Bioabsorbable mesh use in midline abdominal wall prophylaxis and repair achieving fascial closure:a cross-sectional review of stage of innovation

Background: Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterise the stage of innovation for bioabsorbable mesh devices used during both midline closure prophylaxis and complex abdominal wall reconstruction and to evaluate the quality of current evidence.Methods: A systematic review of published and ongoing studies was performed until 31st December 2019. Inclusion criteria were studies where bioabsorbable mesh was used to support fascial closure either prophylactically after midline laparotomy or for repair of incisional hernia with midline incision. Exclusion criteria were: (1) study design was a systematic review, meta-analysis, letter, review, comment, or conference abstract; (2) included less than p patients; (3) only evaluated biological, synthetic or composite meshes. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the risk of bias in non-randomised studies of interventions (ROBINS-I) criteria for study quality.Results: Twelve studies including 1287 patients were included. Three studies considered mesh prophylaxis and nine studies considered hernia repair. There were only two published studies of IDEAL 2B. The remainder was IDEAL 2A studies. The quality of the evidence was categorised as having a risk of bias of a moderate, serious or critical level in nine of the twelve included studies using the ROBINS-I tool.Conclusion: The evidence base for bioabsorbable mesh is limited. Better reporting and quality control of surgical techniques are needed. Although new trial results over the next decade will improve the evidence base, more trials in emergency and contaminated settings are required to establish the limits of indication

The need for multidisciplinarity in specialist training to optimize future patient care

Harmonious interactions between radiation, medical, interventional and surgical oncologists, as well as other members of multidisciplinary teams, are essential for the optimization of patient care in oncology. This multidisciplinary approach is particularly important in the current landscape, in which standard-of-care approaches to cancer treatment are evolving towards highly targeted treatments, precise image guidance and personalized cancer therapy. Herein, we highlight the importance of multidisciplinarity and interdisciplinarity at all levels of clinical oncology training. Potential deficits in the current career development pathways and suggested strategies to broaden clinical training and research are presented, with specific emphasis on the merits of trainee involvement in functional multidisciplinary teams. Finally, the importance of training in multidisciplinary research is discussed, with the expectation that this awareness will yield the most fertile ground for future discoveries. Our key message is for cancer professionals to fulfil their duty in ensuring that trainees appreciate the importance of multidisciplinary research and practice

An international assessment of the adoption of enhanced recovery after surgery (ERAS (R)) principles across colorectal units in 2019-2020

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation

Youth futures and a masculine development ethos in the regional story of Uttarakhand

Research on the Uttarakhand region, which became a new state in 2000, has focused largely on agrarian livelihoods, religious rituals, development demands, ecological politics and the role of women in regional social movements. This essay discusses another dimension of the regional imaginary—that of a masculine development ethos. Based on ethnographic research and print media sources, this essay focuses on stories, politics, mobilities and imaginations of young men in the years immediately after the achievement of statehood. Despite increased outmigration of youth in search of employment, many young men expressed the dream of maintaining livelihoods in the familiar towns and rural spaces of Uttarakhand, describing their home region as a source of power and agency. In rallies and in print media, young (mostly upper caste) men expressed their disillusionment with the government and the promises of statehood, arguing that their aspirations for development and employment were left unfulfilled. Gendered stories of the region, told in Hindi in rallies and print media, contained references to local places, people and historical events and were produced through local connections and know-how, fostering a regional youth politics. The article argues that Uttarakhand as a region is shaped by the politics of local actors as well as embodied forms of aspiration, affiliation and mobility.IS

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results This study included 3208 patients, of whom 78.4% (n = 2515) underwent surgery for malignancy and 11.7% (n = 375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% (n = 3041) of patients, which was handsewn in 38.9% (n = 1183) and stapled in 61.1% (n = 1858). Patients undergoing hand-sewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (P = 0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR = 1.43; 95% CI: 1.04-1.95; P = 0.03). Conclusion Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe.This is the peer-reviewed version of the article: Pinkney, T.; Battersby, N.; Bhangu, A.; Chaudhri, S.; El-Hussuna, A.; Frasson, M.; Nepogodiev, D.; Singh, B.; Kovačević, B.; Autora), (i Jos Puno. Relationship between Method of Anastomosis and Anastomotic Failure after Right Hemicolectomy and Ileo-Caecal Resection: An International Snapshot Audit. Colorectal Disease 2017, 19 (8), O296–O311. [https://doi.org/10.1111/codi.13646

Prevalence, trends and outcomes from smoking in elective surgical systems:a secondary analysis of a prospective observational cohort study across 442 hospitals from 29 countries across Europe

BackgroundSmoking remains a significant public health issue in Europe, with elective surgery offering a key opportunity for intervention. Knowledge gaps exist around its prevalence and the optimal timing for preoperative cessation to improve outcomes, despite current guidelines recommend smoking cessation up to six weeks prior to surgery. This study aims to address this gap in a large observational prospective cohort study of patients undergoing abdominal surgery across Europe.MethodsWe performed a pre-planned secondary analysis of a prospective, international cohort study of patients undergoing elective abdominal surgery between January 24, and May 03, 2022. The primary measure was smoking status and secondary measures were prevalence by age, gender, and number of long-term conditions. Multilevel logistic regression was used to explain the relationship between preoperative smoking status on postoperative overall (primary outcome) and major (secondary outcome) complications. Three-level models were constructed with patients nested within hospitals and countries.Findings16,327 patients from 442 hospitals across 29 countries were included. 3179 patients (19.5%, 95% confidence interval (CI): 18.9%–20.1%) were current smokers, ranging from 8.3% to 31.7% across the included countries. Rates of current smokers were higher in younger patients (18–40 vs 41–60 vs 61–80 vs ≥ 81 years: 26.8% [95% CI: 24.8%–28.9%] vs 25.3% [95% CI: 24.2%–26.4%] vs 15.1% [95% CI: 14.3%–16.0%] vs 5.2% [95% CI: 4.0%–6.8%]), male patients (compared to females: 22.1% [95% CI: 22.0%–23.1%] vs 17.2% [95% CI: 16.5%–18.0%]) and healthy adults (compared to one or two long-term conditions: 24.6% [95% CI: 23.2%–25.9%] vs 19.6% [95% CI: 18.6%–20.7%] vs 16.6% [95% CI: 15.8%–17.5%]). 30-day overall complications were higher across current (OR: 1.14; 95% CI: 1.03–1.27), ex-smoker <6 weeks (1.52, 1.10–2.10), ex-smoker 6 weeks–1 year (1.30, 1.01–1.68) and ex-smoker >1 year (1.13, 1.02–1.26) compared to never smokers. No difference was seen for 30-day major complications across these groups.InterpretationThe high prevalence of smoking among elective surgical patients, especially in younger, healthy patients, expose a need to strengthen preoperative cessation strategies. Although uncertainty exist around perioperative outcomes, smoking cessation in the perioperative window is a good opportunity to reach people for long-term health promotion. Embedding high-value strategies into elective surgical systems may serve as a model for broader healthcare reforms, leading to more efficient, preventive care across the entire health system

The impact of the COVID-19 pandemic upon pancreatic cancer treatment (CONTACT Study): a UK national observational cohort study.

INTRODUCTION: CONTACT is a national multidisciplinary study assessing the impact of the COVID-19 pandemic upon diagnostic and treatment pathways among patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: The treatment of consecutive patients with newly diagnosed PDAC from a pre-COVID-19 pandemic cohort (07/01/2019-03/03/2019) were compared to a cohort diagnosed during the first wave of the UK pandemic ('COVID' cohort, 16/03/2020-10/05/2020), with 12-month follow-up. RESULTS: Among 984 patients (pre-COVID: n = 483, COVID: n = 501), the COVID cohort was less likely to receive staging investigations other than CT scanning (29.5% vs. 37.2%, p = 0.010). Among patients treated with curative intent, there was a reduction in the proportion of patients recommended surgery (54.5% vs. 76.6%, p = 0.001) and increase in the proportion recommended upfront chemotherapy (45.5% vs. 23.4%, p = 0.002). Among patients on a non-curative pathway, fewer patients were recommended (47.4% vs. 57.3%, p = 0.004) or received palliative anti-cancer therapy (20.5% vs. 26.5%, p = 0.045). Ultimately, fewer patients in the COVID cohort underwent surgical resection (6.4% vs. 9.3%, p = 0.036), whilst more patients received no anti-cancer treatment (69.3% vs. 59.2% p = 0.009). Despite these differences, there was no difference in median overall survival between the COVID and pre-COVID cohorts, (3.5 (IQR 2.8-4.1) vs. 4.4 (IQR 3.6-5.2) months, p = 0.093). CONCLUSION: Pathways for patients with PDAC were significantly disrupted during the first wave of the COVID-19 pandemic, with fewer patients receiving standard treatments. However, no significant impact on survival was discerned

UK Head and neck cancer surgical capacity during the second wave of the COVID—19 pandemic: Have we learned the lessons? COVIDSurg collaborative

Objectives The aim of this study was to evaluate the differences in surgical capacity for head and neck cancer in the UK between the first wave (March-June 2020) and the current wave (Jan-Feb 2021) of the COVID-19 pandemic. Design REDcap online-based survey of hospital capacity. Setting UK secondary and tertiary hospitals providing head and neck cancer surgery. Participants One representative per hospital was asked to report the capacity for head and neck cancer surgery in that institution. Main outcome measures The principal measures of interests were new patient referrals, capacity in outpatients, theatres and critical care; therapeutic compromises constituting delay to surgery, de-escalated surgery and therapeutic migration to non-surgical primary modality. Results Data were returned from approximately 95% of UK hospitals with a head and neck cancer surgery specialist service. 50% of UK head and neck cancer patients requiring surgery have significantly compromised treatments during the second wave: 28% delayed, 10% have received radiotherapy-based treatment instead of surgery, and 12% have received de-escalated surgery. Surgical capacity has been more severely constrained in the second wave (58% of pre-pandemic level) compared with the first wave (62%) despite the time to prepare. Conclusions Some hospitals are overwhelmed by COVID-19 and unable to offer essential cancer surgery, but all have neighbouring hospitals in their region retaining good (or even normal) capacity. It is noteworthy that very few patients have been appropriately redirected away from the hospitals most constrained by their burden of COVID-19. The paucity of an effective central or regional strategic response to this evident mismatch between demand and surgical capacity is to the detriment of our head and neck cancer patients

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability