Surgery

Emotional Resilience and Bariatric Surgical Teams: a Priority in the Pandemic (2021)

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Type of publication:
Journal article

Author(s):
Graham, Yitka; Mahawar, Kamal; *Riera, Manel; Islam, Omar; Bhasker, Aparna Ghovil; Wilson, Michael; Tahrani, Abd; Moize, Violeta; Leal, Angela; Hayes, Catherine

Citation:
Obesity Surgery; Apr 2021; vol. 31 (no. 4); p. 1887-1890

Abstract:
The infection control measures implemented as a result of COVID-19 led to a postponement of bariatric surgical procedures across many countries worldwide. Many bariatric surgical teams were in essence left without a profession, with many redeployed to other areas of clinical care and were not able to provide the levels of patient support given before COVID-19. As the pandemic continues, some restrictions have been lifted, with staff adjusting to new ways of working, incorporating challenging working conditions and dealing with continuing levels of stress. This article explores the concept of emotional labour, defined as 'inducing or suppressing feelings in order to perform one's work', and its application to multidisciplinary teams working within bariatric surgery, to offer insight into the mental health issues that may be affecting healthcare professionals working in this discipline.

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Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: A randomised controlled trial (2020)

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Type of publication:
Conference abstract

Author(s):
Grossi U.; McAlees E.; Knowles C.H.; Stevens N.; Di Tanna G.L.; Marlin N.; *Lacy-Colson J.; Brown S.; Scott S.M.; Norton C.; Mason J.

Citation:
Techniques in Coloproctology; 2020; vol. 24 (no. 4); p. 373-374

Abstract:
Background: Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence.
Methods: An individual level, stepped-wedge randomised trial has been designed to allow observer blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) preoperative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates.
Results: An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. Conclusions: In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks).

Three-dimensional versus two-dimensional imaging during laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials (2020)

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Type of publication:
Systematic Review

Author(s):
*Davies S.; Ghallab M.; Hajibandeh S.; Hajibandeh S.; Addison S.

Citation:
Langenbeck's Archives of Surgery; Aug 2020; vol. 405 (no. 5); p. 563-572

Abstract:
Objectives: To evaluate the comparative outcomes of three-dimensional (3D) versus two-dimensional (2D) imaging during laparoscopic cholecystectomy.
Method(s): We conducted a systematic search of electronic information sources and bibliographic reference lists and applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Procedure time, Calot's triangle dissection time, gallbladder removal time, gallbladder perforation, intraoperative bleeding, postoperative complications, conversion to open and intraoperative errors were the evaluated outcome parameters.
Result(s): We identified 6 randomised controlled trials (RCT) reporting a total of 577 patients who underwent laparoscopic cholecystectomy using 3D (n = 282) or 2D (n = 295) imaging. The 3D imaging was associated with significantly shorter procedure time (MD – 4.23, 95% CI – 8.14 to – 0.32, p = 0.03), Calot's triangle dissection time (MD – 4.19, 95% CI – 6.52 to – 1.86, p = 0.0004) and significantly lower risk of gallbladder perforation (RR 0.50, 95% CI 0.28-0.88, p = 0.02) compared to the 2D approach. No significant difference was found in gallbladder removal time (MD – 0.79, 95% CI – 2.24 to 0.66, p = 0.28), intraoperative bleeding (RR 1.14, 95% CI 0.68-1.90, p = 0.61), postoperative complications (RD – 0.01, 95% CI – 0.06 to 0.05, p = 0.85), conversion to open (RD 0.00, 95% CI – 0.02 to 0.03, p = 0.70) or intraoperative errors (RR 0.96, 95% CI 0.79-1.17, p = 0.70) between the two groups.
Conclusion(s): Although our findings suggest that the use of 3D imaging during laparoscopic cholecystectomy may be associated with significantly shorter procedure time, Calot's triangle dissection time and gallbladder injury compared to the 2D imaging, the differences seem to be clinically insignificant. Moreover, both approaches carry s similar risk of postoperative morbidities. The impact of the surgeon's level of experience and difficulty of the procedure on the outcomes of each imaging modality remains unknown.

Duplication of the Gallbladder and its Surgical Challenges (2019)

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Type of publication:
Conference abstract

Author(s):
*Tamvakeras P.; *Riera M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S6; p. 28

Abstract:
Aims: Duplication of the gallbladder is a rare congenital anomaly. However, awareness of this anatomical variation is crucial when treating gallstone disease. We present the case of a patient with two gallbladders, incidentally found during laparoscopic cholecystectomy. We review the literature and discuss the associated surgical challenges.
Methods: Case presentation and literature review of the classification, clinical presentation, radiological diagnosis and management of gallbladder duplication.
Results: A 37 year old healthy man presented with a two year history of post prandial right upper quadrant abdominal pain. Routine blood investigations were normal and ultrasonography (US) demonstrated gallstones with normal biliary ducts. During laparoscopy he was found to have gallbladder duplication with a Y-shaped type cystic duct, this consisted of two ducts joining together to form a main cystic duct which drained into an otherwise normal common bile duct. No cholangiogram was performed. After meticulous dissection and demonstration of the anatomy, the cholecystectomy was performed. The patient recovered uneventfully and was discharged the next day. Histology showed gallstones and chronic inflammation in both
gallbladders.
Conclusions: A duplicate gallbladder is a rare congenital variation. Preoperative diagnosis can be challenging. Understanding its classification based on the relational anatomy to the biliary tree is essential to avoid biliary injuries. Imaging modalities such as US and computed tomography (CT) may not be sensitive enough. MRCP may demonstrate the biliary tree more clearly. Laparoscopic cholecystectomy can be safely performed, in the presence of symptomatic gallstone disease.

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Does perioperative use of tranexamic acid in hip fracture patients increase the risk of venous thromboembolism and reduce the need for postoperative transfusions? (2020)

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Type of publication:
Journal article

Author(s):
Geddes J.; *McConaghie G.

Citation:
Journal of Perioperative Practice; 2020 Dec;30(12):378-382

Abstract:
Perioperative tranexamic acid use is a popular choice among many surgeons for reducing surgical blood loss and its sequelae. While there is evidence in the literature that tranexamic acid use is effective in reducing blood loss in surgery for patients with hip fractures, there is less information on whether it leads to thromboembolic complications. We undertook a retrospective study in patients with hip fractures at two local hospitals to investigate if there was an increased risk of venous thromboembolism in patients who received tranexamic acid, and whether it reduced perioperative blood loss and the need for transfusion. We found that tranexamic acid used in patients undergoing hip fracture surgery reduced the drop in postoperative haemoglobin and the need for postoperative blood transfusion but was not associated with an increased risk of venous thromboembolism.

Cancelled! Cancelled! An audit on cancellation of paediatric surgical cases on the day of surgery in a district general hospital (2019)

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Type of publication:
Conference abstract

Author(s):
Singh M.; *Annadurai S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 90

Abstract:
Surgical case cancellation has significant impacts on operating theatre efficiency and the UK loses a substantial amount of money on these cases [1]. A recent prospective study over a 1-week period in an NHS hospital suggested a adult surgical case cancellation rate between 10% and 14% and the majority of these cases were due to non-clinical reasons [2]. It is distressing for the patient and affects outcomes. We undertook an audit regarding cancellation of paediatric surgical cases on the day of surgery at a district general hospital (DGH) to look for various reasons for the cancellations and to evaluate the services. Methods We collected prospective data from the hospital's database regarding cancelled paediatric surgical procedures over a 6-month period from February 2018 to July 2018 in our DGH. Results We found that a total of 70 paediatric surgical cases were cancelled on the day of surgery out of total of 653 paediatric surgical cases, which is an approximately 10% cancellation rate over the 6-month period with a range of cancellations from 7% in May and June to 18% in February. We observed that 76% of the cancellations were of elective cases. We subdivided the reasons for cancellations into organisational, patient, surgical and anaesthetic factors. Among the organisational factors, 23% of cancellations were due to 'unavailable beds'. We observed that 11% of cancellations occurred because patients 'did not attend', 7% of patients were reported as 'sick' and 3% of patients did not follow preoperative fasting instructions. Surgeons cancelled 15% of cases for the reason 'procedure no longer required', whereas anaesthetist 'sickness' was the reason for cancellation in 9% of cases. Discussion Cancellations prolong the waiting list and worsens patient experiences and clinical outcomes. In our audit, we found that the main reasons for cancellations were non-clinical. To improve the surgical reasons for cancellation, we suggest timely rereview of the need for surgery. Although staff allocation is looked at regularly, some cases were cancelled due to the unavailability of staff, which can be improved on. We discussed the idea of seasonal planning of cases. We plan to re-audit with the aim of investigating cancellation rates in elective cases over a 1-year period to also review the cancellation rate during the winter months.

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Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis (2019)

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Type of publication:
Systematic Review

Author(s):
*Padmanabhan, Hari; Siau, Keith; *Curtis, Jason; Ng, Alex; Menon, Shyam; Luckraz, Heyman; Brookes, Matthew J

Citation:
The Annals of Thoracic Surgery. Dec 2019; vol. 108 (no. 6); p. 1840-1848

Abstract:
BACKGROUND Pre-operative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes following cardiac surgery.METHODS A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and non-anemic patients. RESULTS Out of 1103 studies screened, 22 met the inclusion criteria. A total of 23624 (20.6%) out of 114277 patients were anemic. Anemia was associated with increased mortality (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.32-3.24; I2=69.6%; p<0?001), AKI (OR 3.13, 95% CI 2.37-4.12; I2=71.1%; p<0?001), stroke (OR 1.46, 95% CI 1.24-1.72; I2=21.6%; p<0?001), and infection (OR 2.65, 95% CI 1.98-3.55; I2=46.7%; p<0?001). More anemic patients were transfused than non-anemic (33.3 versus 11.9%). No statistically significant association was found between mortality and blood transfusion (OR 1.35, 95% CI 0.92-1.98; I2=83.7%; p=0.12) but we were not able to compare mortality with or without transfusion in those who were or were not anemic. CONCLUSIONS Preoperative anemia is associated with adverse outcomes following cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models, and as a target for risk modification.

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Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals (2018)

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Type of publication:
Journal article

Author(s):
Wong, D.J.N.; Harris, S.K.; Moonesinghe, S.R

Collaborators at Shrewsbury and Telford Hospital NHS Trust:
*Jane Wright, *Paul Jones, *Riquella Abbott, *Lisa Bacon, *Christopher Godden, *David Howe, *Angela Loughlin, *Helen Moore, *Samuel Passey, *Rebekah Rodgers

Citation:
BJA: The British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 730-738

Abstract:
Background: Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity.Results: We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12-4.02; P<0.001] and the presence of an emergency department in the treating hospital (OR=4.18; 95% CI, 2.22-7.89; P<0.001). Patients undergoing cancer surgery (OR=0.32; 95% CI, 0.22-0.46; P<0.001), obstetric procedures (OR=0.17; 95% CI, 0.08-0.32; P<0.001), and expedited surgery (OR=0.39; 95% CI, 0.27-0.56; P<0.001) were less likely to be cancelled.Conclusions: A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

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