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Huttman MM, Robertson HF, Smith AN, Biggs SE, Dewi F, Dixon LK, Kirkham EN, Jones CS, Ramirez J, Scroggie DL, Zucker BE, Pathak S, Blencowe NS. A systematic review of robot-assisted anti-reflux surgery to examine reporting standards. J Robot Surg 2022; 17:313-324. [PMID: 36074220 PMCID: PMC10076351 DOI: 10.1007/s11701-022-01453-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/11/2022] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Marc M Huttman
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Harry F Robertson
- St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sarah E Biggs
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ffion Dewi
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lauren K Dixon
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Emily N Kirkham
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | - Conor S Jones
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Jozel Ramirez
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Darren L Scroggie
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Benjamin E Zucker
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Samir Pathak
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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Kirkham EN, Jones CS, Higginbotham G, Biggs S, Dewi F, Dixon L, Huttman M, Main BG, Ramirez J, Robertson H, Scroggie DL, Zucker B, Blazeby JM, Blencowe NS, Pathak S. A systematic review of robot-assisted cholecystectomy to examine the quality of reporting in relation to the IDEAL recommendations: systematic review. BJS Open 2022; 6:6770691. [PMID: 36281734 PMCID: PMC9593068 DOI: 10.1093/bjsopen/zrac116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/12/2022] [Accepted: 08/18/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Emily N Kirkham
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Musgrove Park Hospital, Taunton, UK
| | - Conor S Jones
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- North Bristol NHS Foundation Trust, Bristol, UK
| | | | - Sarah Biggs
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ffion Dewi
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lauren Dixon
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Marc Huttman
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Barry G Main
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Dental School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research centre, Bristol, UK
| | - Jozel Ramirez
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Harry Robertson
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Imperial College Healthcare NHS Trust, London
| | - Darren L Scroggie
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Benjamin Zucker
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research centre, Bristol, UK
| | - Natalie S Blencowe
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical research centre, Bristol, UK
| | - Samir Pathak
- Correspondence to: Sami Pathak, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK (e-mail: )
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Dewi F, Scroggie D, Pathak S, Blencowe N, Hollowood A, Strong S, Jah A, Smith A, Van Laarhoven S. P-O05 Deconstructing Operations to Improve Recording of Surgical Training Experience. Br J Surg 2021. [PMCID: PMC9383123 DOI: 10.1093/bjs/znab430.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
A new outcomes-based curriculum is soon to be implemented for UK surgical trainees. Performance will be evaluated against the standard expected of a new consultant. Accurate recording of operative experience and performance will therefore be crucial to demonstrate achievement of this standard. The current eLogbook system for recording surgical experience has many benefits including simplicity and accessibility, but may misrepresent actual experience because most operations are considered as a whole; unlike some colorectal operations, involvement in steps within many upper gastrointestinal (UGI) operations cannot be recorded.
Methods
Impact on training by the COVID-19 pandemic led to discussion and identification of cultural and logistical barriers to accurate recording of experience. To address these, a modification to enhance the current eLogbook system was developed by trainees and trainers at a university teaching hospital. An existing typology was used to deconstruct common UGI operations into their component steps, which can be recorded at this more detailed level.
Results
The modified deconstructed logbook concept is described using a worked example, which can be applied to any operation. We also describe the integration of a component-based training discussion into the surgical team brief and debrief; this complements the deconstructed logbook by promoting a training culture.
Conclusions
Using the described techniques, trainees of all levels can comprehensively and accurately describe their surgical experience. Senior trainees will benefit from recording complex operations which they are not expected to complete in their entirety, whilst less experienced trainees will benefit from the ability to record their involvement in more basic parts of operations. The suggested approach will reduce misrepresentation of experience, encourage proactive planning of training opportunities, and reduce the impact of crises such as pandemics on surgical training.
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Affiliation(s)
- Ffion Dewi
- South West Surgical Deanery, Bristol, United Kingdom
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Darren Scroggie
- Bristol Centre for Surgical Research, Bristol, United Kingdom
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
- NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom
| | - Samir Pathak
- Bristol Centre for Surgical Research, Bristol, United Kingdom
- NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom
- Department of Surgery, St James' University Hospital, Leeds, United Kingdom
| | - Natalie Blencowe
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
- Bristol Centre for Surgical Research, Bristol, United Kingdom
- NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom
| | - Andrew Hollowood
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Sean Strong
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Asif Jah
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew Smith
- Department of Surgery, St James' University Hospital, Leeds, United Kingdom
| | - Stijn Van Laarhoven
- Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
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Biggs S, Dixon L, Brankin-Frisby T, Dewi F, Torkington A, Olivier J, Kirkham E. 1165 Reporting Patient Selection in Robotic Cholecystectomy: Less than IDEAL? A Systematic Review. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Laparoscopic cholecystectomy is the gold standard definitive treatment option for benign biliary disease. There has been increasing interest in novel robotic surgical techniques; robotic cholecystectomy (RC) represents the most recent innovation in the management of gallstones. The IDEAL Collaboration has provided guidance for the rigorous and comprehensive reporting of surgical innovations, despite this, transparency in patient selection has been limited. We aimed to assess the reporting of patient selection in studies reporting RC.
Method
A collaborative, systematic review was conducted in accordance with the PRISMA guidance to identify all published studies reporting RC. Study specific inclusion and exclusion criteria were detailed in a protocol.
Results
Searches identified 1425 abstracts; 90 papers were included for data extraction. Inclusion criteria were reported in 38 (42%) studies. The most frequently cited were age (20%), aetiology (20%), presence of symptoms (16%) and comorbidities (10%). Forty-nine (54%) studies reported exclusion criteria. Numerous and variably reported exclusion criteria were reported; acute cholecystitis (26%), previous abdominal surgery (25%), comorbidity (17%), pregnancy (13%), common bile duct stones (13%) and pancreatitis (10%) among others. Seven reported no exclusion criteria. Three reported numbers of patients who declined RC.
Conclusions
Patient selection criteria were inconsistently reported and when present lacked standardisation. Concern persists around patients being “cherry picked” for inclusion in studies reporting innovative robotic surgical procedures, making interpretation and applicability of results impossible. Standardised inclusion criteria are needed to enable greater transparency and reproducibility to ensure the safe adoption of new technologies into clinical practice.
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Affiliation(s)
- S Biggs
- University Hospital Bristol, Bristol, United Kingdom
| | - L Dixon
- University Hospital Bristol, Bristol, United Kingdom
| | | | - F Dewi
- University Hospital Bristol, Bristol, United Kingdom
| | | | - J Olivier
- Severn Deanery, Bristol, United Kingdom
| | - E Kirkham
- Gloucestershire Hospitals NHS Trust, Gloucester, United Kingdom
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5
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Jones CS, Dada M, Dewhurst M, Dewi F, Pathak S, Main BG, Blencowe NS. O2 Facilitating engagement in surgical research through a virtual systematic review network: The RoboSurg Collaborative. BJS Open 2021. [PMCID: PMC8030212 DOI: 10.1093/bjsopen/zrab033.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction For students and trainees, COVID-19 has restricted opportunities for training and development. We sought to develop a virtual network to facilitate remote engagement and training in surgical research during COVID-19. RoboSurg aims to conduct a series of systematic reviews, to summarise and critique the reporting of studies of robot-assisted surgery across seven upper gastrointestinal procedures. Methods A protocol was developed based on previously published work. Searches were undertaken to identify studies evaluating robotic pancreas, liver, oesophagus, stomach, gallbladder, bariatric and anti-reflux surgery. Participants were identified through social media and collaborative research networks. Abstracts were screened for inclusion by two participants. Data extraction is completed by teams of collaborators, entered into a bespoke REDCap database and verified by senior team member. Changes are logged, with rationale and feedback provided to collaborators and reviewed by a third reviewer to assess consistency. Results of each review will be summarised in narrative syntheses. Results A total of 134 collaborators have registered, with 73 active participants. Collaborators range from second year medical students to surgical registrars across the UK. To date, 9444 abstracts and 1653 full texts have been screened with 422 eligible articles identified. Data extraction for two systematic reviews, including 193 articles, has been completed using this approach. Conclusion RoboSurg has developed a network and methodological framework for the remote conduction of complex systematic reviews, which can be utilised to engage and train students and trainees in surgical research.
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Newton L, Dewi F, McNair A, Gane D, Rogers J, Dean H, Pullyblank A. The community burden of surgical site infection following elective colorectal resection. Colorectal Dis 2021; 23:724-731. [PMID: 33131179 DOI: 10.1111/codi.15420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/04/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Lydia Newton
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Ffion Dewi
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Angus McNair
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dawn Gane
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Jodie Rogers
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Harry Dean
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Anne Pullyblank
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
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Carter B, Law J, Hewitt J, Parmar KL, Boyle JM, Casey P, Maitra I, Pearce L, Moug SJ, Ross B, Oleksiewicz J, Fearnhead N, Jump C, Boyle J, Shaw A, Barker J, Hughes J, Randall J, Tonga I, Kynaston J, Boal M, Eardley N, Kane E, Reader H, Mahapatra SR, Garner-Jones M, Tan JJ, Mohamed S, George R, Whiteman E, Malik K, Smart CJ, Bogdan M, Chaudhury MP, Sharma V, Subar D, Patel P, Chok SM, Lim E, Adhiyaman V, Davies G, Ross E, Maitra R, Steele CW, Roxburgh C, Griffiths S, Blencowe NS, Kirkham EN, Abraham JS, Griffiths K, Abdulaal Y, Iqbal MR, Tarazi M, Hill J, Khan A, Farrell I, Conn G, Patel J, Reddy H, Sarveswaran J, Arunachalam L, Malik A, Ponchietti L, Pawelec K, Goh YM, Vitish-Sharma P, Saad A, Smyth E, Crees A, Merker L, Bashir N, Williams G, Hayes J, Walters K, Harries R, Singh R, Henderson NA, Polignano FM, Knight B, Alder L, Kenchington A, Goh YL, Dicurzio I, Griffiths E, Alani A, Knight K, MacGoey P, Ng GS, Mackenzie N, Maitra I, Moug S, Ong K, McGrath D, Gammeri E, Lafaurie G, Faulkner G, Di Benedetto G, McGovern J, Subramanian B, Narang SK, Nowers J, Smart NJ, Daniels IR, Varcada M, Gala T, Cornish J, Barber Z, O'Neill S, McGregor R, Robertson AG, Paterson-Brown S, Raymond T, Thaha MA, English WJ, Forde CT, Paine H, Morawala A, Date R, Casey P, Bolton T, Gleaves X, Fasuyi J, Durakovic S, Dunstan M, Allen S, Riga A, Epstein J, Pearce L, Gaines E, Howe A, Choonara H, Dewi F, Bennett J, King E, McCarthy K, Taylor G, Harris D, Nageswaran H, Stimpson A, Siddiqui K, Lim LI, Ray C, Smith L, McColl G, Rahman M, Kler A, Sharma A, Parmar K, Patel N, Crofts P, Baldari C, Thomas R, Stechman M, Aldridge R, O'Kelly J, Wilson G, Gallegos N, Kalaiselvan R, Rajaganeshan R, Mackenzie A, Naik P, Singh K, Gandraspulli H, Wilson J, Hancorn K, Khawaja A, Nicholas F, Marks T, Abbott C, Chandler S. Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy. Br J Surg 2020; 107:218-226. [DOI: 10.1002/bjs.11392] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/20/2019] [Accepted: 09/12/2019] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.
Methods
The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.
Results
A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.
Conclusion
Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.
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Affiliation(s)
- B Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - J Law
- Department of Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - J Hewitt
- Department of Population Medicine, Cardiff University, Cardiff, UK
| | - K L Parmar
- Manchester Cancer Research Centre, Manchester, NorthWest Deanery, UK
| | - J M Boyle
- Royal College of Surgeons of England, London, UK
| | - P Casey
- Health Education North West, Manchester, NorthWest Deanery, UK
| | - I Maitra
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - L Pearce
- Department of Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
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Davies A, Pang WS, Fowler T, Dewi F, Wright T. Preoperative fasting in the department of plastic surgery. BMJ Open Qual 2018; 7:e000161. [PMID: 30515463 PMCID: PMC6231091 DOI: 10.1136/bmjoq-2017-000161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 07/21/2018] [Accepted: 08/21/2018] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Davies
- Department of Orthopaedics, North Bristol NHS Trust, Bristol, UK
| | | | - Timothy Fowler
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
| | - Ffion Dewi
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
| | - Thomas Wright
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, UK
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Dewi F, Egan RJ, Abdelrahman T, Morris C, Stechman MJ, Lewis WG. Prognostic Significance of Acute Kidney Injury Following Emergency Laparotomy: A Prospective Observational Cohort Study. World J Surg 2018; 42:3575-3580. [PMID: 30097705 DOI: 10.1007/s00268-018-4744-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients' risk profile and consequent mortality. METHODS Consecutive 239 patients of median age 68 (IQR 51-76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality. RESULTS Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p < 0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p < 0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152-37.659, p < 0.001]. CONCLUSION Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.
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Affiliation(s)
- F Dewi
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - R J Egan
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - T Abdelrahman
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - C Morris
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - M J Stechman
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - W G Lewis
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK.
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Davies A, Dewi F, Pang J, Wright T. Reducing Patient Fasting Time on the Plastic Surgery Trauma List. Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Arnaout A, Khashaba H, Dobbs T, Dewi F, Pope-Jones S, Sack A, Estela C, Nguyen D. The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature. Burns 2017; 43:e1-e6. [DOI: 10.1016/j.burns.2017.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 11/11/2016] [Accepted: 01/05/2017] [Indexed: 11/28/2022]
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12
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Arnaout A, Dewi F, Nguyen D. Re: Burn injuries from exploding electronic cigarette batteries: An emerging public health hazard. J Plast Reconstr Aesthet Surg 2017; 70:981-982. [PMID: 28283387 DOI: 10.1016/j.bjps.2017.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Ali Arnaout
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK.
| | - Ffion Dewi
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Dai Nguyen
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
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Egan RJ, Dewi F, Arkell R, Ansell J, Zouwail S, Scott-Coombes D, Stechman M. Does elective parathyroidectomy for primary hyperparathyroidism affect renal function? A prospective cohort study. Int J Surg 2016; 27:138-141. [DOI: 10.1016/j.ijsu.2016.01.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/07/2016] [Accepted: 01/21/2016] [Indexed: 11/25/2022]
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14
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Dewi F, Henry A, Tennyson C, Fardy M, Bhatia S. Routine post-operative radiographs following orif of mandibular fractures: clinical need or unnecessary radiation? Int J Oral Maxillofac Surg 2013. [DOI: 10.1016/j.ijom.2013.07.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Dewi F, Sanapala C, Fardy M, Thomas C. An audit of blood ordering practices and transfusion requirements in head and neck free flap surgery. Int J Oral Maxillofac Surg 2013. [DOI: 10.1016/j.ijom.2013.07.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Gray D, Dewi F, Cronin A, Caccamese J. Le Fort 1 osteotomy - USA vs UK - Why the difference? Int J Surg 2012. [DOI: 10.1016/j.ijsu.2012.06.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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