International Journal of Surgery 15 (2015) 140e141

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Editor's perspectives e March 2015 In my last editorial last month I alluded to the two great problems with the UK National Health Service-the fact that no country can afford free medical care at the point of delivery and the swamping of the service with emergencies. These problems are not just in the UK but are worldwide. Every country I visit has a problem with the emergency work load; it seems even greater in the developing world. This problem inevitably leads to a decrease in elective work which, in turn, leads to disgruntled or, worse still, neglected patients. One hears of delays in diagnosis and treatment. In a few instances this probably does not matter too much, unless you are the patient losing days at work perhaps. In some cases however, such as patients needing cancer treatment, it may really be a difference between “cure” and misery. My solution to this problem, which I have been expounding for more than 25 years, is to divorce elective and emergency work. To do this one has to completely separate emergency admissions from elective work and these patients must be treated in separate hospitals. It is no good to “protect” beds for elective surgery. We all know that if a bed is empty and there is a patient requiring admission in the Accident and Emergency Department, the patient will be admitted to that bed and the elective surgical patient will be sent home or informed there are no available beds. How disruptive to one's life this must be. Time taken off from work or family moving in to look after children, let alone the psychological trauma through anxiety to the patient. I suggest every large district or conurbation has a major Hub hospital which takes all the emergencies and high technical/ complicated surgery and other treatment. There are then 3 other hospitals in the district-the first is for all elective work. All surgery that does not require Intensive Care or High Dependency Units would be admitted to this well equipped but non-high technical hospital. Also medical elective work, endoscopy or other investigations would be performed there and no patient would ever be cancelled as no emergencies will fill the beds. The third hospital would be a rehabilitation and chronic diseases hospital with for example Renal Dialysis, excellent Physiotherapy and Occupational Therapy units. Lastly a combined hospital to look after the geriatric patients together with a hospice unit would complete the hub and spoke set up for every region. There would have to be more flexibility of medical personnel working at both the hub and spoke hospitals. I believe doctors in training would have much improved education as in the elective spoke hospitals the “pressure would be off” and there would be increased time for teaching and training, especially with respect to operative skills. These units would include Day Care surgery. I am sure there will be resistance from some members of the Profession who would prefer to work in one geographical location. However, once they tried it, I feel certain they would soon enjoy 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

their time out of the hub hospital where they could work in a less pressurized unit still with their team who would spend the week, or whatever allotted time is deemed suitable, in the spoke hospital. I also feel certain this approach could lead to better patient care with continuity of treatment and a return to team working which is sadly lacking in the present UK NHS structure. There are no papers in this issue on this theme. Therefore I suggest any readers who would like to comment should write a letter to the Editor which we would be pleased to publish, as usual after suitable peer review. This issue contains 27 varied papers from all over the world. There are two articles on abdominal aortic aneurysms (AAA). The first retrospectively studied the Neutrophil to Lymphocyte Ratio in 80 consecutive cases of ruptured AAA and found that a preoperative ratio of >5 is an independent predictive marker of 30 day morbidity. The British authors add that this is similar in elective AAA repairs. The second paper on this subject looked at the outcomes of AAA in the elderly. The Dutch authors studied 211 patients over the age of 70 and found that the patients over the age of 80 had a significantly higher mortality if treated by EVAR than the 70e80 year olds. There was no difference in the two groups for those treated by conservative methods or open operations. I will not discuss the article but strongly recommend the paper on the Management of the Diabetic Foot from India for all our readers involved with this increasing problem which creates a huge work load for us in The Caribbean. Papers are still being written about acute appendicitis. The first from the Netherlands discusses the impact of appendicitis in pregnancy. It seems that both perforated appendicitis and negative appendicectomy during pregnancy are associated with a high risk of premature birth. The authors recommend an MRI scan if U/S is inconclusive. A British paper asks the question “How good are surgeons at identifying acute appendicitis”. In a multi-centre study of over 3000 patients 496 were assessed as normal histologically whilst 138 revealed pathology. Of 2642 assessed as inflamed 254 were in fact normal. The grade of the surgeon made no difference. The only anxiety I have is the probable lack of standardization of the histology in 95 different centres. Once again there is a paper on adhesions. In an experimental study it is shown that clinoquil reduced adhesions by a significant amount by decreasing the inflammation and fibroblastic activity in the adhesion induced rat. Compared to carboxymethylcellulose it also does not induce a foreign body reaction. Haemangiopericytoma of the spleen is extremely rare. From Italy there is a report of 5 cases to add to the 14 to date in the medical literature. There is an interesting paper showing that CA19-9 is a powerful predictive marker for bladder cancers if > 37 especially in those with muscular invasion. We include two orthopaedic topics. The first

Editorial / International Journal of Surgery 15 (2015) 140e141

from China concerning the topical application of tranexamic acid in total hip replacement. It decreased the volume of drainage and the fall in haemoglobin was reduced due to decreased blood loss resulting in a reduction in transfusions. Also there were no adverse reactions. The second is from France showing that minimally invasive spine surgery has lower costs and a shorter hospital stay. I always learn a lot from the Best Evidence Topics (BET). The first on the routine use of radiological assessment following oesophagectomy with a cervical anastomosis vindicates my practice of not performing it as there is an inherent risk of aspiration as well as the fact that the sensitivity is poor. Another BET from the UK informs us that robotic parathyroidectomy is feasible with a superior cosmetic result compared to targeted open parathyoidectomy but expensive. Another BET looks at the role of the venous diameter in predicting A/V maturation. The best size is probably between 2.5 and 4 mm. The authors from Ireland also showed that a tourniquet was useful and that a vein 9 mm, and if the perforation duration was >12.5 h. Another paper on laparoscopic conversion rates but after cholecystectomy shows it is related to the C-reactive protein (CRP). If > 200 mgs it is predictive of gangrenous cholecystitis with 100% sensitivity and 87.9% specificity. A raised CRP predicted an increased inflammation and a more difficult operation. The role of fast track pancreaticoduodenectomy was retrospectively studied in 635 Chinese patients. They demonstrated lower post-operative hospitalization, decreased expense and lower post-operative complications. Also from China is a study on perioperative antiviral therapy in patients with hepatitis B related hepatocellular carcinoma following hepatectomy. In 112 patients 70 received the antiviral therapy which resulted in decreased morbidity and also sped up the recovery of post-operative liver function. We include a paper on patients who underwent surgery for either stricturing or non-perineal fistulizing forms of Crohn's disease. There appeared to be no specific clinical factors to


differentiate these types. However, the histopathology was different with pseudo polyps, micro-abscesses, granuloma, mononuclear inflammation and deep fissures being significantly more common in those with non-perineal fistulizing disease. There is an excellent review from Sweden on post-operative nausea and vomiting with respect to predicting these symptoms and factors influencing their occurrence as well as the management of this common problem. The authors discuss the use of the Apfel score which is highly predictive of these post-operative disturbing symptoms. Our American cardiac colleagues bring to our attention of general surgical emergencies following cardio-pulmonary bypass procedures. In a retrospective study of 945 operations in 914 patients 23 were referred post-operatively to the general surgeons, the majority with small bowel obstruction/ileus or cholecystitis. There appears to be a changing trend in these patients. Finally it was fascinating to read the article from Ghana on the quality of referrals for elective surgery to a tertiary care hospital. Over two months 643 referrals were assessed and none revealed all essential items. If the referral was by letter 50% of 5 or more items were missing compared to 8% when a structured form was used. The form reduced the number of missing essential items but not enough as up to 3 items were missing in 45% of the referrals. Obviously a structured referral form is helpful but not the complete answer. Once again let me thank all the contributors as well as all our hard worked reviewers. Ethical approval None required. Funding None. Author contribution None. Conflicts of interest None. Guarantor None. R. David Rosin, Professor University of the West Indies, Barbados E-mail address: [email protected]

Editor's perspectives - March 2015.

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