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Background A number of published economic evaluations of elective endovascular aneurysm repair ( EVAR) versus open repair for abdominal aortic aneurysm ( AAA) have come to differing conclusions about whether EVAR is cost-effective. This paper reviews the current evidence base and presents up-to-date cost-effectiveness analyses in the light of results of four randomized clinical trials: EVAR-1, DREAM, OVER and ACE. Methods Markov models were used to estimate lifetime costs from a UK perspective and quality-adjusted life-years ( QALYs) based on the results of each of the four trials. The outcomes included in the model were: procedure costs, surveillance costs, reintervention costs, health-related quality of life, aneurysm-related mortality and other-cause mortality. Alternative scenarios about complications, reinterventions and deaths beyond the trial were explored. Results Models based on the results of the EVAR-1, DREAM or ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to £30 000 per QALY). EVAR seemed cost-effective according to models based on the OVER trial. These results seemed robust to alternative model scenarios about events beyond the trial intervals. Conclusion These analyses did not find that EVAR is cost-effective compared with open repair in the long term in trials conducted in European centres. EVAR did appear to be cost-effective based on the OVER trial, conducted in the USA. Caution must be exercised when transferring the results of economic evaluations from one country to another. [ABSTRACT FROM AUTHOR]

Background Designing RCTs in surgery requires consideration of existing evidence, stakeholders' views and emerging interventions, to ensure that research questions are relevant to patients, surgeons and the health service. When there is uncertainty about RCT design, feasibility work is recommended. This study aimed to assess how feasibility work could inform the design of a future pilot study and RCT (Bluebelle, HTA - 12/200/04). Methods This was a prospective survey of dressings used to cover abdominal wounds. Surgical trainees from 25 hospitals were invited to participate. Information on patient risk factors, operation type and type of wound dressings used was recorded for elective and unplanned abdominal procedures over a 2-week interval. The types of dressing used were summarized, and associations with operation type and patient risk factors explored. Results Twenty hospitals participated, providing data from 727 patients (1794 wounds). Wounds were predominantly covered with basic dressings (1203 of 1769, 68·0 per cent) and tissue adhesive was used in 27·4 per cent (485 of 1769); dressing type was missing for 25 wounds. Just 3·6 per cent of wounds (63 of 1769) did not have a dressing applied at the end of the procedure. There was no evidence of an association between type of dressing used and patient risk factors, type of operation, or elective and unscheduled surgery. Conclusion Based on the findings from this large study of current practice, the pilot study design has evolved. The inclusion criteria have expanded to encompass patients undergoing unscheduled surgery, and tissue adhesive as a dressing will be evaluated as an additional intervention group. Collaborative methods are recommended to inform the design of RCTs in surgery, helping to ensure they are relevant to current practice. [ABSTRACT FROM AUTHOR]

Background Intraoperative goal-directed therapy ( GDT) was introduced to titrate intravenous fluids, with or without inotropic drugs, based on objective measures of hypovolaemia and cardiac output measurements to improve organ perfusion. This meta-analysis aimed to determine the effect of GDT on the recovery of bowel function after abdominal surgery. Methods MEDLINE, Embase, the Cochrane Library and PubMed databases were searched for randomized clinical trials and cohort studies, from January 1989 to June 2013, that compared patients who did, or did not, receive intraoperative GDT, and reported outcomes on the recovery of bowel function. Time to first flatus and first bowel motion, time to tolerate oral diet, postoperative nausea and vomiting, and primary postoperative ileus were included. Results Thirteen trials with 1399 patients were included in the analysis. GDT shortened the time to the first bowel motion (weighted mean difference ( WMD −0·67, 95 per cent c.i. −1·23 to −0·11; P = 0·020) and time to tolerate oral intake ( WMD −0·95, −1·81 to −0·10; P = 0·030), and reduced postoperative nausea and vomiting (risk difference −0·15, −0·26 to −0·03; P = 0·010). When only high-quality studies were included, GDT reduced only the time to tolerate oral intake ( WMD −1·18, −2·03 to −0·33; P = 0·006). GDT was more effective outside enhanced recovery programmes and in patients undergoing colorectal surgery. Conclusion GDT facilitated the recovery of bowel function, particularly in patients not treated within enhanced recovery programmes and in those undergoing colorectal operations. [ABSTRACT FROM AUTHOR]

Background: Postoperative ileus is a common problem after abdominal surgery. It was postulated that coffee intake would decrease postoperative ileus after colectomy. Methods: This was a multicentre parallel open-label randomized trial. Patients with malignant or benign disease undergoing elective open or laparoscopic colectomy were assigned randomly before surgery to receive either coffee or water after the procedure (100 ml three times daily). The primary endpoint was time to first bowel movement; secondary endpoints were time to first flatus, time to tolerance of solid food, length of hospital stay and perioperative morbidity. Results: A total of 80 patients were randomized, 40 to each group. One patient in the water arm was excluded owing to a change in surgical procedure. Patient characteristics were similar in both groups. In intention-to-treat analysis, the time to the first bowel movement was significantly shorter in the coffee arm than in the water arm (mean(s.d.) 60·4(21·3) versus 74·0(21·6) h; P = 0·006). The time to tolerance of solid food (49·2(21·3) versus 55·8(30·0) h; P = 0·276) and time to first flatus (40·6(16·1) versus 46·4(20·1) h; P = 0·214) showed a similar trend, but the differences were not significant. Length of hospital stay (10·8(4·4) versus 11·3(4·5) days; P = 0·497) and morbidity (8 of 40 versus 10 of 39 patients; P = 0·550) were comparable in the two groups. Conclusion: Coffee consumption after colectomy was safe and was associated with a reduced time to first bowel action. Registration number: NCT01079442 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Focuses on clinical trial of vertical or transverse laparotomy for abdominal aortic aneurysm repair. Hernia repair; Incidence of incisional hernia; Reasons for incisional hernia occurrence; Risk factors for postoperative hernia.

Background: The Ligasure™ Vessel Sealing System is a haemostatic device designed primarily for use in abdominal surgery. Randomized trials have demonstrated that it is safe and quick for haemorrhoidectomy, but there is no evidence that it contacts any advantage in complicated gastrointestinal surgery. The aim of the present study was to examine the value of the Ligasure™ system in extended lymph node dissection (D2) during gastrectomy for cancer in a randomized clinical trial. Methods: D2 gastric resection performed with the Ligasure™ system was compared with resection using conventional haemostatic methods in a prospective randomized trial. Central randomization (40 patients in each group) was performed after a staging laparotomy. The main outcome measures were operating time, intraoperative blood loss, postoperative course and complications. Results: Ligasure™ was associated with less intraoperative blood loss (mean(s.d.) 142(73) versus 239(124) ml; P = 0·001) and a shorter operating time (mean(s.d.) 169(25) versus 222(28) min; P = 0.001) than conventional operation. Postoperative drainage fluid volumes were greater in the Ligasure™ group (mean(s.d.) 1577(940) versus 886(542) ml; P = 0·020). There were no differences in postoperative complications or hospital stay. Conclusion: The Ligasure™ Vessel Sealing System is safe for use in extended lymph node dissection for gastric cancer, and is associated with a shorter operating time and decreased blood loss compared with conventional haemostatic techniques. [ABSTRACT FROM AUTHOR]

Background: Oral Gastrografin® has been used to differentiate partial from complete small bowel obstruction (SBO). It may have a therapeutic effect and predict the need for early surgery in adhesive SBO. The aim of this study was to determine whether contrast examination in the management of SBO allows an early oral intake and reduces hospital stay. Methods: Eighty-three patients admitted between February 2000 and November 2001 with 90 episodes of symptoms and signs suggestive of postoperative adhesive SBO were randomized into two groups, a control group and Gastrografin® group. Patients in the control group were treated conservatively. If symptoms of strangulation developed or the obstruction did not resolve spontaneously after 4-5 days, a laparotomy was performed. Patients in the Gastrografin® group received 100 ml Gastrografin®. Those in whom the contrast medium reached the colon in 24 h were considered to have partial SBO, and were fed orally. If Gastrografin® failed to reach the colon and the patient did not improve in the following 24 h a laparotomy was performed. Results: Conservative treatment was successful in 77 episodes (85·6 per cent) and 13 (14·4 per cent) required operation. Among patients treated conservatively, hospital stay was shorter in the Gastrografin® group (P < 0·001). All patients in whom contrast medium reached the colon tolerated an early oral diet. Gastrografin® did not reduce the need for operation (P = 1·000). No patient died in either group. Conclusion: Oral Gastrografin® helps in the management of patients with adhesive SBO and allows a shorter hospital stay. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]