Setting up a Complex Abdominal Wall Reconstruction Unit: Our first 12 months' experience in a District General Hospital (2023)

Type of publication:Conference abstract

Author(s):*Bhandari M.; *George J.; *Chakravartty S.; *Parampalli U.; *McCloud J.; *Cheetham M.

Citation:British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Harrogate United Kingdom. 110(Supplement 6) (pp vi50-vi51), 2023.

Abstract:Aims: Incisional hernias are distressing post-operative complications which develop in 25% of surgical incisions. We present our initial experience of setting up a Complex Abdominal Wall Reconstruction (CAWR) unit in line with international guidelines and Get It Right First Time (GIRFT) model of care. Method(s): A bespoke CAWR Multidisciplinary Team was established in our trust in January 2022, comprising 2 colorectal surgeons, 2 bariatric surgeons and anaesthetists (who performed the preoperative Botox injections and optimized high-risk patients). The unit had support from radiologists, the weight management service, and the orthotics department. We had approval from our governance, drugs and therapeutics team. Pathways for risk stratification, risk modification with pre-optimisation, standardised surgical techniques and post-operative care were created. Result(s): Between January and December 2022, 8 MDT meetings held and 52 patients were discussed. The average BMI was 34 (22-50.5) All patients underwent a preoperative CT scan to delineate the anatomy of the hernia. The median size of the defect was 6 cm (range 3 to 22 cm). Open Rives-Stoppa repair was performed in 19 patients, with transversus abdominal muscle release in 6 and 3 patients had laparoscopic repair. One recurrence and 2 superficial surgical site infections were noted. 38.4% patients had BOTOX, 40.3% advised preoperative weight loss and 5.7% for bariatric surgery before hernia repair. A high-risk anaesthetic opinion was obtained in for 7.6% and 17% were deemed unfit. Conclusion(s): Our initial experience and data highlight the feasibility of delivery of CAWR service at a non-tertiary unit in line with GIRFT principles. The initial follow-up indicates improved patient outcomes and experience.

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Saving inpatient beds: are day-case total parathyroidectomies possible and safe? (2023)

Type of publication:Conference abstract

Author(s):*Sultana E.; *McDonald S.; Al-Saadi N.; Chang J.; *Sandhu K.; *Houghton A.

Citation:British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Harrogate United Kingdom. 110(Supplement 6) (pp vi12), 2023.

Abstract:Introduction: Total parathyroidectomy on patients with hyperparathyroidism traditionally required an inpatient hospital stay to monitor patients for postoperative hypocalcaemia. Our centre developed a safe protocol in 2015 which enables total parathyroidectomies to be carried out as a day-case procedure. This protocol, developed in conjunction with the renal physicians, involves giving the patient oral alfacalcidol preoperatively for 5 days and close monitoring of the calcium levels postoperatively to permit safe same day discharge. Method(s): A single centre retrospective study was carried out on all patients who underwent a total parathyroidectomy for hyperparathyroidism between 2005 and 2022. A comparison study was done before and after the protocol was introduced in 2015. Data were collected regarding the patient comorbidities, peri-operative calcium level, post-operative calcium, potassium and parathyroid levels, length of hospital stay, operative procedure details, hospital readmission, and 30-day morbidity. Result(s): 57 patients underwent total parathyroidectomy during the study period (22 before protocol and 35 after the protocol). After introduction of the protocol, 40% of patients were discharged on the same day, compared to only 4.54% previously. The duration of inpatient hospital stay was reduced from 0-13 days to 0-3 days. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patient required readmission during the 30-day post-operative period. Conclusion(s): Day-case surgery for total parathyroidectomy can be achieved safely in patients with a preoperative regimen of alfacalcidol and close monitoring of calcium levels post-operatively, emulating a virtual ward round.

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Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes (2023)

Type of publication:Journal article

Author(s):Joyner, J; Ayyaz, F M; *Cheetham, M; Briggs, T W R; Gray, W K.

Citation:Hernia. 2023 Oct 18.

Abstract:PURPOSE: Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery. METHODS: This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged >= 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. RESULTS: A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021-22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58-0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74-0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04-1.40, p = 0.015). CONCLUSIONS: For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery.

Life Expectancy of Octogenarians Following EVAR (2023)

Type of publication:
Conference abstract

Author(s):
*Sultana E.; *Seraj S.; *Jones S.

Citation:

British Journal of Surgery. Conference: ASiT Surgical Conference 2023. Liverpool United Kingdom. 110(Supplement 7) (pp vii183), 2023.

Abstract:
Background: The aim of elective Abdominal Aortic Aneurysm (AAA) repair is to prevent premature death from rupture. The Endovascular Aneurysm Repair (EVAR) 2 trial showed that patients with AAA who are not fit for open repair do not benefit in terms of life-expectancy from EVAR. In our region, the average life expectancy for men is above the national average but controversy remains when offering octogenarians expensive procedures with the aim of prolonging life. This study aimed to quantify the life-expectancy following an EVAR between octogenarians and younger patients. Method(s): A retrospective review was performed of the electronic notes of all patients receiving EVAR at our unit between October 2009 to October 2019. Survival post EVAR was compared between the octogenarian group and the younger patient group. A survival analysis was undertaken using the SPSS software to calculate a Kaplan-Meier curve. Result(s): 294 patients received EVAR between 2009-2019. Patients were between ages 45 and 89 (Median: 75); 87.4% were male. 169 patients died during follow up (n = 64 >=80 years, n = 105 <80 years). Time of death post-EVAR in octogenarians (average age 82.91 years) ranged between 0 – 131 months, whilst those under 80 years (average age 71.77 years) ranged between 1 – 152 months. Log rank (Mantel-Cox) analysis demonstrated statistical significance (p = 0.017). Median years post-EVAR for >=80 years was 3.02 – 4.98 and <80 years was 5.12 – 6.87. Conclusion(s): Octogenarians undergoing EVAR have a shorter life-expectancy compared to those under 80 years of age. This should be considered when discussing elective options with patients and their relatives.

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Impelling Factors for Contracting COVID-19 Among Surgical Professionals During the Pandemic: A Multinational Cohort Study (2023)

Type of publication:Journal article

Author(s):Yang, Wah; Bangash, Ali Haider; Kok, Johnn Henry Herrera; Cheruvu, Chandra; Parmar, Chetan; Isik, Arda; Galanis, Michail; Di Maggio, Francesco; Atici, Semra Demirli; Abouelazayem, Mohamed; *Bandyopadhyay, Samik Kumar; Viswanath, Yirupaiahgari K S.

Citation:Journal of Clinical Medicine Research. 15(4):233-238, 2023 Apr.

Abstract:Background: Medical workers, including surgical professionals working in coronavirus disease 2019 (COVID-19) treating hospitals, were under enormous stress during the pandemic. This global study investigated factors endowing COVID-19 amongst surgical professionals and students. Methods: This global cross-sectional survey was made live on February 18, 2021 and closed for analysis on March 13, 2021. It was freely shared on social and scientific media platforms and was sent via email groups and circulated through a personal network of authors. Chi-square test for independence, and binary logistic regression analysis were carried out on determining predictors of surgical professionals contracting COVID-19. Results: This survey captured the response of 520 surgical professionals from 66 countries. Of the professionals, 92.5% (481/520) reported practising in hospitals managing COVID-19 patients. More than one-fourth (25.6%) of the respondents (133/520) reported suffering from COVID-19 which was more frequent in surgical professionals practising in public sector healthcare institutions (P = 0.001). Thirty-seven percent of those who reported never contracting COVID-19 (139/376) reported being still asked to practice self-isolation and wear a shield without the diagnosis (P = 0.001). Of those who did not contract COVID-19, 75.7% (283/376) were vaccinated (P < 0.001). Surgical professionals undergoing practice in the private sector (odds ratio (OR): 0.33; 95% confidence interval (CI): 0.14 – 0.77; P = 0.011) and receiving two doses of vaccine (OR: 0.55; 95% CI: 0.32 – 0.95; P = 0.031) were identified to enjoy decreased odds of contracting COVID-19. Only 6.9% of those who reported not contracting COVID-19 (26/376) were calculated to have the highest "overall composite level of harm" score (P < 0.001). Conclusions: High prevalence of respondents got COVID-19, which was more frequent in participants working in public sector hospitals. Those who reported contracting COVID-19 were calculated to have the highest level of harm score. Self-isolation or shield, getting two doses of vaccines decreases the odds of contracting COVID-19.

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Surgical experience and identification of errors in laparoscopic cholecystectomy (2023)

Type of publication:
Journal article

Author(s):
Humm, Gemma L; Peckham-Cooper, Adam; *Chang, Jessica; Fernandes, Roland; Gomez, Naim Fakih; Mohan, Helen; Nally, Deirdre; Thaventhiran, Anthony J; Zakeri, Roxanna; Gupte, Anaya; Crosbie, James; Wood, Christopher; Dawas, Khaled; Stoyanov, Danail; Lovat, Laurence B.

Citation:
British Journal of Surgery. 2023 Aug 23. [epub ahead of print]

Abstract:
BACKGROUND: Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS: Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS: Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION: This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

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Pre-Assessment Information (2022)

Type of publication:
Service improvement case study

Author(s):
*Rachael Bollands, *Rachel Bladen, *Rachel Hanmer, *Paul Adams, *Jemima Hughes

Citation:
SaTH Improvement Hub, September 2022

Abstract:
Patients are required to have an information pack following their assessment to share the required information prior to surgery. A QR code was generated to share this information reducing time spent creating the packs to release additional time for patient care.

Link to PDF poster [no password required]

Health and Wellbeing (2022)

Type of publication:
Service improvement case study

Author(s):
*Andrena Weston, *Lisa Baker-Murray, *Alison Mattey, *Steve Turner, *Claire Oborn, *Theatre Teams- RSH and PRH, *Sabeena Khanna

Citation:
SaTH Improvement Hub, June 2022

Abstract:
In order to improve the Health and Wellbeing, vacancy rates and reduce sickness within Theatres, a number of interventions were trialled.

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Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation (2021)

Type of publication:
Conference abstract

Author(s):
Grossi U.; *Lacy-Colson J.; Brown S.; Cross S.; Eldridge S.; Scott S.M.; Taheri S.; Knowles C.

Citation:
Colorectal Disease. Conference: 16th Scientific and Annual Meeting of the European Society of Coloproctology, ESCP 2021. Virtual. 23(Supplement 2) (pp 3), 2021. Date of Publication: October 2021.

Abstract:
Aim: Effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse (IRP) is poorly evidenced. A UK-based multicentre randomized controlled trial (RCT) was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. Method(s): A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR with those who had undergone surgery.Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to 3 arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was measured as a 1.0-point reduction in PAC-QOL and PAC-SYM scores at 24 weeks. Secondary outcome measures included 14-day diary data, GAD7, PHQ9, St Marks incontinence score, PISQ12, CC-BRQ, and BIPQ. Result(s): Of 42 eligible patients, 28 (67%) females were randomized from 6 institutions. Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the 3 arms. Compared to baseline, significant reduction in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (-1.09 [95%CI -1.76, -0.41], P = 0.0019, and -0.92 [-1.52, -0.32], P = 0.0029). As opposed to PAC-QOL (-1.38 [-2.94, 0.19], P = 0.0840 at 72 weeks), improvements in PAC-SYM scores persisted to 72 weeks (-1.51 [-2.87, -0.16], P = 0.0289). Compared to baseline, no differences were found on secondary outcomes, except for significant improvements on CC-BRQ and BIPQ at 24 and 48 weeks. Conclusion(s): There was evidence of a short-term effect of LVMR for IRP up to 36 weeks. Improvements in quality of life declined over follow-up up to 72 weeks.

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Bariatric surgeons' experiences of working in the first year of the pandemic (2023)

Type of publication:
Journal article

Author(s):
Graham Y.N.H.; Mahawar K.; Singhal R.; Madhok B.; Yang W.; *Riera M.; Martinez-Duartez P.; Pouwels S.; Sharma M.; Hayes C.

Citation:
Obesity Science and Practice. 9(4) (pp 329-336), 2023. Date of Publication: August 2023.

Abstract:
Background: The first year of the Covid-19 pandemic saw drastic changes to bariatric surgical practice, including postponement of procedures, altered patient care and impacting on the role of bariatric surgeons. The consequences of this both personally and professionally amongst bariatric surgeons has not as yet been explored. Aim(s): The aim of this research was to understand bariatric surgeons' perspectives of working during the first year of the pandemic to explore the self-reported personal and professional impact. Method(s): Using a retrospective, two phased, study design with global participants recruited from closed, bariatric surgical units. The first phase used a qualitative thematic analytic framework to identify salient areas of importance to surgeons. Themes informed the construction of an on-line, confidential survey to test the potential generalizability of the interview findings with a larger representative population from the global bariatric surgical community. Finding(s): Findings of the study revealed that the first year of the pandemic had a detrimental effect on bariatric surgeons both personally and professionally globally. Conclusion(s): This study has identified the need to build resilience of bariatric surgeons so that the practice of self-care and the encouragement of help-seeking behaviors can potentially be normalized, which will in turn increase levels of mental health and wellbeing.

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