Objective The aim of this systematic review was to evaluate outcomes of direct revascularisation (DR) versus indirect revascularisation (IR) of infrapopliteal arteries to the affected angiosome for ...critical limb ischaemia. Both open and endovascular techniques were included. Methods A systematic review of key electronic journal databases was undertaken from inception to 22 March 2014. Studies comparing DR versus IR in patients with localised tissue loss were included. Meta-analysis was performed for wound healing, limb salvage, mortality, and re-intervention rates, with numerous sensitivity analyses. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results Fifteen cohort studies reporting on 1,868 individual limbs were included (endovascular revascularisation, 1,284 limbs; surgical revascularisation, 508 limbs; both methods, 76 limbs). GRADE quality of evidence was low or very low for all outcomes. DR resulted in improved wound healing rates compared with IR (odds ratio OR 0.40, 95% confidence interval CI 0.29–0.54) and improved limb salvage rates (OR 0.24, 95% CI 0.13–0.45), although this latter effect was lost on high-quality study sensitivity analysis. Wound healing and limb salvage was improved for both open and endovascular intervention. There was no effect on mortality (OR 0.77, 95% CI 0.50–1.19) or reintervention rates (OR: 0.44, 95% CI 0.10–1.88). Conclusion DR of the tibial vessels appears to result in improved wound healing and limb salvage rates compared with IR, with no effect on mortality or reintervention rates. However, the quality of evidence on which these conclusions are based on is low.
Objective The aim of this systematic review and meta-analysis was to evaluate the effects of using an intraoperatively placed perineural catheter (PNC) with a postoperative local anaesthetic infusion ...on immediate and long-term outcomes after lower limb amputation. Methods A systematic review of key electronic journal databases was undertaken from inception to January 2015. Studies comparing PNC use with either a control, or no PNC, were included. Meta-analysis was performed for postoperative opioid use, pain scores, mortality, and long-term incidence of stump and phantom limb pain. Sensitivity analysis was performed for opioid use. Quality of evidence was assessed using the GRADE system. Results Seven studies reporting on 416 patients undergoing lower limb amputation with PNC usage ( n = 199) or not ( n = 217) were included. Approximately 60% were transtibial amputations PNC use reduced postoperative opioid consumption (standardised mean difference: −0.59, 95% CI −1.10 to −0.07, p = .03), maintained on sensitivity analysis for large ( p = .03) and high-quality ( p = .003) studies, but was marginally lost ( p = .06) on studies enrolling patients with peripheral arterial disease only. PNC treatment did not affect postoperative pain scores ( p = .48), in-hospital mortality ( p = .77), phantom limb pain ( p = .28) or stump pain ( p = .37). GRADE quality of evidence for all outcomes was very low. Conclusion There is poor-quality evidence that PNC usage significantly reduces opioid consumption following lower limb amputation, without affecting other short- or long-term outcomes. Well-performed randomised studies are required.
This observational study aimed to evaluate the impact of intensity of radiological surveillance on survival following resection of retroperitoneal sarcoma.
Retrospective cohort study of patients ...undergoing primary resection of soft tissue sarcoma arising in the retroperitoneum, abdomen or pelvis at a single, high-volume sarcoma centre. Intensity of follow-up regimes up to 5 postoperative years were categorized as ‘European Society for Medical Oncology (ESMO) compliant’ (intense), or ‘non-ESMO compliant’ (less-intense). The primary outcome measure was overall survival (OS). The secondary outcome measures were disease-free survival (DFS) and reoperation rate. Analyses were stratified by high (grade 2 or 3) or low (grade 1) tumour grade.
Of 168 patients, 67.1% had high-grade and 32.9% had low-grade disease. Overall, 40.0% of patients had ESMO-compliant radiological follow-up (high-grade:25.7%, low-grade:66.7%). 41.7% of patients died and 48.2% suffered local or distant recurrence by cessation of follow up. Upon univariable analysis for high-grade tumours, ESMO compliance reduced DFS (p = 0.066) but had no impact on OS. There was no significant difference in the reoperation rate in patients with ESMO-compliant and non-compliant follow-up (p = 0.097). In low-grade tumours, ESMO compliance significantly reduced DFS (p < 0.001), but without effecting OS. In risk-adjusted models for high-grade tumours, ESMO compliant follow-up was associated with reduced OS (HR:3.47, 1.40–8.61, p = 0.007) and no difference in DFS. In low-grade tumours, there was no association between overall ESMO compliance and OS or DFS.
This study did not find a benefit for high-intensity radiological surveillance and overall survival in patients undergoing primary resection for high or low-grade retroperitoneal sarcoma.
Surgery is a carbon-heavy activity and creates a high volume of waste. Surgical teams around the world want to deliver more environmentally sustainable surgery but are unsure what to do and how to ...create change. There are many interventions available, but resources and time are limited. Capital investment into healthcare and engagement of senior management are challenging. However, frontline teams can change behaviours and drive wider change. Patients have a voice here too, as they would like to ensure their surgery does not harm their local community but are concerned about the effects on them when changes are made. Environmentally sustainable surgery is at the start of its journey. Surgeons need to rapidly upskill their generic knowledge base, identify which measures they can implement locally and take part in national research programmes. Surgical teams in the NHS have the chance to create a world-leading programme that can bring change to hospitals around the world. This article provides an overview of how surgeons see the surgical team being involved in environmentally sustainable surgery.
Background
Over the past 10 years, the National Health Service in England has started to publish surgeon‐specific outcomes publicly. The aim of this study was to investigate how this has affected ...training case exposure for surgeons in training.
Methods
Anonymized data were collected from the Intercollegiate Surgical Curriculum Programme database for operations in each specialty with published surgeon outcomes, involving surgical trainees on an approved training programme between 1 January 2011 and 31 December 2016. Trainee and supervisor involvement in operations before and after the start of publication of surgeon‐specific outcomes were compared using mixed‐effects models.
Results
A total of 163 076 recorded operative procedures were included. A statistically significant improvement in exposure to training procedures was observed for anterior resection of rectum, carotid endarterectomy, gastrectomy, meningioma excision, prostatectomy and thyroidectomy following the introduction of publication of surgeon outcomes. In coronary artery bypass grafting (CABG) and total hip replacement (THR), however, there was a reduction in involvement in training procedures. This was apparent for both trainee and supervisor involvement in CABG, and for trainee involvement in THR.
Conclusion
Exposure to training procedures has improved rather than declined in the UK in the majority of surgical specialties, since the publication of surgeon‐specific outcomes.
The aim of this study was to investigate how surgeon‐specific outcome reporting has affected training case exposure for surgeons in training. Anonymized data were collected from the Intercollegiate Surgical Curriculum Programme database for operations in each specialty with published surgeon‐specific outcomes involving surgical trainees on an approved training programme between 1 January 2011 and 31 December 2016. A total of 163 076 recorded procedures showed a statistically significant improvement in exposure to training cases for anterior resection of rectum, carotid endarterectomy, gastrectomy, meningioma excision, prostatectomy and thyroidectomy following the introduction of surgeon‐specific outcomes. In coronary artery bypass grafting (CABG) and total hip replacement (THR), however, there was a reduction in involvement in training cases. This was apparent for both trainee and supervisor involvement in CABG, and for trainee involvement in THR.
Surprisingly, improves access to training
Introduction Solitary extramedullary plasmacytoma are rare, solid-mass tumours which appear immunophenotypically similar to multiple myeloma. The diagnosis and management of gastrointestinal ...plasmacytoma is complex and requires multidisciplinary input. This study presents a narrative review of intra-abdominal extramedullary plasmacytoma, illustrated with two case studies. Methods The PubMed database was searched without date restrictions for reports of intra-abdominal extramedullary plasmacytoma to synthesise a narrative review. Electronic records were reviewed at a high-volume, quaternary soft-tissue sarcoma centre to identify patients with histopathologically confirmed extramedullary plasmacytoma affecting the gastrointestinal tract. Results Gastrointestinal extramedullary plasmacytomas can present with mass effect or organ-specific dysfunction. Techniques for tissue diagnosis of extramedullary plasmacytoma vary dependent on location, with a formal diagnosis often being made from a resected specimen. Management can include surgery, radiotherapy, systemic chemotherapy or a combination. No high-quality evidence base exists to guide treatment. Two case studies of operated gastrointestinal extramedullary plasmacytoma are presented at different phases of disease progression, with a resultant impact on survival. Conclusion Intra-abdominal extramedullary plasmacytoma is a rare and heterogeneous condition that lacks consensus guidelines for diagnosis and management. Collaboration between international specialist centres will create better quality evidence for treatment of this cohort.
Background
Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterize the stage of innovation for biological mesh devices used ...during complex abdominal wall reconstruction and to evaluate the quality of current evidence.
Methods
A systematic review was performed of published and ongoing studies between January 2000 and September 2017. Eligible studies were those where a biological mesh was used to support fascial closure, either prophylactically after midline laparotomy, or for reinforcement after repair of incisional hernia with midline incision. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the GRADE criteria for study quality.
Results
Thirty‐five studies including 2681 patients were included. Four studies considered mesh prophylaxis, 23 considered hernia repair, and eight reported on both. There was one published randomized trial (IDEAL stage 3), none of which was of high quality; the others were non‐randomized studies (IDEAL stage 2a). A detailed description of surgical technique was provided in most studies (27 of 35); however, no study reported outcomes according to the European Hernia Society consensus statement and only two described quality control of surgical technique during the study. From 21 ongoing randomized trials and observational studies, 11 considered repair of incisional hernia and 10 considered prophylaxis (seven in elective settings).
Conclusion
The evidence base for biological mesh is limited, and better reporting and quality control of surgical techniques are needed. Although results of ongoing trials over the next decade will improve the evidence base, further study is required in the emergency and contaminated settings.
Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterize the stage of innovation for biological mesh devices used during complex abdominal wall reconstruction and to evaluate the quality of current evidence. Of the 35 studies including 2681 patients, four considered mesh prophylaxis, 23 considered hernia repair, and eight reported on both. There was only one published randomized trial, and none of the studies was of high quality. The evidence base for biological mesh is limited and further studies are required in the emergency and contaminated settings.
Biological mesh needs more evidence
Recommendations for Randomised Trials in Surgical Oncology Glasbey, J.C.; Magill, E.L.; Brock, K. ...
Clinical oncology (Royal College of Radiologists (Great Britain)),
December 2017, 2017-Dec, 2017-12-00, 20171201, Letnik:
29, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Trials of surgical procedures in the treatment of malignant disease face a unique set of challenges. This review aimed to describe recommendations for the design, delivery and reporting of randomised ...trials in surgical oncology. A literature search was carried out without date limits to identify articles related to trial methodology research in surgery and surgical oncology. A narrative review was framed around two open National Institute of Health Research portfolio trials in colon and rectal cancer: the STAR-TREC trial (ISRCTN14240288) and the ROCCS trial (ISRCTN46330337). Twelve specific challenges were highlighted: standardisation of technique; pilot and feasibility studies; balancing treatments; the recruitment pathway; outcome measures; patient and public representation; trainee-led networks; randomisation; novel techniques and training; learning curves; blinding; follow-up. Evidence-based recommendations were made for the future design and conduct of surgical oncology trials. Better understanding of the challenges facing trials in the surgical treatment of cancer will accelerate high-quality evaluation and rapid adoption of innovation for the benefit of patient care.
PDF
