A Systematic Review to Summarise and Appraise the Reporting of Surgical Innovation: a Case Study in Robotic Roux-en-Y Gastric Bypass.

Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations.

A systematic review of robot-assisted anti-reflux surgery to examine reporting standards.

Robot-assisted anti-reflux surgery (RA-ARS) is increasingly being used to treat refractory gastro-oesophageal reflux disease. The IDEAL (Idea, Development, Exploration, Assessment, Long-term follow up) Collaboration's framework aims to improve the evaluation of surgical innovation, but the extent to which the evolution of RA-ARS has followed this model is unclear. This study aims to evaluate the standard to which RA-ARS has been reported during its evolution, in relation to the IDEAL framework. A systematic review from inception to June 2020 was undertaken to identify all primary English language studies pertaining to RA-ARS. Studies of paraoesophageal or giant hernias were excluded. Data extraction was informed by IDEAL guidelines and summarised by narrative synthesis. Twenty-three studies were included: two case reports, five case series, ten cohort studies and six randomised controlled trials. The majority were single-centre studies comparing RA-ARS and laparoscopic Nissen fundoplication. Eleven (48%) studies reported patient selection criteria, with high variability between studies. Few studies reported conflicts of interest (30%), funding arrangements (26%), or surgeons' prior robotic experience (13%). Outcome reporting was heterogeneous; 157 distinct outcomes were identified. No single outcome was reported in all studies.The under-reporting of important aspects of study design and high degree of outcome heterogeneity impedes the ability to draw meaningful conclusions from the body of evidence. There is a need for further well-designed prospective studies and randomised trials, alongside agreement about outcome selection, measurement and reporting for future RA-ARS studies.

A systematic review of robot-assisted cholecystectomy to examine the quality of reporting in relation to the IDEAL recommendations: systematic review.

INTRODUCTION: Robotic cholecystectomy (RC) is a recent innovation in minimally invasive gallbladder surgery. The IDEAL (idea, development, exploration, assessment, long-term study) framework aims to provide a safe method for evaluating innovative procedures. This study aimed to understand how RC was introduced, in accordance with IDEAL guidelines. METHODS: Systematic searches were used to identify studies reporting RC. Eligible studies were classified according to IDEAL stage and data were collected on general study characteristics, patient selection, governance procedures, surgeon/centre expertise, and outcome reporting. RESULTS: Of 1425 abstracts screened, 90 studies were included (5 case reports, 38 case series, 44 non-randomized comparative studies, and 3 randomized clinical trials). Sixty-four were single-centre and 15 were prospective. No authors described their work in the context of IDEAL. One study was classified as IDEAL stage 1, 43 as IDEAL 2a, 43 as IDEAL 2b, and three as IDEAL 3. Sixty-four and 51 provided inclusion and exclusion criteria respectively. Ethical approval was reported in 51 and conflicts of interest in 34. Only 21 reported provision of training for surgeons in RC. A total of 864 outcomes were reported; 198 were used in only one study. Only 30 reported a follow-up interval which, in 13, was 1 month or less. CONCLUSION: The IDEAL framework was not followed during the adoption of RC. Few studies were conducted within a research setting, many were retrospective, and outcomes were heterogeneous. There is a need to implement appropriate tools to facilitate the incremental evaluation and reporting of surgical innovation.

The community burden of surgical site infection following elective colorectal resection.

AIM: Surgical site infection (SSI) is common after colorectal surgery. Recent attempts to measure SSI have focused on inpatient SSI and readmissions. This study examined patient-reported SSI at 30 days over 8 years. METHODS: The Health Protection Agency questionnaire was used to prospectively measure 30-day patient-reported SSI in patients undergoing elective colorectal operations between February 2011 and April 2019. Questionnaires were sent by post and followed up with a phone call. Data relating to hospital stay were prospectively recorded on an enhanced recovery database. RESULTS: In all, 80.7% (1268) of 1559 patients responded to the questionnaire with an overall SSI rate of 15.9% (201/1268). The majority of patients who reported SSI presented in the community (66.7%) of whom 65% consulted their general practitioner and 35% saw a community nurse. Patient-reported SSI was validated by a health professional in over 90% of cases. Overall, only 1.5% of readmissions and 2% of ward attendances were due to an isolated wound problem. Patients who developed SSI during their index admission had a longer length of stay (11 days vs. 4 days) but there was no difference in delayed discharge or complications between patients with and without SSI, suggesting that a previously described association between SSI and increased length of stay may be due to observational bias. CONCLUSION: Existing surveillance audits are suboptimal for monitoring SSIs following colorectal surgery as most SSIs present after discharge. There is a need for robust 30-day surveillance with a standardized methodology if comparisons are to be made between units.

Preoperative fasting in the department of plastic surgery.

Preoperative fasting is necessary to reduce the risk of regurgitation of gastric contents and pulmonary aspiration in patients undergoing general anaesthetic and procedural sedation. Excessive fasting is associated with metabolic, cardiovascular and gastrointestinal complications and patient discomfort. We aimed to reduce the fasting time for patients on the plastic surgery trauma list. Adult inpatients awaiting surgery were asked to complete a preoperative assessment sheet. Questions included the length of preoperative fasting, clarity of instructions and wellness scores. Three cycles of data collection were performed over a 12-month period, patients who declined to participate or were unable to consent were excluded. The first cycle revealed the need for significant improvement. Interventions included staff education, patient information sheets, preoperative drinks, greater availability of ward snacks and improved communication between the ward staff and surgical team through our electronic trauma database. The initial audit of 15 patients revealed a mean fasting time of 16.3 hours for fluid (range 10-22) and a mean of 19.3 hours for solid food (range 10-24). The mean wellness score was 6/10 (10 being very well), 67% of patients felt they were given clear information. The final cycle demonstrated clear improvement in all domains. The mean fasting time declined to 5.1 hours for fluid (range 3-10 hours) and 13 hours for solid food (range 7.5-17 hours). The mean wellness score (10=very well) increased from 6 to 8, the mean thirst score declined from 6.1 to 5.1 and 100% patients felt they had been given clear information. Removal of the traditional 'NBM from midnight', patient education, a clear fasting routine with preoperative drinks and improved communication between the full multidisciplinary team has led to a reduction in the fasting times on our trauma list.

Postoperative radiographs after open reduction and internal fixation of mandibular fractures: clinical need or unnecessary radiation?

Postoperative radiographs are conventionally taken after open reduction and internal fixation (ORIF) of mandibular fractures, but routine radiographic exposure in patients who have no clinical signs may not be justified. To find out whether radiographs influence immediate postoperative management, and whether they can be used to predict long-term complications, we retrospectively reviewed the radiographs and case notes of 92 patients who had ORIF of isolated mandibular fractures between June 2010 and June 2012. We evaluated them for the adequacy of reduction and fixation using locally agreed criteria, and correlated them with immediate and long-term outcomes as recorded in the case notes. Eleven patients had complications, usually infection. All 4 patients who required repeat ORIF had worrying signs and symptoms despite the immediate postoperative radiograph looking favourable. The radiographs of 7 patients looked unfavourable, but no patient required another operation, and none developed complications. Routine postoperative radiographs after ORIF of mandibular fractures seem to have little value in the management of patients, as the decision to reoperate is based on clinical signs rather than radiographic appearance, and radiographic appearance is not associated with long-term outcomes. Our findings suggest that radiographs are valuable only in patients with clear clinical indications and, in view of the risk and cost of radiation, we question their continued use.

Does elective parathyroidectomy for primary hyperparathyroidism affect renal function? A prospective cohort study.

INTRODUCTION: Major surgery is associated with acute kidney injury (AKI). This study examines associations between elective parathyroid surgery and post-operative renal impairment. METHODS: Consecutive patients undergoing elective parathyroidectomy were evaluated, and demographic data and relevant blood parameters collected. A renal risk score was calculated for each patient based on locally agreed criteria. RESULTS: 62 patients were evaluated. Mean ± standard deviation creatinine increased between pre-operative and day 1 post-operative (72 ± 19 vs. 76 ± 20 µmol/L; p < 0.010). Mean eGFR reduced between baseline and day 1 (78 ± 15 vs. 75 ± 16; p < 0.010) and baseline and follow-up (78 ± 15 vs. 73 ± 17; p < 0.050). 19 patients (30.7%) had a creatinine increase of ≥10% on day 1 post-operatively and 7 (11.3%) a rise of >20%. At follow-up, 14 (30.4% of 46 patients with follow up creatinine measurements) and 5 (10.9%) patients had a creatinine of >10% and >20% higher than pre-operative or day 1 values respectively. Those with an increase in serum creatinine of ≥10% (at any time point) had a greater renal risk score [median 2 (inter-quartile range, IQR 0-3) vs. 1 (0-2); p = 0.040]. CONCLUSION: A significant minority of patients undergoing elective parathyroid surgery demonstrate worsening renal function post-operatively. A pre-operative risk stratification tool may identify those at risk in the clinical setting.