International Journal of Surgery 25 (2016) 178e179
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Editorial
Editor's perspectives e January 2016
Let me start by wishing all our readers a Happy, Healthy, Peaceful and Prosperous New Year. Once again my thanks to all at Elsevier for helping us produce such an impressive, informative Surgical Journal. I would especially like to thank our journal manager, Rachel Skinner, for her dedication and expertise. I must add our heartiest congratulations to one of our esteemed Board members, Lord Ara Darzi, who has just been honoured by Her Majesty The Queen with the Order of Merit. Our raison d'etre is to treat patients and I have been reflecting upon just how much time is actually spent doing just that. As a trainee one is immersed in clinical work but there are long periods of “hitting the books” preparing for postgraduate examinations and also performing research and publishing one's work. Then when one becomes a consultant surgeon, there are suddenly multiple committees. The time wasted sitting on these committees soon mounts up and it is no good saying to oneself, well I'll not attend, as, in one's absence, one is more often or not proposed to run some sub-committee or worse. Then there is the teaching load which increases exponentially especially with larger Medical Schools and that more and more teaching is carried out by NHS/ Government Surgeons in other hospitals than teaching centres. To further one's career one usually moves from being an internal examiner to become an external one and then possibly for the Royal College of Surgeons or its equivalent. Examining can be very time consuming as not only is it the days away from clinical practice, but also many hours marking papers; this has been made easier in some countries with MCQs marked by the computer. Most surgeons wish to continue with some type of research, usually clinical, but this can also take one away from one's patients. Then there is reviewing for Journals and writing papers. CPD necessitates us attending conferences and presenting at them. More time away from clinical practice. For the ambitious there are positions on Councils of one's specialty association or College which eat into one's time. Something usually has to give and for many of us it is/ was our private practices, so less patient care. I haven't even mentioned family life. The divorce rate is high amongst surgeons due to not finding enough time for one's spouse. Life is better than it was in my day for trainees, but not really for consultants. One needs to see one's children grow up, take holidays with them, and spend quality time with them which is often difficult due to work pressures. And let us not forget the pursuit of one's own interests outside work-sport, reading non-surgical books, theatre, hobbies etc., etc. Travel one can often manage by combining it with a conference. When I was younger I would visit exotic countries and cities only to
see the inside of a conference hall and hotel. I learnt to take a few days either before or after the conference so as to immerse myself in other peoples’ cultures and experience all the wonderful sights. So I would ask you at the beginning of this new year to muse on how much time you are spending actually treating patients, the reason we all became surgeons, and perhaps try to change our priorities. Let me move on to mention some of the articles in our first edition for 2016. As usual it is not possible to discuss every paper, so forgive me if yours is not mentioned. It is wonderful to receive articles from more and more countries. In this issue from New Zealand, Mexico, Tunisia and Denmark amongst others from Europe, Asia and the Americas. As I always learn so much from Best Evidence Topics I will commence with one from the UK on the benefits of rectal washout for anterior resection and (L) sided resections. The authors found 24 articles on this subject of which 17 were relevant and 8 represented best evidence including 3 prospective non-randomized studies, 1 retrospective non-randomized study and 4 meta-analyses. It would seem washout does not stop local recurrence but may decrease the incidence. There is need for a randomized control trial. I would also like to see some studies on its effect on anastomotic healing in view of the increased use of stapling and the potential of implanting faecal material in the staple line in a rectum with faeces. Another review is on robotic -assisted selective and modified radical modified neck dissection in head and neck cancer patients. Between 2010 and 2015 the German authors found 18 articles which included 177 patients. Different extra-cervical approaches were used-axilla, auricular, etc. with no conversions. They state there are similar clinical and oncological outcomes with excellent cosmetic satisfaction. However, the operating time is longer and it is more expensive and they ask if this is justified just for cosmesis. The jury is still out. Whilst on the subject of scars there is a paper from my previous institution in London, UK, on the perception of scar cosmesis following thyroid and parathyroid surgery. The commonest post-operative problems in 120 patients studied were scar related. This was especially so in Asian and Afro-Caribbean patients. They found that extra-cervical “scarless” surgery was preferred. Another review taken from the ACS National Cancer Data Base concerns a nationwide analysis of short-term surgical outcomes of minimally invasive oesophagectomy for malignancy. From 2010 to 2011 3050 patients underwent open oesophagectomy and another 997 by minimally invasive surgery (24.6%). In the latter group there was an increase in nodal retrieval and a shorter hospital stay. However, 13.5% had to be converted and these patients had
http://dx.doi.org/10.1016/j.ijsu.2016.01.003 1743-9191/© 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Editorial / International Journal of Surgery 25 (2016) 178e179
a longer hospital stay. The authors conclude that minimally invasive oesophagectomy is increasingly being performed with probably better short term outcomes. We have few gynaecological papers and even fewer onophthalmology, so it is pleasing to publish an article on blepharoptosis correction transconjunctivally using a buried suture technique. The Korean authors operated using this method of surgery on 458 eyelids in 245 patients. 89% had successful corrections. In the uncorrected eyelids 16 required further surgery. They state there is an excellent predictability and successful outcome in mild and moderate ptosis. From China we include a paper on the clinical efficacy and safety of laparoscopic nerve-sparing radical hysterectomy for locally advanced cervical cancer.120 patients who had all received neo-adjuvant chemotherapy were divided equally into 2 groups-either routine radical hysterectomy or a nervesparing operation. In the latter group the urinary catheter could be removed earlier with intestinal and bladder function recovering more rapidly. The influence of diversion stoma on the surgical outcome and recurrence rates in patients with rectovaginal fistula comes from 62 patients studied retrospectively in Germany of whom 42 had stomas. The overall fistula recurrence rate was 44% with no statistical difference between the 2 groups. A stoma had no influence on complications, wound infections or the number of revision operations. However, it must be noted that the ASA grades were higher in the stoma group as was the in hospital stay. Therefore, although a stoma does not influence the outcome in their patients the sicker patients received a stoma. The rest of the papers upon which I will comment, apart from the last on training, are all on GI subjects, mostly colorectal. From Mexico we learn that serum fibrinogen is a predictive factor for perforation in complicated appendicitis, whilst our Tunisian colleagues performed a retrospective study on the benefits of operating within the first 24 h following the onset of acute cholecystitis symptoms compared to the 2nd or 3rd day. There were an increased number of diabetic patients in the 80%. The results on low positive predictive value showed low reliability. Overall, CEA did not detect treatable recurrence at an early stage and a clinically relevant effect on patient mortality remains to be proven. Improving results of surgery for faecal peritonitis due to perforated colorectal disease from a single centre in Italy is the next paper I shall mention. There were 74 patients studied retrospectively with equal groups treated before and after 2010. There were many fewer overall and major complications and the mortality was
179
halved. They showed that patients with a lower Mannheim Peritonitis Index had better outcomes. The last colorectal article is an interesting cohort study from New Zealand examining accurate triage of lower GI bleeding. 668 patients over a single year were retrospectively studied. 83 (20%) had severe bleeds. Four independent risk factors were discovered-!)aspirin, 2) a history of collapse, 3) a haemoglobin level
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Editorial
Editor's perspectives e January 2016
Let me start by wishing all our readers a Happy, Healthy, Peaceful and Prosperous New Year. Once again my thanks to all at Elsevier for helping us produce such an impressive, informative Surgical Journal. I would especially like to thank our journal manager, Rachel Skinner, for her dedication and expertise. I must add our heartiest congratulations to one of our esteemed Board members, Lord Ara Darzi, who has just been honoured by Her Majesty The Queen with the Order of Merit. Our raison d'etre is to treat patients and I have been reflecting upon just how much time is actually spent doing just that. As a trainee one is immersed in clinical work but there are long periods of “hitting the books” preparing for postgraduate examinations and also performing research and publishing one's work. Then when one becomes a consultant surgeon, there are suddenly multiple committees. The time wasted sitting on these committees soon mounts up and it is no good saying to oneself, well I'll not attend, as, in one's absence, one is more often or not proposed to run some sub-committee or worse. Then there is the teaching load which increases exponentially especially with larger Medical Schools and that more and more teaching is carried out by NHS/ Government Surgeons in other hospitals than teaching centres. To further one's career one usually moves from being an internal examiner to become an external one and then possibly for the Royal College of Surgeons or its equivalent. Examining can be very time consuming as not only is it the days away from clinical practice, but also many hours marking papers; this has been made easier in some countries with MCQs marked by the computer. Most surgeons wish to continue with some type of research, usually clinical, but this can also take one away from one's patients. Then there is reviewing for Journals and writing papers. CPD necessitates us attending conferences and presenting at them. More time away from clinical practice. For the ambitious there are positions on Councils of one's specialty association or College which eat into one's time. Something usually has to give and for many of us it is/ was our private practices, so less patient care. I haven't even mentioned family life. The divorce rate is high amongst surgeons due to not finding enough time for one's spouse. Life is better than it was in my day for trainees, but not really for consultants. One needs to see one's children grow up, take holidays with them, and spend quality time with them which is often difficult due to work pressures. And let us not forget the pursuit of one's own interests outside work-sport, reading non-surgical books, theatre, hobbies etc., etc. Travel one can often manage by combining it with a conference. When I was younger I would visit exotic countries and cities only to
see the inside of a conference hall and hotel. I learnt to take a few days either before or after the conference so as to immerse myself in other peoples’ cultures and experience all the wonderful sights. So I would ask you at the beginning of this new year to muse on how much time you are spending actually treating patients, the reason we all became surgeons, and perhaps try to change our priorities. Let me move on to mention some of the articles in our first edition for 2016. As usual it is not possible to discuss every paper, so forgive me if yours is not mentioned. It is wonderful to receive articles from more and more countries. In this issue from New Zealand, Mexico, Tunisia and Denmark amongst others from Europe, Asia and the Americas. As I always learn so much from Best Evidence Topics I will commence with one from the UK on the benefits of rectal washout for anterior resection and (L) sided resections. The authors found 24 articles on this subject of which 17 were relevant and 8 represented best evidence including 3 prospective non-randomized studies, 1 retrospective non-randomized study and 4 meta-analyses. It would seem washout does not stop local recurrence but may decrease the incidence. There is need for a randomized control trial. I would also like to see some studies on its effect on anastomotic healing in view of the increased use of stapling and the potential of implanting faecal material in the staple line in a rectum with faeces. Another review is on robotic -assisted selective and modified radical modified neck dissection in head and neck cancer patients. Between 2010 and 2015 the German authors found 18 articles which included 177 patients. Different extra-cervical approaches were used-axilla, auricular, etc. with no conversions. They state there are similar clinical and oncological outcomes with excellent cosmetic satisfaction. However, the operating time is longer and it is more expensive and they ask if this is justified just for cosmesis. The jury is still out. Whilst on the subject of scars there is a paper from my previous institution in London, UK, on the perception of scar cosmesis following thyroid and parathyroid surgery. The commonest post-operative problems in 120 patients studied were scar related. This was especially so in Asian and Afro-Caribbean patients. They found that extra-cervical “scarless” surgery was preferred. Another review taken from the ACS National Cancer Data Base concerns a nationwide analysis of short-term surgical outcomes of minimally invasive oesophagectomy for malignancy. From 2010 to 2011 3050 patients underwent open oesophagectomy and another 997 by minimally invasive surgery (24.6%). In the latter group there was an increase in nodal retrieval and a shorter hospital stay. However, 13.5% had to be converted and these patients had
http://dx.doi.org/10.1016/j.ijsu.2016.01.003 1743-9191/© 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Editorial / International Journal of Surgery 25 (2016) 178e179
a longer hospital stay. The authors conclude that minimally invasive oesophagectomy is increasingly being performed with probably better short term outcomes. We have few gynaecological papers and even fewer onophthalmology, so it is pleasing to publish an article on blepharoptosis correction transconjunctivally using a buried suture technique. The Korean authors operated using this method of surgery on 458 eyelids in 245 patients. 89% had successful corrections. In the uncorrected eyelids 16 required further surgery. They state there is an excellent predictability and successful outcome in mild and moderate ptosis. From China we include a paper on the clinical efficacy and safety of laparoscopic nerve-sparing radical hysterectomy for locally advanced cervical cancer.120 patients who had all received neo-adjuvant chemotherapy were divided equally into 2 groups-either routine radical hysterectomy or a nervesparing operation. In the latter group the urinary catheter could be removed earlier with intestinal and bladder function recovering more rapidly. The influence of diversion stoma on the surgical outcome and recurrence rates in patients with rectovaginal fistula comes from 62 patients studied retrospectively in Germany of whom 42 had stomas. The overall fistula recurrence rate was 44% with no statistical difference between the 2 groups. A stoma had no influence on complications, wound infections or the number of revision operations. However, it must be noted that the ASA grades were higher in the stoma group as was the in hospital stay. Therefore, although a stoma does not influence the outcome in their patients the sicker patients received a stoma. The rest of the papers upon which I will comment, apart from the last on training, are all on GI subjects, mostly colorectal. From Mexico we learn that serum fibrinogen is a predictive factor for perforation in complicated appendicitis, whilst our Tunisian colleagues performed a retrospective study on the benefits of operating within the first 24 h following the onset of acute cholecystitis symptoms compared to the 2nd or 3rd day. There were an increased number of diabetic patients in the 80%. The results on low positive predictive value showed low reliability. Overall, CEA did not detect treatable recurrence at an early stage and a clinically relevant effect on patient mortality remains to be proven. Improving results of surgery for faecal peritonitis due to perforated colorectal disease from a single centre in Italy is the next paper I shall mention. There were 74 patients studied retrospectively with equal groups treated before and after 2010. There were many fewer overall and major complications and the mortality was
179
halved. They showed that patients with a lower Mannheim Peritonitis Index had better outcomes. The last colorectal article is an interesting cohort study from New Zealand examining accurate triage of lower GI bleeding. 668 patients over a single year were retrospectively studied. 83 (20%) had severe bleeds. Four independent risk factors were discovered-!)aspirin, 2) a history of collapse, 3) a haemoglobin level
