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Background: Colorectal cancer (CRC) is the second most common solid organ cancer. Traditional treatment is with surgery and chemotherapy. Immunotherapy has recently emerged as a neoadjuvant therapy that could change treatment strategy in both primary resectable and metastatic CRC. Methods: A literature review of PubMed with a focus on studies exploring upfront immunotherapy in operable CRC, either for primary resectable stage I-III cancers or for (potentially) operable liver metastasis. Results: Immune checkpoint blockade by the programmed cell death 1 (PD-1) receptor inhibitors nivolumab and pembrolizumab and the cytotoxic T cell-associated protein 4 (CTLA-4) inhibitor ipilimumab has shown good results in both early-stage and advanced CRC. The effects of immune checkpoint inhibitors have so far been demonstrated in small phase I/II studies and predominantly in treatment-refractory stage IV disease with defect Mismatch repair (dMMR). However, recent data from phase I/II (NICHE-1) studies suggest an upfront role for immunotherapy in operable stage I-III disease. By blocking crucial immune checkpoints, cytotoxic T cells are activated and release cytotoxic signals that initiate cancer cell destruction. The very high complete response rate in dMMR operable CRC with neoadjuvant immunotherapy with nivolumab and ipilimumab, and even partial pathological response in some patients with proficient MMR (pMMR) CRC, calls for further attention to patient selection for neoadjuvant treatment, beyond MMR status alone. Conclusion: Early data on the effect of immunotherapy in CRC provide new strategic thinking of treatment options in CRC for both early-stage and advanced disease, with prospects for new trials. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic appendicectomy is a common procedure early in surgical training. A minimum number is usually required for certification in general surgery. However, data on proficiency are scarce. This study aimed to investigate steps towards proficiency in laparoscopic appendicectomy. Methods: This was a prospective observational cohort study of laparoscopic appendicectomies performed by junior trainees under supervision scored on a six-point performance scale. Structured assessment was done within a defined programme. Procedures performed for uncomplicated appendicitis in adults were included. The procedures were evaluated with LOWESS graphs generated to investigate inflection points. Factors associated with proficiency rates were reported with odds ratios and 95 per cent confidence intervals. Results: In total 142 laparoscopic procedures were included for 19 trainees (58 per cent female). The cumulative number of procedures during the study was a median of 20 (i.q.r. 8–33). For overall proficiency, an inflection point occurred at 30 procedures. Proficiency rate increased from 51 per cent for 30 or fewer procedures to 93 per cent for more than 30 procedures (odds ratio 11.9 (95 per cent c.i. 3.4 to 40.9); P < 0.001). Inflection points for proficiency for each procedure step varied considerably, with lowest numbers (fewer than 15 procedures) for removing the specimen, and highest for dividing the mesoappendix (more than 55 procedures). Operating time was significantly reduced by a median of 7 minutes after 30 procedures, from median 62 (i.q.r. 25–120) minutes to median 55 (i.q.r. 30–110) minutes for more than 30 procedures. Conclusion: For junior trainees, variation in proficiency is related to specific procedure steps. Targeted training on specific procedure skills may reduce numbers needed to achieve proficiency in laparoscopic appendicectomy during training. [ABSTRACT FROM AUTHOR]

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Background: The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery. Methods: This was a scoping review of all available literature pertaining to COVID‐19 and surgery, using electronic databases, society websites, webinars and preprint repositories. Results: Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross‐cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning. Conclusion: Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase. [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: Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer. Methods: A systematic PubMed search of the English literature to May 2018 was conducted. Results: The search identified 12 systematic reviews and meta‐analyses, in addition to several consensus reports, multi‐institutional series and national audits. Some 0·25–0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one‐third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5‐year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross‐sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET‐avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port‐site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused. Conclusion: Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection. Selective approach to re‐resection [ABSTRACT FROM AUTHOR]

Background: Length of hospital stay (LOS) may serve as a surrogate measure of healthcare quality and resource use, particularly when transfers of care and readmissions are accounted for. This study aimed to benchmark true hospital stay by measuring index, transfer and readmission stays across the range of digestive cancer surgery. Methods: A cohort study of all patients undergoing resection for cancer of the oesophagus, stomach, liver, pancreas, colon or rectum in 2012–2016 was undertaken. Index LOS, transfer and readmission stays were merged into an ‘aggregated’ length of stay (a‐LOS), and compared between organ sites and between open and minimal‐access approaches. Results: In total, 24 354 resections were reported (mean age of patients 68·3 years; 51·3 per cent were men). Resections were reported as laparoscopic for 9151 procedures (37·6 per cent), with a further 283 (3·0 per cent) described as converted to open surgery. Use of a‐LOS compared with standard LOS added a median of 5 days for pancreatoduodenectomy, 4 days for major liver resections, 3 days for oesophageal and gastric resections, and 2 days for minor liver, distal pancreatic and rectal resections. Conclusion: Overall hospital stay across organ sites and procedures is better described by a‐LOS. The study benchmarks the use of total hospital days during the first 30 days in a universal healthcare system. [ABSTRACT FROM AUTHOR]

Background: Blood is the most extensively studied body fluid and, because it contains circulating tumour cells (CTCs) and circulating tumour‐derived cell‐free DNA (ctDNA), it may represent a liquid biopsy for cancer. Methods for enrichment and detection of CTCs and ctDNA, their clinical applications and future opportunities in gastrointestinal cancers were the focus of this review. Methods: The PubMed database was searched for literature up to 24 June 2017, with a focus on the past 10 years. Identified articles were further scrutinized for relevant references. Articles were those in English relating to colorectal, gastric and pancreatic cancer. Results: Both CTCs and ctDNA are in low abundance compared with other cellular components of blood, but effective enrichment and highly sensitive techniques are available for their detection. Potential clinical applications of these liquid biopsies include screening, prognostic stratification, therapy administration, monitoring of treatment effect or resistance, and surveillance. Liquid biopsies provide opportunities to reduce the need for invasive tissue sampling, especially in the context of intratumoral heterogeneity and the need for tumour genotyping. Conclusion: Liquid biopsies have applications in gastrointestinal cancers to improve clinical decision‐making. [ABSTRACT FROM AUTHOR]

Background The lack of uniform criteria for coding of gastroenteropancreatic neuroendocrine neoplasia ( GEP-NEN) has hampered previous epidemiological studies. The epidemiology of GEP-NEN was investigated in this study using currently available criteria. Methods All patients diagnosed with GEP-NEN between January 2003 and December 2013 in a well defined Norwegian population of approximately 350 000 people were included. Age- and sex-adjusted incidence rates were calculated. The current 2010 World Health Organization criteria, European Neuroendocrine Tumour Society classification and International Union Against Cancer ( UICC) classification were used. Results A total of 204 patients (114 male, 55·9 per cent) were identified. The median age at diagnosis was 61 (range 10-94) years. The annual overall crude incidence was 5·83 per 100 000 inhabitants, with an increasing trend ( P = 0·033). The most frequent location was small intestine (60 patients, 29·4 per cent) followed by appendix (48 patients, 23·5 per cent) and pancreas (33 patients, 16·2 per cent). Grade 1 tumours were more common in gastrointestinal (100 patients, 58·5 per cent) than in pancreatic (9 patients, 27 per cent) NEN. According to the UICC classification, 77 patients (37·7 per cent) had stage I, 17 patients (8·3 per cent) stage II, 37 patients (18·1 per cent) stage III and 70 patients (34·3 per cent) had stage IV disease. No patient with stage I disease had grade 3 tumours; advanced tumour grade increased with stage. Conclusion A high crude incidence of GEP-NEN, at 5·83 per 100 000 inhabitants, was noted together with a significant increasing trend over time. [ABSTRACT FROM AUTHOR]

The article talks about the neoadjuvant treatment that has gained recognition in gastrointestinal malignancies, chemotherapy and radiotherapy used in cancers and postoperative complications that is common in pancreatic cancer. It talks about the use of neoadjuvant therapy in pancreatic cancer, benefits from the surgery to the patients, the reduction in positive resection margins and improving survival with proponents of neoadjuvant therapy.

Background Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care. Methods This was a narrative review based on a PubMed/ MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient. Results The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care. Conclusion Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited. [ABSTRACT FROM AUTHOR]

Background Ageing is the inevitable time-dependent decline in physiological organ function that eventually leads to death. Age is a major risk factor for many of the most common medical conditions, such as cardiovascular disease, cancer, diabetes and Alzheimer's disease. This study reviews currently known hallmarks of ageing and their clinical implications. Methods A literature search of PubMed/ MEDLINE was conducted covering the last decade. Results Average life expectancy has increased dramatically over the past century and is estimated to increase even further. Maximum longevity, however, appears unchanged, suggesting a universal limitation to the human organism. Understanding the underlying molecular processes of ageing and health decline may suggest interventions that, if used at an early age, can prevent, delay, alleviate or even reverse age-related diseases. Hallmarks of ageing can be grouped into three main categories. The primary hallmarks cause damage to cellular functions: genomic instability, telomere attrition, epigenetic alterations and loss of proteostasis. These are followed by antagonistic responses to such damage: deregulated nutrient sensing, altered mitochondrial function and cellular senescence. Finally, integrative hallmarks are possible culprits of the clinical phenotype (stem cell exhaustion and altered intercellular communication), which ultimately contribute to the clinical effects of ageing as seen in physiological loss of reserve, organ decline and reduced function. Conclusion The sum of these molecular hallmarks produces the clinical picture of the elderly surgical patient: frailty, sarcopenia, anaemia, poor nutrition and a blunted immune response system. Improved understanding of the ageing processes may give rise to new biomarkers of risk or prognosis, novel treatment targets and translational approaches across disciplines that may improve outcomes. [ABSTRACT FROM AUTHOR]

Background Perforated peptic ulcer ( PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed. Methods PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials ( RCTs), systematic reviews and meta-analyses were preferred. Results Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3·8-14 per 100 000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk ( RR) reduction of 0·63 (95 per cent confidence interval (c.i.) 0·41 to 0·97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term ( RR 2·97, 95 per cent c.i. 1·06 to 8·29) and 1-year ( RR 1·49, 1·10 to 2·03) risk of ulcer recurrence. Conclusion Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies. [ABSTRACT FROM AUTHOR]

Background: With an increased use of magnetic resonance imaging, the indications for endoscopic retrograde cholangiopancreatography (ERCP) have changed. Consequently, the patterns and factors predictive of complications after ERCP performed during current routine clinical practice are not well known. Methods: A prospective multicentre cohort study was undertaken in 11 Norwegian hospitals. Complications and mortality within 30 days after ERCP were analysed by univariable and multivariable regression analysis. Results: There were 2808 ERCP procedures, of which 2573 (91·6 per cent) were therapeutic. More than half of the patients were aged 70 years or more. Common bile duct cannulation was achieved in 2557 procedures (91·1 per cent). Complications occurred in 327 (11·6 per cent) of the procedures, including cholangitis in 100 (3·6 per cent), pancreatitis in 88 (3·1 per cent), bleeding in 66 (2·4 per cent), perforation in 25 (0·9 per cent) and cardiovascular-respiratory events in 32 (1·1 per cent). In the multivariable regression analysis, older age, increasing American Society of Anesthesiologists fitness score, centre ERCP volumes of more than 150 procedures annually and precut sphincterotomy were predictive factors for severe complications. The overall 30-day mortality rate was 2·2 per cent (63 patients), with a procedure-related mortality rate of 1·4 per cent (39 patients). Malignancy was diagnosed in 46 (73 per cent) of the patients who died. Conclusion: ERCP is a procedure with considerable risk for complications. Morbidity and mortality are related to patient age and co-morbidity, as well as hospital volume of ERCP procedures and the type of intervention. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Reliable, quick tests leading to specific treatments still required [ABSTRACT FROM AUTHOR]

National treatment strategy improves survival [ABSTRACT FROM AUTHOR]

The greatest surgical challenge [ABSTRACT FROM AUTHOR]

The author reflects on the areas of interest on trauma chain of survival. It explores the transnational aspects pathophysiology in trauma care. The author discusses changes in concepts and paradigms and evidence even where this is still guided by expert opinion and limited data. The author argues that randomized clinical trials, systematic reviews and meta-analyses demonstrate that rigorous methodology can be applied in trauma studies which result in better quality evidence.

A call for action now [ABSTRACT FROM AUTHOR]

Surgeons need to get involved [ABSTRACT FROM AUTHOR]

A plea for basic research [ABSTRACT FROM AUTHOR]

The author opines on the research "Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres" by D. Metcalfe and colleagues. Topics discussed include improving outcomes for injured patients, migration due to cancer research facilities, and transfer of patients to a trauma centre for treatment. The author mentions that it is important to justify mortality and critical care resources for improvements in centralization of care.

Merits much greater attention by the surgical community [ABSTRACT FROM AUTHOR]

The article focuses on the study concerning epidemiology of major trauma in which major injury is a leading cause of death and disability. It mentions that major trauma is a generic term and different regions have different dominating injuries. It notes that the injury pattern in blunt trauma is a preponderance of serious head, thoracic and limb injuries and severe thoracic or abdominal injuries affect less than 20% of all blunt trauma victims.

The author reflects on the impact of hyperbaric oxygen therapy used in adhesive postoperative small bowel obstruction. Topics discussed include intra-abdominal adhesions result in readmission to surgical wards, radiation-induced fibrosis emerges from the HOT II trial and mechanisms of adhesion formation such as inflammation due to peritoneal damage, increase in fibrin formation and antifibrinolytic reactions.

The article presents a case study of a 7-year-old boy who was run over by a truck, admitted to hospital awake with the left leg fixed with a vacuum splint and clinical examination on admission revealed a tibial fracture and degloving injury to the foot and underwent skin mesh grafting.

A letter to the editor is presented in response to the Snapshot Quiz 11/04, published in the June 2011 issue.

A response by K.Soreide and T. Glomsaker to a letter to an editor about their article "Surgical training and working time restriction," in the previous issue is presented.