Correspondence
Supporting Information
Conflicts of interests
The video may be found in the online version of this article and also on the Colorectal Disease Journal YouTube and Vimeo channels: Video S1. Laparoscopic marginal artery injury at splenic flexure mobilisation solved by retroileal tunnel.mp4.
No conflicts of interest are declared.
Use of the Endoractor in laparoscopic colorectal surgery – a video vignette
Received 18 August 2014; accepted 19 November 2014; Accepted Article online 2 December 2014
doi:10.1111/codi.12855
Supporting Information
Dear Editor, The laparoscopic approach to colorectal resections is well established; however, to enable deep pelvic dissections, patients are often placed in a steep Trendelenburg position to ensure that bowel does not fall into the operative field. This position impacts negatively on respiratory and cardiac function due to higher intra-thoracic pressure. This position also increases intra-cranial pressure and intra-ocular pressure. We describe a technique using the Endoractor to displace bowel away from the operative field. The Endoractor is a highly hygroscopic cellulose compressed sponge that expands considerably once physiological normal saline has been added and can be used to ‘pack’ the small bowel away from the pelvis, negating the requirement for the steep head-down position. It can be inserted through a 10 mm trocar and then removed through the same wound as the specimen. We have found that allowing pelvic dissection to be completed with the patient in an almost level rather than steep head-down position increases the tidal volume obtained with a given inspiratory pressure. Other potential benefits from avoiding a prolonged steep head-down position are a reduction in brachial plexus neuropathies as well as prevention of increased intracranial and intra-ocular pressure, although to date we have not measured these.
Author contributions The first and second authors edited the video and contributed to the abstract and the narration script. The narration was done by the second, third and fifth authors. The fourth author was responsible for the anaesthesia and monitoring of respiratory parameters relevant to the surgery. The fifth author was the overall supervisor of the project.
S. P. M. Peiris*, D. R. Hanratty*, N. N. Naguib*, M. Aziz† and P. N. Haray* *Department of Colorectal Surgery, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK and †Department of Anaesthesia, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK E-mail: [email protected]
The video may be found in the online version of this article and also on the Colorectal Disease Journal YouTube and Vimeo channels: Video S1. The Endoractor in laparoscopic colorectal surgery.
Local multidisciplinary team or individual surgeons’ performance data: should Wales be different? doi:10.1111/codi.12859
Dear Sir, The publication of surgeon-specific data was first demanded over a decade ago after concerns with paediatric cardiac services in Bristol, UK. Many years later league tables on the NHS Choices website will soon cover about 4000 surgeons from varying specialties. This is thought to make the NHS more transparent but are our patients really better off? Whilst the Association of Coloproctology of Great Britain and Ireland (ACPGBI), as a consequence of a ‘request’ from NHS England, has recently published individual surgical outcomes for elective colorectal cancer resections, such an obligation has not been demanded by the Welsh National Assembly Government. To date, Welsh colorectal surgeons are exempt from having their outcomes published openly. With this in mind we reviewed our prospectively accrued multidisciplinary team (MDT) data (n = 312) for the same period (March 2010 to April 2012) using the same exclusion criteria (n = 46) allowing us to look at the 90-day mortality in 266 unselected consecutive patients. Our overall unadjusted mortality was 3.7%
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
175
Correspondence
although individual surgeon-specific mortality varied (range 1.4–7.1%; all P > 0.2 with respect to the ACPGBI surgeon outcome data). Of the 10 deaths (median age 76; range 63–93 years) two had leaked but the others had cardio-respiratory causes for their demise. These figures are in keeping with published ACPGBI national (English) data and we believe we too have nothing to hide in the Principality. Whilst transparency is important for all concerned we are now in the era of MDTs. The real question that requires an answer is surely different: is the patient’s local MDT providing results outside a range that is considered acceptable? MDT data rather than individual surgeon outcomes would also be able to document and publish the frequency of complications and whether National Institute for Health and Care Excellence guidelines are adhered to. An MDT does ‘what it is says on the tin’ and a team approach would be easier for our patients to comprehend. This should also help avoid reluctant local referral practices and risk-averse surgery [1] by those whose aim has always been to offer the best options to patients with colorectal cancer.
176
Welsh patients and other interested groups may soon become frustrated that no outcome results are made freely available to them; this can possibly engender mistrust of their surgeons. Colorectal surgeons in Wales have nothing to hide. The Welsh Assembly Government may wish to choose to be different and publish MDT results rather than those of individual surgeons.
G. Badham, G. L. Williams and B. M. Stephenson Department of Colorectal Surgery, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK E-mail: [email protected] Received 19 November 2014; accepted 22 November 2014; Accepted Article online 8 December 2014
Reference 1 Westaby S, De Silva R, Petrou M, Bond S, Taggart D. Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. Eur J Cardiothorac Surg 2014. ezu380. [Epub ahead of print].
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
Supporting Information
Conflicts of interests
The video may be found in the online version of this article and also on the Colorectal Disease Journal YouTube and Vimeo channels: Video S1. Laparoscopic marginal artery injury at splenic flexure mobilisation solved by retroileal tunnel.mp4.
No conflicts of interest are declared.
Use of the Endoractor in laparoscopic colorectal surgery – a video vignette
Received 18 August 2014; accepted 19 November 2014; Accepted Article online 2 December 2014
doi:10.1111/codi.12855
Supporting Information
Dear Editor, The laparoscopic approach to colorectal resections is well established; however, to enable deep pelvic dissections, patients are often placed in a steep Trendelenburg position to ensure that bowel does not fall into the operative field. This position impacts negatively on respiratory and cardiac function due to higher intra-thoracic pressure. This position also increases intra-cranial pressure and intra-ocular pressure. We describe a technique using the Endoractor to displace bowel away from the operative field. The Endoractor is a highly hygroscopic cellulose compressed sponge that expands considerably once physiological normal saline has been added and can be used to ‘pack’ the small bowel away from the pelvis, negating the requirement for the steep head-down position. It can be inserted through a 10 mm trocar and then removed through the same wound as the specimen. We have found that allowing pelvic dissection to be completed with the patient in an almost level rather than steep head-down position increases the tidal volume obtained with a given inspiratory pressure. Other potential benefits from avoiding a prolonged steep head-down position are a reduction in brachial plexus neuropathies as well as prevention of increased intracranial and intra-ocular pressure, although to date we have not measured these.
Author contributions The first and second authors edited the video and contributed to the abstract and the narration script. The narration was done by the second, third and fifth authors. The fourth author was responsible for the anaesthesia and monitoring of respiratory parameters relevant to the surgery. The fifth author was the overall supervisor of the project.
S. P. M. Peiris*, D. R. Hanratty*, N. N. Naguib*, M. Aziz† and P. N. Haray* *Department of Colorectal Surgery, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK and †Department of Anaesthesia, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK E-mail: [email protected]
The video may be found in the online version of this article and also on the Colorectal Disease Journal YouTube and Vimeo channels: Video S1. The Endoractor in laparoscopic colorectal surgery.
Local multidisciplinary team or individual surgeons’ performance data: should Wales be different? doi:10.1111/codi.12859
Dear Sir, The publication of surgeon-specific data was first demanded over a decade ago after concerns with paediatric cardiac services in Bristol, UK. Many years later league tables on the NHS Choices website will soon cover about 4000 surgeons from varying specialties. This is thought to make the NHS more transparent but are our patients really better off? Whilst the Association of Coloproctology of Great Britain and Ireland (ACPGBI), as a consequence of a ‘request’ from NHS England, has recently published individual surgical outcomes for elective colorectal cancer resections, such an obligation has not been demanded by the Welsh National Assembly Government. To date, Welsh colorectal surgeons are exempt from having their outcomes published openly. With this in mind we reviewed our prospectively accrued multidisciplinary team (MDT) data (n = 312) for the same period (March 2010 to April 2012) using the same exclusion criteria (n = 46) allowing us to look at the 90-day mortality in 266 unselected consecutive patients. Our overall unadjusted mortality was 3.7%
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
175
Correspondence
although individual surgeon-specific mortality varied (range 1.4–7.1%; all P > 0.2 with respect to the ACPGBI surgeon outcome data). Of the 10 deaths (median age 76; range 63–93 years) two had leaked but the others had cardio-respiratory causes for their demise. These figures are in keeping with published ACPGBI national (English) data and we believe we too have nothing to hide in the Principality. Whilst transparency is important for all concerned we are now in the era of MDTs. The real question that requires an answer is surely different: is the patient’s local MDT providing results outside a range that is considered acceptable? MDT data rather than individual surgeon outcomes would also be able to document and publish the frequency of complications and whether National Institute for Health and Care Excellence guidelines are adhered to. An MDT does ‘what it is says on the tin’ and a team approach would be easier for our patients to comprehend. This should also help avoid reluctant local referral practices and risk-averse surgery [1] by those whose aim has always been to offer the best options to patients with colorectal cancer.
176
Welsh patients and other interested groups may soon become frustrated that no outcome results are made freely available to them; this can possibly engender mistrust of their surgeons. Colorectal surgeons in Wales have nothing to hide. The Welsh Assembly Government may wish to choose to be different and publish MDT results rather than those of individual surgeons.
G. Badham, G. L. Williams and B. M. Stephenson Department of Colorectal Surgery, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK E-mail: [email protected] Received 19 November 2014; accepted 22 November 2014; Accepted Article online 8 December 2014
Reference 1 Westaby S, De Silva R, Petrou M, Bond S, Taggart D. Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. Eur J Cardiothorac Surg 2014. ezu380. [Epub ahead of print].
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
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