Evaluating temporal trends and the impact of surgical subspecialisation on patient outcomes following adhesional small bowel obstruction: a multicentre cohort study.

PURPOSE: Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions commonly remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation on patient outcomes. METHODS: Data was collected for patients admitted acutely with adhesional SBO across acute NHS trusts in Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a potentially non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality. RESULTS: Overall, 2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance, but age and comorbidity increased significantly over time (both p < 0.001). In recent years, more patients were managed operatively with a trend away from delayed surgery also evident (2002-2006: 65.7% vs. 2012-2016: 42.7%, p < 0.001). Delayed surgery was associated with an increased mortality risk on multivariable regression analysis (OR: 2.46 (1.46-4.23, p = 0.001)). CT scanning was not associated with management strategy or timing of surgery (p = 0.369). There was an increased propensity for patients to be managed by gastrointestinal (colorectal and upper gastrointestinal) subspecialists over time. Length of stay (p < 0.001) and 30-day mortality (p < 0.001) both improved in recent years, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality. CONCLUSION: Outcomes for patients presenting with adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.

Patient-focused endpoints in advanced cancer: criterion-based validation of accelerometer-based activity monitoring.

BACKGROUND & AIMS: Objective assessment of daily physical activity (PA) by body-worn accelerometers offers potential as a novel endpoint in the clinical management of advanced cancer patients. This study aimed to assess criterion-based validity of an accelerometer-based activity monitoring system (AM-system), ActivPAL™, using two different methods. METHODS: Advanced cancer in patients and outpatients (Karnofsky Performance Status (KPS) 40-100). ActivPAL™ measurements were validated against (i) observations and (ii) energy expenditure (EE) measured by 2-week doubly-labelled water (DLW) protocol. RESULTS: Absolute errors for mean time spent in different body positions (<0.1%) and number of transfers (0%) were low. Step count error was significantly higher in patients with KPS 40-60 (non-self caring) compared to KPS 70-100 (self-caring) (33 vs. 24%, p = 0.006). Post-hoc mathematical analysis demonstrated that absolute errors for the mean energy expenditure of activity (EEA) (1.4%) and mean total EE (0.4%) were low, but agreement was also low. CONCLUSIONS: AM-systems provide valid estimates of body positions and transfers, but not step count, especially in non-self caring patients. ActivPAL™ can derive estimates of EE but there is considerable variability in results, which is consistent, in part, with the inaccuracy in step count. Further studies are required to assess the validity of different endpoints derived from AM-systems in advanced cancer patients.

Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: a randomised double-blind, crossover study.

BACKGROUND & AIMS: Preoperative starvation has many undesirable effects but the minimum length of fasting is limited by gastric emptying, which may be dependent on nutrient content, viscosity and osmolarity of the feed. We compared the gastric emptying of two types of preoperative metabolic preconditioning drinks [Oral Nutritional Supplement (ONS) (Fresenius Kabi, Germany) and preOp (Nutricia Clinical Care, UK)] in healthy volunteers. METHODS: Twenty (10 male, 10 female) healthy adult volunteers were studied on 3 separate occasions in a randomised crossover manner. Volunteers ingested 400 ml preOp, which is a clear carbohydrate drink (CCD) (50 g carbohydrate, 0 g protein), 70 g ONS (50 g carbohydrate and 15 g glutamine) dissolved in water to a total volume of 400 ml (ONS400) and 300 ml (ONS300). Gastric emptying time was measured using magnetic resonance imaging. RESULTS: Mean (95% CI) T(50) and T(100) gastric emptying times for CCD were significantly lower (p<0.001) compared with ONS400 and ONS300. T(50) was 47 (39-55), 78 (69-87) and 81 (70-92)min for CCD, ONS400 and ONS300 respectively. Correspondingly T(100) was 94 (79-110), 156 (138-173) and 162 (140-184)min. Residual gastric volumes returned to baseline 120 min after CCD and 180 min after ONS400 and ONS300. CONCLUSIONS: The faster gastric emptying for CCD compared to ONS400 and ONS300 signifies that gastric emptying may be more dependent on nutrient load than volume or viscosity in healthy volunteers. While it is safe to give CCD 2h preoperatively, ONS400 and ONS300 should be given at least 3h preoperatively.

Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations.

OBJECTIVES: To describe a consensus review of optimal perioperative care in colorectal surgery and to provide consensus recommendations for each item of an evidence-based protocol for optimal perioperative care. DATA SOURCES: For every item of the perioperative treatment pathway, available English-language literature has been examined. STUDY SELECTION: Particular attention was paid to meta-analyses, randomized controlled trials, and systematic reviews. DATA EXTRACTION: A consensus recommendation for each protocol item was reached after critical appraisal of the literature by the group. DATA SYNTHESIS: For most protocol items, recommendations are based on good-quality trials or meta-analyses of such trials. CONCLUSIONS: The Enhanced Recovery After Surgery (ERAS) Group presents a comprehensive evidence-based consensus review of perioperative care for colorectal surgery. It is based on the evidence available for each element of the multimodal perioperative care pathway.