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Al-Sarireh H, Al-Sarireh A, Mann K, Hajibandeh S, Hajibandeh S. Effect of surgeon's seniority and subspeciality interest on mortality after emergency laparotomy: A systematic review and meta-analysis. Colorectal Dis 2024; 26:1495-1504. [PMID: 38898583 DOI: 10.1111/codi.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 06/21/2024]
Abstract
AIM To evaluate effect of surgeon's seniority (trainee surgeon vs. consultant surgeon) and surgeon's subspeciality interest on postoperative mortality in patients undergoing emergency laparotomy (EL). METHOD A systematic review was conducted and reported according to the Cochrane Handbook for Systematic Reviews and the PRISMA statement standards, respectively. We evaluated all studies comparing the risk of postoperative mortality in patients undergoing EL between (a) trainee surgeon and consultant surgeon, and (b) surgeon without and with subspeciality interest related to pathology. Random effects modelling was applied for the analyses. The certainty of evidence was assessed using the GRADE system. RESULTS Analysis of 256 844 patients from 13 studies showed no difference in the risk of postoperative mortality between trainee-led and consultant-led EL (OR: 0.76, p = 0.12). However, EL performed by a surgeon without subspeciality interest related to the pathology was associated with a higher risk of postoperative mortality compared with a surgeon with subspeciality interest (OR: 1.38, p < 0.00001). In lower gastrointestinal (GI) pathologies, EL done by upper GI surgeons resulted in higher risk of mortality compared with lower GI surgeons (OR: 1.43, p < 0.00001). In upper GI pathologies, EL done by lower GI surgeons resulted in higher risk of mortality compared with upper GI surgeons (OR: 1.29, p = 0.05). CONCLUSION While confounding by indication cannot be excluded, level 2 evidence with moderate certainty suggests that trainee-led EL may not increase the risk of postoperative mortality but EL by a surgeon with subspeciality interest related to the pathology may reduce the risk of mortality.
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Affiliation(s)
| | | | - Karan Mann
- Department of General Surgery, Morriston Hospital, Swansea, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
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2
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Manzo CA, Annicchiarico A, Valiyeva S, Picciariello A, Gallo G, Bislenghi G. Practice of proctology among general surgery residents and young specialists in Italy: a snapshot survey. Updates Surg 2023; 75:1597-1605. [PMID: 37217636 DOI: 10.1007/s13304-023-01540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023]
Abstract
Anal diseases are very common and, in most of the cases, require surgery of minor or medium complexity, and, therefore, are among the most accessible diseases for surgeons in training. Aim of this study is to investigate the status of the training in proctology in Italy. A 31-items questionnaire was administered to residents and young specialists (≤ 2 years) in general surgery, using mailing lists, and the social media accounts of the Italian Society of Colorectal Surgery. Answers from 338 respondents (53.8% males) were included in the final analysis. Overall, 252 respondents (74.5%) were residents and 86 (25.5%) young specialists. Two hundred and fifty-five (75.4%) respondents practiced proctology for the first time early on during their postgraduate training, but only 19.5% did it continuously for ≥ 24 months. Almost all respondents (334; 98.8%) had the chance to participate in proctological procedures, 205 (60.5%) as first surgeon. This percentage decreases according to the complexity of the surgery. In fact, only 11 (3.3%) and 24 (7.1%) of the respondents were allowed to be the first surgeon in more complex proctological diseases such as surgery for rectal prolapse and fecal incontinence. The present survey suggests that, in Italy, most surgeons in training deal with anal diseases. However, only few of them could achieve sufficient professional skills in the management of proctological diseases to be able to practice autonomously as young specialists.
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Affiliation(s)
- Carlo Alberto Manzo
- Department of Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Alfredo Annicchiarico
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Unit of General Surgery, Vaio Hospital, Fidenza, Parma, Italy
| | - Sayali Valiyeva
- Surgical Coloproctology, University of L'Aquila Department of Clinical Medicine and Biotecnology, Val Vibrata Hospital, Sant'Omero, TE, Italy
| | - Arcangelo Picciariello
- Division of General Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", Bari, Italy.
| | - Gaetano Gallo
- Department of Surgery, La Sapienza" University of Rome, Rome, Italy
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Louvain, Belgium
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3
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Zanini A, von Sochaczewski CO, Basson S, Brisighelli G, Di Cesare A, Gabler T, Gentilino V, Gopal M, Grieve A, Harrison D, Patel N, Westgarth-Taylor C, Withers A, Loveland JA. Globalization in Pediatric Surgical Training: The Benefit of an International Fellowship in a Low-to-Middle-Income Country Academic Hospital. Eur J Pediatr Surg 2022; 32:363-369. [PMID: 34407553 DOI: 10.1055/s-0041-1734029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE A relative oversupply of pediatric surgeons led to increasing difficulties in surgical training in high-income countries (HIC), popularizing international fellowships in low-to-middle-income countries (LMIC). The aim of this study was to evaluate the benefit of an international fellowship in an LMIC for the training of pediatric surgery trainees from HICs. METHODS We retrospectively reviewed and compared the prospectively maintained surgical logbooks of international pediatric surgical trainees who completed a fellowship at Chris Hani Baragwanath Academic Hospital in the last 10 years. We analyzed the number of surgeries, type of involvement, and level of supervision in the operations. Data are provided in mean differences between South Africa and the respective home country. RESULTS Seven fellows were included. Operative experience was higher in South Africa in general (Δx̅ = 381; 95% confidence interval [CI]: 236-656; p < 0.0001) and index cases (Δx̅ = 178; 95% CI: 109-279; p < 0.0001). In South Africa, fellows performed more index cases unsupervised (Δx̅ = 71; 95% CI: 42-111; p < 0.0001), but a similar number under supervision (Δx̅ = -1; 95% CI: -25-24; p = 0.901). Fellows were exposed to more surgical procedures in each pediatric surgical subspecialty. CONCLUSION An international fellowship in a high-volume subspecialized unit in an LMIC can be highly beneficial for HIC trainees, allowing exposure to higher caseload, opportunity to operate independently, and to receive a wider exposure to the different fields of pediatric surgery. The associated benefit for the local trainees is some reduction in their clinical responsibilities due to the additional workforce, providing them with the opportunity for protected academic and research time.
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Affiliation(s)
- Andrea Zanini
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Christina Oetzmann von Sochaczewski
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Clinic and Policlinic for Paediatric Surgery, University of Mainz, Mainz, Germany
| | - Sonia Basson
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Antonio Di Cesare
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Policlinico Milano, Italy
| | - Tarryn Gabler
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Valerio Gentilino
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Unit of Pediatric Surgery, Woman and Child Department, Filippo del Ponte Hospital - ASST Sette Laghi, Varese, Italy
| | - Milan Gopal
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew Grieve
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Derek Harrison
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nirav Patel
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Chris Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Aletha Withers
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jerome A Loveland
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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4
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Perioperative and oncologic outcomes of interval colectomy performed by acute care surgeons after stenting as a bridge to surgery for left-sided malignant colonic obstruction are non-inferior to the outcomes of colorectal surgeons in the elective setting: single center experience. Eur J Trauma Emerg Surg 2022; 48:4651-4660. [PMID: 35708740 DOI: 10.1007/s00068-022-02015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To analyze if perioperative and oncologic outcomes with stenting as a bridge to surgery (SEMS-BS) and interval colectomy performed by acute care surgeons for left-sided occlusive colonic neoplasms (LSCON) are non-inferior to those obtained by colorectal surgeons for non-occlusive tumors of the same location in the full-elective context. METHODS From January 2011 to January 2021, patients with LSCON at University Regional Hospital in Málaga (Spain) were directed to a SEMS-BS strategy with an interval colectomy performed by acute care surgeons and included in the study group (SEMS-BS). The control group was formed with patients from the Colorectal Division elective surgical activity dataset, matching by ASA, stage, location and year of surgery on a ratio 1:2. Stages IV or palliative stenting were excluded. Software SPSS 23.0 was used to analyze perioperative and oncologic (defined by overall -OS- and disease free -DFS-survival) outcomes. RESULTS SEMS-BS and control group included 56 and 98 patients, respectively. In SEMS-BS group, rates of technical/clinical failure and perforation were 5.35% (3/56), 3.57% (2/56) and 3.57% (2/56). Surgery was performed with a median interval time of 11 days (9-16). No differences between groups were observed in perioperative outcomes (laparoscopic approach, primary anastomosis rate, morbidity or mortality). As well, no statistically significant differences were observed in OS and DFS between groups, both compared globally (OS:p < 0.94; DFS:p < 0.67, respectively) or by stages I-II (OS:p < 0.78; DFS:p < 0.17) and III (OS:p < 0.86; DFS:p < 0.70). CONCLUSION Perioperative and oncologic outcomes of a strategy with SEMS-BS for LSCON are non-inferior to those obtained in the elective setting for non-occlusive neoplasms in the same location. Technical and oncologic safety of interval colectomy performed on a semi-scheduled situation by acute care surgeons is absolutely warranted.
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5
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Russell T, Chen F. Quality issues in emergency colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hallam S, Bickley M, Phelan L, Dilworth M, Bowley DM. Does declared surgeon specialist interest influence the outcome of emergency laparotomy? Ann R Coll Surg Engl 2020; 102:437-441. [PMID: 32374217 DOI: 10.1308/rcsann.2020.0098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. METHODS Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. RESULTS Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. CONCLUSION Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.
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Affiliation(s)
- S Hallam
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Bickley
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - L Phelan
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Dilworth
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D M Bowley
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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7
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Dissanayake B, Burstow MJ, Jeyakumar A, Yuide PJ, Gundara J, Chua TC. Operative Surgery is Rarely Required in the Acute Management of Diverticulitis in the Modern Era. Am Surg 2020. [DOI: 10.1177/000313482008600426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute diverticulitis is an emergency surgical condition that is commonly managed via an acute surgical unit model. Operative surgery is indicated in selected situations including generalized peritonitis or fistulous disease; however, limited data exist on how borderline patients potentially needing surgery may be salvaged by close clinical management with modern interventional techniques. The aims of the study were to identify the operative surgery rates in acute diverticulitis and predictors for identifying patients with complicated diverticulitis. Retrospective data collection was performed on a prospectively held database at a high-volume acute surgical unit at Logan Hospital, Queensland. Patient demographic data, disease-related factors, and treatment-related factors were collected for reporting and analysis. Over three years (2016–2018), 201 patients (64%) were admitted with uncomplicated diverticulitis and 113 patients (36%) with complicated diverticulitis. An observable downward trend was noted in the number of yearly admissions for uncomplicated diverticulitis. Complicated diverticulitis was associated with male gender ( P = 0.039), increased length of hospital stay ( P < 0.001), temperature ≥37.5 ( P = 0.025), increased white cell count ( P < 0.001), and elevated C-reactive protein ( P < 0.001). Twelve patients (11%) with complicated diverticulitis initially failed conservative management. Seven patients (6%) underwent a definitive Hartmann's procedure, and 5 patients (4%) underwent percutaneous drainage of abscesses. Acute diverticulitis can be safely managed nonoperatively by medical therapy and percutaneous drainage of abscesses, with surgery reserved for patients with complicated diver-ticulitis with sepsis or peritonitis.
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Affiliation(s)
| | - Matthew J. Burstow
- School of Medicine, Griffith University, Gold Coast, Australia and
- Department of Surgery, Logan Hospital, Meadowbrook, Australia
| | - Arunan Jeyakumar
- School of Medicine, Griffith University, Gold Coast, Australia and
| | - Peter J. Yuide
- Department of Surgery, Logan Hospital, Meadowbrook, Australia
| | - Justin Gundara
- School of Medicine, Griffith University, Gold Coast, Australia and
- Department of Surgery, Logan Hospital, Meadowbrook, Australia
| | - Terence C. Chua
- School of Medicine, Griffith University, Gold Coast, Australia and
- Department of Surgery, Logan Hospital, Meadowbrook, Australia
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8
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Could Forming a Stoma Alongside from the Principal Surgery Predict Mortality Among Operative Parameters? Indian J Surg 2019. [DOI: 10.1007/s12262-018-1844-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Ravindran P, Phan-Thien KC, Lubowski DZ. Continuous evolution of the management of sigmoid diverticulitis. ANZ J Surg 2019; 89:991-992. [PMID: 31522484 DOI: 10.1111/ans.15365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 06/20/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Praveen Ravindran
- Department of Colorectal Surgery, St George Hospital and The University of New South Wales, Sydney, New South Wales, Australia
| | - Kim-Chi Phan-Thien
- Department of Colorectal Surgery, St George Hospital and The University of New South Wales, Sydney, New South Wales, Australia
| | - David Z Lubowski
- Department of Colorectal Surgery, St George Hospital and The University of New South Wales, Sydney, New South Wales, Australia
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10
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Ang ZH, Wong S, Truskett P. General Surgeons Australia's 12-point plan for emergency general surgery. ANZ J Surg 2019; 89:809-814. [PMID: 31280492 DOI: 10.1111/ans.15327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022]
Abstract
In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on-call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12-point plan for emergency surgery. Since its release, the 12-point plan has been used as a benchmark of a well-functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12-point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12-point plan is relevant and has good evidence to support its framework.
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Affiliation(s)
- Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shing Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Truskett
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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11
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Ahmadi N, Howden WB, Ahmadi N, Byrne CM, Young CJ. Increasing primary anastomosis rate over time for the operative management of acute diverticulitis. ANZ J Surg 2019; 89:1080-1084. [PMID: 31272133 DOI: 10.1111/ans.15321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/01/2019] [Accepted: 05/12/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over the past two decades, there has been mounting evidence that primary anastomosis (PA) is a safe alternative to Hartmann's procedure (HP) in acute diverticulitis. In addition, specialized colorectal surgeons are more likely to perform PA. This study aimed to analyse if this evidence has led to an increase in the rate of PA in a major tertiary institution over time. METHODS A retrospective observational study of patients requiring operative management of acute diverticulitis from 1 January 2001 to 31 December 2015 at a tertiary teaching hospital. RESULTS One hundred and eighteen patients underwent surgery for acute diverticulitis. Patients who failed initial conservative management were more likely to have PA (43% versus 21%, P = 0.044). There was no difference in medical or surgical complications, readmission rate or mortality between patients who had a PA compared with HP. Patients were more likely to have a PA if a colorectal surgeon was operating compared with a colorectal surgery fellow or general surgeon (36% versus 19% versus 10%, P = 0.039). In patients with modified Hinchey 0-2, there was an increased PA rate within the study period, 21%, 43%, 63% to 57% from the first to the fourth quartile of patients (P = 0.038). CONCLUSIONS The mounting evidence for the safety of performing PA has led to an increase in the PA rates for acute diverticulitis. Patients who were operated by a colorectal surgeon were more likely to have a PA. The morbidity and mortality were similar in patients who had PA compared with HP.
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Affiliation(s)
- Nima Ahmadi
- Department of Colorectal Surgery, Discipline of Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - William B Howden
- Department of Colorectal Surgery, Discipline of Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nazanin Ahmadi
- Department of Colorectal Surgery, Discipline of Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher M Byrne
- Department of Colorectal Surgery, Discipline of Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Discipline of Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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12
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Abstract
BACKGROUND Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN This was a retrospective cohort study. SETTINGS Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.
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13
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Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit. Colorectal Dis 2018; 20 Suppl 6:47-57. [PMID: 30255647 DOI: 10.1111/codi.14373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. METHODS A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5). RESULTS From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. CONCLUSIONS Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.
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Affiliation(s)
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- European Society of Coloproctology (ESCP) Cohort Studies Committee, Hospital Universitari i Politècnic la Fe, València, Spain
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14
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Burmas M, Aitken RJ, Broughton KJ. Outcomes following emergency laparotomy in Australian public hospitals. ANZ J Surg 2018; 88:998-1002. [DOI: 10.1111/ans.14847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/28/2018] [Accepted: 08/04/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Melinda Burmas
- Department of General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - R. James Aitken
- Department of General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Katherine J. Broughton
- Department of General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
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15
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Golda T, Kreisler E, Rodriguez G, Miguel B, Biondo S. From colorectal to general surgeon in the management of left colonic perforation: A cohort study. Int J Surg 2018; 55:175-181. [DOI: 10.1016/j.ijsu.2018.05.732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 12/19/2022]
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16
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Tran S, Choi V, Hepburn K, Hewitt N, Zhou J, Chan DL, Talbot ML. Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care. ANZ J Surg 2017; 87:560-564. [PMID: 28512772 DOI: 10.1111/ans.13986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional 'generalist' general surgery approach or the ASU model. METHOD A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy. RESULTS Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries. CONCLUSION Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.
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Affiliation(s)
- Sonia Tran
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Vincent Choi
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Kirsten Hepburn
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Nathan Hewitt
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Joel Zhou
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel L Chan
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Michael L Talbot
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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17
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Harries RL, Williams AP, Ferguson HJM, Mohan HM, Beamish AJ, Gokani VJ. The future of surgical training in the context of the 'Shape of Training' Review: Consensus recommendations by the Association of Surgeons in Training. Int J Surg 2016; 36 Suppl 1:S5-S9. [PMID: 27562689 DOI: 10.1016/j.ijsu.2016.08.238] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/20/2016] [Indexed: 11/16/2022]
Abstract
ASiT has long maintained that in order to provide the best quality care to patients in the UK and Republic of Ireland, it is critical that surgeons are trained to the highest standards. In addition, it is imperative that surgery remains an attractive career choice, with opportunities for career progression and job satisfaction to attract and retain the best candidates. In 2013, the Shape of Training review report set out recommendations for the structure and delivery of postgraduate training in light of an ever increasingly poly-morbid and ageing population. This consensus statement outlines ASIT's position regarding recommendations for improving surgical training and aims to help guide discussions with regard to future proposed changes to surgical training.
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Affiliation(s)
- Rhiannon L Harries
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK.
| | - Adam P Williams
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Henry J M Ferguson
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Helen M Mohan
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Andrew J Beamish
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Vimal J Gokani
- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
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- Association of Surgeons in Training, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
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18
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Phan-Thien KC, Lubowski DZ. Acute diverticulitis: a complex management challenge. ANZ J Surg 2015; 85:698-9. [DOI: 10.1111/ans.13228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Kim-Chi Phan-Thien
- Department of Colorectal Surgery; St George Hospital; Sydney New South Wales Australia
- University of New South Wales; Sydney New South Wales Australia
| | - David Z. Lubowski
- Department of Colorectal Surgery; St George Hospital; Sydney New South Wales Australia
- University of New South Wales; Sydney New South Wales Australia
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