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Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) reduces blood loss and improves hemodynamics. Complete occlusion results in distal ischemia, limiting its use for prolonged care. This study evaluated two next-generation partial REBOA (pREBOA) catheters and their ability to achieve targeted distal aortic flow., Materials and Methods: Swine underwent hemorrhagic shock, complete aortic occlusion, controlled continuous balloon deflation, and targeted distal perfusion (TDP; 300-mL/min) phases. They were randomized into three groups (n = 6/group), one managed with the current ER-REBOA (ER), and two with the new pREBOA technologies: a bilobed (BL) device and a semicompliant pREBOA-PRO (PRP). Hemodynamics including flow rates and mean arterial pressures at the carotid artery and infrarenal aorta were recorded., Results: Hemodynamics were comparable between groups during hemorrhage and complete occlusion phases. During the controlled continuous balloon deflation phase, the distal aortic flow rate strongly correlated with percent balloon volume in BL and PRP groups, suggesting a precise control of distal perfusion. The slope of flow-balloon-volume curves was greater in the ER group than BL and PRP groups, indicating the change in distal aortic flow rate was more sensitive to the balloon volume (less titratable) when using ER. During the TDP phase, variation in distal aortic flow and mean arterial pressure with respect to the target flow was lower in ER and PRP groups, than the BL group., Conclusions: Pressure-regulated occlusion using the next-generation pREBOA catheters is more controlled than the first-generation ER-REBOA catheter and allow for targeted and precise distal perfusion., (Published by Elsevier Inc.)

Background: A number of pharmaceutical agents have limited water solubility and are therefore often prepared in a lipid emulsion. Emulsion renders plasma opaque and this could interfere with the accuracy of some standardized laboratory measurements, especially for optical or mechanical based assays. We determined the interference on some laboratory diagnostic values of blood specimens after propofol addition in vitro as well as in vivo when infused into swine., Methods: In vitro, laboratory parameters were measured immediately after mixing swine blood diluted with increasing amounts of propofol emulsion in the range of 3 to 23%, v/v. The contact time of a 9% v/v mixture of blood and propofol was also examined over a 3-hours period. Saline-diluted samples served as controls. Cellular volume, hematocrit, hemoglobin, potassium, and coagulation were measured with various instruments. In addition, similar parameters were analyzed from swine blood following a 9 - 10 hours infusion with propofol/fentanyl compared to infusion with ketamine/midazolam., Results: In vitro, blood cell volume increased immediately upon contact with a mixture exceeding 6% propofol. Above 9% of the mixture, the cellular volume expanded significantly with extracellular K+ leakage. Hematocrit increased but the hemoglobin was dependent on the instrument type. Coagulation was altered when the emulsion was present. Interestingly, in vivo these effects were significant less pronounced in blood collected from experimental swine under total intravenous propofol anesthesia, but they departed from water-based anesthesia in control swine., Conclusions: The in vitro studies indicate that results from certain assays of blood samples rich in lipid emulsion may not be accurate due to interference with optical, mechanical or ion selective electrode methodology. Although in vivo samples may be less impacted, there is still a risk of deviation from accuracy.

Introduction There is an increasing trend towards day case surgery for uncomplicated gallstone disease. The challenges of maximising training opportunities are well recognised by surgical trainees and the need to demonstrate timely progression of competencies is essential. Laparoscopic cholecystectomy provides the potential for excellent trainee learning opportunities. Our study builds upon previous work by assessing whether measures of outcome are still affected when cases are stratified based on procedural difficulty. Material and methods A prospective cohort study of all laparoscopic cholecystectomies conducted at a district general hospital between 2009 and 2014, performed under the care of a single consultant. The operative difficulty was determined using the Cuschieri classification. The primary endpoint was duration of operation. Secondary endpoints included length of hospital stay, delayed discharge rate and 30-day morbidity. Results A total of 266 laparoscopic cholecystectomies were performed during the study period. Mean operative time for all consultant-led cases was 52.5 minutes compared with 51.4 minutes for trainees (P = 0.67 unpaired t-test). When cases were stratified for difficulty, consultant-led cases were on average 5 minutes faster. Median duration of hospital stay was equivalent in both groups and there was no statistical difference in re-attendance (12.9% vs. 15.3% P = 0.59) or re-admission rates (3.2% vs. 8.1% P = 0.10) at 30 days. Conclusions Our study provides evidence that laparoscopic cholecystectomy provides a good training opportunity for surgical trainees without being detrimental to patient outcome. We recommend that, in selected patients, under consultant supervision, laparoscopic cholecystectomy can be performed primarily by the surgical trainee without impacting on patient outcome or theatre scheduling.

Background: Oral antiseptics reduce nosocomial infections and ventilator-associated pneumonia in critically ill medical and surgical patients intubated for prolonged periods. However, the role of oral antiseptics given before and after planned surgery is not clear. The aim of this systematic review and meta-analysis is to determine the effect of oral antiseptics (chlorhexidine or povidone-iodine) when administered before and after major elective surgery., Methods: Searches were conducted of the MEDLINE, EMBASE and Cochrane databases. The analysis was performed using the random-effects method and the risk ratio (RR) with 95 % confidence interval (CI)., Results: Of 1114 unique identified articles, perioperative chlorhexidine was administered to patients undergoing elective surgery in four studies. This identified 2265 patients undergoing elective cardiac surgery, of whom 1093 (48.3 %) received perioperative chlorhexidine. Postoperative pneumonia and nosocomial infections were observed in 5.3 and 20.2 % who received chlorhexidine compared to 10.4 and 31.3 % who received a control preparation, respectively. Oral perioperative chlorhexidine significantly reduced the risk of postoperative pneumonia (RR = 0.52; 95 % CI 0.39-0.71; p < 0.01) and overall nosocomial infections (RR = 0.65; 95 % CI 0.52-0.81; p < 0.01), with no effect on in-hospital mortality (RR = 1.01; 95 % CI 0.49-2.09; p = 0.98)., Conclusions: Perioperative oral chlorhexidine significantly decreases the incidence of nosocomial infection and postoperative pneumonia in patients undergoing elective cardiac surgery. There are no randomised controlled studies of this simple and cheap intervention in patients undergoing elective non-cardiac surgery., Trial Registration: This systematic review was registered with the International prospective register of systematic reviews (PROSPERO). The registration number is CRD42015016063.

Introduction: Cholecystectomy is one of the most common general surgical operations performed. Despite level one evidence supporting the role of cholecystectomy in the management of specific gallbladder diseases, practice varies between surgeons and hospitals. It is unknown whether these variations account for the differences in surgical outcomes seen in population-level retrospective data sets. This study aims to investigate surgical outcomes following acute, elective and delayed cholecystectomies in a multicentre, contemporary, prospective, population-based cohort., Methods and Analysis: UK and Irish hospitals performing cholecystectomies will be recruited utilising trainee-led research collaboratives. Two months of consecutive, adult patient data will be included. The primary outcome measure of all-cause 30-day readmission rate will be used in this study. Thirty-day complication rates, bile leak rate, common bile duct injury, conversion to open surgery, duration of surgery and length of stay will be measured as secondary outcomes. Prospective data on over 8000 procedures is anticipated. Individual hospitals will be surveyed to determine local policies and service provision. Variations in outcomes will be investigated using regression modelling to adjust for confounders., Ethics and Dissemination: Research ethics approval is not required for this study and has been confirmed by the online National Research Ethics Service (NRES) decision tool. This novel study will investigate how hospital-level surgical provision can affect patient outcomes, using a cross-sectional methodology. The results are essential to inform commissioning groups and implement changes within the National Health Service (NHS). Dissemination of the study protocol is primarily through the trainee-led research collaboratives and the Association of Upper Gastrointestinal Surgeons (AUGIS). Individual centres will have access to their own results and the collective results of the study will be published in peer-reviewed journals and presented at relevant surgical conferences., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Colorectal cancer (CRC) is the fourth most common cancer in the UK and the incidence has increased over recent decades. Although only 1.5% of cases are diagnosed in those aged under 40 years, it remains an important condition to be aware of in the military population. Patients who are genetically predisposed can have a lifetime risk of 80-100% of developing CRC and are likely to develop symptoms during their service. 20% of patients will present with metastatic disease. While surgical and oncological treatments have improved outcomes, early diagnosis of CRC is essential to reducing mortality. This paper provides an overview of the aetiology, investigations and treatment options for CRC. Explanation of primary surgical options and the principles of adjuvant therapies are included to aid informed discussions with patients.

Mass casualty events (MCE) present health systems with a sudden demand on key services. The overall objective of this study was to describe the experience of the National Blood Service (NBS) following the largest UK MCE in recent times. Data was collated from the NBS database and directly from the hospitals involved. All data was collected immediately following the event and included: all blood components requested, issued and transfused in relation to the bombings, blood stock levels at the time and the injury profiles of the casualties transfused. The total NBS order from hospitals for the event was 1455 units of blood components. All requests were fulfilled, this included: 978 units of red cells (RC), 36 doses of platelets, 141 units of fresh frozen plasma (FFP) and 300 doses of cryoprecipitate. The amount of blood ordered was three times that initially used and the total number of RC transfused in treating all victims from admission to discharge was approximately 440 units. The greatest use of blood components was for those casualties who had sustained traumatic amputations amongst their injury profile. Published data with which to compare these results is lacking, although the RC use was similar to the initial mean individual usage described in previous military and civilian bombings. The overall implication for any blood service remains, there is now likely to be a far greater demand for plasma, platelets and cryoprecipitate in any future incidents involving victims suffering major haemorrhage., (© 2012 The Authors. Transfusion Medicine © 2012 British Blood Transfusion Society.)