Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort.

INTRODUCTION: Colorectal anastomotic leaks (AL) are associated with high morbidity and mortality. Management of AL and its intra-operative decision making is often difficult. The aim of this multi-centre study is to explore different management strategies, including different surgical options, and analyse rates and patterns of failure of initial management. METHODS: All consecutive patients who had a confirmed AL after elective colorectal resections from 1st January 2014 to 31st December 2019 were included at seven hospitals across the East of England Region. Morbidity (length of stay, and failures) and mortality were compared across the different management strategies, and survival analyses were performed (Clinicaltrials.gov ID: NCT05000580). RESULTS: Across all seven hospitals, a total of 3391 elective resection were done during the study period. 201 (5.9%) consecutive patients with confirmed AL were included. The initial treatment was conservative in 102(50.7%). 19 patients (9.5%) had a radiological procedure, 80 (39.8%) of patients required surgery as an initial treatment post AL. Of those who initially did not have a surgical intervention (n = 121), 10% (n = 12/121) eventually required laparotomy, 2 additional patients required transanal drainage. Ultimately 45.8% (n = 92/201) of the whole population eventually required a laparotomy. Patients managed conservatively had a shorter LOS when compared to either radiological drainage or surgical patients. Patients with a defunctioning stoma are more likely to have a successful conservative management and shorter LOS. 90-day mortality across the entire population was 8.1%. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities or whether the leak was right or left sided. CONCLUSION: Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy and over a quarter of patients will have an end stoma.

The usefulness of work-based assessments in higher surgical training: A systematic review.

BACKGROUND: Work-based assessments including procedure based assessments, case based discussions, clinical evaluation exercises and direct observation of procedural skills are used in Higher Surgical Training Program. This systematic review aims to investigate the trainer and trainee's perception of the usefulness of workplace based assessments in Higher Surgical Training Programme. MATERIALS AND METHODS: Embase, MEDLINE and PubMed databases were searched for relevant studies published up to Jan 15, 2021. The following search terms were used: procedure based assessments, case based discussions, clinical evaluation exercises, direct observation of procedural skills, Higher Surgical Training Program (with and without their abbreviations), surgical training, formative assessment. Usefulness was analysed according to van der Vleuten's utility formula, which is the product of educational impact, validity, reliability, acceptability, cost-effectiveness and feasibility. RESULTS: 23 studies were included; Six on procedure based assessments, two on case based discussions, one on mini clinical evaluation exercises, three on direct observation of procedural skills and eleven on multiple methods. Overall, procedure based assessments had positive Kirkpatrick level 1 or 2 impact were valid, reliable and acceptable. Mini clinical evaluation exercises showed positive Kirkpatrick level 1 satisfaction in trainees and trainers and were feasible. Case based discussions were shown to have both positive and negative Kirkpatrick levels 1 and 2 impact and were rated valid and reliable. Direct observation of procedural skills were valid with favourable Kirkpatrick level 1 impact with more usage and modification of the forms. Multiple methods as used in the intercollegiate surgical curriculum programme portfolio was found to be less encouraging in achieving positive higher level of educational impact. The barriers included lack of time, lack of faculty development and lack of engagement. CONCLUSION: It is important that work-based assessments are used properly, so that trainees get the maximum benefit from them. None of the studies included in our systematic review demonstrated an impact on behaviour or society (Kirkpatrick level 3 and 4), towards which future research should be directed to.

Impact on Quality of Life After Parathyroidectomy for Asymptomatic Primary Hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (PHPT) is associated with a poorer quality of life. The role of neuropsychiatric symptoms in asymptomatic patients who do not display classical features of PHPT remains undefined. It is unclear whether parathyroidectomy provides immediate benefit beyond the long-term risk reduction of adverse effects. The aim of the study is to assess the effect on quality of life in patients with asymptomatic PHPT undergoing parathyroidectomy. METHODS: Consecutive patients with PHPT undergoing parathyroidectomy by a single surgeon were recruited from a single center between 2014 and 2019. All patients prospectively completed the validated EQ-5D-3L health status questionnaire preoperatively and postoperatively, comprising two components: (i) five domains including physical and mental health and (ii) visual analog scale (VAS). Biochemical and clinical indices were recorded. RESULTS: Seventy-eight patients were included, 72% female (n = 56), median age 62 y (interquartile range (IQR): 52-70), and 28 (36%) asymptomatic. A global improvement in health-related quality of life was observed with a VAS score increase from 70 (IQR: 50-80) to 80 (IQR: 70-90); P < 0.001. VAS scores also improved significantly in asymptomatic patients increasing from 77 to 85 (P = 0.014), with an overall improvement in all five domains of quality of life. The symptomatic group showed a significant improvement in anxiety/depression levels (P < 0.01), although this was not the primary complaint in any of the cases. CONCLUSIONS: Parathyroidectomy is associated with a significant improvement in the quality of life of patients with asymptomatic PHPT. In symptomatic patients, this includes a reduction in anxiety and depression. Benefits are observed as early as 2 mo postoperatively, and results suggest a potentially important cognitive and social aspect of this disease.

Work-Based Assessments in Higher General Surgical Training Program: A Mixed Methods Study Exploring Trainers' and Trainees' Views and Experiences.

Introduction In the United Kingdom, work-based assessments (WBAs) including procedure-based assessments (PBAs), case-based discussions (CBDs), clinical evaluation exercises (CEXs), and direct observation of procedural skills (DOPS) have been used in Higher General Surgical Training Program (HGSTP) since the introduction of Modernising Medical Careers. Although the Intercollegiate Surgical Curriculum Project states that they should be used for the formative development of trainees using feedback and reflection, there is no study to look at the perception of their usefulness and barriers in using them, particularly in HGSTP. The aim of this study is to investigate trainer's and trainee's perception of their usefulness, barriers in using them, and way forward for their improvement in HGSTP. Methods This was a mixed method study. In phase I, after ethics committee approval, an online survey was sent to 83 trainers and 104 trainees, with a response rate of 33 and 37%, respectively, using Online Surveys (formerly Bristol Online Survey) from July 2018 to December 2018. After analysis of this result, in phase II, semistructured interviews were conducted with five trainees and five trainers who had volunteered to take part from phase I. Thematic analysis was performed to develop overarching themes. Results For professional formative development, 15% of the trainers and 53% of the trainees felt that WBAs had a low value. Among 4 WBAs-CEX, CBD, PBA, and DOPS-PBA was thought to be the most useful WBA by 52% trainers and 74% trainees. More trainers than trainees felt that it was being used as a formative tool (33 vs. 16%). The total number of WBAs thought to be required was between 20 and 40 per year, with 46% of the trainers and 53% of the trainees preferring these numbers. The thematic analysis generated four themes with subthemes in each: theme 1, "factors affecting usefulness," including the mode of validation, trainer/trainee engagement, and time spent in validating; theme 2, "doubt on utility" due to doubt on validity and being used as a tick-box exercise; theme 3, "pitfalls/difficulties" due to lack of time to validate, late validation, e-mail rather than face-to-face validation, trainer and trainee behavior, variability in feedback given, and emphasis on number than quality; and theme 4, "improvement strategies." Conclusions The WBAs are not being used in a way they are supposed to be used. The perception of educational impact (Kirkpatrick levels 1 and 2) by trainers was more optimistic than by trainees. Improvements can be made by giving/finding more time, trainer training, more face-to-face validation, and better trainer trainee interactions.

Diabetes in day case general and vascular surgery: A multicentre regional audit.

BACKGROUND: People with Diabetes Mellitus (DM) are at increased risk of postoperative complications if their HbA1C readings are not well controlled. In the UK, there are clear national guidelines requiring all people with DM to have HbA1C blood testing within 6months before undergoing surgery and that these readings should be below 69 mmol/mol if this is safe to achieve. The aim of this study was to determine whether hospitals in the region were compliant with the guidelines. METHODS: Data were prospectively collected from seven hospitals across the East of England region from 1st October 2017 to 31st March 2018 (6 months) in all people with DM undergoing elective day case procedures in General and Vascular surgery for benign disease. RESULTS: A total of 181 people with DM were included in the study, of whom 77.9% were male patients and the median age was 63 years. The three most commonly performed operations were laparoscopic cholecystectomy (20.9%, n = 38/181), inguinal hernia repair (20.4%, n = 37/181) and umbilical/para-umbilical hernia repair (11.0%, n = 20/181). In keeping with the national guidelines, only 86.7% (n = 157/181) of patients had an HbA1C tested within 6 months prior to their surgery date. Of the patients who had a preoperative HbA1C, 14 (n = 14/157, 8.9%) had an HbA1C ≥ 69 mmol/mol, and 12 (n = 12/14, 85.7%) of these proceeded to surgery without optimisation of their HbA1C. CONCLUSION: A significant proportion of people with diabetes undergoing elective day case procedures in our region do not have HbA1C testing within 6 months of their procedure as recommended by the national guidelines. In patients who do have a high HbA1C, the majority still undergo surgery without adequate control of their DM. Greater awareness amongst healthcare workers and robust pathways are required for this vulnerable group of patients if we are to reduce the risk of developing postoperative complication rates.