Sometimes you read a collection of paper and see common threads. Here are some from BJS Open.
Nihil sub sole novum
The phrase ‘nothing new under the sun’ is often a cry of despair borne from monotony. Is this true for appendicitis? From reading this article from 1893, there are certainly principles that remain constant. There has been a recent flurry of papers on appendicitis published in BJS Open. As I’ve been reading them as they hit early access, I thought it might be interesting to have a look at them and see where they fit in the wider context of the literature and practice.
We enter 2021 with the non-operative management of acute uncomplicated appendicitis being broadly accepted as a viable option. This has likely been increased by the (ongoing) COVID pandemic, with its subsequent impact on surgical resource and workforce availability.
And then we turn our attention to discriminating between complicated and uncomplicated appendicitis. What is the best modality? As a profession, we are keen not to over irradiate our patients with excessive CT scans. Naturally, we look to ultrasound and MRI scans. Unfortunately, a systematic review of diagnostic accuracy in all three modalities found limitations in both US and MRI, and a high negative predictive value when CT is used. So that is settled then, CT to reassure us that the patient has uncomplicated appendicitis and can be managed non-operatively.
Caution was raised by a study from Helsinki, Finland. This looked at 837 patients diagnosed with uncomplicated appendicitis on CT scan, and found that at surgery, 22% had perforated. The data is from 2014/2015, which isn’t *that* long ago, although it feels higher than I expected. So perhaps we need a better test to pick out complicated appendicitis?
Enter Kiss et al, who looked at genetic expression in peripheral blood mononuclear cells. This study found upregulation of genes associated with T & B cell interaction in those patients who had phlegmonous appendicitis, and upregulation of markers of antibacterial activity (e.g. monocytes and neutrophils). Perhaps this is interesting and personalised blood test to explore for the future. Point of care testing anyone? On the point of novel tests, an Irish group looked at the role of circulating fibrocytes in the diagnosis of appendicitis. This is a class of cells that is increased in states of inflammation. Sensitivity and specificity were in the high 60s, but in a modest sample that might be expected. Something to investigate further in a larger sample for sure.
And finally, the role of blood tests in the immunosuppressed, specifically the HIV+ve patient. We classically use blood tests such as leucocyte count or C-reactive protein to aid diagnosis. This study from South Africa showed that, perhaps counterintuitively, CRP levels tended to be higher in HIV+ve patients with appendicitis than HIV-ve patients with appendicitis. Leucocyte levels were lower in the HIV+ve group. Useful to know this data exists as many of the risk models used are not calibrated for this population.
To wrap this up, I want to point out the opening gambit from the paper by Kiss et al:
‘Surgeons know how to treat appendicitis: either surgically with appendicectomy and supporting measures like abscess drainage, or conservatively without operation’
Whilst we may retain the technical principles of surgery, there is work to do. This seems to be around:
Improving the diagnosis of appendicitis, hopefully avoiding radiation in the process.
Accurate estimation of risk of perforation in patients with a diagnosis of appendicitis
Publications arising in the last six months in BJS Open alone suggest that we have a way to go to truly ‘know‘ how to treat appendicitis.
Scientific research can be challenging to follow, especially for those who are not experts in the field. There is lots of interest in COVID-19 from the public. The authors of the paper published in the BJS have provided a plain English summary to help people understand the work.
As we continue in and between subsequent pandemic waves, and patients are booked for surgery, the CovidSurg cancer study data can help to identify where services can best spend resources to protect patients. This paper, published in the BJS evaluates the associations between SARS-CoV-2 testing before operations and serious breathing problems afterward.
SARS-CoV-2 swab testing before planned surgery reduces serious breathing complications
At least 28 million operations were delayed during the first COVID-19 pandemic wave. As we resume operating, we need the ability to identify patients with pre-symptomatic infection and postpone surgery to keep those patients safe. We also need to use resources wisely by testing in situations where it will likely provide a benefit.
To understand the value of preoperative SARS-CoV-2 testing to prevent serious breathing problems after surgery.
To maximise the benefits for patients and guide the use of resources, this study looks at where and when swab testing can change patient outcomes.
Surgical team members in 432 hospitals in 53 countries collected anonymised data for all patients having planned cancer surgery during the pandemic up to 19 April 2020. We included all patients with data about preoperative testing. Patients suspected of having the infection pre-operatively were excluded. Researchers recorded if a patient died or had serious breathing problems up to 30 days after their operation.
2303/8784 patients (23%) were tested for SARS-CoV-2 before their operation. 1458 had a swab test, 521 a CT scan of their chest and 324 had both tests. 6746 major operations and 1087 minor operations were performed in high SARS-CoV-2 risk areas and a minority of operations took place in low risk areas.
Overall, 4% of patients experienced serious breathing problems following surgery. The rate was higher in patients with no test or CT scan-only testing. At least one negative swab before operation reduced the risk of serious breathing problems after surgery. Having repeated swabs did not add extra benefit.
The data showed that swab testing reduced breathing problems in high risk COVID areas but not in low risk areas. It also showed that a swab before major surgery reduced breathing problems but not before minor surgery.
How many patients must be swabbed to prevent one patient having serious breathing problems?
To prevent one patient having serious breathing problems after major surgery, in a high risk area, 18 patients had to be swabbed; 48 had to be swabbed before minor surgery in a high risk area. This increased to 73 patients swabbed before major or 387 before minor surgery in low risk areas, to prevent one patient having breathing problems.
Some evidence also suggested there was a lower death rate among patients who were swabbed before their surgery.
The study group was able to recommend that ‘A single preoperative swab should be performed for patients with no clinical suspicion of COVID-19 before major surgery in both high and low risk areas and before minor surgery in high risk population areas’.
Swab testing before surgery is likely to benefit patients by identifying pre-symptomatic or asymptomatic COVID-19 infection prior to admission. A positive swab result triggers operation delay, protects patients from severe breathing problems after surgery and helps protect other patients from in-hospital infection. Swabs together with other strategies, should be used to protect patients from COVID-19 during hospital care.
Maria Picciochi, Harvinder Mann, Sam Lawday, James Glasbey
On behalf of the COVIDSurg Collaborative
What are the GlobalSurg & COVIDSurg Collaboratives?
GlobalSurg was born in 2013 as a group of frontline surgeons around the world with the aim of improving outcomes for their patients by joining together to collect high-quality data. The CovidSurg collaborative represents the COVID-19 response of the NIHR Global Health Research Unit at the University of Birmingham. The CovidSurg group is made up of an international collaborating group of surgeons, anaesthetists and researchers. They capture and share real world data for international multi-centre research studies. These groups overlap and are an expanding network aiming to improve global surgical care through collaborative research.
Since March the CovidSurg collaborative has run three prospective cohort studies and launched one randomised control trial:
(1) CovidSurg, an international cohort study assessing the outcomes of surgery in patients diagnosed with COVID-19
(2) CovidSurg-Cancer, an cohort study to assess the impact of COVID-19 on cancer surgery
(3) SURG-Week, which took place in October 2020. This set out to determine the optimal timing for surgery following a SARS-CoV-2 infection
(4) PROTECT-Surg, an international platform adaptive randomised trial to evaluate the effectiveness of chemoprophylaxis for SARS-CoV-2 infection in surgical patients.
The CovidSurg Collaborative is proud to announce it has captured outcomes for over 150, 000 patients from 2000 hospitals in 130 countries for these studies to date.
The SURG-Week study is set to be the largest international prospective collaborative study ever conducted, with over 15000 collaborators participating. It is an incredibly exciting time for collaborative research in surgery, encouraging colleagues internationally to take part in research and helping improve surgical outcomes in such unprecedented times.
COVID-19 in surgical patients
Our first study, published in the Lancet, demonstrated severe impact of COVID-19 in patients undergoing surgery. This found that patients with a positive perioperative SARS-CoV-2 test had a 30-day mortality rate was as high as 23.8%. Pulmonary complications occurred in 51.2% of patients and accounted for 81.7% of all deaths.
Certain patient groups were at higher risk. Male sex, older age, ASA grade 3-5, cancer indiciation, emergency, and major surgery, were all associated with postoperative death. These findings have allowed surgeons to optimise selection for surgery. They have already been implemented into several guidelines, and featured in over 400 news articles around the world.
Learning from this data, the COVIDSurg steering group rapidly synthesize evidence to provide a pragmatic global surgical guideline to provide care for surgical patients during the early phases of the pandemic.
The growing problem of cancellation elective surgery
The COVID-19 pandemic has disrupted surgical services worldwide. A modelling study from the COVIDSurg Collaborative published in BJS aimed to estimate the impact on surgical activity around the world. This estimated that 28.4 million elective surgeries would be cancelled or postponed around the world in the first 12 weeks of the pandemic; to clear this backlog, surgical providers would have to provide 120% operative capacity for over one year. With a second wave and lockdown of countries around the world, this is likely to be a gross underestimate. Many patients face progression of time-dependent conditions, or significant delays of quality of life surgery.
Rescheduling and prioritising operations presents a huge challenge to providers. COVIDSurg is supporting decision making in several ways:
COVIDSurg-Cancer will examine the impact of delay on cancer surgery. It will also look at the impact of neoadjuvant therapy on early oncological outcomes to inform prioritisation once surgery restarts.
COVIDSurg and COVIDSurg-Cancer data are being used to create risk stratification scoring systems. These will use principles of machine learning to allow high-fidelity risk estimation and support patient consent.
How to protect patients and safely upscale surgery during COVID-19 waves
COVIDSurg-Cancer provides an opportunity to identify best practises to optimise protective measures for patients during the second SARS-CoV-2 wave and beyond. Our first analysis, published in the Journal of Clinical Oncology demonstrated the use of COVID-19 free surgical pathways to protect patients from perioperative SARS-CoV-2 infection and subsequent complications. COVID-19 free zones throughout the hospital could be created in dedicated hospitals for elective surgery only, and major acute hospitals treating COVID-19 free patients; however, less than a third of patients received their care in totally COVID-19 free zones.
We have also been able to identify best practices for preoperative testing of patients for SARS-CoV-2. In our screening paper, released in BJS on 11th November 2020, obtaining a single negative preoperative nasopharyngeal swab testing was demonstrated to reduce subsequent postoperative pulmonary complications; this was likely due to a reduction in presymptomatic carriage of SARS-CoV-2 into the perioperative setting. Swab testing was most beneficial before major surgery and in high SARS-CoV-2 risk areas. The use of CT imaging for preoperative testing or serial swab testing was, however, had no proven benefit.
Unanswered research questions
SURG-Week unites the COVIDSurg and GlobalSurg Collaborative networks for the first time. It will address the evidence gap about the optimal of surgery for patients previously infected with SARS-CoV-2. Early pilot data from 122 patients published in BJS demonstrated a signal that a minimal interval of at least 4 weeks protected patients from severe complications of SARS-CoV-2.
It will also determine key global surgical indicators for future benchmarking and modelling studies. All hospitals and all surgical specialties can take part and will collect data from all patients operated regardless of their SARS-CoV-2 status during a 7-day period in October. The follow-up will occur at 30 days and will include mortality, pulmonary complications and surgical complications. With 15000 collaborators from over 2000 registered to date, it is set to be the largest prospective study ever to be undertaken. You can read more about this ongoing study on our website: www.globalsurg.org/surgweek.
Sergio M Navarro, MD MBA, Kelsey A Stewart, MD, Hashim Shaikh, BS^, Matthew C, Bobel, MD, Evan J Keil, BS, Jennifer Rickard, MD MPH, Todd M Tuttle, MD MS
^ Department of Surgery, University of California San Francisco, San Francisco, CA, USA
* Department of Surgery, University of Minnesota, Minneapolis, MN, USA Please contact: Sergio M Navarro, MD MBA 420 Delaware St SE, Minneapolis, MN 55455 firstname.lastname@example.org
The Coronavirus disease 2019 (COVID-19) has rapidly evolved and impacted all aspects of health policy and healthcare delivery – including surgery. Recommendations to postpone and provide additional guidelines regarding ‘elective surgery’ has left surgeons, patients, and hospitals with questions on the definition of ‘elective,’ the proper type and use of personal protective equipment (PPE) in surgery, the ethics of delaying medically indicated procedures, and the health and psychological impacts on patients and families. Analysis of social media information enables examination of the impact of COVID-19 and associated policy changes in a unique way and gathering of real-time data more rapidly than traditional methods. [1–4]
From March 1 to March 31, 2020, we conducted a cross-sectional analysis of associated posts on Twitter to collect data related to COVID-19 and surgery. The public domain was queried by filtering for five hashtags: #covidsurg, #covid19surgery, #COVID-19, #Coronavirus and #surgery. A binary scoring system was used for media format, perspective of the author, tone, user and post content, based on 2-person review. Data underwent descriptive and statistical analysis. All specific author information was de-identified. Non-English and non-surgery related tweets were excluded from analysis.
890 posts met the inclusion criteria. Posts an average of 629 Likes, 95 Retweets, and 1.78 hashtags per post. Author categories included physicians (39.7%), news organizations (18.4%), institution/professional organization (13.6%), and patients (11.9%). The majority of posts occurred from Twitter users based in the US (51.3%), followed by the UK (25.3%), and Canada (4.4%). Content included the cancellation of surgery (24.9%), surgical guidelines (20.2%), commentary/other (18.2%), COVID-19 education (16.2%), and PPE availability (7.4%).
Physicians were more likely than patients or patient’s families to post content related to PPE shortages, COVID19 education, research dissemination, as well as commentaries. Patients and patient families emphasized postoperative recovery and postoperative complication. Businesses, media outlets, and institutions posted most frequently about surgery cancellations and surgical guidelines. Authors from low and middle-income countries (LMICs) accounted for 4.4% (33/755) of posts where location of the post was available.
This initial exploration of the impact of COVID19 on surgery worldwide using social media found different perspectives from physicians, patients, families, media outlets, and institutions on various topics including cancellation of surgery, types of ‘non-essential’ surgery, concerns about PPE, and dissemination of surgical guidelines and educational information.
Non-Essential Surgery Cancellations
The cancellation of ‘non-essential’ surgery was the primary focus of content among all groups (25%, 222/890) and 40% (76/191) of posts by patients and families. Physician posts on cancellation comprised only 14.8% of their overall content. Their discussion on cancellation revolved around complex decision making in the designation of ‘non-essential’ surgeries and the inevitable consequences. One healthcare professional in Italy posted about the likely morbidity following lack of access to care and a surgeon in Canada discussed the difficult but important decision to delay surgery to improve healthcare capacity and protect patients from COVID19 exposure. A Urologist in Brazil described a difficult treatment decision for a patient with poor quality of life in need of a ‘non-essential’ surgery, emphasizing just how difficult it is to define ‘essential.’
Subspecialty Surgery Cancellations
A portion of the surgical cancellation content highlighted the ethical and political consequences of possible delays in specific types of surgeries; namely cancer surgery, orthopedic surgery, surgical abortion, and transgender surgeries.[5–8] Twitter served as a platform to discuss these ethical considerations for both surgeons and their affected patients. In one tweet, attention was drawn to a 17-year-old in need of surgery and chemotherapy; however, after spiking a fever he was subject to a two-week delay in care due to awaiting COVID-19 testing results.
Changes to practice
Another individual highlighted his mother’s breast cancer journey, sharing that instead of a partial mastectomy and reconstruction, an entire mastectomy without reconstruction would be performed – all due to changing guidelines regarding procedure safety. In terms of historically politicized surgeries, several state governments made decisions to limit access to abortion and gender affirming surgeries creating dissention within patients and physicians which was highlighted in over 10% of total tweet content where specific subspecialties were mentioned. 
Surgical Guidelines, Education, and Changes in Clinical Management
Throughout the analyzed tweets, several changes were recommended in the routine management of surgical conditions during the COVID-19 epidemic to conserve resources, limit exposure to the virus, and limit the use of PPE. These posts were primarily (46% in total) disseminated by academic institutions, other professional organizations, and media outlets. For example, the ACS and others have recommended limiting the use of laparoscopy which has the potential to aerosolize viral particles. Physicians worldwide have recommended alternate surgical techniques to reduce the risk of exposure to COVID19 including an Otolaryngologist in France who recommended the use of hammer and chisel in place of drilling. However, these changes are not without dissention, highlighted by a bariatric surgeon in the UK who struggled to follow a new guideline that he felt would worsen outcomes for patients.
Safety and Personal Protective Equipment
Surgeons, physicians, and other health professionals focused on commentaries and discussions about safety and PPE more than the other groups- giving insight that they see safety of patients and healthcare workers as the more important information surrounding the COVID-19 pandemic. One post from a trauma surgeon described lessons learned from performing emergency surgery on patients with COVID-19 and the need for clear guidelines and safety measures. The Columbia Chair of Surgery provided updates daily outlining the future need of PPE and justification for supplying a single mask per provider per day even at an early point in the COVID-19 outbreak.
Concerns surrounding the COVID-19 pandemic vary in different regions and countries given their specific burden of disease and capacity to mount a public health response to the disease.[10–13]. High-income countries (HICs) made up an overwhelming majority of the posts and thus a complete picture of the global burden of disease and changes to surgery across the globe may not be able to be formed. It is known that LMIC authors are often underrepresented in the global social media sphere in regard to global surgery which we further affirm here. Inclusion of LMICs in both the discussion and dissemination of global guidelines in regard to the COVID-19 pandemic ought to be a priority by the global surgical community. Some of the emphasized concerns from LMICs include internet outages that impact accessing surgical guidelines, hospital exposure of patients to the virus, as well as the dissemination of guidelines from other countries.
In this cross-sectional analysis, surgeons, physicians, and organizations expressed concerns about the impact of COVID-19 on surgical guidelines, the delay and cancellation of surgery, and the availability of PPE while disseminating COVID-19 education and information. We found minimal variation in the levels of mention regarding the impact of COVID-19 on surgical cancellations or delays, but the community of surgeons and physicians made more mention of PPE availability to conduct surgeries. These findings provide an indicative sampling of the key surgical perceptions of COVID-19 on these important populations.
1. Sorice SC, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social Media and the Plastic Surgery Patient. Plast Reconstr Surg. 2017;140: 1047–1056. doi:10.1097/PRS.0000000000003769
2. Navarro SM, Haeberle HS, Cornaghie MM, Hameed HA, Ramkumar PN. The Impact of Social Media in Medicine: An Examination of Orthopaedic Surgery. Social Media: Practices, Uses, and Global Impact. 2017.
3. Ni hIci T, Archer M, Harrington C, Luc JGY, Antonoff MB. Trainee Thoracic Surgery Social Media Network: Early Experience With TweetChat-Based Journal Clubs. Annals of Thoracic Surgery. 2020. doi:10.1016/j.athoracsur.2019.05.083
4. Henderson ML, Adler JT, Van Pilsum Rasmussen SE, Thomas AG, Herron PD, Waldram MM, et al. How Should Social Media Be Used in Transplantation? A Survey of the American Society of Transplant Surgeons. Transplantation. 2019. doi:10.1097/TP.0000000000002243
5. Couloigner V, Schmerber S, Nicollas R, Coste A, Barry B, Makeieff M, et al. COVID-19 and ENT Surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2020. doi:10.1016/j.anorl.2020.04.012
6. Iyengar KP, Jain VK, Vaish A, Vaishya R, Maini L, Lal H. Post COVID-19: Planning strategies to resume orthopaedic surgery –challenges and considerations. Journal of Clinical Orthopaedics and Trauma. 2020. doi:10.1016/j.jcot.2020.04.028
7. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.02.017
8. Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020. doi:10.1002/bjs.11746
9. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic – Ensuring Access to an Essential Health Service. N Engl J Med. 2020. doi:10.1056/NEJMp2008006
10. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395: 1225–1228. doi:10.1016/S0140-6736(20)30627-9
11. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi:10.1016/S0140-6736(20)30566-3
12. Fauci AS, Lane HC, Redfield RR. Covid-19 – Navigating the uncharted. New England Journal of Medicine. 2020. doi:10.1056/NEJMe2002387
13. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020. doi:10.1016/S0140-6736(20)30567-5
14. Navarro SM, Mazingi D, Keil E, Dube A, Dedeker C, Stewart KA, et al. Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study. World J Surg. 2020. doi:10.1007/s00268-020-05553-8
Professor Steven R Brown, Sheffield Teaching Hospitals.
Based on the BJS Lecture at ACPGBI 2020
A success story
There is more and more convincing evidence that the number of patients undergoing surgery for Crohn’s disease is decreasing substantially (1,2). Of course this as a huge success story and testament to tremendous advances in medical therapy occurring particularly over the last 20-30 years, isn’t it? Not necessarily. Some would suggest the newer medications have made little to no difference in reducing the need for surgery (3,4). Other factors may be more pertinent. To give gastroenterologists credit, earlier recognition of disease and potential complications and better disease monitoring are likely to have played a role. On the other hand it may be nothing to do with medical care and there is a simple epidemiological explanation; for instance there are less smokers now than there was 30 years ago (5).
Or is it?
There is another more concerning explanation. The plethora of medical options for patients with Crohn’s disease continues to expand. As a simple surgeon it is difficult to keep up with the various biosimilars, protein kinase, IL , CAM and JAK3 inhibitors that are available or being developed. It is like a candy shop of choice for the physician and a huge temptation for the patient to at least try one or more of these cutting edge medical therapies. Give medical treatment ‘just one more go’ is an obvious impulsion. But the medical literature is consistent in suggesting over 70% of patients with Crohn’s Disease eventually come to surgery (6). This can only mean that an increasing proportion of those undergoing surgery have experienced protracted medical therapy and are likely to have more complex disease. Although difficult to confirm this is certainly the perception of many in the surgical community (7-9).
Naturally all clinicians strive for the ultimate goal of never requiring surgery for Crohn’s Disease, but we are not there yet. Indeed some argue that the trend for less surgery should be reversed and surgery offered for more patients much earlier in their treatment pathway.
Buying a car
I like to think that the choice of surgery or medical therapy is analogous to buying a car. When making such a decision there are various factors that should be considered. These include safety, comfort, reliability, cost and perhaps most important of all what your partner thinks. The car may seem perfect in terms of all of these factors but he/she does not like the salesman, the brand or the colour.
So when it comes to the choice of the medical or surgical ‘car’ option, safety is in some respects paramount. There is a justifiable fear of surgery and a dread by many for the need for a stoma. However, optimisation of the patient, use of minimally invasive techniques, minimal resection and enhanced recovery mean that many of these fears are unfounded in the majority of patients (10). Indeed there are not insignificant risks associated with the alternative long-term immunosuppression.
Car comfort translates to quality of life. We know from the LIRIC study that quality of life is pretty much equivalent when it comes to medical or surgical options (11). No obvious winner here. However, when it comes to reliability or the chance of needing surgery there is an outright winner. As mentioned earlier the universally consistent literature suggests a greater that 70% chance of Crohn’s patients eventually needing surgery despite enhanced medical therapy (6). The ‘shiny medical sports car’ is very likely to break down. Compare with the ‘banger’ that is the surgical car. This just keeps going.
Additionally, long-term studies suggest at least 50% of patients will be symptom free 10 years after resection and two thirds will avoid further surgery (6). If this were the data for a new drug it would undoubtedly become a best seller. Furthermore it may be possible to customize the surgical ‘banger’ to make it even more reliable and attractive to the discerning customer. The Kono-S anastomosis and more radical mesenteric resection have both been touted as techniques that may reduce recurrence even further (12,13).
What does the data say?
Two recent publications back up these observations. A recent meta-analysis comparing early surgery with medical therapy decreases the risk of overall relapse (OR 0.53) , surgical relapse (OR 0.47) and the need for biological maintenance therapy (OR 0.24) whilst showing no difference in morbidity (14). Perhaps more significantly, long term analysis of the LIRIC data suggests nearly half of those treated with biological end up having surgery within 5 years and the rest remain on medication, switch or escalate treatment. Compare that with the surgical group were although about a quarter of the group required medical therapy for symptomatic recurrence, no one has required further surgery (15) Add to that cost, another clear winner for the surgical ‘banger’. Data again from LIRIC suggests it is €9000 cheaper than the medical option and almost 100% likely to be cost effective (16).
Therefore, it seems that the surgical car is cheaper, more reliable and, despite the looks, is as comfortable and safe as the shiny new medical sports car. However, the unpredictable factor is of course what your partner (patient) thinks. A study by Scott and Hughes (17) suggested about 80% of patients who underwent iloecaecal resection for Crohn’s disease said they ‘wished they had had surgery sooner’. Whilst a pre-biological era study and full of potential bias, many surgeons would be familiar with this phrase from the happy patient sitting in front of them, having undergone successful resection.
How do we proceed?
So there is a quandary here. Every doctor, regardless of specialty, wishes to reduce the need for surgery in Crohn’s but I would argue the evidence points to this being a less favorable option in many. The solution in my view lies in the underlying principle of good care for IBD, a multidisciplinary approach. Patients with Crohn’s Disease who require escalation of treatment should be fully informed of the risks and benefits of both medical and surgical options and make their own mind up. The only way this can be done fully and in an unbiased fashion is by meeting the surgeon earlier, preferably together with the physician in a joint clinic.
Kalman TD, Everhov ÅH, Nordenvall C, et al. Decrease in primary but not in secondary abdominal surgery for Crohn’s disease: nationwide cohort study, 1990-2014 [published online ahead of print, 2020 May 26]. Br J Surg. 2020;10.1002/bjs.11659.
Beelen EMJ, van der Woude CJ, Pierik MJ, et al. Decreasing Trends in Intestinal Resection and Re-Resection in Crohn’s Disease: A Nationwide Cohort Study [published online ahead of print, 2019 Jun 10]. Ann Surg. 2019;10.1097/SLA.0000000000003395.
Lakatos PL, Golovics PA, David Get al. Has there been a change inthe natural history of Crohn’s disease? Surgical rates and medicalmanagement in a population based inception cohort from Western Hungary between 1977–2009. Am J Gastro2012;107: 579–88.
Jeuring SF, van den Heuvel TR, Liu LY, et al. Improvements in the Long-Term Outcome of Crohn’s Disease Over the Past Two Decades and the Relation to Changes in Medical Management: Results from the Population-Based IBDSL Cohort. Am J Gastroenterol. 2017;112(2):325-336.
Cosnes J. Smoking and diet: impact on disease course? Dig Dis. 2016;34:72–77
Latella G, Caprilli R, Travis S. In favour of early surgery in Crohn’s disease: a hypothesis to be tested. J Crohns Colitis. 2011;5:1-4.
Buskens CJ, Bemelman WA. The surgeon and inflammatory bowel disease. Br J Surg. 2019;106:1118-1119
Macfie J. Commentary: Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:208.
Mege D, Garrett K, Milsom J, Sonoda T, Michelassi F. Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:200-207.
2015 European Society of Coloproctology (ESCP) collaborating group. Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate. World J Gastrointest Surg. 2019;11:261-270.
Ponsioen CY, de Groof EJ, Eshuis EJ, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial Lancet Gastroenterol Hepatol. 2017;2:785-792.
Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn’s disease: a systematic review [published online ahead of print, 2020 May 17]. Colorectal Dis. 2020;10.1111/codi.15136.
Coffey CJ, Kiernan MG, Sahebally SM, et al. Inclusion of the Mesentery in Ileocolic Resection for Crohn’s Disease is Associated With Reduced Surgical Recurrence. J Crohns Colitis. 2018;12:1139-1150.
Ryan ÉJ, Orsi G, Boland MR, et al. Meta-analysis of early bowel resection versus initial medical therapy in patient’s with ileocolonic Crohn’s disease. Int J Colorectal Dis. 2020;35:501-512.
Stevens TW, Haasnoot ML, D’Haens GR, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastro hepatol. 2020 Available on line 30 June.
de Groof EJ, Stevens TW, Eshuis EJ, et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn’s disease: the LIR!C Trial. Gut. 2019;68(10):1774-1780.
Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn’s disease–the patient’s view. Gut. 1994;35:656-657.
It is a surgical aphorism that it is more difficult to decide when not to operate than when to operate.
In the study “Learning from Regret”1, surgeons contributing to Queensland’s Audit of Surgical Mortality were asked to reflect on deaths following surgery. They were asked whether they would have done anything differently in retrospect. The aim was to explore surgeon’s reflections on what might have been done differently for patients who died under their care. The secondary aim was to assess for the presence of regret – defined as the presence of personal responsibility and realisation that another decision could have been better.
Post-decision regret was explicitly identified in 16.9% of responses. One of the scenarios specifically referred to was regret surrounding with proceeding to surgery in cases where the likelihood of survival was slim (“the decision entailed the alternative of certain death rather than probable death”). The fields of behavioural economics and psychology give us several reasons why we shouldn’t reflexively regret decision-making in these types of charged scenarios – because regret is the de facto outcome of a decision to operate in this scenario.
Firstly, the fact of operating rather than palliating in this scenario makes us more likely to regret it in retrospect when the outcome is poor by the mere fact of one having acted rather than not acted. Actions are more salient (i.e. easier to recall) than inaction and, therefore, more prone to regret upon reflection from a psychological perspective2. Humans also tend to regret action (acts of commission) more than inaction (acts of omission) because having acted, we then attempt to mitigate the cognitive dissonance that arises between our ideal and actual selves by reducing the dissonance by deriving lessons learned from the perceived error3.
The authors of “Learning from Regret”1 highlighted that surgical decision-making in cases associated with deaths were uncertain, complex and subject to situational pressures. In not operating, the surgeon would have to violate the norms of usual surgical behaviour4 that in the face of certain death without an operation, an operation should be performed.
In fact, in scenarios where treatment is highly likely to be futile, expected utility theory would tell us that our choices are very limited. In classical economics, expected utility theory is the theory of how rational actors make decisions. That is, that rational beings choose the option to maximise the risk: benefit ratio. When applying expected utility theory to medical decision-making, as the net treatment benefits increase, we become more uncomfortable withholding treatment even when the probability of a good outcome is relatively low and the risks are substantial. Therefore, when the counterfactual treatment outcome is certain death, if we apply traditional rational economic decision-making theory, then there are few circumstances in which the certainty of this poor outcome can outweigh the small possibility of a good outcome (especially where survival and not functional outcome is the primary outcome).
Furthermore, we increasingly recognise that medical decision-making employs dual-processing theory5. Rather than employing the neural pathways utilised in rational decision analysis, medical decision-making also draws from type 1 or emotional decision-making. This tends to make medical decision makers more risk-averse. Dual-processing of this nature also means that it is more challenging to apply rational thinking behaviours to decision involving how we must act, than it is to rationally decide how others should act6.
Clearly, aiming to avoid futile treatment that increases suffering at the end of life is an important goal in emergency surgery, however, making these types of decisions will always be difficult because surgeons are human and prone to all of the cognitive biases inherent to this state.
One of the consequences of COVID-19 has been greater attention on the risks of infection to clinicians. Much has been made of the need for personal protective equipment, including FFP3 masks, visors, and respirator hoods. Unfortunately these can also impact on communication. This can be due to muffled speech, or loss of ability to read lips. This is important in an operating theatre, where clear communication is critical.
Experience suggests that surgeons probably use some gestures to aid communication when operating. The use of sign language in clinical settings has been previously addressed in the literature, mainly as a proposal to manage increased noise levels in the OR. Sign language has also been suggested as an alternative to handle language differences in surgical team members of varied nationalities, as well as to improve action response within a procedure.
A new sign-language?
To reduce verbal communication that may be limited by impaired speech or hearing, the authors have proposed a surgery-specific sign language. The vocabulary consists of technical information that is easy to learn and replicate and allows fluent communication in the OR. These are summarised in the video above.
A full version of this article can be found in special correspondence to the editor on the BJS website.
BJSOpen is a fully-online and open access journal & is proud to publish high-quality surgical research. This month, papers span surgical oncology, methdology, benign disease, and global surgery. The full table of contents is here.
This month features two interesting clinical reviews on conditions of interest to all general surgeons.
The first of these addresses the role of prophylactic mesh reinforcement in prevention of incisional hernia after midline laparotomy in a predominantly elective cohort. It showed reduction in mesh use vs suture closure, regardless of where the mesh was placed. The authors also undertook a trial sequential analysis which suggested that more than enough information was available to reach this conclusion. Rates of seroma were higher with onlay mesh vs suture, and there was no difference in the rates of surgical site infection. Will this change your practice?
Oesophagectomy is a high stakes operation, and is technically challenging. This paper from Birmingham in the UK, examines the outcomes of 430 patients who underwent oesphagectomy over an 11 year period. They show that increasing severity complications are associated with worse overall AND worse disease free survival, particularly when Clavien Dindo II or greater.
A paper from Cardiff, Wales, looked at the effect of systemic inflammatory response in oesophageal cancer. Specifically, it looked at the relationship between neutrophil:lymphocyte ratio (NLR) and survival. Lower NLR was associated with poor response to neoadjuvant chemo, and also with worse overall survival. Read it here.
Pancreatic fistula is a recognised complication of pancreatic surgery. This cohort study reviewed outcomes of 108 patients undergoing pancreatoduodenectomy or distal pancreatectomy. They found that enterobacter was frequently found in drain fluid of patients with pancreatic fistula after surgery. Where enterobacter or multidrug resistant organisms were found, this was associated with higher grade complications.
Other studies include a study of en bloc resection of the retropancreatic portal vein in patients undergoing surgery for pancreatic adenocarcinoma. Whilst a cohort study, it suggests benefit in terms of longer disease free and overall survival compared to standard resection approaches.
What’s the role of Liver Transplant in patients with unresectable colorectal liver mets? This was investigated as part of the SECA II ‘D’ arm. Median disease‐free and overall survival was 4 and 18 months respectively.
Anastomotic leakage is a popular topic in journals, often due to its importance to patients and clinicians. This Italian study of 1500 patients undergoing resection compared the performance of the Dutch Leakage Score, CRP alone, and Procalcitonin in predicting anastomotic leakage (amongst other things). It showed good negative predictive value of all tools on day 2,3, and 6 (approx 97%). The positive predictive value was poor (around 10-20%).
This really neat study looked at potential early biomarkers of sepsis (of varying degrees) in surgical patients. It looked at a panel of biomarkers of endothelial dysfunction, neutrophil degranulation, and granulopoesis. They noted that markers of endothelial dysfunction were higher in patients with sepsis vs infection, suggesting this is an early event in the development of sepsis. Definitely worth a read!
This is not all the papers from this issue, but a selection which we think will have particular appeal to a broad part of our readership. We hope you enjoy them, and look forward to discussing them with you online!
James Ashcroft (@JamesAshcroftMD) Academic Clinical Fellow, Department of Surgery, Cambridge, UK;
Salomone Di Saverio (@salo75) Consultant General and Colorectal Surgeon, Professor of Surgery, University of Insubria, Regione Lombardia, Italy;
Justin Davies (@jdcamcolorectal) Consultant General and Colorectal Surgeon and Deputy Medical Director, Addenbrooke’s Hospital, Cambridge, UK.
Key questions in the diagnosis and management of appendicitis
Throughout my surgical training, decision making and risk prediction in patients with a clinical suspicion of appendicitis has been a prominent challenge. The accurate diagnosis of appendicitis should lead to improved healthcare provision to the patient, however there is still debate amongst the use of tools and imaging to assist this. The appropriate use of antibiotics to manage appendicitis, and the use of operative techniques to remove the appendix, have recently become a global debate.
Diagnosis of appendicitis
I have personally found the diagnosis of appendicitis to be challenging, with presenting history and examination of patients with right iliac fossa pain variable and often confounded. Clinical risk scores have recently been investigated through prospective international collaborative studies.1 The Alvarado score was one of the earliest scores demonstrating efficacy in appendicitis diagnosis when confirmed to histopathological diagnosis leading to its widespread uptake.2 However, this been superseded by the Appendicitis Inflammatory Response score (AIRS) in males and Adult Appendicitis Score (AAS) in females which have demonstrated improved performance in a pragmatic clinical setting.1
I have often been taught that appendicitis is a diagnosis made on clinical judgement alone and I feel this has become one of the most prominent dogmas present in surgical practice. The use of AIRS and AAS have been recognised to decrease negative appendicectomy rates in low-risk groups and reduce the need for imaging.1,3 I believe that the use of risk scoring should be taught to all surgical trainees routinely as a standard work up for the assessment of right iliac fossa pain.
Recent news reports have disseminated to the public that “Thousands of young women have their appendix removed unnecessarily”4 and although this may represent the appropriate conservative approach to imaging in females, it emphasises that we cannot justify ignoring the diagnostic tools at our disposal. Point of care ultrasound is recommended by the World Society of Emergency Surgery for decision making as a first point of call in both adults and children, however operator variability is noted.3
In my experience, and as per the general consensus of the departments I have worked in, ultrasound imaging is often useful in female patients to identify any ovarian cause of right iliac fossa pain and inconclusive for appendicitis. However, I can envision the use of ultrasound as part of clinical-radiological scores to enhance the sensitivity of diagnosis and could assist in avoiding radiation exposure through CT scan, which remains a pertinent research question.
Non-operative and operative management of appendicitis
Mirroring teachings in the diagnosis of appendicitis, in my experience it is taught that there is only one definitive management plan for simple appendicitis – an emergency appendicectomy. When considering modern sources of evidence, my belief is that the UK national normal appendicectomy rate (NAR) of around 20% is too high, when compared to countries such as Switzerland where the NAR has been found to be around 6%.5 The high NAR in the UK was again picked up by British media outlets who published headlines such as ‘Unnecessary appendix surgery performed on thousands in UK’.4
Antibiotic-first strategy has been found to be safe and effective in selected patients with uncomplicated acute appendicitis however, the risk of recurrence has been suggested to be up to 39% after 5 years.3 A 2019 meta-analytical review of 20 studies (7 prospective RCTs, 8 prospective cohort studies, 4 retrospective cohort studies and 1 quasirandomised study) investigated outcomes in non-operative management with antibiotics in appendicitis with an overall moderate quality of evidence when regarding complications and treatment efficacy.6 Overall antibiotic therapy achieved a significantly lower post-intervention complication rate including postoperative abscesses, surgical site infections, incisional hernias, obstructive symptoms, and other general operative complications at 5 years compared to index event surgery.6 However, there was a lower complication free treatment success rate and a non-significantly higher rate of complicated appendicitis with delayed surgery in patients receiving initial antibiotic therapy.6
I feel that the stratifying of patients by risk and utilisation of outpatient surgical ambulatory units with repeated history taking, observations, and blood tests could be effective in reducing the NAR in the UK with or without imaging. Accurate diagnostic imaging in the form of a CT scan could reduce the UK’s NAR further, improving patient outcomes, surgical planning, and healthcare service provision at an organisational level. This may outweigh the impact of radiation exposure of a CT abdomen scan which has been well described by Aneel Bhangu the lead director of the RIFT/West Midlands Collaborative as giving “the same radiation as flying to New York”.4 T
his is a risk which I believe many would not be concerned about when travelling. This view is in opposition to that of the recently updated World Society of Emergency Surgery guidelines which suggest that CT imaging may be avoided prior to laparoscopic operation, but it should be noted that there was debate regarding this within the writing committee.3
I believe that more care must be taken in patients with suspected appendicitis to undertake a discussion around imaging use, operative management, and non-operative management which is unbiased and evidence based. Those opting for conservative management should be warned of the possibility of failure and misdiagnosis of complicated appendicitis. In my training so far, conservative management has been discussed in those judged to be low-risk however this does not come without the risk of the on call surgeon’s bias seeping into conversation. Further research should be undertaken to identify precisely which cohort of patients are optimal for non-operative outpatient management.
Appendicitis and COVID-19
Recent research into risk scoring in appendicitis has demonstrated a clear benefit in stratifying patients into risk categories to guide management plans.1,3 As highlighted I believe that all patients presenting with right iliac fossa pain should undergo scoring, by either AIRS or AAS. It has been suggested that due to local population characteristics and health systems, risk scores should be validated locally prior to routine adoption.7 It has further been emphasised that risk score models should not replace clinical judgement and should be used as an adjunct to enhance decision making.8
In the current COVID-19 pandemic the use of non‐operative management has been suggested to be increased for acute surgical conditions such as appendicitis9 and this has been the experience of my department. The evidence at present suggests that this is safe and feasible, and therefore the COVID-19 pandemic presents a unique period for investigation.10 It could be a valuable endeavour for all centres to perform local analyses of the impact of conservative management on patients presenting with right iliac fossa pain in the COVID-19 period.
This is also being undertaken on a national level in the COVID- HAREM Study: Had Appendicitis and Resolved/Recurred Emergency Morbidity/Mortality. Locally, one year clinical outcomes could be measured for those diagnosed with appendicitis pre-COVID and during the COVID period. Finally, with the restoration of normal patient pathways post-COVID, risk scoring could be introduced to local departments with a pre-COVID / post-COVID comparison to allow for the clear demonstration of any benefit to the patient.
1. The RIFT Study Group and the West Midlands Research Collaborative. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2019:73-86. doi:10.1002/bjs.11440
2. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564. doi:10.1016/S0196-0644(86)80993-3
3. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):1-42. doi:10.1186/s13017-020-00306-3
5. Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg. 2011;98(4):589-595. doi:10.1002/bjs.7395
6. Podda M, Gerardi C, Cillara N, et al. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: A systematic review and meta-analysis. Ann Surg. 2019;270(6):1028-1040. doi:10.1097/SLA.0000000000003225
7. The RIFT Study Group and the West Midlands Research Collaborative. Author response to: Comment on: Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11542
8. The RIFT Study Group and the West Midlands Research Collaborative. Author response to: RIFT study and management of suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11552
9. Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056
10. COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020;(March). doi:10.1002/bjs.11646
The Young BJS represents a community of early-career researchers with enthusiasm for surgical academia. The ethos is aligned with that of the BJS with a mission to promote excellence in clinical and scientific research. Specific goals of the group will be to network, educate, and innovate in surgical publishing on a global scale.
The Young BJS is led by surgical trainees under the guidance and governance of the BJS and BJS Open Editorial teams and the BJS Society. Membership is free of charge and open to everyone from junior consultants to medical students. All specialties and countries are welcome to join such that the resultant spectrum of research experience, career stage, and geographic distribution will provide a welcomed diversity to the community. Members should have a reasonable command of English but this is not essential.
The aim of Young BJS is to nurture the future leaders of surgical academia by
Providing early-career researchers with an opportunity to gain editorial experience
Encouraging national and international collaborative efforts
Acting as an educational forum for surgeons-in-training
The Young BJS will provide members with the opportunity to complete formal certified training in reviewing journal manuscripts through the Young BJS Reviewer Mentoring Programme in collaboration with the Editorial team and board, the BJS Society, and the planned BJS Academy. Upon commendation trainees will enter the BJS reviewer database as certified Young BJS reviewers. They may then be invited by members of the BJS editorial team to review manuscripts.
The Young BJS will provide a platform to promote national and international collaborative projects. Members will have the opportunity to inform the community of studies involving multiple institutions, thereby encouraging connectivity among young researchers on a global scale.
The Young BJS will act as an educational forum for surgeons in training to develop a digital learning platform, complementing the aims of the BJS Academy. Members will be encouraged to complete BJS delivered or supported writing courses and workshops to develop their editorial skills.
The Young BJS will have a strong and vibrant social media presence through its own Twitter account and posts on the BJS Cutting Edge blog. One of the specific goals of the group is balancing global disparities through better access to published works.
There is huge scope as to what we can achieve as a group with plenty of opportunities for members to participate in all aspects of the initiative. So far we have over 200 students and trainees involved from over 40 countries and representing every inhabited continent in the world.
So what can you do to get involved?
Enthusiasm is all that is required. Those interested in becoming part of Young BJS, please email your details including name, institution, career stage and specialty interest (if applicable) to email@example.com. We will inform you of upcoming projects, educational opportunities, and collaborative efforts.
We look forward to welcoming you.
The Young BJS coordinating team
(On behalf of the BJS / BJS Open editorial teams and BJS Society)