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Background: The benefit and harm of three‐field lymphadenectomy for oesophageal cancer are still unknown. The aim of this study was to compare overall survival and morbidity and mortality between three‐ and two‐field lymphadenectomy in patients with oesophageal squamous cell carcinoma. Methods: Between March 2013 and November 2016, patients with squamous cell carcinoma of the middle or distal oesophagus were assigned randomly to open oesophagectomy with three‐field (cervical–thoracic–abdominal) or two‐field (thoracic–abdominal) lymphadenectomy. No chemo(radio) therapy was given before surgery. This paper reports on the secondary outcomes of the study: pathology and surgical complications. Results: Some 400 patients were randomized, 200 in each group. A median of 37 (i.q.r. 30–49) lymph nodes were dissected in the three‐field group, compared with 24 (18–30) in the two‐field group (P < 0·001). Some 43 of 200 patients (21·5 per cent) in the three‐field group had cervical lymph node metastasis. More patients in the three‐field group had pN3 disease: 21 of 200 (10·5 per cent) versus 10 of 200 (5·0 per cent) (P = 0·040). The rate and severity of postoperative complications were comparable between the two groups, except that six patients in the three‐field arm needed reintubation compared with none in the two‐field group (3·0 versus 0 per cent; P = 0·030). The 90‐day mortality rate was 0 per cent in the three‐field group and 0·5 per cent (1 patient) in the two‐field group (P = 1·000). Conclusion: Oesophagectomy with three‐field lymphadenectomy increased the number of lymph nodes dissected and led to stage migration owing to a 21·5 per cent rate of cervical lymph node metastasis. Postoperative complications were largely comparable between two‐ and three‐field lymphadenectomy. Registration number: NCT01807936 (https://www.clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Background Recruitment into surgical RCTs can be threatened if new interventions available outside the trial compete with those being evaluated. Adapting the trial to include the new intervention may overcome this issue, yet this is not often done in surgery. This paper describes the challenges, rationale and methods for adapting an RCT to include a new intervention. Methods The By-Band study was designed in the UK in 2009-2010 to compare the effectiveness of laparoscopic adjustable gastric band and Roux-en- Y gastric bypass for severe obesity. It contained a pilot phase to establish whether recruitment was possible, and the grant proposal specified that an adaptation to include sleeve gastrectomy would be considered if practice changed and recruitment was successful. Information on changing obesity surgery practice, updated evidence and expert opinion about trial design were used to inform the adaptation. Results The pilot phase recruited over 13 months in 2013-2014 and randomized 80 patients (79 anticipated). During this time, major changes in obesity practice in the UK were observed, with gastric band reducing from 32·6 to 15·8 per cent and sleeve gastrectomy increasing from 9·0 to 28·1 per cent. The evidence base had not changed markedly. The British Obesity and Metabolic Surgery Society and study oversight committees supported an adaptation to include sleeve gastrectomy, and a proposal to do so was approved by the funder. Conclusion Adaptation of a two-group surgical RCT can allow evaluation of a third procedure and maintain relevance of the RCT to practice. It also optimizes the use of existing trial infrastructure to answer an additional important research question. Registration number: ISRCTN00786323 (/). [ABSTRACT FROM AUTHOR]

Background: Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of a J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application. Methods and results: Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search. Conclusion: The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed. [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: 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]

The article presents abstracts on papers presented at the 100th Annual Congress of the Swiss Society of Surgery held in Berne, Switzerland from June 12-14, 2013 on topics including laparoscopic sleeve gastrectomy, complications linked with Roux-en-Y gastric bypass, and intra-operative infiltration.

Background: Thoracic epidural anaesthesia (TEA) is used widely in colorectal surgery. However, there is increasing concern that epidurals are associated with postoperative hypotension, mediating a potential reduction in splanchnic flow. The aim was to review the literature on the effects of TEA on splanchnic blood flow. Methods: PubMed and Cochrane databases were searched. Search terms used were: English language, 'thoracic epidural splanchnic flow', 'thoracic epidural gut blood flow', 'thoracic epidural intestinal blood flow' and 'thoracic epidural colonic blood flow'. Abstracts were reviewed by two independent researchers and irrelevant studies excluded. The full text of the remaining articles was then retrieved. Results: Twenty-two abstracts were reviewed and three excluded. Nineteen papers were reviewed in full and seven irrelevant articles excluded. Five human studies investigated the effects of TEA on splanchnic flow. Two studies measured splanchnic flow directly and found an epidural-mediated fall in flow, unresponsive to intravenous fluids and requiring vasopressors or inotropes to restore baseline flow. The remaining three studies had inconsistent findings and haemodynamic stability was maintained. The seven animal studies identified were heterogeneous in both methodology and findings. Three suggested a protective role for thoracic epidurals in septic shock and pancreatitis. Conclusion: These findings are inconsistent; however, the two studies that investigated the effects of vasoconstrictors on splanchnic blood flow directly both found a significant epidural-mediated reduction in splanchnic blood flow that was unresponsive to fluid therapy. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Stapled haemorrhoidopexy is a well recognized alternative to haemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. This paper reports all published cases of life-threatening sepsis following stapled haemorrhoidopexy, identifies causative factors and makes recommendations. Methods: A systematic review of the literature was performed by searching the major electronic databases. All relevant references were reviewed for possible inclusion. All references of the relevant articles were screened for any further articles that were not identified in the initial search. Results: From 2000 to the present, 29 articles reporting complications in 40 patients were identified. Thirty-five patients underwent laparotomy with faecal diversion and a further patient was treated by low anterior resection. A specific complication was rectal perforation with peritonitis. Factors that led to life-threatening sepsis were identified in 30 patients. Despite surgical treatment and resuscitation, there were four deaths. Conclusion: Severe sepsis can complicate stapled haemorrhoidopexy. Rectal perforation and peritonitis are a particular risk of this technique and the associated mortality rate is high. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. Methods: A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. Results: Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. Conclusion: Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: This study aims to establish the risk of developing a metachronous contralateral inguinal hernia (MCIH) following open repair of a unilateral inguinal hernia in children. Methods: A systematic review was performed using a defined search strategy. Studies in which children undergoing open repair of a unilateral inguinal hernia without contralateral exploration and who were followed up for MCIH development were included. Results: Of 5937 titles and abstracts screened, 154 full-text articles were identified for review; 49 papers were analysed with data on 22 846 children. The incidence of MCIH was 7.2 per cent overall, 6.9 per cent in boys and 7.3 per cent in girls (P = 0.381). Children with a left-sided inguinal hernia had a significantly higher risk of developing a MCIH than those with a right-sided hernia (10.2 versus 6.3 per cent respectively; P < 0.001). Conclusion: Overall, in both boys and girls, 14 contralateral explorations are required to prevent one metachronous hernia. The risk of developing a MCIH appears unchanged in early childhood, with a slight reduction after 12 years of age. Children with a left-sided hernia have the greatest risk of developing a contralateral hernia, but ten explorations are still required to prevent one metachronous hernia. Most MCIHs occur in the first 5 years after unilateral inguinal hernia repair. [ABSTRACT FROM AUTHOR]

Background: This systematic review examined the use of immunomodulators and the risk of postoperative complications after abdominal surgery in patients with inflammatory bowel disease. Methods: Electronic databases (PubMed, Embase, Ingenta, Zetoc and Ovid) were searched and the reference lists in all articles identified were hand-searched for further relevant papers. Studies were included if they evaluated postoperative complications and defined exposure to individual immunomodulators. Results: All 11 studies that met the inclusion criteria were observational studies; two were reported only in abstract form. Five studies reported risks associated with azathioprine, five reported risks associated with cyclosporin and three reported risks associated with infliximab. None showed an increased risk of either total or infectious complications associated with immunomodulator use. However, subgroup analysis in one study, published as an abstract, suggested increased rates of anastomotic complications and reoperation associated with azathioprine. Conclusion: Available evidence does not suggest an increased rate of postoperative complications associated with immunomodulator use. [ABSTRACT FROM AUTHOR]

Presents the abstracts of several papers on endocrine surgery presented to the 2003 Annual Meeting of the British Association of Endocrine Surgeons. "Cancellations For Thyroid Surgery: Unacceptable to Everyone," by R. Hughes, P.M. Mackey, A. Asderakis and D.M. Scott-Coombes; "Does Thyroidectomy Exacerbate or Relieve Globus Pharyngeus?," by D. Mather, S.L. Atkin and R.J.A. England; "Osteoprotegerin is a Survival Factor for Thyroid Cancer Cells In Vitro," by J.L. Scoffiled, B.J. Harrison and C.L. Eaton.

Background The aim of this study was to determine whether the routine use of an antibiotic-bonded gelatin-coated Dacron graft could reduce the incidence of prosthetic graft infection. Extra-anatomic grafts were chosen for study as they have the highest risk of graft infection. This paper reports early results up to 1 month after surgery. Methods This multicentre study involved 14 vascular units in the UK. A total of 257 patients underwent extra-anatomic bypass. Patients were randomized to rifampicin bonding (1 mg/ml rifampicin soak for 15 min before graft insertion) or a control group. Routine three-dose antibiotic prophylaxis was administered to patients in both groups. Results There were 178 men and 79 women of median age 69 (range 43–92) years. Rifampicin-bonded (n=123) and control (n=134) groups were well matched for clinical details, risk factors and operative techniques. No side-effects were noted from rifampicin bonding. Only one patient (in the control group) developed a graft infection and this proved fatal. There were no significant differences between bonded and unbonded grafts in terms of perioperative mortality rate (9 and 5 per cent respectively), median hospital stay (10 days for both groups), total infective complications (15 and 21 per cent respectively) or need for postoperative antibiotics (13 and 18 per cent respectively). Conclusion Early results from this study have not identified any significant advantage in the routine use of rifampicin bonding, but the rate of graft infection was very low (0·4 per cent). Gelatin coating alone may provide protection against infection. Definitive recommendations about the role of antibiotic bonding cannot be made until longer follow-up becomes available. [ABSTRACT FROM AUTHOR]

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]

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]

The author discusses a study which explores the short-term benefits of laparoscopic subtotal colectomy in patients with inflammatory bowel disease (IBD). The author believes that the study's findings are important in determining the role of laparoscopic approach in acute and subacute conditions. The author mentions the lack of randomized trials and clear definitions of complications as the paper's major limitation.

SummaryBackground: Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with severe secondary peritonitis remains unacceptably high. This article presents various surgical treatment strategies for severe secondary peritonitis, emphasizing the role of open management of the abdomen and planned relaparotomies. Methods: Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. Results and conclusion: Surgical treatment of severe secondary peritonitis is highly demanding and very complex. The combination of improved surgical techniques, antimicrobial therapy and intensive care support has improved the outcome of such peritonitis following perforation or anastomotic disruption of the digestive tract, or infected necrotizing pancreatitis. However, aggressive surgical treatment strategies, such as open management of the abdomen and planned relaparotomies, may have reached their limits. [ABSTRACT FROM AUTHOR]

Background: A large number of scoring systems for assessing a patient’s risk of complications or death has been developed over recent years. This is a review of those that are of relevance to general surgeons. Methods: A Medline literature search was performed to identify all articles concerning ‘severity of illness’, ‘morbidity’, ‘mortality’ and ‘postoperative complications’ in the field of surgery from 1966 to 1997. Further searches were performed to find papers about specific identified scoring systems, and relevant articles from the reference lists of these were also sought. Results and conclusion: The advantages of an accurate assessment of a patient’s risk include, on an individual level, the opportunity to give a more accurate prognosis and choose the most appropriate treatment. If the risk of an adverse outcome is known for a group of patients, the actual outcome can be compared with the predicted outcome, and comparison can be made between groups in different surgical units for the purposes of audit or research. The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is the most appropriate of the currently available scores for general surgical practice. [ABSTRACT FROM AUTHOR]