Natalie S Blencowe

Core information set for oesophageal cancer surgery

Surgeons provide patients with information before surgery, although standards of information are lacking and practice varies. The development and use of a ‘core information set’ as baseline information before surgery may improve understanding. A core set is a minimum set of information to use in all consultations before a specific procedure. This study developed a core information set for oesophageal cancer surgery.

Demonstration of the IDEAL recommendations for evaluating and reporting surgical innovation in minimally invasive oesophagectomy.

The Idea, Development, Evaluation, Assessment and Long term study (IDEAL) framework makes recommendations for evaluating and reporting surgical innovation and adoption, but remains untested.

Spontaneous oesophageal rupture

A 50 year old man presented to his local emergency department complaining of central chest pain and breathlessness that had begun after an episode of vomiting. Physical examination revealed diminished breath sounds at the left lung base and a temperature of 38°C. An erect chest radiograph showed a small, left sided pleural effusion. An initial diagnosis of pneumonia was made, and the patient was started on intravenous antibiotics. The next morning he had deteriorated, and a repeat chest radiograph showed an increase in the pleural effusion and pneumomediastinum. Computed tomography with oral and intravenous contrast revealed contrast in the left pleural cavity, suggesting a diagnosis of oesophageal rupture. The patient was stabilised and subsequently underwent thoracotomy and wash-out, placement of an oesophageal stent, and insertion of a feeding jejunostomy. Spontaneous rupture of the oesophagus (Boerhaave’s syndrome) is a complete disruption of the oesophageal wall in the absence of pre-existing pathology and occurs with a sudden rise in intraoesophageal pressure, typically during vomiting. The left posterolateral lower oesophagus is most often affected, about 2-3 cm from the gastro-oesophageal junction. #### How common is spontaneous oesophageal rupture?

Interventions in randomised controlled trials in surgery: issues to consider during trial design

Until recently, insufficient attention has been paid to the fact that surgical interventions are complex. This complexity has several implications, including the way in which surgical interventions are described and delivered in trials. In order for surgeons to adopt trial findings, interventions need to be described in sufficient detail to enable accurate replication; however, it may be permissible to allow some aspects to be delivered according to local practice. Accumulating work in this area has identified the need for general guidance on the design of surgical interventions in trial protocols and reports. Key issues to consider when designing surgical interventions include the identification of each surgical intervention and their components, who will deliver the interventions, and where and how the interventions will be standardised and monitored during the trial. The trial design (pragmatic and explanatory), comparator and stage of innovation may also influence the extent of detail required. Thoughtful consideration of surgical interventions in this way may help with the interpretation of trial results and the adoption of successful interventions into clinical practice.

Systematic review of surgical innovation reporting in laparoendoscopic colonic polyp resection

The IDEAL framework (Idea, Development, Exploration, Assessment, Long‐term study) proposes a staged assessment of surgical innovation, but whether it can be used in practice is uncertain. This study aimed to review the reporting of a surgical innovation according to the IDEAL framework.

Systematic review of intervention design and delivery in pragmatic and explanatory surgical randomized clinical trials

Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials (RCTs) within the context of explanatory and pragmatic study designs.

Accounting for intervention complexity in rcts in surgery: new approaches for intervention definition and methods for monitoring fidelity

The recognition that surgical interventions are complex has major implications for the design of RCTs, including the need for methods to describe interventions in study protocols to allow delivery and fidelity to be accurately assessed. We report approaches to defining and describing surgical interventions and assessing intervention fidelity. Some 81 RCTs evaluating 135 surgical interventions, published between 2010 and 2011, were systematically identified. A subset of reports were scrutinised and iterative discussions developed a classification framework for intervention definition and fidelity. Two researchers independently read and re-read articles, discussed with the research team, and re-worked the classification to inform the framework which was reapplied to all papers. The whole surgical intervention, component parts and individual steps were classified. Whole interventions were categorised into four groups: i) resection, ii) reconstruction, iii) resection and reconstruction, and iv) exploration. Components of interventions included i) incision, ii) dissection, iii) haemostasis, and iv) closure. Individual steps within each component included categories such as length of incision or extent of dissection. Descriptions of whole interventions, component parts and individual steps were each classified as mandatory, prohibited or optional. Mandatory elements included those delivered flexibly, within limits, or exactly. Intervention fidelity was similarly categorised as relating to the whole intervention, component parts and individual steps. Descriptions and categorisation of surgical interventions is feasible and the precise level of detail required will depend upon trial design and the nature of the research question. Further work to explore the application of this system to new trials is now required.

Providing adequate and practical descriptions in surgical trials

Cook and colleagues highlight that descriptions of non-pharmacological interventions in randomised controlled trials are inadequate.1 Although reporting standards need to be improved, the level of information they suggest may not always be necessary. Surgical interventions are complex, comprising many components that are delivered with multiple concomitant interventions (such as anaesthesia and postoperative care), so it may be impractical to control them all. Individual surgeons …

Surgical ward rounds in England: a trainee-led multi-centre study of current practice

BackgroundRecent guidance advocates daily consultant-led ward rounds, conducted in the morning with the presence of senior nursing staff and minimising patients on outlying wards. These recommendations aim to improve patient management through timely investigations, treatment and discharge. This study sought to evaluate the current surgical ward round practices in England.MethodsInformation regarding timing and staffing levels of surgical ward rounds was collected prospectively over a one-week period. The location of each patient was also documented. Two surgical trainee research collaboratives coordinated data collection from 19 hospitals and 13 surgical subspecialties.ResultsData from 471 ward rounds involving 5622 patient encounters was obtained. 367 (77.9%) ward rounds commenced before 9am. Of 422 weekday rounds, 190 (45%) were consultant-led compared with 33 of the 49 (67%) weekend rounds. 2474 (44%) patients were seen with a nurse present. 1518 patients (27%) were classified as outliers, with 361 ward rounds (67%) reporting at least one outlying patient.ConclusionRecommendations for daily consultant-led multi disciplinary ward rounds are poorly implemented in surgical practice, and patients continue to be managed on outlying wards. Although strategies may be employed to improve nursing attendance on ward rounds, substantial changes to workforce planning would be required to deliver daily consultant-led care. An increasing political focus on patient outcomes at weekends may prompt changes in these areas.

Standardizing and monitoring the delivery of surgical interventions in randomized clinical trials

The complexity of surgical interventions has major implications for the design of RCTs. Trials need to consider how and whether to standardize interventions so that, if successful, they can be implemented in practice. Although guidance exists for standardizing non‐pharmaceutical interventions in RCTs, their application to surgery is unclear. This study reports new methods for standardizing the delivery of surgical interventions in RCTs.