The European Working Time Directive: Will Modern Surgical Training in the United Kingdom Be Sufficient?

Purpose The introduction of the European Working Time Directive in 2009 limits doctors in the United Kingdom to a 48-hour working week. The reduction in surgical training time raises concern over the ability of future surgeons to deliver safe and effective care. Methods This interview-based qualitative study was conducted within a tertiary referral centre in the United Kingdom. Nine consultant general surgeons were interviewed with the aim of investigating how surgical trainees can comply with the European Working Time Directive whilst gaining sufficient knowledge, skill and experience to be safe surgeons. Results Consultants felt that the European Working Time Directive has impacted surgical training, patient care, service provision, and the professional attitudes of trainees. They felt that current surgical trainees have a relative lack of experience compared to previous generations, which has impacted their ability to manage complex patients. The consultant-trainee relationship was felt to have suffered due to shorter working hours. Furthermore, the move towards shift work has resulted in a lack of continuity of care for patients. Consultants suggested reconfiguring theatre lists to maximise opportunities for trainees. They also recommended that trainees seek out alternative learning methodologies such as simulation, and consider clinical fellowships at the completion of their training to maximise their experience and surgical skills prior to consultancy. Conclusion This study highlights the concerns that senior surgeons working in a busy tertiary referral centre have towards the European Working Time Directive and modern surgical training. The authors recommend that both trainees and consultants have a responsibility to maximize opportunities during training, and that mentorship will need to continue at the consultant level. Further research in other centres can determine whether these sentiments are widespread, and whether institutional steps should be taken to change the way that modern surgeons are trained.

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques.

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

What Every Bariatric Surgeon Should Know: How to Relieve Obstruction at the Jejuno-jejunostomy After Roux-en-Y Gastric Bypass.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) remains one of the key bariatric procedures worldwide. In addition to bleeding and anastomotic leak, there are rarely occurring complications such as obstruction at the jejuno-jejunostomy in the early postoperative phase. PATIENT AND METHODS: A 51-year-old lady (weight 122 kg; BMI 46 kg/m2; with type 2 diabetes mellitus and hypertension) underwent RYGB in our tertiary referral centre 3 days prior to admission. She originally recovered well from the uneventful operation, but began vomiting on day 3. At this point, she complained of no other symptoms. An urgent CT scan identified a gastric remnant dilatation, and an obstructed jejuno-jejunostomy. An urgent laparoscopic exploration was performed, which identified obstruction at this level. RESULTS: Within our video-presentation, detailed technical steps are described. First, gastric remnant decompression was performed by inserting a tube gastrostomy. Secondly, the obstruction was identified. Consequently, a new jejuno-jejunostomy was created, proximal to the original anastomosis, using a linear stapler, and direct suture closure of the enterotomy defects. After thorough washout, drains were placed in the pelvis and alongside the jejuno-jejunostomy. The patient was discharged home after a 2-week hospital stay which included 5 days of invasive ventilation on the ITU. CONCLUSION: A high-level of suspicion is required to suspect, diagnose and treat post-RYGB complications. A bariatric on-call rota with appropriately trained personnel is essential.

Obstructive Sleep Apnoea Screening Preoperatively with the Epworth Questionnaire: Is It Worth It ?

BACKGROUND: The prevalence of obstructive sleep apnoea (OSA) in the bariatric population has been reported to be as high as 60-83%. The Epworth Sleepiness Scale (ESS) is a validated, self-administrated eight-item questionnaire that measures subjective daytime sleepiness and thus helps to identify high-risk for OSA. OBJECTIVES: To find the prevalence of OSA in patients undergoing bariatric surgery who do not routinely undergo polysomnography (PSG) and are screened by the ESS. METHODS: All consecutive 425 patients who underwent bariatric surgery in our tercier referral centre from January 2012 to June 2017 were included in this prospective study. Patient demographics and ESS score were recorded prior to the bariatric surgery and patients were divided into low-risk (ESS < 11), high-risk (≥ 11) and "known-OSA" groups. RESULTS: The community-based OSA prevalence was 14% (59 patients). ESS-positive predictive value was 60%. There was no significant difference in BMI and excess body-weight, but patients with OSA were older and had a lower female ratio (75% vs 42%). The unplanned ICU admission rate was comparable amongst the low- and high-ESS group (2.2% and 2.1%, respectively); similarly, the respiratory and chest complication rate were similar. The median hospital stay for patients diagnosed with OSA was a half day longer; the high-score patients stayed significantly longer than the low-score patients (p = 0.017). CONCLUSION: In our study, the OSA prevalence was low (20%). We think that the ESS does not have significant predicting value before bariatric surgery and overall the OSA is "overhyped" in the bariatric pathway.

Gastric band port site fixation: which method is best?

Laparoscopic adjustable gastric banding is a popular and successful bariatric surgical technique. Although short-term complications are few in number, long-term complications are more common. One such complication is flippage of the gastric band port. This study compares three popular methods of port fixation and demonstrates that fixation with nonabsorbable mesh helps to prevent port flippage when compared to other techniques, reducing the need for repositioning operations.

Intra-abdominal injury from extra-peritoneal ballistic trauma.

Over the last century sporadic reports have described intra-abdominal injury without penetration of the abdominal cavity but the underlying mechanism of energy transfer appears variable. This article reviews the 19 documented cases of this phenomenon and discusses the mechanism of energy transfer in both primary blast injury and ballistic injury that may be responsible.

A study examining the complications associated with gastric banding.

BACKGROUND: Gastric banding is a well-recognized and common method of weight reduction surgery. Between November 2001 and September 2011, 1,100 laparoscopic adjustable gastric banding operations were performed in Sheffield. This study examines the long-term complication rate. METHODS: All available medical notes for patients undergoing gastric banding by one surgeon were reviewed. Data were available for 1,079 patients. RESULTS: A total of 932 females and 147 males underwent gastric banding. Mean weight was 120 kg, with body mass index of 43.3. Complications occurred in 347 patients (32.1 %). One hundred three (13.2 %) patients experienced band slippage; re-operation was required in half of these cases. Eighty-two patients had their band removed due to complications; there was slippage in 60, erosion in 17, and band intolerance in 5. One hundred thirty-six (12.6 %) patients experienced problems with their port or port tubing. Thirty-seven ports were flipped, noted during clinical or radiological fills (3.4 %), and 17 patients experienced port infection (1.5 %). Fifty ports required repositioning (4.6 %); 16 (1.4 %) were removed or replaced including five for cutaneous erosion. Eleven patients experienced tubing problems. Four patients required procedures to deal with intraoperative complications. Eighteen patients had a concurrent procedure. One postoperative death was due to biliary peritonitis in a patient who had undergone simultaneous cholecystectomy. CONCLUSION: Complication rates reflect those in the literature. Slippage rate may appear higher in our patients, but this is a reflection of the fact that most patients undergo radiological band fills; hence, many non-symptomatic slippages are detected. Only half of our slippages (6.6 % of all patients) were clinically apparent or needed any intervention.

Atrial myxomas: a single unit's experience in the modern era.

BACKGROUND: Although an atrial myxoma is the commonest cardiac tumor, it is still relatively rare, with an annual incidence of approximately 0.5 per million. In our unit, which performs 1000 major cardiac procedures per year, this equates to approximately 3 patients annually. We therefore sought to evaluate our experience of managing this type of tumor over the last 5 years. METHODS: A retrospective review was performed of prospectively collected data from the departmental database. We analyzed consecutive patients who were operated upon between 2002 and 2007. Three patients with a papillary fibroelastoma on histological examination were excluded from this study. RESULTS: We have performed excision of atrial myxoma in 18 patients. Twelve patients (66%) were female; the median age was 64 years (range, 35-80 years), and the median logistic euroSCORE was 5.22% (range, 1.51-27.82%). Fifteen patients (83%) were deemed urgent, 2 elective, and 1 emergency. Sixteen tumors (89%) were left sided. Symptoms attributable to the tumor were found in 16 of the 18 patients (embolic, n = 9; chest pain, n = 3; palpitations, n = 2; incidental finding, n = 2, others n = 4), and the mean time from diagnosis to operation was 3 days (range, 0-22 months). The median cardiopulmonary bypass time was 87 minutes (range, 28-228 minutes), with the median aortic cross clamp time being 61 minutes (16-175 minutes).The approaches used were transeptal via right atriotomy (n = 8), biatrial/Dubost (n = 4), left atrial (n = 4), and right atrial (n = 2); the interatrial septum was involved in 14 patients. The resultant defect was closed using a pericardial (n = 8) or prosthetic patch (n = 5) or directly sutured (n = 5). Concomitant procedures were performed in 8 patients (coronary artery bypass graft [CABG], n = 4; mitral valve replacement [MVR], n = 2; valve + grafts, n = 2). All tumors were completely excised.Postoperatively there were no deaths within 30 days of the procedure. Indeed, only 2 patients have died at 4 and 25 months postoperatively, respectively, both of unrelated causes. Median intensive therapy unit (ITU) stay was 2 days (range, 1-9 days), and median hospital stay was 10 days (range, 5-20 days). A permanent pacemaker was required in only 1 patient, and median blood loss was 340 mL (range, 140-1760 mL). Atrial fibrillation was the commonest complication affecting 6/18 patients (33%). CONCLUSIONS: Excision of atrial myxoma can be performed using a variety of intraoperative approaches and closure techniques, all with acceptable postoperative morbidity and low mortality rates. To date, no recurrences have been found at median 2-year follow-up.