermic Insufflation to Prevent Perioperative Hypothermia and Improve Quality of Recovery in Elective Colectomy Patients: Protocol for a Randomized Controlled Trial.

BACKGROUND: Perioperative hypothermia during laparoscopy for bowel resection is a risk factor for postoperative medical complications and surgical wound infections. Despite various warming methods used during surgery, a significant number of patients experience perioperative hypothermia. Use of dry, unwarmed insufflation carbon dioxide (CO2) during laparoscopic procedures may contribute to this problem. Evidence exists that the HumiGard device, which humidifies and heats CO2 for insufflation, can reduce the risk of perioperative hypothermia. OBJECTIVE: The aim is to determine if insufflation with warmed, humidified CO2 using the HumiGard device, alongside standard perioperative warming techniques, can improve patient recovery, including pain, surgical site infections, complications, and the use of analgesia compared with standard care alone. METHODS: The study is a multicenter, randomized, blinded (patient, surgeon, and assessor), sham device-controlled, parallel group-controlled trial of 232 patients. The study aims to recruit patients undergoing elective laparoscopic, segmental, or total colectomy. Patients will be randomized to receive HumiGard plus standard care or standard care alone (1:1 ratio). The primary outcome is patient-reported quality of recovery, measured by the validated QoR-40 (quality of recovery) questionnaire, from baseline to postoperative day 1. Secondary outcomes include postoperative pain, the incidence of hypothermia, and the rate of postoperative complications. RESULTS: The information gathered during a small-scale service evaluation at a single hospital was used to inform this study protocol. Before applying for a grant for this full randomized controlled trial, the authors will conduct a feasibility study of 40 patients to ensure that the protocol is feasible and to inform our sample size calculation. CONCLUSIONS: The randomized controlled trial is designed to provide high-quality evidence on the effectiveness of the HumiGard device in potentially reducing the risk of perioperative hypothermia in patients scheduled for laparoscopic colectomy. The results will be used to improve the maintenance of adequate patient body temperature during surgery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/14533.

Image-defined resolution following radiosurgery for hypothalamic hamartoma.

The authors present the rare case of complete image-defined resolution of a hypothalamic hamartoma (HH) following Gamma Knife surgery (GKS). A 9-month-old girl presented with an episode of generalized tonic-clonic seizures. Magnetic resonance imaging revealed a left-sided HH, which remained radiologically stable. By 3 years of age the patient had a development delay of 12 months, and experienced 8 gelastic seizures per day while on 2 antiepileptic medications. Thirty-one months after presentation, the patient underwent elective GKS to treat the HH. She has since been seizure free for 22 months, while receiving 3 antiepileptic medications. Twelve months after radiosurgery, MRI revealed complete radiological resolution of the lesion. The authors discuss alternative management options for HH, including microsurgical resection, endoscopic disconnection, stereotactic radiofrequency thermocoagulation, and interstitial radiosurgery. Gamma Knife surgery is a minimally invasive procedure associated with a lower morbidity rate than that of published surgical results. The present case demonstrates the potential for complete image-defined resolution of an HH post-GKS, without long-term neurological sequelae, emphasizing the safety and efficacy of this therapeutic option for the control of epileptic seizures produced by small-volume, surgically inaccessible HHs.