Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy.

Background: Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods: Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results: Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion: A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

Antecedentes: La patología biliar aguda litiásica es una de las urgencias con más volumen de casos en cirugía general, con amplias variaciones en la calidad de la atención prestada en todo el Reino Unido. En este estudio de cohortes controlado se valoró si la participación en un enfoque colaborativo de mejora de la calidad disminuía el tiempo hasta la cirugía en pacientes con patología biliar aguda litiásica a menos de 8 días desde la presentación, de acuerdo con la guía nacional. Métodos: Se identificó a los pacientes que precisaron un ingreso hospitalario por patología biliar aguda en Inglaterra y Gales, del 1 de abril de 2014 al 31 de diciembre de 2017, a partir de datos de las estadísticas de episodios hospitalarios. Se crearon series temporales de actividad trimestral para Chole­QuIC y para todos los demás hospitales de agudos del NHS (grupo control). Se utilizó un modelo de regresión binomial negativa para comparar la proporción de pacientes sometidos a cirugía dentro de los primeros 8 días en los periodos basal y de intervención. Resultados: De los 13 sitios invitados a unirse a Chole­QuIC, 12 participaron durante toda la colaboración, que se desarrolló entre octubre de 2016 y enero de 2018. De los 7.944 ingresos, en 1.160 pacientes se realizó la colecistectomía dentro de los 8 días posteriores a su ingreso, una mejora significativa (P < 0,05) en comparación con el periodo previo a la intervención. Esto representó un cambio relativo de 1,56 (i.c. del 95%: 1,38 a 1,75) en comparación con 1,08 para el grupo de control. A nivel de cada uno de los hospitales, ocho de los 12 centros Chole­QuIC presentaron una mejora significativa (P < 0,05), y en cuatro de ellos el porcentaje de cirugía en 8 días aumentó a más del 20% de todos los ingresos urgentes, muy por encima del promedio de 15,3% para hospitales de control. Conclusión: Un enfoque colaborativo de mejora de la calidad dirigido por el cirujano mejoró la atención a los pacientes que precisan una colecistectomía urgente.

Variation in outcomes and use of laparoscopy in elective inguinal hernia repair.

Background: The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally. Methods: All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011-2012 to 2016-2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots. Results: Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals. Conclusion: The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Validation of the acute cholecystectomy rate as a quality indicator for emergency general surgery using the SWORD database.

INTRODUCTION: Despite an increasing emphasis on data-driven quality improvement, few validated quality indicators for emergency surgical services have been published. The aims of this study therefore were: 1) to investigate whether the acute cholecystectomy rate is a valid process indicator; and 2) to use this rate to examine variation in the provision of acute cholecystectomy in England. MATERIALS AND METHODS: The Surgical Workload and Outcomes Research Database (SWORD), derived from the Hospital Episode Statistics database, was interrogated for the 2012-2017 financial years. All adult patients admitted with acute biliary pancreatitis, cholecystitis or biliary colic to hospitals in England were included and the acute cholecystectomy rate in each one examined. RESULTS: A total of 328,789 patients were included, of whom 42,642 (12.9%) underwent an acute cholecystectomy. The acute cholecystectomy rate varied significantly between hospitals, with the overall rate ranging from 1.2% to 36.5%. This variation was consistent across all disease groupings and time periods, and was independent of the annual number of procedures performed by each NHS trust. In 41 (29.9%) trusts, fewer than one in ten patients with acute gallbladder disease underwent cholecystectomy within two weeks. CONCLUSIONS: The acute cholecystectomy rate is easily measurable using routine administrative datasets, modifiable by local services and has a strong evidence base linking it to patient outcomes. We therefore advocate that it is an ideal process indicator that should be used in quality monitoring and improvement. Using it, we identified significant variation in the quality of care for acute biliary disease in England.

Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre.

INTRODUCTION: Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM. METHODS: A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013. RESULTS: Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the non-operated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05). CONCLUSIONS: SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.

Prediction, prevention and management of postresection liver failure.

BACKGROUND: Postresection liver failure (PLF) is the major cause of death following liver resection. However, there is no unified definition, the pathophysiology is understood poorly and there are few controlled trials to optimize its management. The aim of this review article is to present strategies to predict, prevent and manage PLF. METHODS: The Web of Science, MEDLINE, PubMed, Google Scholar and Cochrane Library databases were searched for studies using the terms 'liver resection', 'partial hepatectomy', 'liver dysfunction' and 'liver failure' for relevant studies from the 15 years preceding May 2011. Key papers published more than 15 years ago were included if more recent data were not available. Papers published in languages other than English were excluded. RESULTS: The incidence of PLF ranges from 0 to 13 per cent. The absence of a unified definition prevents direct comparison between studies. The major risk factors are the extent of resection and the presence of underlying parenchymal disease. Small-for-size syndrome, sepsis and ischaemia-reperfusion injury are key mechanisms in the pathophysiology of PLF. Jaundice is the most sensitive predictor of outcome. An evidence-based approach to the prevention and management of PLF is presented. CONCLUSION: PLF is the major cause of morbidity and mortality after liver resection. There is a need for a unified definition and improved strategies to treat it.

Prospective randomized trial using cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease.

BACKGROUND: This randomized controlled trial compared the cost-utility of early laparoscopic cholecystectomy with that for conventional management of newly diagnosed acute gallbladder disease. METHODS: Adults admitted to hospital with a first episode of biliary colic or acute cholecystitis were randomized to an early intervention group (36 patients, operation within 72 h of admission) or a conventional group (36, elective cholecystectomy 3 months later). Costs were measured from a National Health Service and societal perspective. Quality-adjusted life year (QALY) gains were calculated 1 month after surgery. RESULTS: The mean(s.d.) total costs of care were pound 5911(2445) for the early group and pound 6132(3244) for the conventional group (P = 0.928), Mean(s.d.) societal costs were pound 1322(1402) and pound 1461(1532) for the early and conventional groups respectively (P = 0.732). Visual analogue scale scores of health were 72.94 versus 84.63 (P = 0.012) and the mean(s.d.) QALY gain was 0.85(0.26) versus 0.93(0.13) respectively (P = 0.262). The incremental cost per additional QALY gained favoured conventional management at a cost of pound 3810 per QALY gained. CONCLUSION: In this pragmatic trial, the cost-utilities of both the early and conventional approaches were similar, but the incremental cost per additional QALY gained favoured conventional management.

Intra-operative culture swabs in acute appendicitis: a waste of resources.

INTRODUCTION: Antibiotics gained a place in the management of acute appendicitis when the bacterial aetiology was demonstrated. Culture swabs were obtained routinely during appendicectomies to guide antibiotic use. Although current antimicrobial therapy use has become prophylactic, empirical and broad spectrum, this age-old practice still remains. Our study questions the value of this traditional practice. MATERIALS AND METHODS: All adult and paediatric patients undergoing emergency appendicectomy over three years were retrospectively reviewed. Microbiology and appendix histology reports were retrieved. Occurrence of infective post-operative morbidity was recorded via hospital notes. RESULTS: A total of 652 appendectomies (age 1 month to 81 years, median 20 years) were performed in a 36 month period. Four hundred and thirty-five/six hundred and fifty-two (66.7%) had intra-operative swabs taken. One hundred and forty/four hundred and thirty-five (32%) revealed presence ofa pathogens. One hundred and twenty-two/four hundred and thirty-five (28%) were sensitive to broad spectrum empirical antibiotics and only 18/435 (4.1%) cultured resistant strains. Forty-two/six-hundred and fifty-two (6.4%) patients had postoperative infective complications. Twenty-nine/forty-two (68%) had a different organism responsible for this complication. The highest proportion of positive cultures and post-operative infective complications was observed in the extremes of ages (< 10 and > 50 years) and in gangrenous appendicitis. CONCLUSION: A majority of intra-operative swabs were negative or isolated commensal flora. Pathogens causing postoperative morbidity were frequently different from those isolated intra-operatively. None of the patients had a change of management based on the swab results. Hence routine intra-peritoneal swabs remains of little clinical value.

From small acorns--developing a laparoscopic colorectal surgical service.

INTRODUCTION: Randomised controlled trials have shown that laparoscopic colorectal surgery is equal in terms of safety to open surgery. Benefits have been seen for length of stay, blood loss, immune suppression and analgesia requirements. The aim of this study was to assess the safety and feasibility of introducing laparoscopic colorectal surgery to our unit. PATIENTS AND METHODS: Prospectively collected cases of all patients undergoing laparoscopic colorectal surgery between July 2003 and July 2007 were reviewed. RESULTS: A total of 143 patients (75 males and 68 females) with a mean age of 65.8 years (range, 21-95 years) underwent surgery. Laparoscopic resection for colorectal malignancy was performed in 93 patients (65%). The conversion rate for all cases was 14.7%. Mean operative time was 203 min (range, 100-400 min), with a mean blood loss of 180 ml. The mean number of lymph nodes in malignant cases was 13.8 with clear resection margin in all but one case. The mean postoperative stay was 5.6 days (median, 4 days; range, 2-35 days). UKCCR standard for lymph node retrieval was achieved in 62.6% of cases. There were four postoperative deaths. The overall 30-day morbidity rate was 21.7%. The service is consultant-led with 9.8% of cases performed by senior trainees and 37% of procedures performed by two consultants. CONCLUSIONS: Laparoscopic colorectal surgery is technically feasible and safe in our hands. Although operative time is longer, this is counterbalanced by shorter hospital stay. The results from this series support the findings of others and continuing development of this service.

Guidelines on the management of common bile duct stones (CBDS).

The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.

Brunner's gland hyperplasia at the ampulla of Vater.

Brunner's gland hyperplasia (BGH) is a diagnostic challenge where in the pathophysiology and natural history remain poorly understood. This Case Report describes BGH arising at the ampulla of Vater, causing abdominal pain and vomiting in a 46-year-old man. Owing to the inconclusive nature of imaging studies and suspicious intraoperative findings, a Whipple resection was performed without any complications. Histological analysis showed that the obstructing lesion was BGH, with no evidence of malignancy. This is only the second such case of its kind at the ampulla of Vater to be reported. In addition, we present the previously unreported endoscopic ultrasound findings. The subsequent literature review focuses on the pathophysiology, clinical presentation, diagnosis and management of BGH.

The effect of jaundice on the generation of anti-gastrin antibodies in G17DT immunized patients with advanced pancreatic cancer.

AIM: The aim of this study was to determine the ability of G17DT to generate anti-gastrin antibodies in jaundiced patients with biliary obstruction due to advanced pancreatic cancer. METHODS: G17DT was administered to 41 patients with advanced pancreatic adenocarcinoma by intramuscular (i.m.) injection at a dose of 250mcg at weeks 0, 1 and 3 of the study. RESULTS: Thirty-five of 41 patients participating in the study were categorized as responders in terms of their gastrin-17 antibody response. There was no correlation between the maximum G17 antibody response and the bilirubin level at either week 0 or week 12. The median survival of patients from the time of the first injection of G17DT was 204 days with 25% of patients surviving for or=305 days. CONCLUSION: This study shows that G17DT administered to jaundiced patients with advanced pancreatic cancer is immunogenic and well tolerated.

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux.

BACKGROUND: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

Validation of direct intraabdominal pressure measurement using a continuous indwelling compartment pressure monitor.

BACKGROUND: According to recommendations, intraabdominal pressure should be monitored every 8 hours for patients at high risk of abdominal compartment syndrome. Continuous intraabdominal pressure monitoring may be valuable for these patients. METHODS: For 15 patients undergoing laparoscopic surgery, a pressure monitor was introduced after formation of pneumoperitoneum. During the procedure, the laparoscopic insufflator pressure was varied. The pressure monitor values and the time to equilibrium were recorded. RESULTS: Altogether, 152 pressure recordings were taken for the patients studied. The measurements from the insufflator and pressure monitor were compared using a Bland-Altman plot. The mean difference between the techniques was 0.04 +/- 3.8, and 95% of the points from the pressure monitor were within two standard deviations of the mean difference. Pressure changes were essentially "real time." CONCLUSIONS: The intracompartmental pressure monitor provides accurate, rapid, and direct measurement of intraabdominal pressure, and may be a useful tool for continuous intraabdominal pressure measurement among patients at risk of abdominal compartment syndrome.

Improving diagnostic yield of biliary brushings cytology for pancreatic cancer and cholangiocarcinoma.

Biliary brushings are currently the best accepted method to obtain a cytological diagnosis of pancreatic cancer or cholangiocarcinoma. The technique has good specificity but poor sensitivity. Two dedicated pathologists reviewed 137 consecutive biliary brushings from 127 patients between February 1997 and February 2000. The ultimate diagnosis was determined by review of radiology, operative diagnosis and patient outcome. The sensitivity, specificity, positive predictive value and negative predictive value of the original results and the review results were calculated and compared. Additional diagnostic categories 'suspicious' and 'atypical possibly benign' were included on review. After review, the sensitivity improved from 49.4% to 89.0% and the specificity remained 100%. The use of the additional diagnostic category 'suspicious' increased the sensitivity to 90.4%, at the expense of a fall of the specificity to 66.7%. We conclude that review by two dedicated pathologists and additional diagnostic categories can improve the diagnostic accuracy of biliary brushings.

Liver tissue partial pressure of oxygen and carbon dioxide during partial hepatectomy.

BACKGROUND: Data on tissue oxygen partial pressure (PtO2) and carbon dioxide partial pressure (PtCO2) in human liver tissue are limited. We set out to measure changes in liver PtO2 and PtCO2 during changes in ventilation and a 10 min period of ischaemia in patients undergoing liver resection using a multiple sensor (Paratrend Diametrics Medical Ltd, High Wycombe, UK). METHODS: Liver tissue oxygenation was measured in anaesthetized patients undergoing liver resection using a sensor inserted under the liver capsule. PtO2 and PtCO2 were recorded with FIO2 values of 0.3 and 1.0, at end-tidal carbon dioxide partial pressures of 3.5 and 4.5 kPa and 10 min after the onset of liver ischaemia (Pringle manoeuvre). RESULTS: Data are expressed as median (interquartile range). Increasing the FIO2 from 0.3 to 1.0 resulted in the PtO2 changing from 4.1 (2.6-5.4) to 4.6 (3.8-5.2) kPa, but this was not significant. During the 10 min period of ischaemia PtCO2 increased significantly (P<0.05) from 6.7 (5.8-7.0) to 11.5 (9.7-15.3) kPa and PtO2 decreased, but not significantly, from 4.3 (3.5-12.0) to 3.3 (0.9-4.1) kPa. CONCLUSION: PtO2 and PtCO2 were measured directly using a Paratrend sensor in human liver tissue. During anaesthesia, changes in ventilation and liver blood flow caused predictable changes in PtCO2.

The 'two-week' target for the diagnosis of pancreatic carcinoma: an achievable aim?

AIM: The aim of this study was to evaluate the current diagnostic process for patients with pancreatic cancer in a University teaching hospital and to determine whether the 'two-week' target for rapid assessment was being met. METHODS: The notes of all patients with pancreatic cancer from June 1998 to June 2000 were reviewed to determine the time to diagnosis, investigations and procedures performed, number of admissions, length of hospital stay and survival RESULTS: There were 146 patients in total with a median (range) age of 71 (38-92) years. 18 (12%) had resectable lesions, while the remaining 128 patients had 134 palliative interventions (33 surgical; 101 radiological or endoscopic). The median number of hospital admissions for each patient was 2 (range 1-6) with a median length of hospital stay of 9 days (range 1-35 days). The median (IQR) time to diagnosis was significantly less in the jaundiced patients [7 (6-10) days vs. 32 (18-46) days, P<0.0001]. There was no significant correlation between age and time to diagnosis (r=0.08, P=0.36). There were 105 (72%) deaths in the study population, 82 in the jaundiced group and 23 in the non-jaundiced group. There was no significant difference in median (IQR) duration from referral to death in the jaundiced and non-jaundiced groups [59.5 (18-175) days vs. 35 (16-137) days, P=0.45]. CONCLUSIONS: A diagnosis within 14 days was achieved in 77% of patients. Patients with jaundice were more likely to have an earlier diagnosis than those without jaundice but this had no impact on survival.

Finding the best from the rest: evaluation of the quality of patient information on the Internet.

INTRODUCTION: Information is of utmost importance for patients at risk of developing cancer who require regular screening. Quality assessment is vital to ensure correct information is published on the Internet. METHOD: A postal questionnaire was sent to patients under follow-up for Barrett's oesophagus and colonic polyps. Questions related to computer/Internet access, where patients had previously sought information, whether web-sites would be of use, and what information they would like displayed. A review of on-line patient literature for Barrett's oesophagus and colorectal adenomas was performed. RESULTS: Of the 200 questionnaires sent, 161 patients responded (80.1%). The majority of patients (88%, n = 141) wanted more information on their condition, with 45% (73) having home Internet access and a further 32% (52) having web access from other sources. Only 8% (12) had used the Internet as a source of information; however, the majority of patients (57%) would access a recommended web-site. The Barrett's search resulted in 10/200 sites with full information (i.e. score > 8/10 points). For colorectal polyps there were 12/200 sites. CONCLUSIONS: Accessing quality Internet health information is very time consuming. Recommended web-sites that provide the best information would help patients avoid being overwhelmed with irrelevant and confusing literature.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.

BACKGROUND: The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. METHODS: A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. RESULTS: Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). CONCLUSION: Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.