Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.
This study assessed whether playing video games enhanced laparoscopic skill acquisition for precl... more This study assessed whether playing video games enhanced laparoscopic skill acquisition for preclinical medical students with no past surgical exposure. By the second attempt on a peg transfer task, there was no significant difference in timing between the two groups, indicating that video games did not confer a skill acquisition benefit in the gamer group.
Haemorrhoidal disease represents one of the most common conditions, for which there are numerous ... more Haemorrhoidal disease represents one of the most common conditions, for which there are numerous treatment strategies, both surgical and non-surgical. This paper aims to present evidence from the literature for the current trends in the management of haemorrhoids.
Background The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having... more Background The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery. Methods A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination. Results A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ2 = 87.162, P < 0.001). Alternative training resources (webinars...
Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node... more Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node (LN) retrieval in colorectal cancer (CRC) resection. Methods. The study population was 213 consecutive patients undergoing CRC resection by a single surgeon, at two units: unit one 110 operations (2002-2005) and unit two 103 (2005-2009). LN yields and case mix were compared. Results. Median LN harvests were significantly different between the two centres: unit 1: 13 nodes/patient and unit 2: 22 nodes/patient (P < .001). In unit one 42% of cases were LN positive and in unit two 48% (P = .398). There was no difference in case mix. Multivariate analysis identified unit (P < .001) and pathologist (P = .007) as independent predictors of harvest. Conclusions. A surgeon moving units can experience significantly different LN yield following CRC resection. Both units comply with national standards, but the "surgeon's results" at the two units appear to be pathologist dependen...
Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging pat... more Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging patients with change in bowel habit (CIBH) and ⁄ or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfactory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice. Method This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malignancy over a 4-year period. Two-week-wait referral proforma and case notes were analysed for mode of presentation. Results Of 206 elective right hemicolectomies performed, 20 ⁄ 206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. Twelve patients had polyposis identified in the left colon and eight patients had no left-sided colonic pathology. One patient had a strong family history of colon cancer (two first-degree relatives) in the group absent of left-sided pathology. Conclusion Twelve patients who had left-sided polyposis and one patient with a strong family history would have undergone whole colonic imaging based on current colorectal cancer management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and ⁄ or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer.
A 17-year-old adolescent with long-standing mega-colon and defaecatory dysfunction presented to t... more A 17-year-old adolescent with long-standing mega-colon and defaecatory dysfunction presented to the emergency department complaining of abdominal pain and difficulty in breathing. He was otherwise fit and well with minor learning difficulties, but no preexisting respiratory disease. He had a diagnosis of idiopathic constipation, as previous full thickness rectal biopsy for Hirschsprung’s disease were negative, supported by a normal recto-anal inhibitory reflex on anorectal manometry. Previous barium enema was normal showing no structural abnormality. On examination, the patient was dehydrated and tachypnoeic, with a respiratory rate of 23 breaths per minute, blood pressure 140 ⁄ 80 mmHg and a heart rate of 95 ⁄ min. Initial oxygen saturations were 99% on air. Abdominal examination revealed a grossly distended, tympanic, tender abdomen with a palpable descending colon. Chest X-ray (Fig. 1a) showed an elevated left hemidiaphragm with significant mediastinal shift to the right, whilst a supine abdominal film (Fig. 1b) revealed grossly dilated colon impacted with faeces. Urgent CT scan of the thorax and abdomen demonstrated a grossly distended colon causing elevation of the left hemi-diaphragm that, in turn, was causing mediastinal shift to the right side. Shortly after CT imaging, the patient deteriorated, becoming tachycardic (170 beats ⁄ min), tachypnoeic (60 breaths ⁄ min), and hypoxic (SaO2 70%). He was immediately intubated, and transferred to emergency theatre for a laparotomy. Intra-operatively, a massively dilated colon and rectum were encountered and a subtotal colectomy and end ileostomy were undertaken. Postoperative recovery was uneventful. Histopathology of the resected specimen was neither typical of hollow visceral myopathy nor Hirschprung’s disease because of the presence of ganglion cells in the resected specimen, suggesting a cause of chronic idiopathic constipation.
A 31-year-old Caucasian man was admitted with a 4-month history of productive cough with faeculen... more A 31-year-old Caucasian man was admitted with a 4-month history of productive cough with faeculent expectoration and fluctuating pyrexia that had been refractory to antibiotics. He had been diagnosed with Crohn’s colitis 14 years previously but he had no intestinal symptoms, was taking no medication and had been lost to gastroenterological follow up. He was an ex-smoker. On clinical examination, he was thin (body mass index = 21.1 kg ⁄ m). There were no abdominal signs. Chest examination revealed crepitations at the left lower base, and the sputum was dark brown with a faeculent smell. The only significant blood abnormality was an elevated C-reactive protein concentration of 312 mg ⁄ dl. The patient was started on empirical intravenous antibiotics for suspected bronchiectasis and underwent a computed tomography (CT) scan of the thorax and the abdomen. This demonstrated a fistulous track originating from the descending colon, communicating with the left lower lobe via a subphrenic abscess (Fig. 1). Flexible sigmoidoscopy demonstrated inflamed mucosa in the descending colon and active proctitis. Upon surgery, a chronic subphrenic abscess was confirmed. The patient underwent an uncomplicated subtotal colectomy with ileostomy and disconnection of the fistula. Histology of the resected specimen confirmed active Crohn’s pancolitis. He was reviewed 1 month following discharge, the cough had settled and he was well.
Background Computed tomographic colonography (CTC) is now an established method for imaging the c... more Background Computed tomographic colonography (CTC) is now an established method for imaging the colon and rectum in the screening and symptomatic setting. Additional benefit of CTC is the ability to assess for extracolonic findings especially in patients presenting with colorectal symptoms. Purpose To determine prevalence of extracolonic findings (ECF) in symptomatic patients undergoing CTC and determine accuracy of CTC for exclusion of significant abdominal disease and extracolonic malignancy (ECM). Material and Methods A total of 1359 unenhanced prone and postcontrast supine CTC studies were performed between March 2002 and December 2007. ECF were retrospectively classified according to C-RADS criteria into E1 to E4 findings. For ECM, a gold standard of clinical and/or radiological follow-up supplemented with data from the regional cancer registry with a median follow-up of 42 months was created. Sensitivity and negative predictive values for ECM was calculated. Results Following ...
Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as ind... more Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.
This study assessed whether playing video games enhanced laparoscopic skill acquisition for precl... more This study assessed whether playing video games enhanced laparoscopic skill acquisition for preclinical medical students with no past surgical exposure. By the second attempt on a peg transfer task, there was no significant difference in timing between the two groups, indicating that video games did not confer a skill acquisition benefit in the gamer group.
Haemorrhoidal disease represents one of the most common conditions, for which there are numerous ... more Haemorrhoidal disease represents one of the most common conditions, for which there are numerous treatment strategies, both surgical and non-surgical. This paper aims to present evidence from the literature for the current trends in the management of haemorrhoids.
Background The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having... more Background The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery. Methods A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination. Results A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ2 = 87.162, P < 0.001). Alternative training resources (webinars...
Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node... more Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node (LN) retrieval in colorectal cancer (CRC) resection. Methods. The study population was 213 consecutive patients undergoing CRC resection by a single surgeon, at two units: unit one 110 operations (2002-2005) and unit two 103 (2005-2009). LN yields and case mix were compared. Results. Median LN harvests were significantly different between the two centres: unit 1: 13 nodes/patient and unit 2: 22 nodes/patient (P < .001). In unit one 42% of cases were LN positive and in unit two 48% (P = .398). There was no difference in case mix. Multivariate analysis identified unit (P < .001) and pathologist (P = .007) as independent predictors of harvest. Conclusions. A surgeon moving units can experience significantly different LN yield following CRC resection. Both units comply with national standards, but the "surgeon's results" at the two units appear to be pathologist dependen...
Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging pat... more Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging patients with change in bowel habit (CIBH) and ⁄ or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfactory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice. Method This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malignancy over a 4-year period. Two-week-wait referral proforma and case notes were analysed for mode of presentation. Results Of 206 elective right hemicolectomies performed, 20 ⁄ 206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. Twelve patients had polyposis identified in the left colon and eight patients had no left-sided colonic pathology. One patient had a strong family history of colon cancer (two first-degree relatives) in the group absent of left-sided pathology. Conclusion Twelve patients who had left-sided polyposis and one patient with a strong family history would have undergone whole colonic imaging based on current colorectal cancer management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and ⁄ or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer.
A 17-year-old adolescent with long-standing mega-colon and defaecatory dysfunction presented to t... more A 17-year-old adolescent with long-standing mega-colon and defaecatory dysfunction presented to the emergency department complaining of abdominal pain and difficulty in breathing. He was otherwise fit and well with minor learning difficulties, but no preexisting respiratory disease. He had a diagnosis of idiopathic constipation, as previous full thickness rectal biopsy for Hirschsprung’s disease were negative, supported by a normal recto-anal inhibitory reflex on anorectal manometry. Previous barium enema was normal showing no structural abnormality. On examination, the patient was dehydrated and tachypnoeic, with a respiratory rate of 23 breaths per minute, blood pressure 140 ⁄ 80 mmHg and a heart rate of 95 ⁄ min. Initial oxygen saturations were 99% on air. Abdominal examination revealed a grossly distended, tympanic, tender abdomen with a palpable descending colon. Chest X-ray (Fig. 1a) showed an elevated left hemidiaphragm with significant mediastinal shift to the right, whilst a supine abdominal film (Fig. 1b) revealed grossly dilated colon impacted with faeces. Urgent CT scan of the thorax and abdomen demonstrated a grossly distended colon causing elevation of the left hemi-diaphragm that, in turn, was causing mediastinal shift to the right side. Shortly after CT imaging, the patient deteriorated, becoming tachycardic (170 beats ⁄ min), tachypnoeic (60 breaths ⁄ min), and hypoxic (SaO2 70%). He was immediately intubated, and transferred to emergency theatre for a laparotomy. Intra-operatively, a massively dilated colon and rectum were encountered and a subtotal colectomy and end ileostomy were undertaken. Postoperative recovery was uneventful. Histopathology of the resected specimen was neither typical of hollow visceral myopathy nor Hirschprung’s disease because of the presence of ganglion cells in the resected specimen, suggesting a cause of chronic idiopathic constipation.
A 31-year-old Caucasian man was admitted with a 4-month history of productive cough with faeculen... more A 31-year-old Caucasian man was admitted with a 4-month history of productive cough with faeculent expectoration and fluctuating pyrexia that had been refractory to antibiotics. He had been diagnosed with Crohn’s colitis 14 years previously but he had no intestinal symptoms, was taking no medication and had been lost to gastroenterological follow up. He was an ex-smoker. On clinical examination, he was thin (body mass index = 21.1 kg ⁄ m). There were no abdominal signs. Chest examination revealed crepitations at the left lower base, and the sputum was dark brown with a faeculent smell. The only significant blood abnormality was an elevated C-reactive protein concentration of 312 mg ⁄ dl. The patient was started on empirical intravenous antibiotics for suspected bronchiectasis and underwent a computed tomography (CT) scan of the thorax and the abdomen. This demonstrated a fistulous track originating from the descending colon, communicating with the left lower lobe via a subphrenic abscess (Fig. 1). Flexible sigmoidoscopy demonstrated inflamed mucosa in the descending colon and active proctitis. Upon surgery, a chronic subphrenic abscess was confirmed. The patient underwent an uncomplicated subtotal colectomy with ileostomy and disconnection of the fistula. Histology of the resected specimen confirmed active Crohn’s pancolitis. He was reviewed 1 month following discharge, the cough had settled and he was well.
Background Computed tomographic colonography (CTC) is now an established method for imaging the c... more Background Computed tomographic colonography (CTC) is now an established method for imaging the colon and rectum in the screening and symptomatic setting. Additional benefit of CTC is the ability to assess for extracolonic findings especially in patients presenting with colorectal symptoms. Purpose To determine prevalence of extracolonic findings (ECF) in symptomatic patients undergoing CTC and determine accuracy of CTC for exclusion of significant abdominal disease and extracolonic malignancy (ECM). Material and Methods A total of 1359 unenhanced prone and postcontrast supine CTC studies were performed between March 2002 and December 2007. ECF were retrospectively classified according to C-RADS criteria into E1 to E4 findings. For ECM, a gold standard of clinical and/or radiological follow-up supplemented with data from the regional cancer registry with a median follow-up of 42 months was created. Sensitivity and negative predictive values for ECM was calculated. Results Following ...
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Papers by S. Badiani