Recent Submissions

  • Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

    Watson, Nicholas; Gercek, Yuksel; Guy, Kramer; Holden, Douglas; Whysall, Karen (BJS, 2019-01)
    Background: The Clavien-Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien-Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods: This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien-Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results: A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien-Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion: Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.
  • Turning 'waiting lists' for elective surgery into 'preparation lists'

    Selwyn, David (2021-01)
    Waiting lists for surgery are an integral part of the UK National Health Service (NHS); they are used as a construct to ration surgery and to reduce costs, whilst simultaneously attempting to distribute limited health resources in an equitable manner. 1 They are a feature of health services that have central funding, financed mainly through general taxation, and are present in several other European countries including Italy, Greece, and Spain, where there is a need to manage the dynamics of capacity and demand. Waiting lists are rarer in countries that rely on private healthcare provision (including insurance) or rely on funding through social security (e.g. USA, Austria, Germany, and France). 2 Nevertheless, independent of the healthcare system, there is an inevitable period of time between diagnosis of an illness that may be amenable to surgery and admission for elective surgery. It is now acknowledged that this time can be better spent in preparing patients for surgery in order to improve the patients' experience of healthcare (including quality outcomes and satisfaction), improve population/public health, and reduce the per capita costs of healthcare.
  • A safe method to evacuate pneumoperitoneum during laparoscopic surgery in suspected COVID-19 patients.

    Hanbali, N.; Herrod, Philip; Patterson, Jane (, 2020-05)
    The COVID-19 pandemic has introduced new challenges to surgery and protection of staff in the operating theatre. Aerosol and surface viability of the virus has been shown to last at least hours, with viability lasting days on certain surfaces.[ 1] Uncontrolled evacuation of pneumoperitoneum during laparoscopy may pose an increased risk to staff and other patients. This has led to recent intercollegiate guidance advising against the use of laparoscopy unless there is a clear mortality benefit from laparoscopy over open surgery.[ 2] Several solutions have been proposed including gas filters, traps, or careful deflation.[ 2],[ 3] Here, we offer a more efficient method.
  • What is CPOC and why now?

    Selwyn, David (2019-12)
    Clearly almost all organisations and healthcare systems are under pressure and something needs to change. For this reason, in May this year, the Centre for Perioperative Care (CPOC) was created and hosted by the Royal College of Anaesthetists (RCoA). This is a joint venture with the Royal College of Physicians (RCP), the Royal College of Surgeons of England, the Royal College of Nursing, the Royal College of General Practitioners and the Association of Anaesthetists, with a mandate to deliver transformation change across our surgical pathways. I am incredibly proud to have been appointed as CPOC’s inaugural director and believe working together, across our different specialties, we can make real improvements for our patients on their surgical journey and for ourselves in our organisation of traditional surgical pathways.
  • An assessment of ultrasound guided foam sclerotherapy (UGFS) using the Aberdeen Varicose Vein Questionnaire (AVVQ).

    Makhdoomi, Khalid R (2013-10)
    Aims: The effectiveness of ultrasound guided foam sclerotherapy (UGFS) on health-related quality of life (HRQL) in varicose vein treatment is unknown. We evaluated this using the Aberdeen Varicose Vein Questionnaire (AVVQ). Methods: 146 patients with venous disease of clinical severity class 1-6 completed the AVVQ prior to and 6-weeks after UGFS. Paired t-test analysis was performed. Results: Following UGFS there was a significant improvement in HRQL, assessed by AVVQ scoring: mean 20.1 ± SD 11.5 versus 15.3 ± SD 12.1 (p< 0.02). Improvements in pain in the right leg (0.58 vs. 0.31, p< 0.02) and left leg (0.64 vs. 0.4, p=0.007) and ability to perform daily activities (0.7 vs. 0.4, p<0.0001) were evident postoperatively. There was a significant reduction in pruritis bilaterally: right leg (1.3 vs. 0.5, p< 0.0001); left leg (1.0 vs. 0.6, p<0.008). Treatment led to a reduced concern over cosmetic appearance (2.88 vs. 1.91, p=0.0002) and choice of clothing (2.13 vs. 1.91, p=0.02). A significant reduction of analgesic usage, ankle swelling or stocking use was not demonstrated. Conclusion: UGFS is associated with significant improved functional performance and HRQL. A randomised control trial is indicated to compare the long-term clinical outcomes of UGFS with conventional techniques.
  • Preoperative fasting: a clinical audit.

    Roberts, Stuart (2013-01)
    This clinical audit examines the adherence to guidelines suggested by the Royal College of Nursing (2005); the results uphold previous studies of a preoperative starving period for patients undergoing elective surgical procedures. Patients excessively starved of food or fluids report problems relating to their health. These include hunger, distress and complaints of nausea.
  • Use of a venting PEG tube in the management of recurrent acute gastric dilatation associated with Prader-Willi syndrome

    Mohammed, Ahmed M.A. (2016-01)
    A patient with Prader-Willi Syndrome was admitted to the ICU with features of recurrent acute gastric dilatation, aspiration pneumonia and a massive pulmonary embolus. He was initially managed with intubation, assisted ventilation, intravenous fluids and anticoagulation. Decompression of the stomach was achieved with a nasogastric tube. After ventilator weaning, he did not tolerate the nasogastric intubation that led to a further episode of aspiration pneumonia as a result of non-resolving gastric dilatation. He required readmission to intensive care for a further period of ventilatory support. While the patient was sedated and ventilated, a venting percutaneous endoscopic gastrostomy (PEG) with a jejunal feeding extension was placed, permitting both continued decompression of the stomach and enteral feeding. The patient tolerated the PEG-J well and his nutritional needs were successfully addressed. Oral intake was slowly re-established with ongoing decompression of the stomach with the PEG. He was discharged from hospital with the PEG in place.
  • Spontaneous rupture of the spleen as a result of primary splenic lymphoma

    Mohammed, Ahmed M.A.; Majid, Zulqarnain I.; Villatoro, Eduardo A. (2016-01)
    Spontaneous rupture of the spleen is a true surgical emergency that requires immediate management to prevent rapid exsanguination. It occurs mostly as a result of splenic infiltration by infectious or haematological diseases. We present a case of a 79-year-old male who was admitted to our emergency department with 3 days history of feeling unwell, abdominal pain, and dizziness, with no history of trauma. He was hypotensive, but all other observations were within normal limits. Examination revealed abdominal tenderness, mainly on the left side, with no palpable organs or masses. Computed tomography scan showed an abnormal spleen with signs of intraabdominal bleeding; emergency splenectomy was performed successfully. Histological examination showed infiltration of the spleen by diffuse large B cell lymphoma, which was later confirmed to be primary. The patient went through an uneventful post-operative recovery, and remains disease free so far.
  • Small bowel obstruction 5 years following the ingestion of serrated scissors

    Limb, Richard; Karam, Edward (2016-05)
    Ingested foreign bodies are common in the cohort of psychiatric patients, however clinical quiescence in this group is rare. We present a case of a 45-year-old female with emotionally unstable personality disorder (borderline type) presenting with partial intestinal obstruction 5 years after the known ingestion of serrated metallic scissors. In the asymptomatic interim a conservative approach of tracking the blades radiologically was taken. Following discussion, we conclude the following: early surgical intervention is encouraged if natural passage does not occur within 3 days following ingestion, and that any concurrent surgical needs should be addressed at this time.