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Only 8 patients (5.9%) had a new finding on second or subsequent visits (colonic polyp in 6 patients, renal cancer in one patient and benign adrenal adenoma in one patient). For patient with screen and surveillance detected AAA the median times from diagnosis to first clinic review was 8-days and 17-days; and from diagnosis to surgery 43-days (7 [59%] of patients were operated on within 40-days) and 76-days (only 20 [30%] of patients were operated on within 40-days) respectively. WS 6.3 Patient reported surgical site infection after elective colorectal surgery - patient reported... Lydia Newton, Ffion Dewi, Harry Dean, Cara Swain, Dawn Gane, Anne Pullyblank North Bristol NHS Trust Aims: 30-day surgical site infection (SSI) after colorectal resection is difficult to measure as patients are discharged quickly within enhanced recovery programmes. WS 13.3 Z-Plasty is an effective management for colostomy stenosis in high risk patients Judith Johnston, Mohamed Basheer Midyorkshire Hospital Trust Aims: To ascertain which patients are managed with Z-plasty for stomal stenosis To assess the effectiveness of using Z-plasty in treating stomal stenosis Methods: Operative information around all patients from 2010-2019 who underwent Z-plasty for stomal stenosis was collected and analysed on Excel. [Extracted from the article]

Methods: Electronic patient records of 1088 patients who underwent ANC Patients had their USS the same day and 26% of patients had to return the Cases, 6 patients developed septicemia, 2 patients developed ARF, 2 patients Vital role in providing treatment services to patients, Patient reported outcome Timeline of each case from the time the patient was sent for till the patient goes. [Extracted from the article]

Background: Small bowel neuroendocrine tumours often present with locally advanced or metastatic disease. The aim of this paper is to provide evidence-based recommendations regarding (controversial) topics in the surgical management of advanced small bowel neuroendocrine tumours. Methods: A working group of experts was formed by the European Society of Endocrine Surgeons. The group addressed 11 clinically relevant questions regarding surgery for advanced disease, including the benefit of primary tumour resection, the role of cytoreduction, the extent of lymph node clearance, and the management of an unknown primary tumour. A systematic literature search was performed in MEDLINE to identify papers addressing the research questions. Final recommendations were presented and voted upon by European Society of Endocrine Surgeons members at the European Society of Endocrine Surgeons Conference in Mainz in 2023. Results: The literature review yielded 1223 papers, of which 84 were included. There were no randomized controlled trials to address any of the research questions and therefore conclusions were based on the available case series, cohort studies, and systematic reviews/meta-analyses of the available non-randomized studies. The proposed recommendations were scored by 38–51 members and rated 'strongly agree' or 'agree' by 64–96% of participants. Conclusion: This paper provides recommendations based on the best available evidence and expert opinion on the surgical management of locally advanced and metastatic small bowel neuroendocrine tumours. This paper provides evidence-based recommendations on the surgical management of locally advanced and metastatic small bowel neuroendocrine tumours, primary tumour resections in the setting of metastatic disease, and surgical indications for grade 3 small bowel neuroendocrine tumours and small bowel neuroendocrine carcinomas. The recommendations are the result of a working group of experts, created by the European Society of Endocrine Surgeons. The group addressed 11 relevant clinical questions regarding surgery for advanced disease, emphasizing and confirming the key role of the surgeon for advanced small bowel neuroendocrine tumours. [ABSTRACT FROM AUTHOR]

Several abstracts are presented which includes one on Compliance Audit in Day Surgery Unit (DSU), the other on improving postoperative information transfer and the third on the use of "Hip Precautions" after hip hemiarthroplasty.

The article presents abstracts of articles on surgery topics including one on the relationship between disease severity and Aberdeen varicose vein questionnaire (AVVQ), another on influence of obesity on insulin resistance, and the effects of genetic polymorphisms on aortic growth.

Several abstracts are presented related to non-profit organization Association Of Surgeons Of Great Britain & Ireland (ASGBI) including analysis of surgical competence, using social media to share surgical evidence and using simulation with Frozen Cadaveric model for training medical students.

Several abstracts related to trauma and military surgery are presented including surgical options to control laparotomy, study on electrolyte variability in military trauma patients and psychological effects of extracorporeal hemofiltration in hind limb ischemia-reperfusion injury in Sus scrofa.

Several abstracts related to perioperative care and clinical science are presented including effect of beta-blockade on physical fitness physical fitness in patients with abdominal aortic aneurysms, tumour pathology in Colorectal Cancer and study of surgical care in an African District Hospital.

The article presents abstracts on medical topics which include the Great Britain higher surgical training, the Laparoscopic adrenal contouring using fluorescence imaging and validation of Microrna Signatures for detecting pancreatic malignant transformation.

The article presents abstracts on medical topics which include an audit to identify factors involved in making recommendations to decrease unplanned readmissions, study to determine safety profile following gastrointestinal surgery and thromboprophylaxis after major abdominal cancer surgery.

Several abstracts on surgery are presented which includes one on the use of serum osteonectin for screening pancreatic cancer, the other on appendectomy and the third on post -traumatic stress disorder.

Ambulatory Management of Right Iliac Fossa Pain: A Five-year Review Dale Thompson, Sarah Richards Royal United Hospitals, Bath Aim: Acute appendicitis is the most common indication for emergency surgery. The investigation and management of patients presenting with right iliac fossa (RIF) pain is usually on an in-patient basis in the UK. We present a 5-year experience of managing patients with RIF pain on an ambulatory basis in Emergency Surgical Ambulatory Care (ESAC). [Extracted from the article]

To FLOT chemotherapy in a cohort of patients treated with radical intent. Methods: Patients receiving perioperative FLOT for oesophagogastric ade- Chemotherapy-related toxicity was encountered in 6/24 (25%) patients Chemotherapy was completed in 9/17 (52.9%) patients. [Extracted from the article]

Background: Australia's unique national surgical mortality audit has had a long-term focus on the avoidance of futile surgery. The 30-day mortality rate after emergency laparotomy in Australia is lower than in other countries. Early death (within 72 h) after emergency laparotomy may reflect futile surgery. This paper considers whether Australia's national mortality audit is the reason for its lower mortality rate after emergency laparotomy. Methods: Data were extracted from the Australia and New Zealand Emergency Laparotomy Audit--Quality Improvement (ANZELA-QI) from 2018 to 2022. The time elapsed from emergency laparotomy to death was determined for each patient. The cumulative daily mortality rate was calculated for the first 30 days and expressed as a proportion of all emergency laparotomies, and 30-day and inhospital mortality. Mortality data were compared with those in the only three similar overseas studies. The mortality rate after emergency laparotomy for patients who required but did not undergo surgery was calculated for each hospital. The proportion of patients with high-risk characteristics was compared with that in the National Emergency Laparotomy Audit (NELA). Results: Compared with overseas studies, there was a lower early (within 72 h) mortality rate in ANZELA-QI. Although the lower mortality rate in ANZELA-QI persisted to 30 days, there was a relative increase after 14 days that likely reflected known poor compliance with care standards. Australian patients had fewer high-risk characteristics than those in NELA. Conclusion: The present findings support the hypothesis that the lower mortality rate after emergency laparotomy in Australia is likely a consequence of its national mortality audit and the avoidance of futile surgery. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include risk associated with management of patients with intermittent claudication, a study on abdominal aortic aneurysms via modulation of glucose transporters, and analysis of human venous valve in patients with lymphoedema.

The article presents abstracts on medical topics which include prediction of autogenous Arterio-venous fistula maturity, a study on the use of pragmatic structured education programme to increase walking in people with intermittent claudication, and thrombolysis in vascular patients.

The article presents abstracts on medical topics which include identification of abdominal aortic aneurysm, a study on implementation of dual anti-platelet therapy to reduce recurrent neurological events prior to surgery, and duplex ultrasound surveillance to maintain stent patency.

Background: The Clinical Treatment Score post-5 years (CTS5) integrates four clinicopathological variables to estimate the residual disease recurrence risk in hormone receptor-positive breast cancer patients who have been treated with five years of adjuvant endocrine therapy. This study aimed to determine the accuracy of the CTS5. Methods: A systematic review was performed in accordance with the PRISMA statement. Studies relevant for inclusion in the current review were identified from The Cochrane Library, EBSCO, Ovid, PubMed, and Embase. Results: Six papers reported on 30 354 postmenopausal patients (age range 42 to 91 years). The pooled hazard ratio (HR) of distant recurrence relative to the low-risk CTS5 category was 5.41 (95% c.i. 4.50 to 6.51; P,0.05) for the high-risk CTS5 category and 2.32 (95% c.i. 1.90-2.84; P,0.05) for the intermediate CTS5 category. Three papers reported on 10 425 premenopausal patients (age range 18 to 54 years). The pooled HR of distant recurrence relative to the low-risk CTS5 category was 5.42 (95% c.i. 2.26 to 13.01; P, 0.05) for the high-risk CTS5 category and 2.82 (95% c.i. 1.35 to 5.88; P,0.05) for the intermediate CTS5 category. Relative to highrisk postmenopausal patients, the mean observed 10-year distant recurrence risk for the high CTS5 category was 13.83 per cent, which differs significantly from the CTS5 estimation of 10-year distant recurrence risk (20.3 per cent, 95% c.i. 17.2 to 24; P=0.000). Conclusion: The CTS5 can predict late distant recurrence risk in pre- and postmenopausal hormone receptor-positive breast cancer patients. CTS5 overestimates the risk for high-risk patients and thus, its use in these patients warrants caution. [ABSTRACT FROM AUTHOR]

Background: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. Methods: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. Results: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. Conclusion: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions. [ABSTRACT FROM AUTHOR]

Background: Tissue adhesive, adhesive tape, and sutures are used to close surgical incisions. However, it is unclear which produces the best results in children, and whether combination wound closure is better than sutures alone. Methods: In this parallel randomised controlled trial (ANZCTR: ACTRN12617000158369), children (aged 18 years or less) undergoing elective general surgical or urological procedures were randomized to skin closure with sutures alone, sutures and adhesive tape, or sutures and tissue adhesive. Participants were assessed 2 weeks, 6 weeks, and more than 6 months after operation. Outcomes included wound cosmesis (clinician- and parent-rated) assessed using four validated scales, parental satisfaction, and wound complication rates. Results: 295 patients (333 wounds) were recruited and 277 patients (314 wounds) were included in the analysis. Tissue adhesive wounds had poorer cosmesis at 6 weeks: median 10-point VAS score 7.7 with sutures alone, 7.5 with adhesive tape, and 7.0 with tissue adhesive (P=0.014). Respective median scores on a 100-point VAS were 80.0, 77.2, and 73.8 (P=0.010). This difference was not sustained at over 6 months. There was no difference in parent-rated wound cosmesis at 6 weeks (P=0.690) and more than 6 months (P=0.167): median score 9.0 with sutures alone, 10.0 with adhesive tape, and 10.0 with tissue adhesive at both stages. Parental satisfaction was similar at all points, with a median score of 5 (very satisfied) for all groups. There was one instance of wound dehiscence in the tissue adhesive group and no wound infections. Conclusion: Short-term wound cosmesis was poorer with tissue adhesive although it is unclear whether this difference is sustained in the long-term. There were no differences between techniques for the study outcomes. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) protocols are now widely practiced in major surgery, improving postsurgical outcomes. Uptake of these programmes have been slow in kidney transplantation due to challenges in evaluating their safety and efficacy in this high-risk cohort. To date, there are no unified guidance and protocols specific to ERAS in kidney transplantation surgery. This paper aims to summarise current evidence in the literature and develop ERAS protocol recommendations for kidney transplantation recipients. Methods: PubMed, Cochrane, Embase and Medline databases were screened for studies relevant to ERAS protocols in kidney transplantation, up to August 2021. A secondary search was repeated for each ERAS recommendation to explore the specific evidence base available for each section of the protocol. Randomised controlled trials, case-control and cohort studies were included. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to evaluate the quality of evidence available and recommendations. Results: We identified six eligible studies with a total of 1225 participants. All studies found a reduction in length of hospital stay without affecting readmission rates. The evidence behind specific pre-operative, intra-operative and post-operative interventions included in current ERAS protocols are reviewed and discussed. Conclusion: Compared to other surgical specialties, the evidence base for ERAS in kidney transplantation remains lacking, with further room for research and development. However, significant improvements to patient outcomes are already possible with application of the currently available evidence. This has shown that ERAS in kidney transplantation surgery is safe and feasible, with improved postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort. Methods: Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres. Results: The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent) recurrences in patients with primary and 80 of 124 (64.5 per cent) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort. Conclusion: A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study. [ABSTRACT FROM AUTHOR]

Background: Global surgery research is often generated through collaborative partnerships between researchers from both low‐ and middle‐income countries (LMICs) and high‐income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research. Methods: This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda. Results: Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding. Conclusion: It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement. Power dynamics in the field of global surgery research lead to inequitable opportunities for researchers in low‐ and middle‐income countries. This paper describes the authors' own experiences in Rwanda, and outlines strategies to develop a strong global surgery research portfolio and fair partnerships. Probity is key [ABSTRACT FROM AUTHOR]

Background: With the well established shift to neoadjuvant treatment for locally advanced rectal cancer, there is increasing focus on the use of radiosensitizers to improve the efficacy and tolerability of radiotherapy. There currently exist few randomized data exploring novel radiosensitizers to improve response and it is unclear what the clinical endpoints of such trials should be. Methods: A qualitative systematic review was performed according to the PRISMA guidelines using preset search criteria across the PubMed, Cochrane and Scopus databases from 1990 to 2017. Additional results were generated from the reference lists of included papers. Results: A total of 123 papers were identified, of which 37 were included; a further 60 articles were obtained from additional referencing to give a total of 97 articles. Neoadjuvant radiosensitization for locally advanced rectal cancer using fluoropyrimidine‐based chemotherapy remains the standard of treatment. The oral derivative capecitabine has practical advantages over 5‐fluorouracil, with equal efficacy, but the addition of a second chemotherapeutic agent has yet to show a consistent significant efficacy benefit in randomized clinical assessment. Preclinical and early‐phase trials are progressing with promising novel agents, such as small molecular inhibitors and nanoparticles. Conclusion: Despite extensive research and promising preclinical studies, a definite further agent in addition to fluoropyrimidines that consistently improves response rate has yet to be found. Promising agents coming [ABSTRACT FROM AUTHOR]

Background: Surgical interventions, such as paraoesophageal hernia (POH) repair, are complex with multiple components that require consideration in the reporting of clinical trials. Many aspects of POH repair, including mesh hiatal reinforcement and fundoplication type, are contentious. This review summarizes the reporting of components and outcomes in RCTs of POH repair. Methods: Systematic searches identified RCTs of POH repair published from 1995 to 2020. The patient selection criteria for RCT involvement were noted. The components of the surgical interventions in these RCTs were recorded using the CONSORT guidelines for non-pharmacological treatments, Template for Intervention Description and Replication (TIDieR) and Blencowe frameworks. The outcomes were summarized and definitions sought for critical variables, including recurrence. Results: Of 1918 abstracts and 21 screened full-text articles, 12 full papers reporting on six RCTs were included in the review. The patient selection criteria and definitions of POH between trials varied considerably. Although some description of trial interventions was provided in all RCTs, this varied in depth and detail. Four RCTs described efforts to standardize the trial intervention. Outcomes were reported inconsistently, were rarely defined fully, and overall trial conclusions varied during follow-up. Conclusion: This lack of detail on the surgical intervention in POH repair RCTs prevents full understanding of what exact procedure was evaluated and how it should be delivered in clinical practice to gain the desired treatment effects. Improved focus on the definitions, descriptions and reporting of surgical interventions in POH repair is required for better future RCTs. [ABSTRACT FROM AUTHOR]

Background: This paper describes the development and validation of an electronic personal assessment questionnaire for vascular conditions (ePAQ‐VAS) that captures the symptomatology, quality of life and clinically relevant data of patients presenting to vascular services. Methods: A two‐stage survey was conducted in patients attending a tertiary vascular department. Patients completed the ePAQ‐VAS remotely online, or on site using an electronic tablet. In the first stage of the survey, the responses were used to perform confirmatory factor analysis to assess the construct validity and remove redundant items. The internal reliability of disease‐specific scales was investigated. In the second stage of the survey, the acceptability, known‐group validity, test–retest reliability, and responsiveness of ePAQ‐VAS was assessed. Results: In total, 721 patients completed ePAQ‐VAS. Their mean(s.d.) age was 63·5(15·7) years and 468 (64·9 per cent) were men. Some 553 patients (76·7 per cent) completed the questionnaire in clinic and the remainder completed the questionnaire online. The results of the confirmatory factor analysis confirmed the conceptual model for ePAQ‐VAS structure and eliminated six items. Internal reliability was acceptable for all the scales (Cronbach's α greater than 0·7). The test–retest reliability measured by the intraclass correlation coefficient ranged from 0·65 to 0·99. The results showed that the instrument was responsive over time with the standardized response mean ranging from 0·69 to 1·60. Conclusion: ePAQ‐VAS is a holistic data‐collection process that is relevant to vascular service users and has potential to contribute to patient‐focused care and the collection of aggregate data for service evaluation. A demonstration version of the final version of ePAQ can be viewed at http://demo‐questionnaire.epaq.co.uk/home/project?id=VASC_1.7&page=1. [ABSTRACT FROM AUTHOR]

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: Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients. Methods: A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta‐analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non‐obese populations were used. Results and conclusion: Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery. [ABSTRACT FROM AUTHOR]

Background: Magnetic sphincter augmentation (MSA) is reported to be an innovative alternative to antireflux surgery for patients with gastro‐oesophageal reflux disease. Although used in practice, little is known about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of MSA and its introduction into clinical practice, in the context of guidelines (such as IDEAL) for evaluating innovative surgical devices. Methods: Systematic searches were used to identify all published studies reporting MSA insertion. Data collected included patient selection, governance arrangements, surgeon expertise, technique description and outcome reporting. Results: Searches identified 587 abstracts; 39 full‐text papers were included (1 RCT 5 cohort, 3 case–control, 25 case series, 5 case reports). Twenty‐one followed US Food and Drug Administration eligibility criteria for MSA insertion. Twenty‐six documented that ethical approval was obtained. Two reported that participating surgeons received training in MSA; 18 provided information about how MSA insertion was performed, although techniques varied between studies. Follow‐up ranged from 4 weeks to 5 years; in 14 studies, it was less than 1 year. Conclusion: Most studies on MSA lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness. [ABSTRACT FROM AUTHOR]

Background: A video and medical data recorder in the operating theatre is possible, but concerns over privacy, data use and litigation have limited widespread implementation. The literature on legal considerations and challenges to overcome, and guidelines related to use of data recording in the surgical environment, are presented in this narrative review. Methods: A review of PubMed and Embase databases and Cochrane Library was undertaken. International jurisprudence on the topic was searched. Practice recommendations and legal perspectives were acquired based on experience with implementation and use of a video and medical data recorder in the operating theatre. Results: After removing duplicates, 116 citations were retrieved and abstracts screened; 31 articles were assessed for eligibility and 20 papers were finally included. According to the European General Data Protection Regulation and US Health Insurance Portability and Accountability Act, researchers are required to make sure that personal data collected from patients and healthcare professionals are used fairly and lawfully, for limited and specifically stated purposes, in an adequate and relevant manner, kept safe and secure, and stored for no longer than is absolutely necessary. Data collected for the sole purpose of healthcare quality improvement are not required to be added to the patient's medical record. Conclusion: Transparency on the use and purpose of recorded data should be ensured to both staff and patients. The recorded video data do not need to be used as evidence in court if patient medical records are well maintained. Clear legislation on data responsibility is needed to use the medical recorder optimally for quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Background: In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. Methods: Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. Results: Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. Conclusion: Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution. This paper examines the availability, comparability and utility of six global surgery indicators. Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution. An update, and a plea for improvement [ABSTRACT FROM AUTHOR]

Background: Bullying, undermining behaviour and harassment (BUBH) have been reported in entertainment, politics and sport. Such behaviours may also be common in surgery, and are frequently associated with poor patient care and inferior outcomes. The aim was to define the prevalence and impact of this behaviour in the international surgical workplace, and to explore counterstrategies. Methods: A systematic review was conducted by searching EMBASE, Medline, PsycINFO and the Cochrane Database of Systematic Reviews in August 2017. Original research studies (Oxford Centre for Evidence‐based Medicine levels 1–4) investigating the prevalence and impact of BUBH in surgery, and/or counterstrategies, were eligible for inclusion. The review was conducted in accordance with PRISMA guidelines. Results: Of 2692 papers, 32 were eligible for inclusion. Twenty‐two reported the prevalence of BUBH in surgery, 11 studied the impact of this behaviour and six investigated counterstrategies. Prevalence data showed that BUBH are common in the surgical workplace. Their impact can be profound, compromising mental health, reducing job satisfaction, and inducing suicidal ideation. Formal reporting systems were perceived as ineffective and even potentially harmful to victims. Conclusion: Bullying, undermining behaviour and harassment are highly prevalent within surgery, and extremely damaging to victims. There is little high‐quality research into counterstrategies, although professionalism training using simulated scenarios may be useful. [ABSTRACT FROM AUTHOR]

Background: Hilar cholangiocarcinoma is staged using the AJCC staging system. Numerous other prognostically important histopathological and demographic characteristics have been reported. The objective of this meta‐analysis was to assess statistically the effect of postresectional tumour characteristics on overall survival of patients undergoing attempted radical curative resection for hilar cholangiocarcinoma. Methods: Relevant studies were identified by searching the Ovid MEDLINE and PubMed databases. The search was limited to studies published between 2009 and 2017. Papers referring to intrahepatic or distal cholangiocarcinoma were excluded from review. Data extraction used standard Parmar modifications to determine pooled univariable hazard ratios (HRs). Results: Twenty‐four articles, containing 4599 patients, were assessed quantitatively. In pooled analyses, age (HR 1·16, 95 per cent c.i. 1·04 to 1·28), T category (HR 1·49, 1·30 to 1·70), lymph node involvement (HR 1·78, 1·65 to 1·93), microvascular invasion (HR 1·49, 1·34 to 1·68), perineural invasion (HR 1·54, 1·40 to 1·68) and tumour differentiation (HR 1·54, 1·38 to 1·72) were significant prognostic factors, with low heterogeneity. Portal vein resection (HR 1·54, 1·15 to 1·70) and resection margin status (HR 1·77, 1·57 to 1·99) had significant effects, but with high heterogeneity. Sex, tumour size and preoperative carbohydrate antigen 19‐9 levels did not have a statistically significant effect on postoperative prognosis. Conclusion: Several tumour biological variables not included in the seventh edition of the AJCC classification affect overall survival. These require incorporation into prognostic models to ensure a personalized approach to prognostication and treatment. [ABSTRACT FROM AUTHOR]

Background A large number of studies have examined the potential complications of calf deep vein thrombosis ( DVT). There is no consensus on when or how to treat patients to prevent these complications. This systematic review assessed the rate of proximal propagation, pulmonary embolism, major bleeding and recurrence in patients with isolated calf DVT. Methods Database searches of MEDLINE, the Cochrane Library, Scopus, CINAHL and Web of Science were undertaken along with extensive cross-referencing. Two independent reviewers screened the papers using stringent inclusion and exclusion criteria. Included studies were graded on six methodological standards. Data on propagation, pulmonary embolism, recurrence and major bleeding were abstracted. Results A total of 4261 papers were found; 15 met the inclusion criteria, including five randomized clinical trials and ten prospective cohort studies. The propagation rate to the popliteal vein or above was around 9 per cent and the rate of pulmonary embolism was close to 1·5 per cent. No studies found anticoagulant therapy to reduce the rate of adverse outcomes. Conclusion The literature on calf DVT is heterogeneous, limiting conclusions from data analysis. Adverse outcomes are infrequent and studies do not suggest that they are reduced by anticoagulation. [ABSTRACT FROM AUTHOR]

Background Paget's disease of the breast is a rare condition that is associated with underlying breast cancer in the majority of patients. The conventional treatment for Paget's disease has been mastectomy, but there is an increasing trend to consider breast-conserving surgery ( BCS) in selected patients. Owing to the uncommon nature of the disease, research studies tend to be small and retrospective. This systematic review presents the published evidence regarding BCS for patients with Paget's disease with a focus on patient selection and oncological safety. Methods A search of Ovid and PubMed databases was conducted to identify all papers published regarding BCS for Paget's disease. Results The search identified 172 papers of which 43 were clinically relevant. BCS is a safe alternative to mastectomy, provided a clear surgical margin is achieved and adjuvant radiotherapy used. However, patients with Paget's disease should be assumed to have underlying breast cancer, and these cancers tend to have poor biological profiles. When BCS is considered, careful preoperative investigation should be undertaken to identify the presence and extent of an underlying cancer. These cancers can be mammographically occult, multifocal or multicentric. Although the evidence is limited, there may be a role for MRI in selecting patients with Paget's disease for BCS. Conclusion Patients with Paget's disease are candidates for breast conservation with appropriate preoperative investigations. Oncological outcomes are equivalent to those of mastectomy if surgical margins are achieved and adjuvant radiotherapy is given. [ABSTRACT FROM AUTHOR]

Background Acellular dermal matrix ( ADM) may improve outcomes in implant-based breast reconstruction ( IBBR). The aim of this study was critically to appraise and evaluate the current evidence for ADM-assisted IBBR. Methods Comprehensive electronic searches identified complete papers published in English between January 2000 and August 2013, reporting any outcome of ADM-assisted IBBR. All systematic reviews, randomized clinical trials ( RCTs) and non-randomized studies ( NRSs) with more than 20 ADM recipients were included. Studies were critically appraised using AMSTAR for systematic reviews, the Cochrane risk-of-bias tool for RCTs and its adaptation for NRSs. Characteristics and results of identified studies were summarized. Results A total of 69 papers (8 systematic reviews, 1 RCT, 40 comparative studies and 20 case series) were identified, all of which were considered at high risk of bias, mostly due to patient selection and selective outcome reporting. The median ADM group sample size was 51.0 (i.q.r. 33.0-127.0). Most studies were single-centre (54), and they were often single-surgeon (16). ADM was most commonly used for immediate (40) two-stage IBBR (36) using human ADM (47), with few studies evaluating ADM-assisted single-stage procedures (10). All reported clinical outcomes (for example implant loss) and more than half of the papers (33) assessed process outcomes, but few evaluated cosmesis (16) or patient-reported outcomes (10). Heterogeneity between study design and, especially, outcome measurement precluded meaningful data synthesis. Conclusion Current evidence for the value of ADMs in IBBR is limited. Use in practice should therefore be considered experimental, and evaluation within registries or well designed and conducted studies, ideally RCTs, is recommended to prevent widespread adoption of a potentially inferior intervention. [ABSTRACT FROM AUTHOR]

The section presents Spanish translations of abstracts of papers published within the issue, including one on the molecular mechanism of action of negative pressure wound therapy, another on surgical demonstrations in medical training and a paper on selecting endpoints in breast cancer research.

Background: Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization. Methods: A discrete‐choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery. Results: Responses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups. Conclusion: Respondents' preferences in this selected sample were consistent with centralization. [ABSTRACT FROM AUTHOR]

Background Surgical task-sharing may be central to expanding the provision of surgical care in low-resource settings. The aims of this paper were to describe the set-up of a new surgical task-sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in contributing to surgical volume. Methods This prospective observational study from a consortium of 16 hospitals evaluated crude in-hospital mortality over 5 years and productivity of operations performed during and after completion of a 3-year surgical training programme. Results Some 48 trainees and nine graduated surgical assistant community health officers ( SACHOs) participated in 27 216 supervised operations between January 2011 and July 2016. During training, trainees attended a median of 822 operations. SACHOs performed a median of 173 operations annually. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in-hospital mortality rates after caesarean sections and laparotomies were 0·7 per cent (13 of 1915) and 4·3 per cent (7 of 164) respectively for operations performed by trainees, and 0·4 per cent (5 of 1169) and 8·0 per cent (11 of 137) for those carried out by SACHOs. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was lower for operations performed by trainees ( OR 0·47, 95 per cent c.i. 0·32 to 0·71; P < 0·001) and SACHOs ( OR 0·16, 0·07 to 0·41; P < 0·001) compared with those conducted by trainers and supervisors. Conclusion SACHOs rapidly and safely achieved substantial increases in surgical volume in Sierra Leone. [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 Pressurized intraperitoneal aerosol chemotherapy ( PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks. Methods This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included. Results Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83-100 and 38-82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3-5 events reported in 0-37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62-88, 71-86 and 70-100 per cent respectively. Conclusion PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy. [ABSTRACT FROM AUTHOR]