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Aim: Surgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre‐, peri‐ and postoperative factors and multiple interventions can be combined into 'bundles'. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle. Method: This is a single‐centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered. Results: In the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013–2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015–2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection. Conclusion: A successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI. [ABSTRACT FROM AUTHOR]

Background: Complex lower limb trauma is a challenging problem. Achieving optimal long-term outcomes requires multi-disciplinary input, while patients are in hospital, and after discharge. The aim of this study was to evaluate the long-term health services resource use of patients with such injuries, in the context of a publicly funded health system. Methods: This is a population-based retrospective cohort study. Data were obtained from the Information Services Division (ISD) Scotland. We included patients with isolated lower extremity injuries, sustained between 1997 and 2015, with follow-up to 2017. Cases were identified defined by ICD-10 and OPCS-4 procedural codes and divided into two groups, complex and simple injuries and analysed for their subsequent contacts with the health service. Results: There were 42,601 patients with isolated lower limb injuries. 2976 (7.0%) had suffered complex injuries. The in-hospital mortality of these patients was 1.9%. 538 (18.1%) of the patients who sustained complex injuries underwent reconstructive surgery. Just over half attended an orthopaedic outpatient clinic in the first year, and 31.7% attended a plastic surgery clinic. Very few patients attended pain management clinics, or other clinics that might provide pain services. Conclusions: Only a small proportion of patients who undergo reconstructive surgery are followed up by specialist services. The reasons for such low follow-up rates are not obvious. Our findings raise the question of whether the health service in Scotland has sufficient resources to optimise functional outcome in this patient group. Level of evidence: Level III, risk / prognostic study [ABSTRACT FROM AUTHOR]

Background: Outcomes in locally advanced rectal cancer are improved by neoadjuvant therapy followed by surgical resection. Some patients respond completely to preoperative treatment. Therefore, predicting the pathological response to preoperative therapy is of clinical importance. Accurate prediction would allow for tailored approaches to neoadjuvant therapy. Methods: All patients undergoing resection of rectal adenocarcinoma after neoadjuvant therapy between 2006 and 2015 were included in this cohort study. Patients were identified from a prospectively collected database and data were supplemented retrospectively with full blood count at diagnosis. Specimens resected following neoadjuvant therapy were graded according to pathological response. Follow-up data was obtained from the national registry. The primary outcome was complete pathological response. Results: Of 330 patients, 71 (21.5%) responded completely to preoperative therapy. Median age was 66 and 65% were male (n = 215). White cell count (WCC) was the most predictive marker, for predicting pCR; area under the curve (AUC) 0.666. This was higher than neutrophil/platelet ratio (AUC 0.652) or neutrophil/lymphocyte ratios (AUC = 0.437). Kaplan-Meier survival analysis showed those patients with WCC > 8 had poorer survival than those with WCC < 8 (p = 0.009). Conclusion: Routinely collected haematology samples at the point of diagnosis can assist in predicting for complete response to neoadjuvant therapy. Although novel biomarkers will have a greater predictive value, this clinically available value test could help to assist in risk stratification of patients using routinely collected laboratory tests. [ABSTRACT FROM AUTHOR]

Sarcopaenia, or decreased muscle mass, has been the subject of a large quantity of recent literature in both medical and surgical disciplines. It has been shown, as outlined below, to be of great prognostic importance, and also may be used in certain circumstances to guide treatment. The greatest volume of research into this topic is in oncological surgical populations, in whom the prevalence of sarcopaenia has been shown to be high. However it is being increasingly studied in other patient groups. Interest in using sarcopaenia as an objective and potentially modifiable marker of frailty is increasing, especially with regards to pre-operative risk stratification and amelioration. In this review we consider the current literature regarding the cause and effect of sarcopaenia, the methods by which it may be identified and the potential ways in which it may be treated, in the interest of improving outcomes for surgical patients. [ABSTRACT FROM AUTHOR]

There was no change to the measurement of our primary outcome during the course of the study and we feel there has been demonstrable improvement in SSI rates as a consequence of the bundle. Reducing surgical site infection rates in colorectal surgery - A quality improvement approach to implementing a comprehensive bundle The subgroup analysis would involve complex comparisons of SSI rates in those cases where compliance to individual aspects of the bundle was lacking. [Extracted from the article]

Aims The Scottish National Bowel Cancer Screening Programme aims to detect asymptomatic colorectal carcinomas and improve outcomes by identifying tumours at an earlier stage. We describe the characteristics of bowel cancers diagnosed through the screening programme since it was established in June 2007 by comparison with colorectal carcinomas from all other referral sources. Methods All patients with colorectal cancer discussed by our regional colorectal multidisciplinary team ( MDT) from June 2007 to August 2011 were included. Patient and tumour characteristics were collated prospectively from MDT records. The database was then reviewed retrospectively. Results During the study 209 916 (58%) of 364 759 invitations to participate in screening were accepted yielding 3895 (1.9%) positive results. The 255 (17%) screening-detected ( SD) patients and 1232 (83%) other referrals ( ORs) were discussed at the MDT within this period. Median age at diagnosis was 65.5 years for SD vs. 71.6 in OR ( P < 0.001) with 64% vs. 53% male [ SD vs. OR ( P < 0.001)]. There were more left-sided tumours in SD ( P = 0.005). Tumours were less advanced in SD group ( P = 0.02) and more likely to undergo a laparoscopic resection ( P = 0.003). Thirty (11.7%) of SD patients were dead at last follow-up compared with 458 (37.2%) of those from other sources ( P < 0.001). Conclusions This cohort from a centre with an established screening programme supports the effect of screening in detecting earlier stage. Those with screen-detected tumours were more likely to survive than patients from the OR group. [ABSTRACT FROM AUTHOR]

Thomas More was appointed joint keeper of the exchanges in London for foreign exchange and at Calais in 1520, in partnership with a Genoese merchant, George Ardison. This article explores the background to this appointment, investigating the regulation of exchange payments to the Roman curia and the business links between Ardison and the London bank of his fellow Genoese Antony Vyvold. Ardison was the last in a series of Genoese farmers of the exchanges. The exchanges were granted to Thomas Boleyn in 1509, and from 1511 to 1520 Ardison was in partnership with another courtier, John Sharp. [ABSTRACT FROM AUTHOR]

Aim: Temporary stoma formation remains a common part of modern‐day colorectal surgical operations. At the time of reversal, a second procedure is required when the bowel is anastomosed and the musculature is closed. The rate of incisional hernia at these sites is 30%–35% with conventional suture closure. Mesh placement at this site is therefore an attractive option to reduce hernia risk, particularly as new mesh types, such as biosynthetic meshes, are available. The aim of this work was to conduct a systematic review and meta‐analysis assessing the use of mesh for prophylaxis of incisional hernia at stoma closure and to explore the outcome measures used by each of the included studies to establish whether they are genuinely patient‐centred. Method: This is a systematic review and meta‐analysis assessing the published literature regarding the use of mesh at stoma site closure operations. Comprehensive literature searches of major electronic databases were performed by an information specialist. Screening of search results was undertaken using standard systematic review principles. Data from selected studies were input into an Excel file. Meta‐analysis of the results of included studies was conducted using RevMan software (v.5.4). Randomized controlled trial (RCT) and non‐RCT data were analysed separately. Results: Eleven studies with a total of 2008 patients were selected for inclusion, with various mesh types used. Of the included studies, one was a RCT, seven were nonrandomized comparative studies and three were case series. The meta‐analysis of nonrandomized studies shows that the rate of incisional hernia was lower in the mesh reinforcement group compared with the suture closure group (OR 0.21, 95% CI 0.12–0.37) while rates of infection and haematoma/seroma were similar between groups (OR 0.7, 95% CI 0.41–1.21 and OR 1.05, 95% CI 0.63–1.80, respectively). The results of the RCT were in line with those of the nonrandomized studies. Conclusion: Current evidence indicates that mesh is safe and reduces incisional hernia. However, this is not commonly adopted into current clinical practice and the literature has minimal patient‐reported outcome measures. Future work should explore the reasons for such slow adoption as well as the preferences of patients in terms of outcome measures that matter most to them. [ABSTRACT FROM AUTHOR]

Background: The development of prolonged post-operative ileus (POI) remains a significant problem in the general surgical patient population. The aetiology of ileus is poorly understood and management options/preventative measures are currently extremely limited. The pathophysiology leading to a post-operative ileus is relatively poorly understood, and there is no validated method to estimate ileus occurrence or duration. Ileus in the post-operative period commonly occurs following major colorectal surgery and leads to painful abdominal distension, vomiting, nutritional deficit, pneumonia, prolonged hospital stays and susceptibility to hospital-acquired infection. An increased hospital stay, the burden of treatment costs and the burden on the health system highlight the importance of future research on finding definitions, preventions and predictions of ileus. Methods: A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing the rate of ileus on various treatments for prolonged post-operative ileus following colorectal surgery. A confidence evaluation in a meta-analysis were performed using CINeMA. Direct and indirect comparisons of all interventions were simultaneously carried out using a network meta-analysis. The level of certainty was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The method of assessing the risk of bias, the quality assessment, used the Cochrane Risk of Bias 2 tool (RoB2). Results: Among the seven included studies, the majority suffered from considerable within-study bias, affecting the confidence rates of study findings. Heterogeneity and incoherence made the pairwise meta-analysis and ranking of interventions unfeasible. Indirect comparisons were considered unreliable due to this incoherence. Conclusions: This systematic review, with a confidence evaluation in the network meta-analysis, determined that there is a knowledge gap in the field of study on prolonged ileus following digestive surgery. The current evidence suffers from heterogeneity and incoherence more than imprecision. There is a gap in the data on ileus occurrence in interventional trials for digestive surgery. This could inform clinicians and trialists to better appraise the current literature and plan future trials. [ABSTRACT FROM AUTHOR]

Background: Sarcopaenia, loss of lean muscle mass and quality, has prognostic significance and can be used to guide the management of oncology patients.1 However, there is limited research into the prevalence and effect of sarcopaenia in vascular populations. We aim to investigate the prevalence of this measure of physiological reserve in a vascular patient group.Methods: All patients admitted to a tertiary vascular unit in a single year were considered for the study. Patients with an abdominal CT scan (available for analysis) within 12 months of admission were included. Patient data were extracted from electronic patient records and hospital case notes. CT scans were analysed at L3 vertebral body to calculate body composition indices, as previously described.1 Sarcopaenia was defined as skeletal muscle index of <41 cm2/m2 in female patients and non-obese males and <53 cm2/m2 in obese males. Outcome at 3-years was ascertained.Results: Of 314 patients, 129 (41.1%) were sarcopaenic. Female patients were more likely to be sarcopaenic (p < 0.0001). The prevalence of sarcopaenia increased with age (p < 0.001). Rates of sarcopaenia didn't differ between occlusive and aneurysmal diagnoses. In a potentially unique finding in vascular literature to date, mortality and non-home discharge were not significantly different between the groups. On multivariate analysis, sarcopaenia was not significantly associated with earlier death (p = 0.55).Conclusions: Sarcopaenia is highly prevalent in vascular surgical patients. In our analysis, sarcopaenia was not independently associated with mortality. Potentially the associated cardiovascular risk of patients with end stage vascular disease may negate the additional risk of altered body composition. [ABSTRACT FROM AUTHOR]

An abstract of the article "Role of the Aryl Hydrocarbon Receptor Nuclear Translocator in Establishing Lymphocyte and Innate Lymphoid Cells of the Intestinal Tract and the Skin," by George Ramsay, Mahima Swamy and Doreen Cantrell is presented.

Aims: Complete mesocolic excision (CME) has been proposed as a way to improve the oncological outcomes in patients with colon cancer. To investigate whether there is rationale for adopting the technique in Scotland, our aim was to define the incidence of disease recurrence following standard right hemicolectomy and to compare this with published CME outcomes.Methods: Data was collected on consecutive patients undergoing right or extended right hemicolectomy for colonic adenocarcinoma (2012-2017) at three hospitals in Scotland (Raigmore Hospital, Aberdeen Royal Infirmary and Glasgow Royal Infirmary). Emergency or palliative surgery was excluded. Patients were followed up with CT scans and colonoscopy for a minimum of 3 years.Results: 689 patients (M 340, F 349) were included. 30-day mortality was 1.6%. Final pathological stage was Stage I (14%), Stage II (49.8%) and Stage III (36.1%). During follow-up, 10.5% developed loco-regional recurrence and 12.2% developed distant metastases. The 1, 3 and 5-year disease-free survival (DFS) was 94%, 84% and 82% respectively. Primary determinants of recurrence were T stage (p < 0.001), N stage (p < 0.001), apical node involvement (p < 0.001) and EMVI (p < 0.001). When compared to the literature, 30-day mortality was lower than many published series and DFS rates were similar to the largest CME study to date (4 year DFS 85.8% versus 83%).Conclusion: The outcomes of patients undergoing right hemicolectomy in Scotland compare favourably with many published CME studies. The technique demands further evaluation before it can be recommended for adoption into routine surgical practice. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair is most popular, but there are concerns about the risk of chronic groin pain. Laparoscopic repair is increasingly accepted due to the lower risk of chronic pain, although its recurrence rate is still unclear. The aim of this overview is to compare the risk of recurrence and chronic groin pain in laparoscopic versus open repair for inguinal hernia. Methods: We searched Ovid MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. Only reviews of randomised controlled trials (RCTs) in adults published in English were included. Conference proceedings and editorials were excluded. The quality of the systematic reviews was assessed using the AMSTAR 2 checklist. Two outcomes were considered: hernia recurrence and chronic pain. Results: Twenty-one systematic reviews and meta-analyses were included. Laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair. In the four systematic reviews assessing any laparoscopic versus any open repairs, laparoscopic repair was associated with a statistically significant (range: 26–46%) reduction in the odds or risk of chronic pain. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair considered or the types of hernia that were studied, but most reviews had wide confidence intervals and we cannot rule out clinically important effects favouring either type of repair. Conclusion: Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs. [ABSTRACT FROM AUTHOR]

Aim: Neoadjuvant treatment (NaT) for locally advanced rectal cancer prior to surgery has led to improved outcomes. However, the relationship between pathological response to NaT and survival is not entirely clear. The aim of this study was to assess the degree of pathological response to NaT on survival outcomes. Methods: Clinical and pathological data were collected from a prospectively maintained pathology database between 2005 and 2017. The primary outcome was the overall survival based on pathological response categorized as complete, good partial, partial and minimal. Univariate and multivariate analyses were conducted to identify variables predictive of survival. Cox proportional hazard ratios were used for survival. Results: A total of 596 patients had surgery following NaT for locally advanced rectal cancer. The median follow‐up was 4.57 years (interquartile range 2.21–8.15 years). The overall survival for complete pathological response was 75.6% vs. 37.3% for minimal response (P < 0.001). The overall survival at the end of the study in the good partial vs. partial response groups was 58.9% vs. 39% (P < 0.001). On multivariate analysis, the degree of pathological response remains an independent variable for overall and disease‐specific survival across all categories. Discussion: In addition to other pathological variables, the degree of pathological response to NaT is an independent predictor for survival outcomes. Future verification of these findings elsewhere could support NaT response being used for adjuvant therapy decision making. [ABSTRACT FROM AUTHOR]

Aim: There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence‐based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. Methods: Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology‐based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence‐based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. Results: All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. Conclusion: These guidelines provide an up to date and evidence‐based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting. [ABSTRACT FROM AUTHOR]

Introduction: Patients with screened detected colorectal cancer (CRC) have a better survival than patients referred with symptoms. This may be because of cancers being identified in a younger population and at an earlier stage. In this study, we assess whether screened detected CRC has an improved outcome after controlling for key pathological and patient factors known to influence prognosis.Method: This is a cohort study of all CRC patients diagnosed in NHS Grampian. Patients aged 51-75 years old between June 2007 and July 2017 were included. Data were obtained from a prospectively maintained regional pathology database and outcomes from ISD records. All-cause mortality rates at 1 and 5 years were examined. A Cox proportional hazards regression model was used to estimate the effect of screening status, age, gender, Duke stage, tumour location, extramural venous invasion (EMVI) status and lymph node ratio (LNR) on overall survival.Results: Of 1618 CRC cases, 449 (27.8%) were screened and 1169 (72.2%) were symptomatic. Screened CRC patients had improved survival compared to non-screened CRC at 1 year (88.9% vs 83.9% p < 0.001) and 5-years (42.5% vs 36.2%; p < 0.001). On multivariable analysis of patients who had no neoadjuvant therapy (n = 1272), screening had better survival (HR 0.57; 95% CI 0.44-0.74; p < 0.001). EMVI (HR 2.22; CI 1.76 to 2.79; p < 0.001) and tumour location were found to affect outcome.Conclusion: Patients referred through screening had improved survival compared with symptomatic patients. Further research could be targeted to determine if screened CRC cases are pathologically different to symptomatic cancers or if the screening cohort is inherently more healthy. [ABSTRACT FROM AUTHOR]

Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations. • Patients with high travel burden encounter the cancer treatment pathway differently. • They spend more time in hospital in the first year following cancer diagnosis. • Island dwellers have fewer outpatient appointments; this negatively affects survival. • Better configuration of cancer services is needed for dispersed populations. [ABSTRACT FROM AUTHOR]

Background. Novel strategies are required to efficiently manage the increasing number of patients diagnosed with chronic kidney disease (CKD). We sought to identify factors predicting outcome in patients with stage 4 CKD and to determine whether low-risk patients could be managed in primary care. Methods. We performed a two-centre, retrospective cohort study including 396 patients with stage 4 CKD referred to nephrology clinics from 1998 to 2002. We utilized electronic databases to determine the incidence of renal replacement therapy (RRT) and mortality and the rate of deterioration in estimated glomerular filtration rate (eGFR) to the year end 2005. Results. This was an elderly cohort, with 71.7% of patients aged ≥65 years. The risk of surviving to require dialysis fell with increasing age (HR 0.44; 95% CI: 0.23–0.84 for those >74 years verses those <65 years), in part due to the slower rate of decline in renal function in older patients (median fall in eGFR was −2.25, −1.38 and −0.86 ml/ min/1.73 m2/year in those aged <65 years, 65–74 years and >74 years, respectively, P < 0.0001). Additional independent risk factors predicting RRT included: high baseline proteinuria (HR 6.26; 95% CI: 2.74–14.23 for >3 g/24 h versus <0.3 g/24 h), greater early decline in renal function (HR 3.86; 95% CI: 2.34–6.38 for ≥4 ml/min/1.73 m2/year versus <4 ml/min/1.73 m2/year), low baseline eGFR (HR 2.92; 95% CI: 1.61–5.30 for 15–19 versus 25–29 ml/min/1.73 m2) and low haemoglobin (HR 3.16; 95% CI: 1.64–6.08 for <10 versus >12 g/dl). The 98 (24.7%) patients discharged to primary care had more stable renal function than those remaining under nephrology care (median change in eGFR of +0.20 versus −1.88 ml/ min/1.73 m2/year, P = 0.0001). Conclusions. Most patients with stage 4 CKD, in particular the elderly, die without commencing RRT. Patients at low risk of progression can be identified and discharged safely to primary care with an active management plan. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is a leading cause of mortality worldwide and in the UK. Surgical resection is the main curative treatment modality available and using a laparoscopic vs. an open approach may have a direct influence on the inflammatory response, influencing cancer biology and potentially the recurrence kinetics by promoting cancer growth. Methods: This systematic review aims to compare laparoscopic with open surgery for the treatment of colon cancer with a specific focus on the moment of the recurrence. We included randomised controlled trials in intended curative surgery for colon cancer in adults. Interventions: Studies investigating laparoscopic vs. open resection as an intended curative treatment for patients with confirmed carcinoma of the colon. The two co-primary outcomes were the time to recurrence and the overall survival (OS) and disease-free survival (DFS) at three and five years. Meta-analyses were done on the mean differences. Results: After selection, we reviewed ten randomised controlled trials. Most of the trials did not display a statistically significant difference in either DFS or OS at three or at five years when comparing laparoscopic to open surgery. Groups did not differ for the OS and DFS, especially regarding the time needed to observe the median recurrence rate. The quality of evidence (GRADE) was moderate to very low. Conclusion: We observed no difference in the recurrence kinetics, OS or DFS at three or five years when comparing laparoscopic to open surgery in colon cancer. [ABSTRACT FROM AUTHOR]