Teaching corner--"lumps and bumps": a practical guide to minor surgery for the Core Surgical Trainee.

The first local anaesthetic operating list faced by a Core Surgical Trainee (CT) can appear a daunting task. Fresh from Foundation Year (FY) posts, (s)he will lack experience in basic surgical techniques. At present, there is no formal training in minor surgical skills for FY doctors, and exposure to operative surgery can be variable. This review provides an introduction and practical guide to the operative management of minor surgical pathologies.

Ventilatory and intensive care requirements following oesophageal resection.

INTRODUCTION: The aim of this study was to analyse the results of early postoperative extubation following oesophagectomy. PATIENTS AND METHODS: All patients who had undergone oesophageal resection between 1994 and 2001 were identified from a prospectively collected database. Their records were then reviewed in order to analyse morbidity and mortality along with intensive care unit (ICU) and ventilatory requirements. All patients were extubated immediately following surgery and monitored on a surgical high dependency unit (HDU). RESULTS: A total of 98 resections were undertaken (76 men; mean age, 64.3 years; range, 40-80 years). Surgical procedures were Ivor-Lewis (71), left thoraco-abdominal (15) and transhiatal (12) oesophagectomies. Overall, 8 patients died and 13 patients had anastomotic leaks. Sixteen patients required ventilation and admission to ICU, of whom 5 died. Three patients died on HDU following an elective decision not to transfer to ICU. Reasons for ventilation and ICU admission were anastomotic leaks (6), respiratory problems (6), left ventricular failure (1), cardiac arrest (1), small bowel herniation through the hiatus (1) and ischaemic stomach requiring revision of anastomosis (1). No patient required ventilation and admission to ICU within 48 h of original surgery. CONCLUSIONS: Patients undergoing oesophageal resection can be safely managed on a surgical HDU without routine postoperative ventilation. Although ventilation and ICU will be required in a significant number due to postoperative complications, this is unlikely to occur in the first 48 h. The requirement for an ICU bed to be available on the day of surgery should, therefore, no longer be considered necessary. This has important implications for the scheduling of elective oesophageal surgery.

Gastric adenocarcinoma missed at endoscopy.

BACKGROUND AND PURPOSE: The diagnosis of gastric cancer is based on histological confirmation at endoscopy with the emphasis on early detection to improve prognosis. The aims of this study were to identify the proportion of patients with gastric adenocarcinoma in whom the diagnosis was missed at first endoscopy and the subsequent delay which occurred before the histological diagnosis was established. METHODS: Retrospective review of 137 consecutive patients with biopsy-proven gastric adenocarcinoma presenting to one surgical unit over a five-year period. RESULTS: Two patients with a biopsy diagnosis at laparotomy and 6 patients in whom case notes could not be traced were excluded from the study. Of the remaining 129 patients, the diagnosis of gastric adenocarcinoma was missed at first endoscopy in 18 (14%). The median delay to histological diagnosis in this subgroup of patients was 13 weeks (range 3-102). CONCLUSION: Delays in establishing the diagnosis of gastric adenocarcinoma following initial endoscopy occur in a number of patients. Greater suspicion and a more rigorous protocol for repeat endoscopy and biopsy must be implemented in order to reduce the number of missed diagnoses after initial endoscopy.

Ivor-Lewis oesophagectomy for middle and lower third oesophageal lesions--how we do it.

"The early case means less sepsis, less malnutrition and easier and quicker operations. Early diagnosis should thus be rewarded by reasonable operative mortality, good relief of symptoms and at any rate a fair number of five year cures. It is disappointing that, for the moment, the outlook is not brighter. For no field in surgery presented more dangers and difficulties; in none was the challenge taken up with more persistent endeavour in the face of repeated failures."

Consultant supervision of surgical trainees: an objective assessment of how much actually occurs.

Consultant-supervised operative experience must be at the core of any training programme. The level of consultant supervision of United Kingdom trainees is largely unknown. In this study, the unique Lothian Surgical Audit database was used to assess consultant supervised training.

Total gastrectomy with extended lymphadenectomy for "curable" stomach cancer: experience in a non-Japanese Asian center.

BACKGROUND: Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan. STUDY DESIGN: A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit. RESULTS: The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p < 0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative. CONCLUSIONS: Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

Surgical training: an objective assessment of recent changes for a single health board.

The reduction in doctors' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.

Comparative assessment of surgical training using objective criteria.

The aims of the study were to develop and validate an objective method of assessing the operative experience of surgical trainees. Data were retrieved from a prospectively recorded computer database of operating activity in a single surgical unit over a three-year period. Operations were weighted using intermediate equivalent (IE) values. The number of operations performed (caseload), IE workload, consultant involvement and a subjective assessment of operative ability by consultant was obtained for each of 3 SHO IIIs and 7 SHO Is. The total caseload correlated poorly with subjective grading. The total workload correlated well with the subjective assessment of the SHO IIIs and, excluding minor operations, with the SHO Is. SHO IIIs' workload consisted of a higher number of more complex procedures than SHO Is' and for both types of trainee the degree of complexity increased during the tenure of each one year post. A consultant was the assistant in 50 per cent of the intermediate and major operations performed by the SHO Is in the first quarter of each one year post dropping to 30 per cent in the remaining three-quarters. In conclusion an objective assessment was easily obtained and interpreted. Similar data from other surgical units are required to place this work in perspective and to allow formulation of guidelines.

Training in surgical outpatients.

The consultants in this department, where the trainees are predominantly SHOs, organise their outpatient clinics such that one consultant sees mainly new patients (A), another mainly follow-up patients (C) and the third a mixture (B). A prospective audit was conducted to assess the impact of these different arrangements on training. Details of the training received were recorded at 32 consecutive clinics. A training episode (TE) occurred if the trainee and consultant jointly reviewed, or directly discussed, the patient in the clinic. A total of 550 patients attended and trainees were involved with 254 (46 per cent). A TE occurred in only 88 (16 per cent). The 235 (43 per cent) new patients produced 66 (28 per cent) TE and the 315 follow-up patients 22 (7 per cent) TE. Seventeen of 46 (37 per cent) procedures were a TE. The TE for the individual consultants were (new and follow-up): A 0, 8 (7 per cent); B 19 (22 per cent), 7 (8 per cent); C 47 (57 per cent), 7 (6 per cent). Outpatient training was greatly influenced by clinic organisation. Follow-up patients, who often have complex problems, rarely generate a TE. Training in surgical outpatients has not received the same attention as operative training and this deficiency needs to be addressed.

An objective assessment of surgical training.

The aim of this study was to determine the feasibility of assessing surgical training from routine, prospectively collected data and to establish whether weighted workload assessed surgical training more objectively than caseload (case counting). The surgeons in this surgical unit prospectively documented details of all operations and endoscopic procedures (caseload) on a database. Over a six-month period the workload was calculated by weighting the caseload using Intermediate Equivalent (IE) values. Some 1827 procedures were documented. The three consultants performed 796 (44 per cent) procedures, the senior registrar (SR) 137 (7.5 per cent), the registrar 241 (13 per cent) and the three senior house officers (SHO) 644 (35 per cent). The consultant was first assistant in 185 (66 per cent) procedures performed by the SHOs, in 52 (61 per cent) by the registrar in 9 (13 per cent) by the SR. When assessed by caseload one SHO (as a representative example) performed 224 procedures compared to 137 by the SR. The IE workloads were 156 and 166 respectively. This better reflected the greater complexity of the operations performed by the SR. This study has shown that details of surgical training can be easily retrieved from existing administrative databases. This can be used to document the number and type of operations performed by a trainee and the degree of consultant supervision. The degree of surgical training is better assessed by weighted workload rather than caseload.

Written discharge advice sheets reduce visits to the general practitioner.

A prospective audit of early post-operative morbidity in patients who would not normally receive routine outpatient review was undertaken. One-hundred-and forty-seven (92 per cent) of 162 patients invited returned for assessment. Thirty-five patients (24 per cent) had complications. These were of a minor nature with infected wounds being most numerous. Much of this morbidity appeared avoidable if the patients had received appropriate advice whilst in hospital. Also noted was the surprising frequency with which patients required to consult their general practitioner (GP) for guidance regarding an otherwise uncomplicated convalescence. Written advice sheets for the patients were drawn up and the study repeated. One-hundred-and-fifty (93 per cent) of 162 patients attended including 11 (7.3 per cent) who did not receive an advice sheet. Twenty-five (16.7 per cent) had complications. Although the overall complication rate was not significantly different there were significantly fewer wound infections in the second group (6 (4 per cent) versus 15 (10 per cent); p < 0.05). The number of GP visits was also reduced (24 (16.3 per cent) versus 13 (8.7 per cent); p < 0.05). Written post-operative advice sheets should be given to all patients following minor surgery.

Surgical management of the septic complications of diverticular disease.

This retrospective study has reviewed the surgical management of the septic complications of diverticular disease involving the left colon in 77 patients who presented between 1980 and 1992. Over this period, Hartmann's resection continued to be the predominant surgical procedure. The overall mortality and morbidity rates in the study period were 10% and 31%, respectively. However, a marked improvement in survival was recorded in the latter half of the study (17% vs 6%). The mortality from Hartmann's resection was also reduced substantially in the second half of the study (24% vs 7.5%). These improvements occurred despite having a higher number of poor-risk patients (APACHE II score) with more severe pathology (generalised peritonitis, 35% vs 50%; faecal peritonitis, 9% vs 25%) in the latter half. There was a significantly worse survival in patients who were over 70 years of age (P < 0.03), those who had a severe concomitant medical illness (P < 0.02), those who had a generalised peritonitis (P < 0.02), and in those patients who had an APACHE II score of over 11 (P < 0.05) (Fisher's exact test). There was no difference in outcome (morbidity, mortality) between the various grades of surgeon involved in performing the emergency surgical procedures.

Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage.

Endoscopic haemostasis by injection of adrenaline was attempted in 135 consecutive patients with active upper gastrointestinal bleeding. Initial haemostasis was obtained in 127 patients following injection of 5-15 ml 1:10,000 adrenaline; eight patients in whom haemostasis was not achieved underwent immediate laparotomy. There was further haemorrhage in 25 patients, which was successfully treated by further injection of adrenaline in ten. Fifteen patients had major rebleeding requiring emergency surgery. Stepwise logistic regression analysis identified three factors that, taken together, were highly predictive of the need for surgery: pulse rate on admission, the position of the ulcer and whether the patient was obese. A scoring system was derived from the logistic analysis equation that was found to predict correctly the need for emergency surgery in 84 per cent of patients. In patients with a high probability of rebleeding surgery should be considered after initial endoscopic haemostasis and stabilization. In the majority of patients endoscopic treatment alone is sufficient for permanent haemostasis.

Reversal of Hartmann's colostomy.

From January 1980 to December 1992, sixty-two Hartmann's procedures were performed for septic complications of sigmoid diverticular disease, in the Professorial Unit at Aberdeen Royal Infirmary. Colorectal continuity was subsequently restored in 53% of the fifty-three surviving patients. The overall morbidity and mortality was 34% and 0% respectively. There were two anastomotic leaks (7%) while two patients (7%) developed anastomotic stenoses requiring multiple dilations. Closure of Hartmann's colostomy was carried out by consultants (48%), senior registrars (38%) and registrars with consultant supervision (14%). Fifteen anastomoses were hand sewn and fourteen were stapled. Twenty-one per cent of patients had closure of colostomy in less than 3 months, 48% between 3 and 6 months and 31% of reversals were carried out more than 6 months following their formation. The grade of surgeon had no influence on the outcome of reversal. Although the numbers were small, the morbidity was found to be highest in those patients in whom colostomy closure was carried out within 3 months of colostomy formation. Also, there was an increased incidence (7%) of anastomotic stenoses in the stapled anastomosis group.

Acute mesenteric ischaemia: the continuing difficulty in early diagnosis.

Five cases of acute intestinal ischaemia due to occlusion of the superior mesenteric artery, all with a delay in diagnosis, are reported here. These cases illustrate the continuing difficulties, in clinical practice, in recognizing mesenteric ischaemia before intestinal infarction has occurred, despite the clinical awareness of this condition.

Adrenaline injection for endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage.

Over a 30-month period, 53 patients with actively bleeding non-variceal lesions of the oesophagus, stomach or duodenum were treated by endoscopic injection of 1/10,000 adrenaline. Initial haemostasis was obtained in 50 cases, and permanent haemostasis in 44. Emergency surgery for bleeding was required in nine patients overall, and there were four deaths. All lesions requiring surgery were located on the posterior wall of the duodenum or the lesser curve of the stomach, and all but one had evidence of an exposed arterial vessel. Adrenaline injection is an effective, safe and simple method of endoscopic haemostasis.

Two team synchronous esophagectomy.

A modification of the Lewis esophagectomy for carcinoma of the intrathoracic esophagus is described herein. With the patient in the semilateral position, two surgical teams operate simultaneously. The abdominal team mobilizes the stomach while the thoracic team removes the esophagus. Esophagogastric anastomosis is performed by stapling at the apex of the thorax. The procedure was performed upon 50 patients. There were two anastomotic leaks and one death occurred in the hospital. The two team synchronous approach avoids changes in the position of the patient, shortens operating time and may contribute to lower morbidity rates for patients undergoing esophagectomy.

Intraoperative assessment of lymph node involvement in gastric carcinoma.

This study compares the assessment of lymph nodes by the surgeon, at the time of operation, with the pathologist's assessment on the resected specimen in 85 cases of total gastrectomy with extended lymphadenectomy for gastric carcinoma. There was correlation in 67% of cases, in 28% the disease was overstaged, and in only 5% was it understaged by intraoperative assessment. This has important implications for the comparison of trials and management decisions based on surgical assessment.

Intrathoracic stapled anastomosis after oesophagectomy for cancer.

Fifty consecutive oesophagectomies for cancer are reported which were performed using a two-stage technique with an intrathoracic stapled anastomosis. The oesophagus was resected through a right thoracotomy. Continuity was restored using orthotopic stomach, mobilized through an abdominal incision and anastomosed to the oesophagus at the apex of the thorax. No deaths occurred within 30 days, but two patients died without leaving hospital. Routine contrast study revealed no anastomotic leaks. Major complications were: chylothorax (one), transient bilateral recurrent laryngeal nerve palsy (one), anastomotic bleed (one), respiratory failure (one) and brain abscess (one). Four upper resection margins contained tumour (all in middle third tumours). With this technique, a reliable anastomosis can be made high in the chest. The amount of oesophagus removed is comparable with that obtained with the 'three-stage' or transhiatal procedures. The problem of occult submucosal spread in oesophageal tumours remains.