Nicholas R.A. Symons

Mortality in high-risk emergency general surgical admissions

There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high‐risk emergency general surgery admissions to English NHS hospital Trusts.

Training faculty in nontechnical skill assessment: national guidelines on program requirements.

Objective: To develop guidelines for a faculty training program in nontechnical skill assessment in surgery. Background: Nontechnical skills in the operating room are critical for patient safety. The successful integration of these skills into workplace-based assessment is dependent upon the availability of faculty who are able to teach and assess them. At present, no guidelines exist regarding the training requirements for such faculty in surgical contexts. Methods: The development of the guidelines was carried out in several stages: stage 1—a detailed literature review on current training for nontechnical skill assessors; stage 2—semistructured interviews with a multidisciplinary panel (consisting of clinicians and psychologists/human factors specialists) of experts in surgical nontechnical skills; and stage 3—interview findings fed into an Expert Consensus Panel (ECP) Delphi approach to establish consensus regarding training requirements for faculty assessing nontechnical skills in surgery. Results: The ECP agreed that training in nontechnical skill assessment should be delivered by a multidisciplinary team consisting of clinicians and psychologists/human factors specialists. The ECP reached consensus regarding who should be targeted to be trained as faculty (including proficiency and revalidation requirements). Consensus was reached on 7 essential training program content elements (including training in providing feedback/debriefing) and 8 essential methods of evaluating the effectiveness of a “train-the-trainers” program. Conclusions: This study provides evidence-based guidelines that can be used to guide the development and evaluation of programs to educate faculty in the training and assessment of nontechnical skills. Uptake of these guidelines could accelerate the development of surgical expertise required for safe and high-quality patient care.

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

Objective:To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. Background:Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient. Methods:Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons. Results:Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures. Conclusions:Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

Laparoscopic revision of failed antireflux surgery: a systematic review

BACKGROUND Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery. METHODS We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries. RESULTS The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure. CONCLUSIONS Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication.

The effect of trainee research collaboratives in the UK

Trainee-led networks have pioneered a novel collaborative approach to research in the UK. Established at a similar time to the UK National Institute for Health Research in 2006, collaborative groups have developed new pathways for doctors in full-time specialty training to design, disseminate, and deliver high-quality, multicentre research. In parallel, the National Institute for Health Research set up Clinical Research Networks (CRNs) to coordinate delivery of research across 30 clinical specialties and 15 English regional networks. Analogous networks have also been established by the devolved administrations in Scotland, Northen Ireland, and Wales. CRNs provide infrastructure to promote and coordinate research, including funding research support staff and providing research skills training. Using gastrointestinal surgery as an example, we sought to quantify trainee-led collaborative research network engagement and compare hospital participation with CRN studies. We only considered CRN and trainee-led collaborative studies involving ten or more hospitals with information available about participating sites. We searched the CRN portfolio for closed gastrointestinal and general surgery studies. We contacted trainee networks via a national mailing list to identify trainee studies. We derived denominators from the total number of hospitals offering emergency or major elective gastrointestinal surgery. Overall, 238 (99%) of 241 UK hospitals providing general surgery services participated in one or more trainee-led collaborative studies over the past decade compared with 191 (79%) of 241 for CRN studies. With the three trainee-led studies that had been adopted into the CRN portfolio excluded, participation in trainee-led research remained similar, at 236 (98%) of 241. Trainee groups delivered 15 studies overall: 12 observational studies and three randomised controlled trials (RCTs), coordinated by five regional and two national trainee networks (appendix). These numbers compared with three observational studies and eight RCTs coordinated by the CRN. We noted strong participation in trainee collaborative studies, even in regions with low CRN coverage, with the mean number of studies per hospital greater for collaboratives than for CRNs (appendix). Regions with a Royal College of Surgeons Surgical Trials Centre had greater participation in both trainee and CRN studies: the mean number of studies per hospital was 8·2 versus 6·0 in regions without. Trainee-led collaboratives have driven substantial additional research participation across the UK, on top of that achievable through CRNs alone, and have engaged additional gastrointestinal surgery units with little infrastructure or associated costs. This success is now being replicated in other specialties, with the British Neurosurgical Trainee Research Collaborative engaging 26 of 30 UK adult trauma-receiving neurosurgical units in the RESCUE-ASDH RCT. As the collaborative model is extended globally, it offers a powerful opportunity to promote a collaborative research culture and grow capacity with minimal investment. Synergy between trainee-led networks and CRNs could maximise delivery of high-quality research across the UK.

Para‐neorectal mucinous adenocarcinoma following childhood pull‐through procedure for imperforate anus

1 Drabick JJ. Pentastomiasis. Rev Infect Dis. 1987; 9: 1087–94. 2 Herzog U, Marty P, Zak F. Pentastomiasis: case report of an acute abdominal emergency. Acta Trop 1985; 42: 261–71. 3 Meyers WM, Neafie RC, Connor DH (1976) Pentastomiasis. In: Pathology of Tropical and Extraordinary Disease (eds Binford CH, Conner DH), pp. 546–50. Armed Forces Institute of Pathology, Washington DC. 4 Machado MA, Makdissi FF, Canedo LF et al. Unusual case of pentastomiasis mimicking liver tumor. J Gastroenterol Hepatol 2006; 21: 1218–20.

Multicentre research gets into training

The increasing use of evidence-based medicine in the 21st century has led to a need for data on which to base clinical decisions. As we have become more sophisticated in our use of data, the adequacy of case reports and single centre case series as a useful form of evidence has been called into question. Clinicians increasingly look for multicentre research, particularly randomized controlled trials on which to make decisions on treatment. In surgery, level 1 evidence is conspicuously lacking for many of our common interventions. There is an urgent need for better multicentre evidence for interventions and processes of care in surgery that will allow us to justify our practice to each other, to our patients and to the funders of health care. To meet the need for multicentre evidence, surgical research collaboratives have emerged, often based on large, multicentre, randomized controlled trials. Frequently, however, these groups last only as long as the trial itself and fail to produce a long-standing collaboration. As Bhangu et al. describe in this issue, this research opportunity vacuum has been filled from the grass roots. Surgical trainees, realizing that their local research projects were having little impact, suggested that they should pick the best one and just repeat it in their respective hospitals, instantly transforming a local audit into a multicentre study. This realization was the birth of the United Kingdom’s first trainee-led surgical research collaborative, the West Midlands Research Collaborative (WMRC). It was a popular idea among peers and within a year, several multicentre studies were up and running. But ambitions did not stop there. Eyes turned to interventional research, and success came in the form of ROSSINI, a National Institute for Health Research funded randomized controlled trial of wound-edge protectors in surgery. Since the WMRC, the model of collaborative research has diffused rapidly throughout the trainee community in the United Kingdom, not just in general surgery, but in many other surgical and non-surgical specialties. In general surgery in the United Kingdom where trainees are numerous, collaboratives have been set up on a regional basis. For the smaller specialties, national collaboratives have evolved so as to gain critical mass (www.nationalresearch.org.uk). Interestingly, some collaboratives are not limiting themselves to trainees, with substantial numbers of consultants joining their ranks. The infrastructure provided by research collaboratives has been used to successfully run all types of multicentre research, from exploratory questionnaire studies to randomized controlled trials of surgical interventions. Organizationandparticipation in thesestudiesareall acknowledged and group authorship of papers allows all those involved to become citable authors, searchable via Medline search engines. The management and organization of these trainee-led research groups relies heavily on web-based technologies that facilitate collaboration. These include websites, collaborative document authorship tools, group email software, online shared electronic file storage, online data collection and questionnaire tools and online forums or message boards. Online communication and interaction within and between research collaboratives is crucial to their success as it allows rapid dissemination of information, facilitates document management, aids ‘marketing’ of potential studies to collaborative members and assists in the analysis of data and writing of the final manuscript. In this way, the studies produced by these groups can be truly collaborative. The London Surgical Research Group alone has enabled more than 180 surgical trainees to participate in a variety of multicentre collaborative research projects and simultaneously allowed those trainees to improve their understanding and skills in surgical research (www.lsrg.co.uk/projects/portfolio). Trainee-led surgical research collaboratives have changed the landscape of surgical research in the United Kingdom and they now form an important pillar of the national clinical surgical research initiative led by the Royal College of Surgeons of England. Collaboration is the key to producing the robust multicentre data needed to make evidence-based decisions in surgery. Trainee-led research collaboratives are making a significant contribution to the pool of data available and are likely to form an increasing part of the surgical research community both in the United Kingdom and beyond in the years to come.

PTU-017 Systematic Review of Endoscopic full Thickness Resection (Eftr) Techniques for Colonic Lesions

Introduction Introduction of the English Bowel Cancer Screening Program has resulted in increase in the number of patients diagnosed with endoscopically irresectable colonic polyps. A significant proportion of these patients undergo hemicolectomy associated with a significant risk of death, anastomotic leakage and general complications. The need for an alternative, less invasive treatment option for this patient cohort is becoming increasingly clear. Abstract PTU-017 Table 1 Outcome measures Authors Study Procedure completed Intra-operative complications Procedure duration (min(range)) Specimen size (cm (range)) Survival Schurr et al. A&S 20/20(100%) 5/10(50%) & 0/10(0%) - Over 3 cm* A 20/20(100%) 3/10(30%) & 0/10(0%) - - Rajan et al. S 8/8(100%) 4/8(50%) 30.2 3.6(1.5–5.2) 8/8(100%) Raju et al. S 19/20(95%) 0/19(0%) 50(24.5– 67) 1.7(1–2.5) 19/20(95%) Von Renteln et al. A 9/20(45%) & 8/8(100%) 6/9(67%) & 2/8(25%) 14.8(7–36) & 31.5(21–42) 3.3(2.4–5.5) Rieder et al. A 2/2(100%) 0/2(0%) 33 +/- 4 2.2+/-0.1 Von Renteln et al. S 8/8(88%) 2/8(25%) 3(2–12) 7.6cm2(5.4–11 cm2) 7/8(88%) Kennedy et al. A&S 3/3(100%) & 4/4(100%) 0/3(0%) & 0/4(0%) 233(201–245)** 2.5(2–3) & 3.5(3.5–4) 4/4(100%) Total 101/113(89%) 22/101(22%) 48/50(96%) Abbreviations: A = acute study, S = survival study; *Reported for 5 animals only, ** Reported for survival group only Methods Systematic literature searches identified articles describing EFTR in the colon of adult pigs, published 1990–2012. Complication rates, anastomotic bursting pressures, procedure duration, specimen size and quality, and post-mortem findings were analysed. Results Four EFTR techniques using endoscopic stapling devices, T-tags, compression closure or laparoscopic assistance for defect closure before or after specimen resection were reported. 113 procedures were performed in 99 porcine models (Table 1), with an overall success rate of 89% and a 4% mortality. The intraoperative complication rate was 22% (0% > 67%).Post-resection closure methods (as opposed to simultaneous resection and closure) more commonly resulted in failure to close the defect (5% > 55%) and a high incidence of abnormal findings at post-mortem examination (84%). Significant heterogeneity was observed in procedure duration (average 3 min to 233 min) and size of the excised specimen (average 1.7 cm to 3.6 cm). Anastomotic bursting pressures and specimen quality were poorly documented. Conclusion The technique of EFTR is in development, with experience currently limited to preclinical studies. The inability to close the resection defect reliably is the primary obstacle to further progress. This review highlights the challenges that need to be addressed in future preclinical studies. Disclosure of Interest None Declared