An investigation into managerial support for the psychological wellbeing of national health service doctors during the Covid-19 pandemic: A cross sectional study.

AIM: This study investigates the psychological wellbeing of United Kingdom National Health Service doctors during the Covid-19 pandemic and evaluates how they have been supported managerially. METHOD: A mixed-method sequential study design of online surveys and semi-structured interviews was employed between July-August 2020, with a response rate of 273/300 and 4/4 respectively. The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) and Health and Safety Executive Management Standards (HSE MS) were used as measuring tools. The Jobs Demands Resource (JD-R) model and its relation to psychological wellbeing was determined. Survey findings informed semi-structured interviews, coded using thematic analysis. RESULTS: Overall mean WEMWBS, 43.2 (SD = 9.44), was low as was mean managerial support, 2.38 (SD = 0.78). Overall mean clinical demand score was high (2.6 on reverse scale). First year female trainee respondents from frontline specialties were found to have low psychological wellbeing scores. Key correlations were found between high managerial support, low clinical demands and low psychological wellbeing (r > 0.6). Core themes emerged: (1) breakdown of leadership, (2) vulnerability of wellbeing without support, (3) suboptimal navigation through change and (4) poor physical and human resource management. CONCLUSION: Maintaining the psychological wellbeing of doctors requires physical and psychological resources to meet clinical demands and the enhancement of fundamental managerial principles of control, communication, change management and leadership through adversity.

Laparoscopic Training Opportunities in an Emergency Biliary Service.

BACKGROUND AND OBJECTIVES: Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes. METHODS: A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established. RESULTS: Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, P = .8) or major complications (1% vs 0.9%, P = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, P = .0025).Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4). CONCLUSIONS: Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.

A Glasgow Tipple-transjugular intrahepatic portosystemic shunt insertion prior to Whipple resection.

Abdominal surgery performed in patients with significant liver disease and portal hypertension is associated with high mortality rates, with even poorer outcomes associated with complex pancreaticobiliary operations. We report on a patient requiring portal decompression via transjugular intrahepatic portosystemic shunt (TIPS) prior to a pancreaticoduodenectomy. The 49-year-old patient presented with pain, jaundice and weight loss. At ERCP an edematous ampulla was biopsied, revealing high-grade dysplasia within a distal bile duct adenoma. Liver biopsy was performed to investigate portal hypertension, confirming congenital hepatic fibrosis (CHF). A TIPS was performed to enable a pancreaticoduodenectomy. Prophylactic TIPS can be performed for preoperative portal decompression for patients requiring pancreatic resection. A potentially curative resection was performed when abdominal surgery was initially thought impossible. Notably, CHF has been associated with the development of cholangiocarcinoma in only four previous instances, with this case being only the second reported distal bile duct cholangiocarcinoma.

Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy.

OBJECTIVES: Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF. METHODS: A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140). RESULTS: Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF. CONCLUSIONS: Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.