Making music in the operating theatre Bosanquet, David C; Glasbey, James CD; Chavez, Raphael
BMJ (Online),
12/2014, Letnik:
349, Številka:
dec10 27
Journal Article
nationalresearchcollaborative@gmail.com van Schalkwyk and colleagues discuss the health effects of a no deal Brexit.1 After the United Kingdom’s referendum on European Union (EU) membership, medical ...students and postgraduate trainees from across Europe made a commitment to continue to support pan-European research collaboration.23 International collaboration enables rapid completion of large, high quality studies, producing broadly generalisable data that inform improvements to patient care.4 Now the UK has left the EU, it is meaningful to see studies being published by student and trainee driven European collaboratives.56 These studies have been delivered by actively engaging thousands of students and trainees across Europe to work together for the benefit of patients. Signatories: Riaz A Agha (Academic Surgery Collaborative); Rory J Piper, Angelos Kolias, Aimun Jamjoom (British Neurosurgical Trainee Research Collaborative); Veeru Kasivisvanathan (British Urology Researchers in Surgical Training); Ruth Blanco-Colino, Alessandro Sgrò (European Student Research Collaborative); Carly Welch, Lauren McCluskey (Geriatric Medicine Research Collaborative); Ewen Harrison (GlobalSurg Collaborative); Francesco Pata, Gianluca Pellino (Italian Surgical Research Group); Sarantos Kaptanis (London Surgical Research Group); Joana Simoes, António Sampaio Soares (Portuguese Surgical Research Collaborative); George Ramsay, Michael Wilson (Scottish Surgical Research Group); Natalie Blencowe (Severn and Peninsula Audit and Research Collaborative for Surgeons); Richard Wilkin (Single Use Negative pRessure dressing for Reduction In Surgical site infection following Emergency laparotomy); Kenneth A McLean, Sivesh K Kamarajah, Emily C Mills (Student Audit and Research in Surgery Collaborative); Niall Brindl, Julia Gsenger, Charlotte Kuner, Marius Schwab (Student-Initiated German Medical Audit); Rhianon Reynolds (Welsh Ophthalmic Research Collaborative); James Glasbey, Richard Evans, Dmitri Nepogodiev (West Midlands Research Collaborative); Joshua Burke, Peter Coe (White Rose Surgical Collaborative). Evaluation of appendicitis risk prediction models in adults with suspected appendicitis.
Background
The National Institute for Health Research Global Health Research Unit on Global Surgery is establishing research Hubs in low‐ and middle‐income countries (LMICs). The aim of this study ...was for the Hubs to prioritize future research into areas of unmet clinical need for patients in LMICs requiring surgery.
Methods
A modified Delphi process was overseen by the research Hub leads and engaged LMIC clinicians, patients and expert methodologists. A four‐stage iterative process was delivered to prioritize research topics. This included anonymous electronic voting, teleconference discussions and a 2‐day priority‐setting workshop.
Results
In stage 1, Hub leads proposed 32 topics across six domains: access to surgery, cancer, perioperative care, research methods, acute care surgery and communicable disease. In stages 2 and 3, 40 LMICs and 20 high‐income countries participated in online voting, leading to identification of three priority research topics: access to surgery; outcomes of cancer surgery; and perioperative care. During stage 4, specific research plans to address each topic were developed by Hub leads at a priority‐setting workshop.
Conclusion
This process identified three priority areas for future research relevant to surgery in LMICs. It was driven by front‐line LMIC clinicians, patients and other stakeholders representing a diverse range of settings. The results of the prioritization exercise provide a future framework for researchers and funders.
Priorities agreed
Background
Schwannomas are rare tumours that pose a significant management challenge in the abdomen, retroperitoneum and pelvis. No data are available to inform management strategy.
Methods
A ...collaborative international cohort study, across specialist sarcoma units, was conducted to include adults presenting between 2000 and 2017 with histopathologically confirmed schwannomas within the abdomen, retroperitoneum or pelvis.
Results
Of 485 patients across 12 centres, 38 (7·8 per cent) were discharged without follow‐up, 199 (41·0 per cent) underwent early resection and 248 (51·1 per cent) had radiological monitoring. Of these 248 patients, 96 (38·7 per cent) eventually had surgery, giving an overall resection rate of 60·8 per cent (295 of 485). At baseline, median tumour volume was 90·1 (i.q.r. 26·5–262·0) cm3. The estimated growth rate was 10·5 (95 per cent c.i. 9·4 to 11·6) per cent per year, and was consistent in the short term (within 2 years of diagnosis) and long term (beyond 2 years) (ρ = 0·405, P = 0·021). A decision to operate was more common in symptomatic patients (P < 0·001) and for rapidly growing tumours (growth rate more than 20 per cent per year) (P = 0·025). R0/R1 resection was achieved in 91·6 per cent of patients (263 of 287). Kaplan–Meier long‐term recurrence rates after R0/R1 resection were 2·3 and 6·7 per cent at 3 and 5 years respectively.
Conclusion
Specific recommendations include: indications for early surgery, prediction of growth from radiological monitoring, promotion of selective submacroscopic resection and cessation of postoperative imaging surveillance.
Antecedentes
Los schwannomas son tumores raros que plantean un importante desafío para su tratamiento en el abdomen, retroperitoneo y pelvis. No existen datos disponibles que informen de la estrategia de tratamiento.
Métodos
Se llevó a cabo un estudio de cohortes colaborativo internacional, entre unidades especializadas en sarcomas, que incluía a pacientes adultos con schwannomas de la cavidad abdominal, retroperitoneo o pelvis con confirmación histológica que se presentaron entre 2000 y 2017.
Resultados
De 485 pacientes de los 12 centros, 38 (7,8%) fueron dados de alta sin seguimiento, 199 (41,0%) fueron sometidos a resección precoz y 248 (51,1%) pacientes se incluyeron en seguimiento radiológico, de estos últimos 96 pacientes (38,7%) fueron sometidos finalmente a cirugía, con una tasa global de resección del 60,8% (295/485). Al inicio, la mediana del volumen tumoral fue 90,1 cm3 (rango intercuartílico: 26,5‐262,0). La tasa media de crecimiento fue 10,5% por año (i.c. del 95%: 9,4%‐11,6%), siendo uniforme en el seguimiento a corto (durante los 2 años del diagnóstico) y largo plazo (más allá de los 2 años, rho: 0,405, P = 0,021). La decisión de establecer la indicación quirúrgica fue más frecuente en pacientes sintomáticos (P < 0,001) y en tumores con crecimiento rápido (> 20% por año, P = 0,025). Se consiguió una resección R0/R1 en el 91,6%. Las tasas de recidiva a largo plazo de Kaplan‐Meier tras resección R0/R1 fueron 2% y 7% a 3 y 5 años, respectivamente.
Conclusión
Las recomendaciones específicas incluyen: indicaciones para la cirugía precoz, predicción del crecimiento en el seguimiento radiológico, fomentar la resección submacroscópica selectiva, y cese del seguimiento postoperatorio con pruebas de imagen.
Schwannomas present a significant management challenge, and surgery can result in morbidity. Individualized growth rates predicted after a period of radiological monitoring can help guide decision‐making. There is no role for surveillance after resection.
Practical guidelines
Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies ...makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries.
Centres from a randomized controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle- (India, Mexico) and two lower-middle- (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5 cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated vs contaminated-dirty), country and timing (inpatient vs outpatient).
A total of 335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international Euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases were in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery.
SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.
Aim
Postoperative drains have historically been used for the prevention and early detection of intra‐abdominal collections. However, current evidence suggests that prophylactic drain placement ...following colorectal surgery has no significant clinical benefit. This is reflected in the enhanced recovery after surgery (ERAS) guidelines, which recommend against their routine use. The Ileus Management International study found more than one‐third of participating centres across the world routinely used drains in the majority of colorectal resections. The aim of the present study is to audit international compliance with ERAS guidelines regarding the use of postoperative drains in colorectal surgery.
Method
This prospective, multicentre audit will be conducted via the student‐ and trainee‐led EuroSurg Collaborative network across Europe, South Africa and Australasia. Data will be collected on consecutive patients undergoing elective and emergency colorectal surgery with 30‐day follow‐up. This will include any colorectal resection, formation of colostomy/ileostomy and reversal of stoma. The primary end‐point will be adherence to ERAS guidelines for intra‐abdominal drain placement. Secondary outcomes will include the following: time to diagnosis of intra‐abdominal postoperative collections; output and time to removal of drains; and 30‐day postoperative complications defined by the Clavien–Dindo classification.
Conclusion
This protocol describes the methodology for the first international audit of intra‐abdominal drain placement after colorectal surgery. The study will be conducted across a large collaborative network with quality assurance and data validation strategies. This will provide a clear understanding of current practice and novel evidence regarding the efficacy and safety of intra‐abdominal drain placement in colorectal surgical patients.
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