Day-case laparoscopic Nissen fundoplication (Br J Surg 2003; 90: 560-562).
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Ambulatory Surgical Procedures↗
Biomedical subjects
S Paterson-Brown
Publications and source records attributed to S Paterson-Brown.
Small bowel obstruction--the water-soluble follow-through revisited.
AIMS: The aim of the present study to examine the use of a modified water-soluble follow-through in the diagnosis and management of small bowel obstruction (SBO). MATERIALS AND METHODS: Sixty-two patients were recruited to the study: 33 into the control group and 29 into the study group. A modified small bowel follow-through (SBFT) was performed in the study group patients. The control group was managed conventionally. Assessment was made by questionnaire documenting initial surgical diagnosis and likelihood of operative intervention, final diagnosis and surgical outcome (operative versus non-operative). RESULTS: SBFT changed the diagnosis in 12/24 of the study group (p<0.01). In the study group 8/24 proceeded to surgery whereas 19/33 underwent laparotomy in the control group, representing a relative risk reduction of 52%, but this was not statistically significant (0.10>p>0.05, chi-squared test). CONCLUSION: SBFT remains a valid and useful tool in surgical management of SBO. In particular it aids diagnostic confidence in planning surgical intervention, particularly in uncomplicated patients.
Case-Control Studies↗
Trends in oesophago-gastric surgery in Scotland.
BACKGROUND: The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes in gastro-oesophageal surgery in Scotland during this period. METHODS: A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons. RESULTS: There was a significant increase (p=0.001, chi2) in the number of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p<0.001, chi2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, chi2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units. CONCLUSIONS: Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow.
Adolescent↗
Endoscopic surveillance practice for Barrett' s oesophagus in Scotland and early experience in implementing local guidelines.
Management of columnar lined oesophagus (CLO; Barrett s oesophagus) is controversial. We prospectively audited surveillance practices in Scotland and prospectively assessed the impact of introducing local guidelines for Barrett s surveillance in Edinburgh. Most respondents were gastroenterologists. The majority take random, not four quadrant, biopsies from the CLO. In Edinburgh during 2000, 80 patients underwent surveillance. The guideline protocol was not followed in 30 (37.5%) patients. Follow up of patients without dysplasia generally conformed to the guidelines. Follow up of patients with low grade dysplasia was highly variable while management of those with high grade dysplasia followed the guidelines. Overall we found a wide variability in the management and surveillance of CLO. Early experience suggests that implementation of guidelines is helpful but there is still variation in practice.
Barrett Esophagus↗
Symphysiotomy: a lifesaving procedure.
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Adult↗
Knowledge of aspects of acute care in trainee doctors.
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Acute Disease↗
Transient femoral nerve palsy following ilio-inguinal nerve blockade for day case inguinal hernia repair.
BACKGROUND: Transient femoral nerve palsy (TFNP) has been reported in patients undergoing inguinal hernia repair involving the use of ilio-inguinal nerve block. Ilio-inguinal nerve blocks can be administered under vision by the surgeon or by the anaesthetist using a standard blind technique. There has been no study that has specifically examined the incidence of this complication and whether its development is related to the type of method used to administer the block. PATIENTS AND METHODS: Data on patients undergoing surgery in the Royal Infirmary Edinburgh Day Case Unit are collected prospectively. All patients who undergo inguinal hernia repair are given ilio-inguinal field blocks, either pre-operatively by anaesthetists (blind technique) or peri-operatively under direct vision by surgeons. Several cases of TFNP were initially identified during the process of surgical audit and this led to a retrospective analysis over a period of one year. RESULTS: During a 12-month period, 194 patients underwent 200 open inguinal hernia repairs (188 unilateral and 6 bilateral), under general anaesthesia. Ten patients (5%) developed TFNP resulting in overnight admission. Surgeons administered 101 blocks under direct vision of which 4 (4%) resulted in TFNP, whereas 6 out of 99 (6%) blind blocks resulted in TFNP (p=0.49, df=1, Chi2 test). DISCUSSION AND CONCLUSION: TFNP is a recognised complication following ilioinguinal nerve blockade for inguinal hernia surgery. Our series shows that ilio-inguinal block given under direct vision does not appear to reduce the chance of this complication occurring. This may result from the fact that this complication could be due to local infiltration into the operative field rather than direct infiltration around the femoral nerve. As inguinal hernia repair undertaken as a day case procedure increases, the awareness of this complication is important to avoid morbidity
Adult↗
Gastric adenocarcinoma missed at endoscopy.
BACKGROUND AND PURPOSE: The diagnosis of gastric cancer is based on histological confirmation at endoscopy with the emphasis on early detection to improve prognosis. The aims of this study were to identify the proportion of patients with gastric adenocarcinoma in whom the diagnosis was missed at first endoscopy and the subsequent delay which occurred before the histological diagnosis was established. METHODS: Retrospective review of 137 consecutive patients with biopsy-proven gastric adenocarcinoma presenting to one surgical unit over a five-year period. RESULTS: Two patients with a biopsy diagnosis at laparotomy and 6 patients in whom case notes could not be traced were excluded from the study. Of the remaining 129 patients, the diagnosis of gastric adenocarcinoma was missed at first endoscopy in 18 (14%). The median delay to histological diagnosis in this subgroup of patients was 13 weeks (range 3-102). CONCLUSION: Delays in establishing the diagnosis of gastric adenocarcinoma following initial endoscopy occur in a number of patients. Greater suspicion and a more rigorous protocol for repeat endoscopy and biopsy must be implemented in order to reduce the number of missed diagnoses after initial endoscopy.
Adenocarcinoma↗
Secondary amenorrhoea due to the use of rifampicin as an antimycobacterial agent.
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Adult↗
Association between laparoscopic abdominal surgery and postoperative symptoms of raised intracranial pressure.
Animal models have illustrated that a carbon dioxide (CO(2)) pneumoperitoneum can cause a rise in intracranial pressure (ICP). This study investigated key symptoms and signs of raised ICP in 39 patients after laparoscopic abdominal surgery and compared them with a control group of 33 patients after open operations. The findings show that the incidence of headache and nausea was significantly higher in the laparoscopic group than in the control subjects. End-tidal CO(2) levels were recorded, and no significant difference was found between patients and control subjects. We conclude that these results could be explained by raised intracranial pressure exacerbated by the CO(2) pneumoperitoneum, and that this effect is not mediated by raised expiratory CO(2) levels intraoperatively.
Carbon Dioxide↗
Feasibility, reliability and validity of a new assessment form for use with basic surgical trainees.
BACKGROUND: To establish feasibility, reliability and validity of a newly designed basic surgical training (BST) assessment form. METHODS: The assessment form was evaluated among trainees on the South-east Scotland BST rotation over 18 months. Feasibility was indicated by response rate. Reliability was determined using test-retest analysis and internal consistency of each domain determined by Cronbach's alpha and item-total correlation. Construct validity was evaluated by determining improvement in performance after 1 year of training. RESULTS: Response rate was high (889 of 984 forms [90%]), with similar representation from all disciplines. A highly significant positive correlation was found between test-retest scores for all domains (rho: I, 0.736; II, 0.875; III, 0.671; IV, 0.826; V, 0.859; P = 0.0001 all domains, Spearman's). Internal consistency was excellent for each domain, with Cronbach's alpha ranging from 0.82 to 0.95. Item-total correlation coefficients were greater than the required 0.4 for all but one task. In 101 assessments carried out after 1 year of training, significant improvement in scores was found for all domains except clinical skills (time 0 to time 1 year median [interquartile range]: I, 81 [26 to 100] to 100 [100 to 100], P = 0.008; II, 17 [-19 to 52] to 72 [36 to 100], P = 0.015; III, 85 [51 to 100] to 100 [87 to 100], P = 0.018; IV, 82 [44 to 100] to 92 [69 to 100], P = 0.211; V, 27 [-33 to 64] to 76 [32 to 100], P = 0.004). CONCLUSIONS: The new assessment form is feasible, reliable and valid and would therefore be suitable for extended use with basic surgical trainees.
Clinical Competence↗
Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion.
AIM: To determine what proportion of obstetricians would agree to elective pre-labour CS for 'maternal request'. METHODS: Every fifth consultant on an alphabetical list of obstetricians in England and Wales obtained from the RCOG (243) was surveyed by post and asked (a) "Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for 'maternal request?"' and (b) if yes, in relation to this 'Has your practice changed over recent years?" RESULTS: 155 questionnaires were returned (63% response rate -- four unanswered, leaving 151 for analysis). One hundred and four (69%) consultants said they would agree to 'maternal request' for CS. Of the 'yes' respondents, 62 (60%) claimed their practice had changed recently. CONCLUSION: This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications.
Attitude of Health Personnel↗
Validity of surgical simulation for the assessment of operative skill.
BACKGROUND: Surgical simulators are being promoted as a means of assessing a surgeon's technical skills. Little evidence exists that simulator performance correlates with actual technical ability. This study was undertaken to determine the criterion and construct validity of currently available surgical simulations in the evaluation of technical skill. METHODS: Simulator assessment was carried out on 36 basic surgical trainees, 37 surgically naïve first-year medical students and 16 experienced general surgical consultants. Some 26 trainees and 36 students underwent repeat assessment after 6 months. A previously validated, 19-point technical skill assessment form, based on direct observation of trainee performance in the operating theatre, was also completed by each trainee's supervising consultant. RESULTS: An insignificant or weak correlation was found between simulator performance and both duration of basic surgical experience and consultant assessment of technical skill. Six months of basic surgical training led to an improvement in performance, not seen in an untrained control group, in only one of the six simulations tested. Discrimination between surgically naïve and experienced subjects was only demonstrated, in part, for four of the six tasks. CONCLUSION: The assessment of technical skill needs to be improved. Work is needed to establish the reliability and validity of currently available simulation models before they are formally introduced for high-stakes assessment.
Clinical Competence↗
Physical sequelae of caesarean section.
The complications and recovery from caesarean section are dominated by the medical condition of the woman pre-operatively. Evidence regarding risks directly attributable to the caesarean section is scanty, and often derived from obstetric practice that differs from the current day. Mortality associated with the procedure is anything up to five times that for vaginal delivery, with emergency caesarean section associated with almost twice the risk of elective procedures. Data regarding placenta praevia and placenta praevia-accreta come from population series where antibiotics were not routinely used for caesarean section, but there is no doubt that previous caesarean section increases the risk of both. Antibiotic and thromboprophylaxis at the time of caesarean section decrease morbidity in the index pregnancy, but can also reasonably be expected to reduce future pregnancy complications.
Adult↗
Separating elective and emergency surgical care (the emergency team).
The purpose of this study was to evaluate the influence on general surgical activity following the separation of elective from emergency surgical care in one large teaching hospital. A prospective audit of elective and emergency general surgical activity between 1994 and 1999 inclusive was carried out. Elective and emergency surgical activity was separated in January 1996, with a dedicated 'Emergency Team' of one consultant for one week, two registrars, two senior house officers and four house officers for two weeks, in addition to a 20 bed acute admission ward and a 24 hour emergency theatre. The consultant cancelled the majority of his/her elective work during the on-call week. A prospective collection was made of all elective and emergency operations carried out between 1994 and 1999 using the Lothian Surgical Audit system. Out of hours operative activity was analysed retrospectively from data collected using the Operating Room Schedule of Surgery (ORSOS) and outpatient clinic and day case activity collected from the Hospital Administration System. Comparisons were made between years 1994/1995 and 1996/7/8/9. Emergency surgical admissions rose by 86% from 1973 patients in 1994 to 3675 in 1999. During the same period, elective in-patient activity remained fairly steady, but there was an increase in day surgery from 469 to 2089 cases per annum. Despite the on-call consultant cancelling his/her outpatient clinics, overall outpatient activity also increased from 9911 to 12,335. However a proportion of this reflects the appointment of two new consultants in April 1998. Emergency operations increased from 941 in 1994 to 1351 in 1999, with a two-fold reduction in operations carried out between 0000-0800 hours from 16% in 1994 to 7.9% in 1999. A separate and dedicated 'Emergency Team' is an efficient method of managing acute general surgical admissions. It permits elective work to carry on uninterrupted, reduces the number of operations performed after midnight, and provides a better environment for teaching and training. This scenario might also be applicable to other medical specialties who have a large emergency commitment.
Elective Surgical Procedures↗
Opinions of patients and the public regarding NHS priorities.
The purpose of this study was to ascertain the views of patients and the public on NHS priorities. Data were gathered by interview questionnaire throughout Edinburgh city centre, and within various departments of one large teaching hospital. Of the 1502 responses, 462 were from within the hospital and 1040 were from city centre locations. 1497 (99.7%) were in favour of treating emergencies, and 1467 (97.7%) life threatening conditions as a priority. 1315 (88%) agreed that treatable conditions that seriously affect quality of life should also be considered a priority and 1127 (75%) were in favour of treating patients with incurable terminal disease regardless of cost. In order to provide these services 584 (39%) considered it acceptable to make patients with less serious conditions wait longer. Of the 918 (61%) who considered it not acceptable to wait longer 812 (88%) would be prepared to pay more in tax to provide this. The General Public do support the treatment of emergency and life threatening conditions as an absolute priority. The majority also support the prioritization of conditions which are treatable and seriously affect quality of life. If in establishing these priorities waiting times for other conditions are likely to rise, the public would generally accept increased taxation or some form of fee for service.
Adult↗
National obstetric anaesthetic practice in the UK 1997/1998.
In the United Kingdom, the Royal College of Obstetricians and Gynaecologists requires maternity units recognised for training to complete annual statistical returns. Analysis of these data revealed that anaesthetists were directly involved in more than 251 000 procedures in the peripartum period in 1997/1998. There had been an increase in the number of women delivered by Caesarean section (18. 5% of all deliveries) compared with previous reports. The proportion of Caesarean sections performed under regional anaesthesia had increased for both elective and emergency Caesarean section deliveries (85.5% and 70.2%, respectively). For pain relief in labour, there had been neither an increase nor a decrease in the uptake of regional analgesia (23.6%). There were limited training opportunities for anaesthetists in general anaesthesia for Caesarean section and for obstetricians in vaginal breech delivery. The known admissions to intensive care units equated to over 100 women per month in the United Kingdom requiring intensive care as a result of childbirth.
Analgesia, Obstetrical↗
Early outcome after laparoscopic and open floppy nissen fundoplication
AIMS: There remains debate regarding the best operative procedure for gastro-oesophageal reflux. For those who advocate a full 'floppy' Nissen fundoplication there is some scepticism that this can be completed effectively laparoscopically with division of all the short gastric vessels. This study therefore compared the results of patients operated on in two different hospitals in which floppy Nissen fundoplication was carried out either laparoscopically (hospital 1) or by open surgery (hospital 2). METHODS: All patients undergoing antireflux surgery in both hospitals were recorded prospectively and perioperative data were collected retrospectively from the case records. A postoperative questionnaire was sent to each patient to determine the modified DeMeester score and the impact of surgery on daily activities, which were then analysed anonymously by an independent clinician. RESULTS: Operating time was significantly longer (median 150 versus 75 min; P < 0.001), but postoperative stay (2 versus 4 days; P < 0.001) and return to normal activities (14 versus 25 days; P < 0.002) were shorter for the laparoscopic approach. There was no difference in gas bloat (both groups median 1.0, range 0-3), dysphagia (median 1.0 versus 0.0, range 0-3) or modified DeMeester score (both groups median 1.0, range 0-9) between the two techniques (median follow-up 10 and 15 months). CONCLUSIONS: As the postoperative results were comparable this study confirms that a 'floppy' Nissen fundoplication with complete mobilization of the gastric fundus can be performed laparoscopically. The advantages of a shorter hospital stay and earlier return to normal activities are offset by a longer operating time.
Journal Article↗