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Background Radical surgery provides the best chance of cure for adrenocortical carcinoma ( ACC), but perioperative surgical care for these patients is yet to be standardized. Methods A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation ( GRADE) system, and were discussed until consensus was reached within the group. Results Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged. Conclusion The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC. [ABSTRACT FROM AUTHOR]

Background: Suture-hole bleeding in arterial anastomoses prolongs operating time and increases blood loss, particularly with the use of prosthetic grafts. Surgical sealants (such as fibrin) may be used as haemostatic adjuncts in vascular surgery. This is a systematic review and meta-analysis of published studies that investigated the utility of surgical sealants in arterial-to-prosthetic graft anastomoses. Methods: A systematic review was undertaken of papers published until January 2015 on Embase, MEDLINE, PubMed, PubMed Central and Cochrane databases that analysed the use of surgical sealants as haemostatic adjuncts after arterial anastomoses. RCTs were included, with study endpoints of time to haemostasis or haemostasis at 5min. Secondary outcomes included treatment failure, mean difference in estimated blood loss and duration of surgery. Sensitivity and subgroup analyses were performed, as well as funnel plot analysis for publication bias. Results: A total of 2513 citations were reviewed; 19 RCTs comprising 1560 patients were ultimately included in the analysis. The majority of studies compared fibrin sealant with control haemostatic measures. Pooled analysis suggested that surgical sealants reduced the time to haemostasis (mean difference 243·26 (95 per cent c.i. 183·99 to 302·53) s; P <0·001), improved haemostasis at 5 min (odds ratio 4·50, 95 per cent c.i. 2·59 to 7·81; P <0·001), and were associated with less treatment failure, blood loss and shorter duration of surgery. Conclusion: Surgical sealants appear to reduce suture-hole bleeding significantly in vascular prosthetic graft anastomoses compared with standard haemostatic measures. [ABSTRACT FROM AUTHOR]

Background Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials ( RCTs) within the context of explanatory and pragmatic study designs. Methods Systematic searches identified RCTs of surgical interventions published in 2010 and 2011. Included studies were categorized as predominantly explanatory or pragmatic. The extent of intervention details in the reports were compared with the CONSORT statement for reporting trials of non-pharmacological treatments ( CONSORT-NPT). CONSORT-NPT recommends reporting the descriptions of surgical interventions, whether they were standardized and adhered to (items 4a, 4b and 4c). Reporting of the context of intervention delivery (items 3 and 15) and operator expertise (item 15) were assessed. Results Of 4541 abstracts and 131 full-text articles, 80 were included (of which 39 were classified as predominantly pragmatic), reporting 160 interventions. Descriptions of 129 interventions (80·6 per cent) were provided. Standardization was mentioned for 47 (29·4 per cent) of the 160 interventions, and 22 articles (28 per cent) reported measurement of adherence to at least one aspect of the intervention. Seventy-one papers (89 per cent) provided some information about context. For one-third of interventions (55, 34·4 per cent), some data were provided regarding the expertise of personnel involved. Reporting standards were similar in trials classified as pragmatic or explanatory. Conclusion The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice. [ABSTRACT FROM AUTHOR]

Background Anastomotic leak ( AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs. Methods A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment. Results Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented. Conclusion Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: Subclinical Cushing's syndrome (SCS) is a condition of biochemical cortisol excess without the classical clinical features of overt hypercortisolism; it may be associated with some consequences of metabolic syndrome. The most appropriate treatment remains controversial. This study aimed to assess the outcomes of adrenalectomy for SCS. Methods: A systematic review was performed. MEDLINE, Embase and Cochrane Databases (1980-2013) were searched for studies reporting the outcomes of unilateral adrenalectomy with respect to hypertension, diabetes, dyslipidaemia, obesity and osteoporosis in patients with SCS. Studies with a questionable diagnosis of SCS, bilateral adrenal involvement and insufficient data were excluded. Results: Of the 105 papers screened, seven were selected; there were six retrospective studies and one randomized clinical trial, including 230 patients. Data analysis was limited by heterogeneity in definition of SCS and endpoints. Hypercortisolism was cured in all operated patients. Laparoscopy was the preferred approach, with a morbidity rate of 0·8 per cent. A beneficial effect of surgery on blood pressure, glucometabolic control and obesity was evident in all studies, with cure or improvement in 72, 46 and 39 per cent of patients respectively, compared with conservative management. The results for lipid metabolism were equivocal, because of a decrease in triglyceridaemia but discordant effects on cholesterol metabolism among the different studies. No beneficial effects on osteoporosis were found. Conclusion: Laparoscopic adrenalectomy seems to be beneficial in reversing several metabolic effects of hypercortisolism, with a low morbidity rate. However, the heterogeneity and low quality of the available studies preclude definitive recommendations. [ABSTRACT FROM AUTHOR]

Background: Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA. Methods: Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed. Results: Of 2036 records, 43 articles were included in the final analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mortality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20-72) per cent and the biochemical profile in 96-100 per cent of patients. The mean complication rate in 1056 patients was 4·7 per cent. Conclusion: Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients. [ABSTRACT FROM AUTHOR]

Background In the past 30 years surgical practice has changed considerably owing to the advent of minimally invasive surgery ( MIS). This paper investigates the changing surgical landscape chronologically and quantitatively, examining the technologies that have played, and are forecast to play, the largest part in this shift in surgical practice. Methods Electronic patent and publication databases were searched over the interval 1980-2011 for ('minimally invasive' OR laparoscopic OR laparoscopy OR 'minimal access' OR 'key hole') AND (surgery OR surgical OR surgeon). The resulting patent codes were allocated into technology clusters. Technology clusters referred to repeatedly in the contemporary surgical literature were also included in the analysis. Growth curves of patents and publications for the resulting technology clusters were then plotted. Results The initial search revealed 27 920 patents and 95 420 publications meeting the search criteria. The clusters meeting the criteria for in-depth analysis were: instruments, image guidance, surgical robotics, sutures, single-incision laparoscopic surgery ( SILS) and natural-orifice transluminal endoscopic surgery ( NOTES). Three patterns of growth were observed among these technology clusters: an S-shape (instruments and sutures), a gradual exponential rise (surgical robotics and image guidance), and a rapid contemporaneous exponential rise ( NOTES and SILS). Conclusion Technological innovation in MIS has been largely stagnant since its initial inception nearly 30 years ago, with few novel technologies emerging. The present study adds objective data to the previous claims that SILS, a surgical technique currently adopted by very few, represents an important part of the future of MIS. [ABSTRACT FROM AUTHOR]

Background The routine collection of large amounts of clinical data, 'big data', is becoming more common, as are research studies that make use of these data source. The aim of this paper is to provide an overview of the uses of data from large multi-institution clinical databases for research. Methods This article considers the potential benefits, the types of data source, and the use to which the data is put. Additionally, the main challenges associated with using these data sources for research purposes are considered. Results Common uses of the data include: providing population characteristics; identifying risk factors and developing prediction (diagnostic or prognostic) models; observational studies comparing different interventions; exploring variation between healthcare providers; and as a supplementary source of data for another study. The main advantages of using such big data sources are their comprehensive nature, the relatively large number of patients they comprise, and the ability to compare healthcare providers. The main challenges are demonstrating data quality and confidently applying a causal interpretation to the study findings. Conclusion Large clinical database research studies are becoming ubiquitous and offer a number of potential benefits. However, the limitations of such data sources must not be overlooked; each research study needs to be considered carefully in its own right, together with the justification for using the data for that specific purpose. [ABSTRACT FROM AUTHOR]

Background The IDEAL framework (Idea, Development, Exploration, Assessment, Long-term study) proposes a staged assessment of surgical innovation, but whether it can be used in practice is uncertain. This study aimed to review the reporting of a surgical innovation according to the IDEAL framework. Methods Systematic literature searches identified articles reporting laparoendoscopic excision for benign colonic polyps. Using the IDEAL stage recommendations, data were collected on: patient selection, surgeon and unit expertise, description of the intervention and modifications, outcome reporting, and research governance. Studies were categorized by IDEAL stages: 0/1, simple technical preclinical/clinical reports; 2a, technique modifications with rationale and safety data; 2b, expanded patient selection and reporting of both innovation and standard care outcomes; 3, formal randomized controlled trials; and 4, long-term audit and registry studies. Each stage has specific requirements for reporting of surgeon expertise, governance details and outcome reporting. Results Of 615 abstracts screened, 16 papers reporting outcomes of 550 patients were included. Only two studies could be put into IDEAL categories. One animal study was classified as stage 0 and one clinical study as stage 2a through prospective ethical approval, protocol registration and data collection. Studies could not be classified according to IDEAL for insufficient reporting details of patient selection, relevant surgeon expertise, and how and why the technique was modified or adapted. Conclusion The reporting of innovation in the context of laparoendoscopic colonic polyp excision would benefit from standardized methods. [ABSTRACT FROM AUTHOR]

Background A Health Technology Assessment was conducted to evaluate the relative clinical effectiveness and cost-effectiveness of minimally invasive techniques (foam sclerotherapy ( FS), endovenous laser ablation ( EVLA) and radiofrequency ablation ( RFA)) for managing varicose veins, in comparison with traditional surgery. Methods A systematic review of randomized clinical trials ( RCTs) was undertaken to assess the effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, Venous Clinical Severity Score ( VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed. Results The literature search conducted in July 2011 identified 1453 unique citations: 31 RCTs (51 papers) satisfied the criteria for effectiveness review. Differences between treatments were negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Total FS costs were estimated to be lowest, and FS was marginally more effective than surgery. However, relative effectiveness was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs were similar to those for surgery. These findings are subject to various uncertainties, including the risk of bias present in the evidence base and variation in reported costs. Conclusion This assessment of currently available evidence suggests there is little to choose between surgery and the minimally invasive techniques in terms of efficacy or safety, so the relative cost of the treatments becomes one of the deciding factors. High-quality RCT evidence is needed to verify and further inform these findings. [ABSTRACT FROM AUTHOR]

This month saw the release of both the January issue of I BJS i and the entirely free to access joint special issue on perioperative care with I Anaesthesia i journal. @NIHR GSU posted two interesting threads on global surgery, one sharing their favourite papers from the 2019 I BJS i special issue on the topic, including the GlobalSurg Collaborative paper on WHO Surgical Safety Checklist use and mortality after emergency laparotomy[7]. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. [Extracted from the article]

Emile's comments questioned the main outcome of our paper, selection of a process or clinical outcome I versus i a morbidity parameter. Intracorporeal anastomosis (IA) for laparoscopic right colectomy is not merely a technical option in anastomosis formation, it is a different surgical strategy. 4 Gomez M, Peralta G. A prospective observational multi-center 4 cohort study comparing robotic assisted and laparoscopic invasive right colectomy and intracorporeal anastomosis versus extracorporeal anastomosis. [Extracted from the article]

I Editor i We write in reply to Arnold-Foster's insightful paper on resilience[1]. On this principle, Hackman and Vidmar analysed the number of people in a team and the number of one-to-one relationships or links they need to maintain[3]. It is not a coincidence that SAS patrol teams have four members and that four patrol teams make up a troop. [Extracted from the article]

I Editor i The necessity of preoperative blockade for patients with pheochromocytoma has been controversial over the past 15 years. Like most other retrospective studies on the question[2], the paper did not describe side-by-side the tumour characteristics of those who received blockade and those who did not, in most centres[1]. Indeed, data from the only centre where tumour details were provided show that patients were relatively young with relatively small tumours[1]. [Extracted from the article]

I Editor i We read with interest the paper of Lehrskov I et al i .[1] analysing the non-inferiority of intraoperative fluorescence cholangiography compared with X-ray cholangiography during elective laparoscopic cholecystectomy for complicated gallstone disease[1]. Acute cholecystitis was an exclusion criterion, but the authors conclude intraoperative fluorescence cholangiography may be beneficial in patients with acute cholecystitis. In addition to 15 per cent of patients in whom X-ray cholangiography was not performed, intraoperative fluorescence cholangiography was not able to identify the "critical junction" in 18 per cent (11 of 60), so neither of these methods can be an alternative to meticulous surgical preparation and conversion, if necessary. [Extracted from the article]

In their recent paper, Spinelli and Pellino talked about emergency surgery during the COVID-19 pandemic[1]. A 65-4 per cent decrease in emergency surgery activity was observed; the mean number of patients who underwent emergency surgery daily in each hospital decreased from 2-6 during the control period to 0-9 during pandemic period ( I P i < 0-001). Considering these results, those regions where the COVID-19 pandemic is now developing should assume that emergency surgery activity will decrease to one-third of normal. [Extracted from the article]

I Editor i We want to thank Lin Du and Hong-Lin Chen for their interest in our paper[1]. References 1 Haisley M, Sørensen JA, Sollie M. Postoperative pressure injuries in adults having surgery under general anaesthesia: systematic review of perioperative risk factors. [Extracted from the article]

I Editor i Thank you to Xue I et al i . for their review of our paper[1], highlighting common concerns regarding perioperative administration of intravenous contrast media. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. [Extracted from the article]

I Editor i We thank Jones and Baraza for their interest in our paper[1] and for highlighting the omission of the work of Hughes I et al i .[2] from the meta-analysis. The purpose of our review was to appraise the methodology and level of evidence of educational impact of studies assessing cadaveric simulation for postgraduate training. There remains a deficiency of objective evidence of skill transfer to the live operating theatre following cadaveric simulation training. [Extracted from the article]

I Editor i We thank Sall I et al i . for their comments on the 'Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society'[1]. Furthermore, a guideline should be evidence-based and there are no papers describing a "gold standard" method for open preperitoneal mesh repair for umbilical and epigastric hernias. [Extracted from the article]

Although the registry paper included 1000 patients, median follow-up was just 274 days and it is uncertain if all patients undergoing MSA were included and reported. The authors concluded that the device was safe, despite 32 per cent of MSA patients reporting dysphagia, and although no devices were explanted, follow-up was just 6 months. We undertook a detailed analysis over time of reporting of study design, clinical indications, technique standardization, governance arrangements and outcome selection, as an evaluation of how the innovative procedure progressed. [Extracted from the article]

Comment on: Performance of a modified three-level classification in stratifying open liver resection procedures in terms of complexity and postoperative morbidity Kawaguchi I et al i . recently described a three-level classification for stratifying complexity of open liver surgery[1] based on their previously published classification of laparoscopic liver operations[2]. But caudate resection and segmentectomy (Sg) 2/3 resection values are present in the utility method and these fall into the posterosuperior and anterolateral segment groups according to Kawaguchi I et al i .'s original paper[2]. [Extracted from the article]

One of the most popular papers on Twitter this month was Stellingwerf I et al i .'s study on appendicectomy for the treatment of therapy-refractory ulcerative colitis,[1] which received over 10 000 impressions. A Twitter poll showed that despite recent studies showing that antibiotics are unnecessary for uncomplicated diverticulitis[[2]] the majority still prescribe antibiotics in this context. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. [Extracted from the article]

Author response to: Comment on: Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis We thank Dai and Jiang for their interesting comment regarding our paper analysing the effect of appendicectomy in patients with refractory ulcerative colitis (UC)[1]. Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis. [Extracted from the article]

The Global Surgery Journal Club (@GlobalSurgeryJC) held another tweetchat on 10 August, in which they discussed a BJS paper from the special issue on Global Surgery on the use of the WHO Surgical Safety Checklist and mortality after emergency laparotomy[2]. BJS Editor @MalinASund shared slides from the Swedish Surgical Week in Norrköping, including talks by BJS Editor @ksoreide, and this year's BJS lecturer Dion Morton. Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10 mm or less. [Extracted from the article]

Reviews of research papers on topics including prophylactic mesh does not prevent hernia during colostomy, operative surgery for diverticulitis, and comparison between laparoscopic and open adhesiolysis for small bowel obstruction is provided.

The article lists several research papers about clinical trials in surgery which were added to the scientific surgery archive of the journal "British Journal of Surgery".