Category Archives: BJSOPEN

Sign language for surgeons in the COVID-19 pandemic

Sign language might be a useful tool for when PPE affects communication
  • Francisco Alberto Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.
  • Eduardo Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.,
  • Fernando Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.
  • Abelardo Juanz-González Department of Surgery, Hospital General del Estado de Sonora, Hermosillo, México. ,
  • Jorge Arturo Barreras-Espinoza, Department of Surgery, Hospital General del Estado de Sonora, Hermosillo, México.,
  • Ahmed Soualhi, GKT School of Medical Education, King’s College London, London, UK.,
  • Jesús Antonio Ocejo Gallegos, Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México,
  • Martyn Urquijo, Department of Surgery, The University of Arizona Banner Health, Tucson, Arizona.
  • Jesús Martín Ibarra Celaya, Thoracic Surgery Department, Hospital +Querétaro, Querétaro, México.

A COVID challenge

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.

BJS open June 2020 issue published!

Images from the June 2020 issue
Images from the June 2020 issue

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.

Hernia

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?

Umbilical hernia is another common condition, and recurrences can lead to significant disruption of the abdominal wall. Madsen et al from Copenhagen have conducted a thorough & systematic review of the literature on this topic. Essentially, mesh reduces rate of recurrence without increasing risk of chronic pain. Noteworthy in this review is the presentation of differing even rates based on RCT or cohort designs.

Oesophageal surgery

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.

Hepatopancreatobiliary surgery

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.

Colorectal surgery

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%).

Clinical science

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!

Summary

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!

Key questions in the diagnosis and management of appendicitis

questions about treatment of appendicitis

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.

wses diagram on management of appendicitis

Practical WSES algorithm for diagnosis and treatment of adult patients with suspected acute appendicitis.3

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.

References

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

4.            Davis N. Unnecessary appendix surgery “performed on thousands in UK” | Society | The Guardian. Guard. 2020:1-5. https://www.theguardian.com/society/2019/dec/04/unnecessary-appendix-surgery-performed-on-thousands-in-uk.

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

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!

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.