Background: The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention. Methods: This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical). Results: A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays. Conclusions: Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.

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.

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.

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.

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.