Showing papers in "British Journal of Surgery in 2011"

Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins.

Abstract: Background: This randomized trial compared four treatments for varicose great saphenous veins (GSVs). Methods: Five hundred consecutive patients (580 legs) with GSV reflux were randomized to endovenous laser ablation (980 and 1470 nm, bare fibre), radiofrequency ablation, ultrasound-guided foam sclerotherapy or surgical stripping using tumescent local anaesthesia with light sedation. Miniphlebectomies were also performed. The patients were examined with duplex imaging before surgery, and after 3 days, 1 month and 1 year. Results: At 1 year, seven (5· 8p er cent), six (4·8 per cent), 20 (16·3 per cent) and four (4· 8p er cent) of the GSVs were patent and refluxing in the laser, radiofrequency, foam and stripping groups respectively (P < 0·001). One patient developed a pulmonary embolus after foam sclerotherapy and one a deep vein thrombosis after surgical stripping. No other major complications were recorded. The mean(s.d.) postintervention pain scores (scale 0‐10) were 2·58(2·41), 1·21(1·72), 1·60(2·04) and 2·25(2·23) respectively (P < 0·001). The median (range) time to return to normal function was 2 (0‐25), 1 (0‐30), 1 (0‐30) and 4 (0‐30) days respectively (P < 0·001). The time off work, corrected for weekends, was 3·6 (0‐46), 2·9 (0‐14), 2·9 (0‐33) and 4·3 (0‐42) days respectively (P < 0·001). Disease-specific quality-of-life and Short Form 36 (SF-36  ) scores had improved in all groups by 1-year follow-up. In the SF-36  domains bodily pain and physical functioning, the radiofrequency and foam groups performed better in the short term than the others. Conclusion: All treatments were efficacious. The technical failure rate was highest after foam sclerotherapy, but both radiofrequency ablation and foam were associated with a faster recovery and less postoperative pain than endovenous laser ablation and stripping.

Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery.

Abstract: Background: Many studies have shown lower mortality and higher survival rates after pancreatic surgery with high-volume providers, suggesting that centralization of pancreatic surgery can improve outcomes. The methodological quality of these studies is open to question. This study involves a systematic review of the volume–outcome relationship for pancreatic surgery with a meta-analysis of studies considered to be of good quality. Methods: A systematic search of electronic databases up to February 2010 was performed to identify all primary studies examining the effects of hospital or surgeon volume on postoperative mortality and survival after pancreatic surgery. All articles were critically appraised with regard to methodological quality and risk of bias. After strict inclusion, meta-analysis assuming a random-effects model was done to estimate the effect of higher surgeon or hospital volume on patient outcome. Results: Fourteen studies were included in the meta-analysis. The results showed a significant association between hospital volume and postoperative mortality (odds ratio 0·32, 95 per cent confidence interval 0·16 to 0·64), and between hospital volume and survival (hazard ratio 0·79, 0·70 to 0·89).The effect of surgeon volume on postoperative mortality was not significant (odds ratio 0·46, 0·17 to 1·26). Significant heterogeneity was seen in the analysis of hospital volume and mortality. Sensitivity analysis showed no correlation with the extent of risk adjustment or study country; after removing one outlier study, the result was homogeneous. The data did not suggest publication bias. Conclusion: There was a consistent association between high hospital volume and lower postoperative mortality rates with improved long-term survival.

Systematic review and meta-analysis of survival and disease recurrence after radiofrequency ablation for hepatocellular carcinoma

Abstract: Background: Despite being one of the commonest causes of cancer-related death around the world, only 20 per cent of hepatocellular carcinomas (HCCs) are amenable to curative treatment (surgical resection or liver transplantation). Radiofrequency ablation (RFA) has emerged as a popular therapy for unresectable HCC. There is evidence that the disparity in survival after curative RFA and surgery for HCC, especially tumours smaller than 3 cm in diameter, is narrowing. This review examined the survival and disease recurrence rates after RFA for HCC over the past decade. Methods: A systematic review was conducted using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register and the Database of Abstracts of Reviews of Effects from January 2000 until November 2010. Papers reporting on patients with HCC who were treated with RFA, either in comparison or in combination with other interventions, such as surgery or percutaneous ethanol injection (PEI), were eligible for inclusion. Outcome data collected were overall survival, disease-free survival and disease recurrence rates. Only randomized controlled trials (RCTs), quasi-RCTs and non-randomized comparative studies with more than 12 months' follow-up were included. Results: Forty-three articles, including 12 RCTs, were included in the review. The majority of the articles reported the use of RFA for unresectable HCC, often in combination with other treatments such as PEI, transarterial chemoembolization and/or surgery. Overall and disease-free survival rates continue to improve, despite an increase in the size and numbers of tumours treated. More recently some clinicians have used RFA to treat selected patients with resectable HCC, with good outcomes. Conclusion: RFA provides a valuable treatment option for patients with unresectable HCC. It improves survival in those previously considered to have advanced disease. As progress continues to be made, RFA is gradually being used to treat resectable HCC. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery.

Abstract: Epidural analgesia is considered fundamental in enhanced recovery protocols (ERPs). However, its value in laparoscopic colorectal surgery is unclear. The aim of this study was to examine the effects of different analgesic regimens on outcomes following laparoscopic colorectal surgery in fluid-optimized patients treated within an ERP.

the proportion of intra-tumor stroma as a strong prognosticator for stage Ii and Iii colon cancer patients, validation in the Victor trial

Abstract: BACKGROUND The intra-tumor stroma percentage in colon cancer (CC) patients has previously been reported by our group as a strong independent prognostic parameter. Patients with a high stroma percentage within the primary tumor have a poor prognosis. PATIENTS AND METHODS Tissue samples from the most invasive part of the primary tumor of 710 patients (52% Stage II, 48% Stage III) participating in the VICTOR trial were analyzed for their tumor-stroma percentage. Stroma-high (>50%) and stroma-low (≤50%) groups were evaluated with respect to survival times. RESULTS Overall and disease-free survival times (OS and DFS) were significantly lower in the stroma-high group (OS P<0.0001, hazard ratio (HR)=1.96; DFS P<0.0001, HR=2.15). The 5-year OS was 69.0% versus 83.4% and DFS 58.6% versus 77.3% for stroma-high versus stroma-low patients. CONCLUSION This study confirms the intra-tumor stroma ratio as a prognostic factor. This parameter could be a valuable and low cost addition to the TNM status and next to current high-risk parameters such as microsatellite instability status used in routine pathology reporting. When adding the stroma-parameter to the ASCO criteria, the rate of 'undertreated' patients dropped from 5.9% to 4.3%, the 'overtreated' increased with 6.8% but the correctly classified increased with an additional 14%.

Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction

Abstract: BACKGROUND:: Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. METHODS:: This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. RESULTS:: Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76·6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8·55, 95 per cent confidence interval 1·47 to 49·72; P = 0·017). The in-hospital mortality rate was 29·7 per cent. Age (OR 1·21, 1·02 to 1·43; P = 0·027) and failure of fascial closure (OR 44·50, 1·13 to 1748·52; P = 0·043) were independently associated with in-hospital mortality. CONCLUSION:: The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. (Less)

Pathogenesis of postoperative adhesion formation

Abstract: Background: Current views on the pathogenesis of adhesion formation are based on the "classical concept of adhesion formation", namely that a reduction in peritoneal fibrinolytic activity following peritoneal trauma is of key importance in adhesion development. Methods: A non-systematic literature search (1960-2010) was performed in PubMed to identify all original articles on the pathogenesis of adhesion formation. Information was sought on the role of the fibrinolytic, coagulatory and inflammatory systems in the disease process. Results: One unifying concept emerged when assessing 50 years of studies in animals and humans on the pathogenesis of adhesion formation. Peritoneal damage inflicted by surgical trauma or other insults evokes an inflammatory response, thereby promoting procoagulatory and antifibrinolytic reactions, and a subsequent significant increase in fibrin formation. Importantly, peritoneal inflammatory status seems a crucial factor in determining the duration and extent of the imbalance between fibrin formation and fibrin dissolution, and therefore in the persistence of fibrin deposits, determining whether or not adhesions develop. Conclusion: Suppression of inflammation, manipulation of coagulation as well as direct augmentation of fibrinolytic activity may be promising antiadhesion treatment strategies. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy.

Abstract: Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes.

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders.

Abstract: Background: The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions. Methods: This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding. Results: Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12–75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003). Conclusion: Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Prediction, prevention and management of postresection liver failure

Abstract: Background: Postresection liver failure (PLF) is the major cause of death following liver resection However, there is no unified definition, the pathophysiology is understood poorly and there are few controlled trials to optimize its management The aim of this review article is to present strategies to predict, prevent and manage PLF Methods: The Web of Science, MEDLINE, PubMed, Google Scholar and Cochrane Library databases were searched for studies using the terms ‘liver resection’, ‘partial hepatectomy’, ‘liver dysfunction’ and ‘liver failure’ for relevant studies from the 15 years preceding May 2011 Key papers published more than 15 years ago were included if more recent data were not available Papers published in languages other than English were excluded Results: The incidence of PLF ranges from 0 to 13 per cent The absence of a unified definition prevents direct comparison between studies The major risk factors are the extent of resection and the presence of underlying parenchymal disease Small-for-size syndrome, sepsis and ischaemia–reperfusion injury are key mechanisms in the pathophysiology of PLF Jaundice is the most sensitive predictor of outcome An evidence-based approach to the prevention and management of PLF is presented Conclusion: PLF is the major cause of morbidity and mortality after liver resection There is a need for a unified definition and improved strategies to treat it Copyright © 2011 British Journal of Surgery Society Ltd Published by John Wiley & Sons, Ltd

Meta-analysis of neoadjuvant treatment modalities and definitive non-surgical therapy for oesophageal squamous cell cancer

Abstract: Background: The standard treatment for resectable oesophageal squamous cell carcinoma (OSCC) is surgical resection with adequate lymphadenectomy. Most Western patients receive neoadjuvant chemotherapy or chemoradiotherapy (CRT). In recent years some patients have received CRT alone (definitive CRT, dCRT). This meta-analysis sought to clarify the benefits of neoadjuvant and definitive treatment for OSCC. Methods: Eligible randomized controlled trials (RCTs) were identified using the Cochrane database, MEDLINE and Embase. Only RCTs with intention-to-treat analysis, and published hazard ratios (HRs) or estimates from survival data, were included. Results: Nine RCTs involving neoadjuvant CRT versus surgery, eight involving neoadjuvant chemotherapy versus surgery, and three involving neoadjuvant treatment followed by surgery or surgery alone versus dCRT were identified. The HR for overall survival was 0·81 (95 per cent confidence interval 0·70 to 0·95; P = 0·008) after neoadjuvant CRT and 0·93 (0·81 to 1·08; P = 0·368) after neoadjuvant chemotherapy. The likelihood of R0 resection was significantly higher after neoadjuvant treatment (CRT: HR 1·15, P = 0·043; chemotherapy: HR 1·16, P = 0·006). Morbidity rates were not increased after neoadjuvant CRT (HR 0·94, P = 0·363) but 30-day mortality was non-significantly higher with combined treatment. Morbidity (HR 1·03, P = 0·638) and mortality (HR 1·04, P = 0·810) rates after neoadjuvant chemotherapy and surgery did not differ from those after surgery alone. None of the RCTs reporting outcome after dCRT demonstrated a significant survival benefit, but treatment-related mortality rates were lower (HR 7·60, P = 0·007) than with neoadjuvant treatment followed by surgery or surgery alone. Conclusion: For patients with resectable OSCC, a significant survival benefit for neoadjuvant CRT was evident, with no increase in morbidity rate. dCRT did not demonstrate any survival benefit over other curative strategies. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Abstract: Background: Endovenous laser ablation (EVLA) is a popular minimally invasive treatment for varicose veins. Surgical treatment, featuring junctional ligation and inversion stripping, has shown excellent clinical and cost effectiveness. The clinical effectiveness of both treatments was compared within a randomized trial. Methods: Some 280 patients were randomized equally into groups receiving either surgery or EVLA. Participants had primary, symptomatic, unilateral venous insufficiency, with isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein. Outcomes included: quality of life (QoL), Venous Clinical Severity Score (VCSS), pain scores and time taken to return to normal function. Owing to the nature of the procedures, blinding was not possible. Results: Both groups had significant improvements in VCSS after treatment (P < 0·001), which resulted in improved disease-specific QoL (Aberdeen Varicose Vein Questionnaire, P < 0·001) and qualityadjusted life year (QALY) gain (P < 0·001). The pain and disability following surgery impaired normal function, with a significant decline in five of eight Short Form 36 (SF-36  ) domains (P < 0·001 to P = 0·029). Periprocedural QoL was relatively preserved following EVLA, leading to a significant difference between the two treatments in pain scores (P < 0·001), six of eight SF-36

One millimetre is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer.

Abstract: Background: A pathologically involved margin in rectal cancer is defined as tumour within 1 mm of the surgical resection margin. There is no standard definition of a predicted safe margin on magnetic resonance imaging (MRI). The aim of this study was to assess which cut-off (1, 2 or 5 mm) was the best predictor of local recurrence based on preoperative MRI assessment of the circumferential resection margin (CRM). Methods: Data were collected prospectively on the distance between the tumour and mesorectal fascia for patients with documented radiological margin status in the MERCURY study. Positive margin and local recurrence rates were compared for MRI distances from the tumour to the mesorectal fascia of 1 mm or less, more than 1 mm up to 2 mm, more than 2 mm up to 5 mm, and more than 5 mm. The Cox proportional hazard regression method was used to determine the effect of level of margin involvement on time to local recurrence. Results: Univariable analysis showed that, relative to a distance measured by MRI of more than 5 mm, the hazard ratio (HR) for local recurrence was 3·90 (95 per cent confidence interval 1·99 to 7·63; P < 0·001) for a margin of 1 mm or less, 0·81 (0·36 to 1·85; P = 0·620) for a margin of more than 1 mm up to 2 mm, and 0·33 (0·10 to 1·08; P = 0·067) for a margin greater than 2 mm up to 5 mm. Multivariable analysis of the effect of MRI distance to the mesorectal fascia and preoperative treatment on local recurrence showed that a margin of 1 mm or less remained significant regardless of preoperative treatment (HR 3·72, 1·43 to 9·71; P = 0·007). Conclusion: For preoperative staging of rectal cancer, the best cut-off distance for predicting CRM involvement using MRI is 1 mm. Using a cut-off greater than this does not appear to identify patients at higher risk of local recurrence. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Trauma alarmins as activators of damage‐induced inflammation

Abstract: Background: A systemic inflammatory response syndrome (SIRS) is frequently observed after traumatic injury. The response is sterile and the activating stimulus is tissue damage. Endogenous molecules, called alarmins, are reputed to be released by injured tissues but the precise identity of these mediators is unclear. This review summarizes current preclinical and clinical evidence for trauma alarmins and their role in innate immune activation. Methods: A comprehensive literature review of putative alarmins in tissue damage after traumatic injury was conducted. Results: The presence of SIRS at admission is an independent predictor of mortality after trauma. The primary initiators of the human immune response are unclear. Several endogenous substances display alarmin characteristics in vitro. Preclinical studies demonstrate that blockade of certain endogenous substances can reduce adverse clinical sequelae after traumatic injury. Human evidence for trauma alarmins is extremely limited. Conclusion: The magnitude of acute inflammation is predictive of outcome after trauma, suggesting that an early opportunity for immune modulation may exist. An understanding of the mechanisms of innate immune activation following trauma may lead to new therapeutic agents and improved patient survival. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Increase in future remnant liver function after preoperative portal vein embolization

Abstract: Background: Preoperative portal vein embolization (PVE) is performed in patients with insufficient future remnant liver (FRL) to allow safe resection. Although many studies have demonstrated an increase in FRL volume after PVE, little is known about the increase in FRL function. This study evaluated the increase in FRL function after PVE using 99mTc-labelled mebrofenin hepatobiliary scintigraphy (HBS) with single photon emission computed tomography (SPECT) and compared this with the increase in FRL volume. Methods: In 24 patients, computed tomography volumetry and 99mTc-labelled mebrofenin HBS with SPECT were performed before and 3–4 weeks after PVE to measure FRL volume, standardized FRL and FRL function. A hypothetical model was used to assess safe resectability after PVE. The limit for safe resection for FRL function was set at an uptake of 2·69 per cent per min per m2. For FRL volume and standardized FRL, 25 or 40 per cent of total liver volume was used, depending on the presence of underlying liver disease. Results: After PVE, FRL function increased significantly more than FRL volume. The correlation between the increase in FRL volume and FRL function was poor. Using the hypothetical model, seven patients did not achieve a sufficient increase in FRL function to allow safe resection 3–4 weeks after PVE, compared with 12 and nine patients based on FRL volume and standardized FRL respectively. Conclusion: The increase in FRL function after PVE is more pronounced than the increase in FRL volume, suggesting that the necessary waiting time until resection may be shorter than indicated by volumetric parameters. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Improving outcome for patients with pancreatic cancer through centralization.

Abstract: Background: High-volume institutions are associated with improved clinical outcomes for pancreatic cancer. This study investigated the impact of centralizing pancreatic cancer surgery in the south of the Netherlands. Methods: All patients diagnosed in the Eindhoven Cancer Registry area in 1995–2000 (precentralization) and 2005–2008 (implementation of centralization agreements) with primary cancer of the pancreatic head, extrahepatic bile ducts, ampulla of Vater or duodenum were included. Resection rates, in-hospital mortality, 2-year survival and changes in treatment patterns were analysed. Multivariable regression analyses were used to identify independent risk factors for death. Results: Some 2129 patients were identified. Resection rates increased from 19·0 to 30·0 per cent (P < 0·001). The number of hospitals performing resections decreased from eight to three, and the annual number of resections per hospital increased from two to 16. The in-hospital mortality rate dropped from 24·4 to 3·6 per cent (P < 0·001) and was zero in 2008. The 2-year survival rate after surgery increased from 38·1 to 49·4 per cent (P = 0·001), and the rate irrespective of treatment increased from 10·3 to 16·0 per cent (P < 0·001). There was no improvement in 2-year survival in non-operated patients. After adjustment for relevant patient and tumour factors, those undergoing surgery more recently had a lower risk of death (hazard ratio 0·70, 95 per cent confidence interval 0·51 to 0·97). Changes in surgical patterns seemed largely to explain the improvements. Conclusion: High-quality care can be achieved in regional hospitals through collaboration. Centralization should no longer be regarded as a threat by general hospitals but as a chance to improve outcomes in pancreatic cancer. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Interventions to improve teamwork and communications among healthcare staff.

Abstract: Background: Concern over the frequency of unintended harm to patients has focused attention on the importance of teamwork and communication in avoiding errors. This has led to experiments with teamwork training programmes for clinical staff, mostly based on aviation models. These are widely assumed to be effective in improving patient safety, but the extent to which this assumption is justified by evidence remains unclear. Methods: A systematic literature review on the effects of teamwork training for clinical staff was performed. Information was sought on outcomes including staff attitudes, teamwork skills, technical performance, efficiency and clinical outcomes. Results: Of 1036 relevant abstracts identified, 14 articles were analysed in detail: four randomized trials and ten non-randomized studies. Overall study quality was poor, with particular problems over blinding, subjective measures and Hawthorne effects. Few studies reported on every outcome category. Most reported improved staff attitudes, and six of eight reported significantly better teamwork after training. Five of eight studies reported improved technical performance, improved efficiency or reduced errors. Three studies reported evidence of clinical benefit, but this was modest or of borderline significance in each case. Studies with a stronger intervention were more likely to report benefits than those providing less training. None of the randomized trials found evidence of technical or clinical benefit. Conclusion: The evidence for technical or clinical benefit from teamwork training in medicine is weak. There is some evidence of benefit from studies with more intensive training programmes, but better quality research and cost-benefit analysis are needed.

Long-term functional results and quality of life after transanal endoscopic microsurgery

Abstract: Background: Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer. Methods: Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry. Results: Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM. Conclusion: TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation

Abstract: Background: Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU. Methods: This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls. Results: The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38). Conclusion: The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment. Registration number: NCT00624169 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Systematic review and meta‐analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair

Abstract: Background: The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair. Methods: Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. Results: Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81). Conclusion: The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Comparison of open and laparoscopic live donor left lateral sectionectomy

Abstract: Background: The present study was undertaken to determine whether laparoscopic live donor left lateral sectionectomy (LLS) in paediatric liver transplantation is a feasible, safe and reproducible procedure, compared with open live donor left lateral sectionectomy (OLS). Methods: A retrospective review was conducted of all consecutive live donor procedures for paediatric liver transplantation performed between May 2008 and October 2009. All live donor hepatectomies were carried out by a single surgeon. Results: A total of 26 live donor procedures for paediatric liver transplantation were performed, of which 11 were LLS and 11 OLS; four left hepatectomies were excluded. The LLS group had a significantly shorter hospital stay (mean(s.d.) 6·9(0·3) versus 9·8(0·9) days; P = 0·001) and time to oral diet (2·1(0·3) versus 2·7(0·4) days; P = 0·012). Duration of operation, blood loss, warm ischaemia time and out-of-pocket medical costs were comparable between groups. There was no death in either donor group and only one complication, a wound seroma, in the OLS group. Conclusion: LLS seemed to be a safe, feasible and reproducible procedure, and was associated with reduced hospital stay. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Prospective observational study to evaluate NOTSS (Non‐Technical Skills for Surgeons) for assessing trainees' non‐technical performance in the operating theatre

Abstract: Background: Most surgical assessment has been aimed at technical proficiency. However, non-technical skills also affect patient safety and clinical effectiveness. The NOTSS (Non-Technical Skills for Surgeons) assessment instrument was developed specifically to assess the non-technical skills of individual surgeons in the operating theatre. This study evaluated NOTSS as a real-world assessment, with a mix of minimally trained assessors. The evaluation criteria were feasibility, validity and psychometric reliability. Methods: In a standard evaluation of NOTSS, 56 anaesthetists, 39 scrub nurses, two surgical care practitioners and three independent assessors provided 715 assessments of 404 surgical cases of 15 index procedures across six specialties performed by 85 surgical trainees. Results: The assessment was feasible, but important implementation challenges were highlighted. Most respondents considered the method valid, but with reservations about assessing cognition. The factor structure of scores, and their positive relationships with other measures of experience and performance, supported validity. Trainees' non-technical skill scores were relatively procedure-independent and achieved good reliability (generalizability coefficient 0·8 or more) when six to eight assessors observed one case each. Conclusion: Minimally trained assessors, who are typically present in operating theatres, were sufficiently discriminating and consistent in their judgements of trainee surgeons' non-technical skills to provide reliable scores based on an achievable number of observations. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Reproducibility of ultrasound measurement of the abdominal aorta

Abstract: Background: Abdominal aortic aneurysm (AAA) screening and surveillance programmes use ultrasound imaging to measure the anteroposterior (AP) diameter of the infrarenal aorta. The aim of this study was to examine potential observer bias and variability in ultrasound measurements. Methods: Studies were identified for review via a MEDLINE database search (1966–2009). References supplied in accessed papers were also checked for potential relevance. Consistent search terminology, and inclusion and exclusion criteria were used to ensure quality of data. Nine papers were available to review. Results: Variation in intraobserver repeatability and interobserver reproducibility was identified. Six studies reported intraobserver repeatability coefficients for AP aortic diameter measurements of 1·6–4·4 mm. These were below the 5-mm level regarded as acceptable by the UK and USA AAA screening programmes. Five studies had interobserver reproducibility below the level of 5 mm. Four studies, however, reported poor reproducibility (range from − 2 to + 5·2 to − 10·5 to + 10·4); these differences may have had a significant clinical impact on screening and surveillance. Conclusion: The studies used different methodologies with no standardized measurement techniques. Measurements were taken by observers from different medical disciplines of varying grade and levels of training. Standard training and formal quality assurance of ultrasound measurements are important components of an effective AAA screening programme. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Management of late postoperative complications of bariatric surgery.

Abstract: Background: The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon. Methods: A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included. Results: The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention. Conclusion: The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Two-stage hepatectomy for multiple bilobar colorectal liver metastases

Abstract: Background: As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long-term outcome, safety and efficacy of two-stage hepatectomy (TSH) for CLM in a large cohort of patients. Methods: Patients undergoing surgery between December 1996 and December 2009 were reviewed. The early postoperative and long-term outcomes as well as the patterns of failure to complete TSH and its clinical implications were analysed. Results: Eighty patients were scheduled to undergo TSH. Sixty-one patients had completion of TSH combined with (58 patients), or without (3) portal vein embolization/ligation (PVE/PVL). Five patients were excluded after first-stage hepatectomy and 14 after PVE/PVL. The 5-year overall survival rate and median survival in patients who completed TSH were 32 per cent and 39·6 months respectively, and corresponding recurrence-free values were 11 per cent and 9·4 months respectively. Six patients were alive beyond 5 years after TSH. Multivariable logistic regression analysis showed that failure to complete TSH was driven by two independent prognostic scenarios: three or more CLM in the future remnant liver (FRL) combined with age over 70 years predicted tumour progression after first-stage hepatectomy, and three or more CLM in the FRL combined with carcinomatosis at the time of first-stage hepatectomy predicted the development of additional FRL metastases after PVE/PVL. Conclusion: A therapeutic strategy using TSH provided acceptable long-term survival with no postoperative mortality. Further efforts are needed to increase the number of patients who undergo TSH successfully.

Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease.

Abstract: Background: The aim was to compare percutaneous transluminal angioplasty (PTA), a supervised exercise programme (SEP) and combined treatment (PTA plus SEP) for intermittent claudication due to femoropopliteal arterial disease. Methods: Consenting patients with femoropopliteal arterial lesions were randomized to one of three treatment arms: PTA, SEP, or PTA plus SEP. All patients received optimal medical treatment. Patients were assessed at baseline and 1, 3, 6 and 12 months after intervention. Clinical (ankle pressures, walking distances, symptoms) and quality-of-life (QoL) outcomes (Short Form 36, VascuQol) were analysed. Results: A total of 178 patients (108 men, median age 70 years) were included. All three treatment groups demonstrated significant clinical and QoL improvements. One year after PTA (60 patients, 8 withdrew), 37 patients (71 per cent) had improved (16 mild, 16 moderate, 5 marked), nine (17 per cent) showed no improvement and six (12 per cent) had deteriorated. After SEP (60 patients, 14 withdrew), 32 patients (70 per cent) had improved (19 mild, 10 moderate, 3 marked), six (13 per cent) showed no improvement and eight (17 per cent) had deteriorated. After PTA plus SEP (58 patients, 11 withdrew), 40 patients (85 per cent) had improved (18 mild, 20 moderate, 2 marked), seven (15 per cent) showed no improvement and none had deteriorated. On intergroup analysis, PTA and SEP alone were equally effective in improving clinical outcomes, although the effect was short-lived. PTA plus SEP produced a more sustained clinical improvement, but there was no significant QoL advantage. Conclusion: For patients with intermittent claudication due to femoropopliteal disease, PTA, SEP, and PTA plus SEP were all equally effective in improving walking distance and QoL after 12 months. Registration number: NCT00798850 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Abstract: Background: This report describes the clinical effectiveness and recurrence rates from a randomized trial of endovenous laser ablation (EVLA) and surgery for varicose veins. Methods: Some 280 patients were randomized equally using sealed opaque envelopes to two parallel groups: surgery and EVLA. Inclusion criteria included symptomatic disease secondary to primary, unilateral, isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Outcomes were: technical success, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life, assessed by the Aberdeen Varicose Vein Questionnaire (AVVQ). Assessments were at 1, 6, 12 and 52 weeks after the procedure. Results: Initial technical success was greater following EVLA: 99·3 versus 92·4 per cent (P = 0·005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4·0 versus 20·4 per cent (P < 0·001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6·3 (95 per cent confidence interval 4·0 to 12·5). Twelve of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularization. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalization. Clinical recurrence was associated with worse AVVQ scores (P < 0·001). Conclusion: EVLA treatment had lower rates of clinical recurrence than conventional surgery in the short term. Registration number: NCT00759434 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Bile duct injury and use of cholangiography during laparoscopic cholecystectomy

Abstract: Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC).

Author's reply: Randomized clinical trial of laparoscopic versus open left colonic resection

Abstract: The main aim of this study was to compare short‐term results and long‐term outcomes of patients undergoing laparoscopic versus open left colonic resection.

Indicators of the quality of trauma care and the performance of trauma systems

Abstract: Background: Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability. Methods: Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed. Results: Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services. Conclusion: A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.