Author Archives: bjsopen

Visual abstract blog

As Monty Python would say…

Time for an upbeat blog!

The BJS ‘how to write a paper’ session is a fixture at many UK surgical meetings. This covers lots of the ‘nuts and bolts’ of writing a paper. We delivered a short version of this course at the Association of Surgeons in Training Meeting in Birmingham.

One of the fun and developing parts of publishing is the promotion of material on social media. Visual abstracts have emerged as a concise way of sharing the key points of a manuscript online. Therefore it shouldn’t come as a surprise that we cover making visual abstracts in this course.

We discuss things like picking out key points and the use of icons and images. We then give the participants a choice of two abstracts and invite them to submit a visual abstract to our competition. This year we chose this paper on peripheral vascular disease and this paper on oesophageal cancer as subjects for the exercise.

We were pleased to receive a number of visual abstracts, which were of a really high standard. Most participants opted for the peripheral artery disease abstract. The team were really impressed by the abstracts that were submitted to us. Dr Jia Ying Lim (blue background) was the winner, and Dr Rucira Ooi (red background) was awarded the runner up prize. You can see these below.

Please keep an eye out for the course at future meetings. If you would like us to deliver this course at your meetings, please get in touch!

Guest post: CovidSurg – The impact of COVID-19 on surgical patients and the provision of surgical services

Constantine Halkias on behalf of COVIDSurg

The chance to learn about this disease & impact on surgical patients is in our hands.
Photo by Valentin Antonucci from Pexels

Surgery in a pandemic

Policies and public health efforts have not addressed the impact of pandemics on the provision of surgical services and the effects on health-related outcomes on surgical patients. This also applies to the response to Coronavirus disease 2019 (COVID-19). There hasn’t been any related research or analysis despite the impact of the pandemic so far. Understanding the effects of COVID-19 on patients undergoing surgery along with the effects of this pandemic on the provision of surgical services is a fundamental step to understanding the various different effects of a healthcare emergency of that magnitude and to implement policies from the lessons learned.

Impact on surgical patients

Undoubtedly despite the global focus to encounter the pandemic itself and the need to improve provision of services and treatments related to the immediate effects of COVID-19, with intensive care playing a major role, there are still millions of patients who will need surgical treatment. Major focus should be the provision of emergency surgical care, cancer surgery and transplant surgery. There is little or no knowledge on the outcomes of surgical patients with COVID-19 related disease.

Low quality data from a case series of patients who underwent cardiac surgery and acquired Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) did show very high mortality of 83.33% (1). This has major direct implications on the management of emergency surgical patients during the pandemic as well as on the ongoing provision of organ transplantation and cancer related operations. Whether major cancer surgery and organ transplantation should be delayed and for how long, in view of the possible worse outcomes during the pandemic is one of the issues that should be investigated.

Impact on surgical services

We also need to address the effects of the current pandemic on surgical services provision. It is an unprecedented situation that has already changed the way surgeons and health systems worldwide are offering surgical services. There is also very low quality evidence available from the 2003 Hong Kong Severe Acute Respiratory Syndrome (SARS) epidemic that showed significant reduction in the colorectal surgical caseload that had a major negative impact on waiting times and training (2). Although it’s certain that the impact of the current COVID-19 pandemic will be of unprecedented severity, it’s actual consequences and the implications on resources, staff allocation and training are still uncertain. Understanding the effect of the pandemic would also inform future global policy around cancer and transplantation surgery during pandemics, and the provision of surgical services in general.

A new project

There is an urgent need to understand the outcomes of COVID-19 infected patients who undergo surgery. To address the above issues we designed CovidSurg, an international group of surgeons and anaesthetists, with representation from Canada, China, Germany, Hong Kong, Italy, Korea, Singapore, Spain, United Kingdom, and the United States. Our aim is to capture real-world data and share international experience that will inform the management of this complex group of patients who undergo surgery throughout the COVID-19 pandemic, improving their clinical care and to understand the effects of the pandemic on the provision of surgical services. 

References

  1. Outbreak of Middle East Respiratory Syndrome-Coronavirus Causes High Fatality After Cardiac Operations. Nazer RI, Ann Thorac Surg. 2017 Aug;104(2):e127-e129. doi: 10.1016/j.athoracsur.2017.02.072.
  1. Tales from the frontline: the colorectal battle against SARS. Bradford IM Colorectal Dis. 2004 Mar;6(2):121-3. doi: 10.1111/j.1462-8910.2004.00600.x

With the end in mind

Post by Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

We need to talk

A critical role of the surgeon is having difficult conversations with patients and their families. Continuously improving our communication skills is as important an aspect of professional development as staying abreast of technological changes. Recent papers in BJS have highlighted the importance of clear decision making at the end of life regarding when to operate1, 2. Recent global events bring the matter in sharper focus.

One potential barrier to making appropriate decisions is engagement with patients, in a time critical manner, to determine their core values and preferences regarding end of life treatment. In “Learning from Regret” the authors noted that perceived communication barriers, regarding poor prognosis with little prospect of ultimate survival, lead to surgeons undertaking emergency surgery and subsequently regretting this decision when they reviewed their patient’s death retrospectively2. In their leader on a “good surgical death” Chamberlain and Blazeby note the importance of early identification of patient’s goals and warned of the rescue culture and death denial that can results in the surgical arena1. Joliat et al. could only identify seven studies in their systematic review which addressed the impact of patient death on surgeons, none of which included interventions to reduce negative impacts3.

Approaching a difficult conversation

Story telling is a powerful tool for enhancing reflection and a potential way of promoting practice change4. “With the End in Mind” is written by a palliative care specialist Dr Kathryn Mannix. In it, she utilises a series of composite accounts of deaths of patients during her career, to illustrate how the experience of death can be managed, symptoms palliated and people comforted5. This book is available for free download in the UK and Ireland until April 6th through this link.  This book aims to give us permission to directly discuss dying.

From a personal perspective, some of the important themes which led me to reflect on my personal practice included how to address the potential collusion of silence between patients, families and healthcare professionals by ensuring that knowledge is shared and exploring what barriers may exist to a shared understanding of what is happening. This can help promote mutual support within families and facilitate open communication by setting the tone.

By taking the lead on broaching difficult conversations, the healthcare professional can take some of the power of un-named worries away and relieve some of the burden of the taboo. Similarly, by directly addressing the usual trajectory of the decline to death in the metastatic cancer setting as well as the well-recognised in the last days and hours of night as described eloquently by Dr Mannix, I have found a sense of control can be imparted to the dying patient and their supporters.

Infographic prepared by Scottish Quality Safety Fellowship Cohort and Open Change on approaching discussions about dying. Reproduced with authors permission.

How to put it into practice?

Some of the lessons from this book and others have been incorporated into an infographic by cohort 12 of the Scottish Quality Safety Fellowship working with design partner Open Change to illustrate an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. The focus is on breaking down an approach to end of life conversations using honesty and compassion. It provides a framework for the novice and an opportunity to reflect for the more experienced practitioner.

Mastery can enhance a personal sense of control. Mastering communication skills in fraught situations is fundamental to the provision of high quality surgical care and might perhaps, reduce some of the effects of secondary victimhood experience as we care for our dying patients6.

Acknowledgements

With thanks to Dr Lara Mitchell (@laramitchdr), Consultant Geriatrician and Clinical Lead, and Hazel White, Director Open Change (@openchangeuk) for their insight and providing access to their communication resource.

1.            Chamberlain C, Blazeby JM. A good surgical death. BJS 2019; 106(11):1427-1428.

2.            Boyle FM, Allen J, Rey-Conde T, et al. Learning from regret. BJS 2020; 107(4):422-431.

3.            Joliat GR, Demartines N, Uldry E. Systematic review of the impact of patient death on surgeons. British Journal of Surgery 2019.

4.            Zaharias G. What is narrative-based medicine?: Narrative-based medicine 1. Canadian Family Physician 2018; 64(3):176-180.

5.            Mannix K. With the End in Mind: Dying, Death and Wisdom in an Age of Denial. London: Harper Collins, 2017.

6.            Pellino G, Pellino I. Deaths, errors and second victims in surgery: an underestimated problem. BJS 2020; 107(1):152-152.

Prioritising Surgical Treatment in Coronavirus Pandemic “Salford Score”

Prof Gordon Carlson CBE FRCS

Background

In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.

The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.

Cancer Surgery Priority

The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.

PriorityDescription
Priority level 1a• Emergency: operation needed within 24 hours to save life
Priority level 1b• Urgent:operation needed with 72 hours
Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2Elective surgery with the expectation of cure, prioritised according to:
• Surgery within 4 weeks to save life/progression of disease beyond operability.
Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers

NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
Priority level 3Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery

However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;

The “Salford Score” simplifies this to:

  • Priority 1a = score (P)1
  • Priority 1b = score (P)2
  • Priority 2 = score (P)3
  • Priority 3 = score (P)4

Vulnerability

A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).

Vulnerability scoreOutcome in case of COVID infection
Vulnerability level 1• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection
Vulnerability level 2• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality
Vulnerability level 3• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality
Table 2: Vulnerability score

Salford Score

A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.

Guest post: Lessons in preparedness – the response to the COVID-19 pandemic by a surgical department in Singapore

Min-Hoe Chew1, Lester WL Ong1, Frederick H Koh1, Aven Ng1, YHA Tan1, Biauw-Chi Ong2

1 Department of General Surgery, Sengkang General Hospital, Singapore

2 Department of Anaesthesiology, Chairman Medical Board, Sengkang General Hospital, Singapore

Background

On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic. [1] Over 509,164 people have been infected worldwide with 23,335 deaths [2]. (case fatality-rate 4.6%)

The first imported case of COVID-19 in Singapore occurred on 23rd January 2020. [3] Local transmission was confirmed on 4th February 2020 and the Disease Outbreak Response System Condition (DORSCON) was raised (Orange) on 7th February 2020 [4-5]. As of 27th March 2020, there have been 732 cases in Singapore and 2 deaths. [6] Sengkang General Hospital (SKH) is a 1,400-bed hospital serving a population of 900,000. SKH confirmed its first case on 26th January 2020 and has managed 32 cases to date. [7] SKH Department of General Surgery (GS) has developed response measures to ensure all staff were ready to perform surgery for COVID-19 cases, reduce risks of nosocomial infection, and ensure continuity of care for patients. We describe the Preparation Phase in the initial outbreak, the Evolution Phase (DORSCON Orange), and Crisis Phase planning norms (DORSCON Red). [8-9]

Preparation Phase

Preparation Phasebegan before the first case was reported in Singapore. Cases were initially limited to China [10].  Information was limited; thus, planning was based on experience with Severe Acute Respiratory Syndrome (SARS) outbreak in 2002 [11-12]. A departmental task force was formed to enforce measures implemented by the hospital and develop knowledge specific workflows. Importantly, besides fever and upper respiratory tract symptoms, COVID-19 patients could mimic surgical conditions and have diarrhoea and abdominal pain [13-15].

Communication

The task force ensured accuracy of information disseminated. This suppressed falsehood from social media and maintained morale. This also allowed rapid and effective communication between junior and senior staff, and obtained feedback regarding policies.

Internal surveillance measures

Staff conducted twice daily temperature monitoring. Temperatures were entered into web-based forms via personal smartphones. All staff had Radiofrequency Identification tags facilitating contact tracing should there be exposure. Staff who developed symptoms were to only seek medical consultation within the hospital staff clinic. This enabled symptomatic staff to be identified promptly. 

Training and rehearsals

Hospital-wide refresher training on the use of Personal Protective Equipment (PPE) was conducted. This included N95 mask fitting as well as training on Powered Air-Purifying Respirators (PAPR) (CleanSpace® HALOTM, CleanSpace Technology Pty Ltd, Artarmon, NSW, Australia).

Business Continuity Plan (BCP)

The GS department split into two working teams. One team handled all inpatient services, which included emergency admissions, elective and emergency surgeries and ward rounds; the other team managed outpatient clinics and endoscopy procedures. Every seven days, teams would exchange duties.

The segregation of teams ensured that the department would remain functional should any team member fall ill. Under Singapore guidelines, close contacts of confirmed COVID-19 cases without adequate PPE, will serve a 14-day quarantine. [16] A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. [10]

Evolution phase

This BCP was executed when Singapore raised the DORSCON level (Orange) on 7th Feb 2020.

Elective and emergency surgeries

Non-urgent, non-cancer surgeries were postponed. Time-sensitive surgeries, such as cancer-related work and limb salvage procedures, could proceed. Surgeons performed elective surgeries during designated weeks.

Outpatient clinics and endoscopy

Outpatient clinic patient volume was reduced by 30%. Non-urgent endoscopy procedures were postponed. Patients attending appointments had temperature checks and performed declarations of travel history and symptoms. Ill patients were diverted to the Emergency Department (ED).

Operational demands

There was a spontaneous reduction in hospital attendances. ED admissions to the surgical department fell 11% (from a median of 156 per week) initially. (Figure 1) OR utility for surgeries reduced by 13% (from a median of 155 per week). (Figure 2) Median outpatient clinic attendances also decreased by 22% compared to the same period (1674 per week in 2019), without any hospital-initiated postponement. (Figure 3)

However, between the fifth and seventh week, the number of emergency admissions increased by 7 to 14% compared to the past year. OR utility returned to normal and outpatient clinic numbers surpassed previous year numbers by 24% in the seventh week.  This was likely due to increased public confidence in Singapore’s response. [17]

Team segregation was subsequently stopped for junior staff to meet manpower demands. Team segregation for senior staff continued.

Crisis Phase (Preparing for DORSCON Red)

In a Crisis phase, it would necessitate expansion of departments such as ED and Intensive Care Unit (ICU). The objective of Crisis Phase planning was to facilitate manpower allocation while maintaining essential surgical capabilities. (Figure 4)

Key aspects of the Crisis Phase plan are:

  1. Reducing OR workload to allow anesthetists to support ICU
  2. Reducing outpatient clinic and endoscopy workload to free staff for deployment
Figure 4. DORSCON escalation planning norms for Department of General Surgery, Sengkang General Hospital

Discussion

The course for the COVID-19 pandemic is likely to be protracted. [18] A surgical department must plan a stepwise reduction of elective work to allow for sustained deployment of manpower to frontline departments, and team segregation to allow for continuity of essential services.

The protection of healthcare staff is vital. Ng et al. reported 85% of 41 healthcare workers were exposed to a COVID-19 patient during an aerosol generating procedure [19]. None acquired the infection even though not all were in N95. Standard hand hygiene practices remain important.

Our department statistics provide a snapshot of Singapore’s health-seeking behaviors. Postponing elective surgeries did not reduce workload and more patients were admitted as emergency cases.

We acknowledge that we have had a very controlled increase in the number of COVID-19 cases; much of this is a result of a national strategy of rapid detection and isolation of cases and aggressive contact tracing. [20] Nonetheless, it is challenging to strike a balance between complacency and overreaction. Premature implementation of drastic measures can lead to staff burnout and resource wastage. Indecisive action however, may result in nosocomial spread and a loss of confidence in hospital leadership. The department has benefitted from the hindsight of the SARS outbreak in 2002.

Conclusion

In the COVID-19 pandemic battle, there are multiple considerations in how a surgical unit functions. Phases of Preparation, Evolution and Crisis will require hard decisions, strong leadership and decisive communication. A robust BCP is essential to ensure that surgical patients continue to have quality care.

References

1. Ghebreyesus TA. World Health Organization. Coronavirus disease 2019 (COVID-19).  WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. March 11, 2020. Available at:  https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed March 11, 2020.

2. WHO Coronavirus Situation Report 67. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200327-sitrep-67-covid-19.pdf?sfvrsn=b65f68eb_4. Accessed 28th March, 2020.

3. Abdullah Z, Salamat H. Singapore confirms first case of Wuhan virus. January 23, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/wuhan-virus-pneumonia-singapore-confirms-first-case-12312860. Accessed March 14, 2020.

4. Ministry of Health, Singapore. Confirmed cases of local transmission of novel coronavirus infection in Singapore. February 4, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/confirmed-cases-of-local-transmission-of-novel-coronavirus-infection-in-singapore. Accessed March 14, 2020.

5. Ministry of Health, Singapore. Risk assessment raised to DORSCON Orange. February 7, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/risk-assessment-raised-to-dorscon-orange. Accessed March 15, 2020.

6. Ministry of Health Singapore Updates on COVID-19 Local situation. Available on: https://www.moh.gov.sg/covid-19. Accessed March 28, 2020.

7. Channelnewsasia. 4th confirmed case of Wuhan virus in Singapore: MOH. January 26, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/4th-confirmed-case-of-wuhan-pneumonia-virus-in-singapore-moh-12339912. Accessed March 14, 2020.

8. Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020 Apr;5(4):335-337.

9. Ministry of Health, Singapore. Ministry of Health Singapore pandemic readiness and response plan for influenza and other acute respiratory disaeses (revised April 2014). April, 2014. Available from: https://www.moh.gov.sg/docs/librariesprovider5/diseases-updates/interim-pandemic-plan-public-ver-_april-2014.pdf. Accessed on March 20, 2020.

10. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29. doi: 10.1056/NEJMoa2001316. [Epub ahead of print]

11. Tan CC. SARS in Singapore–key lessons from an epidemic. Ann Acad Med Singapore. 2006 May;35(5):345-9.

12. Chow KYLee CELing ML, et al. Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study. BMJ. 2004 Jan 24;328(7433):195.

13. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507-13.

14. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease, (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print]

15. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China. Lancet 2020; 395: 497-506.

16. Ministry of Health, Singapore. Multiple lines of defence to guard against local spread of COVID-19. March 13, 2020. Available from: https://www.gov.sg/article/multiple-lines-of-defence-to-guard-against-local-spread. Accessed on March 22, 2020.

17. Ipsos. Singaporeans are confident in the Government amidst fears of the COVID-19 outbreak. March 16, 2020. Available from: https://www.ipsos.com/en-sg/singaporeans-are-confident-government-amidst-fears-covid-19-outbreak. Accessed on March 22, 2020.

18. Tan A. Covid-19 likely to last till end-2020 at least: Experts. March 9, 2020. Available from: https://www.straitstimes.com/singapore/health/coronavirus-covid-19-likely-to-last-till-end-2020-at-least-experts. Accessed on March 22, 2020.

19. Ng K, Poon BN, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: a case report. Ann Intern Med 2020 Mar 16. Doi:10.7326/L20-0175 (Epub ahead of print)

20. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore-Current Experience: Critical Global Issues That Require Attention and Action. JAMA. 2020 Feb 20. doi: 10.1001/jama.2020.2467. [Epub ahead of print]

BJSOpen April 2020 issue published.

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.

We would also like to draw your attention to the EHS/AHS guidelines on primary hernias in rare locations or special circumstances.

images from this months BJS open
Some of the key images from this months papers

Methodology

Anyone submitting papers to a journal will be familiar with the role of checklists. These are intended to improve the quality of reporting of publications. This review has assessed how well benefits and harms of treatments are reported in surgical trials. It shows that the surgical community needs to do better; outcomes were poorly described, or presented in a manner where it was not possible to interpret effect sizes with any degree of precision.

Randomised trials

Whilst breast cancer surgery aims to conserve breast tissue, mastectomy is still an important tool for the breast surgeon. One of the problems seen here is with bleeding from this typically vascular area. This Norwegian trial randomised 208 patients to either topical tranexamic acid or topical saline to wound edges for haemostasis. There was reduced drain output in the TXA group. There was also a non-significant (but interesting) reduction in the rate of haematomas. 

The pilonidal sinus is a sadly unloved condition. This is despite being a constant presence for the colorectal surgeon. This RCT compared alginate vs DACC (hydrophobic-type) dressings in wound healing after excision of pilonidal sinus. There was no difference in wound healing at 75 days on the per-protocol analysis. The trial needed 222 patients to complete to reach power calculations and managed to retain 200 patients. There might be other things to learn about trial management. This population is quite young and may pose problems with recruiting to trials

Surgical oncology

Other surgical oncology papers this month include a review of outcomes of immediate and delayed autologous breast reconstruction in post-mastectomy radiotherapy. This is a well conducted review and highlights the issues with the literature. On a related note, this patient survey on immediate breast reconstruction is interesting. It looks at some of the important socioeconomic factors that drive patient decision making around this treatment.

For the HPB surgeons, a cohort study shows the outcomes of resection for HCC with tumour thrombus extending into the IVC. In practice, this is a small group with advanced disease and this is shown by a 20 year case series. And not forgetting the oesophagogastric surgeons, we have a retrospective cohort study comparing laparoscopic proximal gastrectomy with double‐flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer. This study was intended to assess the impact on nutrition between these two approaches. No difference in these outcomes were seen.

Advanced cancer

This is a growing field, and this growth is reflected in the many submissions we receive on this topic.Two of the big questions are on the prediction of development of peritoneal disease, and the role of chemotherapy dosing in HIPEC.

A large cohort study from the Danish Colorectal Database has tried to answer the first of these questions. Rates of metastatic peritoneal disease were low, but factors such as advanced tumour or node stage were associated with early presentations, whereas R1 resection was associated with recurrence at 3 years.

The second question was addressed by the PRODIGE 7 trial, which suggested cytoreductive surgery was key in treatment of peritoneal disease. This is reflected in a cohort study of ‘real world’ experience from the Netherlands. This has compared intraperitoneal chemotherapy outcomes based on agents used and adjusted for body surface area. It doesn’t seem to disagree with PRODIGE 7… 

On a related note, the introduction of new technology demands robust assessment. For surgeons this typically follows the IDEAL framework. This review has looked at reports on the development of Pressurized intraperitoneal aerosol chemotherapy (PIPAC), which is based on laparoscopy to deliver intraperitoneal chemotherapy for peritoneal metastases. We now know that we are following the rules with this technology. However, progress is slow and we need bigger definitive studies to understand efficacy.

Global surgery

There are two papers on global surgery this month. One highlights the challenges related to deployment of electrosurgical and laparoscopic kit in LMICS. This shows that equipment is available, but surgeons still had problems using or maintaining it. The second paper shows that traumatic brain injury is common in Uganda, with a male preponderance. The mortality rate in this group is 33%. The authors suggest this may be influenced by limited access to CT and ICP monitoring.

Summary

These are just some of the papers published in this issue of BJSOpen. We welcome direct submissions to the journal. If you think your work would fit in here, please have a look at the instructions for authors page.