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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2007 May;89(4):452. doi: 10.1308/147870807X160470

The Impact of the European Working Time Directive on Operative Exposure

T Bates 1, D Slade 1
PMCID: PMC1963602

Introduction

The introduction of time-limited Calman training in 1994 significantly reduced the length of operative surgical experience for trainees in general surgery in the UK and the New Deal, published in 1991 to curtail excessive hours of on-duty, gradually came into effect at about the same time. Both measures addressed long-standing problems but there is concern that the additional 58-h limit required by the European Working Time Directive (EWTD) in 2004 may have compromised the ability to deliver surgical training within the current time-scale of 6 years.

Materials and Methods

The reported log-book returns from trainees in the six UK regions with available data for the first 6 months of the 58-h limit from 1 August 2004 to 31 January 2005 were compared with the same period of the previous year. The recorded level of operative supervision was also compared.

Results

Trainees who submitted data for both time periods (n = 154) reported a reduction of 15.5% in the number of operations which they carried out. Unpaired data were submitted by 281 trainees for 46,000 operations which showed a similar reduction of 13.5% following the introduction of the 58-h rule. Some operations were reduced by a third, e.g. inguinal hernia repair (27%), mastectomy and axillary clearance (32%), oesophagectomy (38%), grafting of abdominal aortic aneurysm (27%) and varicose vein surgery (44%). Transplant surgery was the only specialty within general surgery where there was an increase in the number of reported operations but the numbers were very small (1.3%) as with paediatric surgery (1.8%) where the effect was neutral. The reduction in the number of index operations, considered most important for training in each specialty, amounted to 21%. The reported level of consultant supervision remained unchanged at 40%.

Conclusions

The introduction of the 58-h requirement of the EWTD in August 2004 has further reduced the operative experience of surgical trainees to a point where it may be difficult to achieve the present level of training required for the Certificate of Completion of Training (CCT) within the current time-scale of 6 years. The further reduction of permitted hours of work to 48 h per week in 2009 is likely to exacerbate the current unsatisfactory situation.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

The Effect on Surgical Service of Withdrawing Specialist Registrars from Emergency Cover at Night in a Large District General Hospital

R Ishak 1, N Johnson 1, S Aspinall 1, K Malynkal 1, P Small 1

Introduction

The Hospital at Night project and European Working Time Directive have resulted in considerable pressure to deliver surgical training during daylight hours as night work is considered to present few training opportunities. This audit was undertaken to examine the impact on consultant work-load when surgical registrars are withdrawn from night cover.

Materials and Methods

Consultant vascular and gastrointestinal (GI) surgical night-time activity in a large district general hospital was monitored prospectively over a 3-month period from January 2005 when surgical SpRs did not provide emergency cover. Hospital cover was provided at senior and pre-registration house officer level. A record was made of calls to consultants overnight and their subsequent return to hospital. Consultants made comment on the likely effect SpR presence would have made on their workload.

Results

Over the study period, 411 patients were admitted to the surgical department. Between midnight and 8 am, consultants were contacted on 47 occasions; GI surgeons were contacted on approximately a third of nights and vascular surgeons 1 in 6 nights. GI surgeons returned to the hospital on 1 in 6 nights and vascular surgeons 1 in 18 nights. Ten operations were performed by GI surgeons and two by vascular surgeons. Consultants estimated the presence of a SpR would reduce calls to GI surgeons by half, but would have less impact for vascular surgeons.

Conclusions

Withdrawing surgical SpRs from night shifts may improve training efficiency but would significantly increase consultant night-time activity. The effect on elective consultant service delivery requires further study, particularly in the light of Modernising Medical Careers.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

Oesophagectomy and Oesophagogastrectomy Practice and Outcomes in England: 1997–2003

A Al-Sarira 1, G David 1, M Kazem 1, V Hanchanale 1, J Slavin 1, M Deakin 1, D Corless 1

Introduction

Oesophageal cancer is a challenging therapeutic problem. It has been reported that there is a wide variation in outcomes after oesophageal surgery between centres. Also, oesophageal resection has a very strong volume–outcome relationship. Based on these facts, centralisation was recommended for oesophageal cancer service in the UK in 2001 by the NHS Executive. The aim of this study is to analyse national trends in the practice and outcomes for oesophagectomy and oesophagogastrectomy in England between April 1997 and April 2004.

Materials and Methods

Hospital Episode Statistics data were obtained from the Department of Health, in England, for the years 1997/1998 to 2003/2004. Patients were included in the study if they had an International Classification of Disease diagnosis code {ICD-10} for malignant neoplasm of the oesophagus or gastro-oesophageal junction, and an operative procedure code {OPCS-4} describing total or partial oesophagectomy and oesophagogastrectomy.

Results

In total, 11,838 oesophagectomy/oesophagogastrectomy were performed between 1997 and 2003. There was no change in the mean age (64.2 years) over the study period. The sex distribution was similar over the study period with a male:female ratio of 3:1. Patients admitted as an emergency decreased from 7.7% to 3.5% (P < 0.001). The median waiting time (time from decision to operate to operation) increased by almost 4 days from 11 days in 1997 to 15 days in 2003 (P < 0.001). In-hospital mortality decreased from 12.5% to 8.3% (P < 0.001) over this period. The median length of hospital stay was 16 days (interquartile range, 13–25 days) and did not change over time. The total number of oesophagectomy/oesophagogastrectomy performed per year decreased by almost 9%, from 1785 in 1997 to 1620 in 2003. The number of centres performed oesophagectomy/oesophagogastrectomy decreased by 38%, from 180 in 1997 to 111 in 2003. The median annual volume per centre increased by 57% from 7 to 11 (P = 0.03).

Conclusions

Centralisation of oesophagectomy/oesophagogastrectomy has occurred. It was associated with a decrease in the in-hospital mortality but an increase in the waiting time. Fewer patients are undergoing oesophagectomy/oesophagogastrectomy.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

Outcome of Equivocal Screening Mammograms – A 2-Year Perspective

VR Velchuru 1, SG Satish 1, E Clark 1, JH Pereira 1, F Holly Archer 1

Introduction

Management of equivocal mammograms has always been controversial. The usual debate is between a conservative approach, such as interval mammograms, or an aggressive approach, such as core biopsy. Our aim was to assess the outcome of patients having indeterminate features on screening mammograms and to identify if there is a role for aggressive management.

Patients and Methods

A retrospective study of all patients who were identified as equivocal (R3) on initial screening mammogram. All patients were recalled, and had core biopsy in accordance with the policy in our breast unit. Outcomes such as ultrasound features, core biopsy results and final histology were documented. All symptomatic patients with indeterminate features were excluded.

Results

The number of screenings in our breast unit over a period of 2 years was 17,000. The total number of equivocal (R3) mammograms identified in our study was 72, out of which 52 patients had indeterminate calcification, 12 had well-defined mass, 6 had ill-defined mass, and an asymmetry was noted in 2 mammograms. Ultrasound was carried out in 51 patients. On scanning, 11 had benign features, 32 were equivocal and 8 patients had features of malignancy. On core biopsy, 45 were benign, 6 were equivocal and 21 were malignant. Nineteen patients had wide local excision and 2 patients had mastectomy for DCIS and carcinoma.

Conclusions

The incidence of equivocal mammograms was 0.42%. Approximately one-third (29.16%) of patients with indeterminate mammograms will subsequently be diagnosed with DCIS or invasive cancer.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

Hyperhidrosis and Endoscopic Thoracic Sympathectomy

M Atwan 1, P Wilson 1, A Abdellaoui 1, JS Abraham 1

Introduction

Endoscopic thoracic sympathectomy has become the preferred method for treating severe primary hyperhidrosis. Our study aimed at evaluating short- and long-term outcome of primary symptoms, complications and patient satisfaction following thoracic sympathectomy in our unit.

Patients and Methods

Retrospective case note review of all patients undergoing ETS between 1998 and 2005. A questionnaire was sent to these patients to find out long-term outcome and patient satisfaction.

Results

The 8-year results were analysed. A total of 101 procedures were performed in 98 patients (including three re-do procedures). There were 67 females and 34 males with a mean age of 28 years. The most common indications were isolated palmar hyperhidrosis (24 patients) and combined hyperhidrosis (24 patients). Bilateral T23 sympathectomy was the most common operation performed at 45.5%. There were no major immediate postoperative complications. The questionnaire response rate was 55%. In 79% of the respondents, the symptoms were better compared to 21% in whom symptoms became worse following the operation. Compensatory sweating was observed in 78% immediately after the procedure and this figure rose to 89% in the long-term. Despite this, 69% of the respondents felt the operation was worth doing.

Conclusions

We believe that endoscopic thoracic sympathectomy is a safe procedure in selected patients. There is a low risk of intra-operative and early complications. However, the rate of compensatory sweating is high and patients must be warned. Detailed pre-operative counselling is mandatory and may explain the high level of patient satisfaction found in our study.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

Botulinum-Toxin and Fissurectomy for Medically Resistant Fissure-in-ano in Women

W Baraza 1, SR Brown 1, AJ Shorthouse 1

Introduction

Botox heals about half the anal fissures resistant to topical therapy. Healing may be enhanced if combined with fissurectomy. Unlike sphincterotomy, this procedure avoids potential continence compromise, particularly important in women. The effectiveness of fissurectomy and Botox injection for topically resistant fissures in women was investigated.

Patients and Methods

The policy in our unit is to offer fissurectomy and Botox to women with chronic fissures who fail medical therapy. Patients who consented underwent excision of the fissure edges (including sentinel pile) and injection of 25–100 units of Botox into the intersphincteric space. All patients were followed up in clinic 2 months after the procedure when symptoms, healing and continence were assessed and at a period of up to 26 months.

Results

Over a 26-month period, 47 female patients underwent the procedure. All patients had had prior treatment with topical glyceryl trinitrate and/or diltiazem. No patient had incontinence symptoms on specific questioning preoperatively. After a median follow-up of 11 months (range, 2–26 months), 8 patients (17%) suffered slow or non-healing fissures at 2 months. Seven patients (15%) suffered from a recurrence in the total follow-up period. There was only one case of incontinence at final assessment with that patient complaining of urge incontinence (Wexner score 8/24) which has interestingly persisted for over 12 months.

Conclusions

Fissurectomy and Botox injection is an effective and safe alternative to surgical sphincterotomy in females with medically resistant anal fissures.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

European Working Time Directive Compliant Shifts for the Surgical Registrar: Training in Emergency Surgery not Compromised

E Tweedle 1, S Chaudhri 1, P Wake 1

Introduction

Most trusts abandoned the rotating ‘on-call’ system in favour of a partial shift rota for surgical registrars in order to become compliant with the European Working Time Directive (EWTD) introduced in August 2004. Previous studies have suggested a high level of concern among trainees about reduced training opportunities after EWTD. We analysed patterns of emergency operating under both systems in order to detect any changes. We aimed to assess whether fears of a reduction in operative exposure out-of-hours was justified.

Materials and Methods

The prospectively recorded emergency theatre log was analysed over a 4-month period. The same group of registrars worked the rotating ‘on-call’ shifts for 2 months and changed to a partial shift pattern for the following 2 months.

Results

Pre-EWTD, there were 346 emergency operations in total and 128 (37.0%) were out-of-hours. Post-EWTD there were 315 emergency operations in total, 94 (29.8%) were out-of-hours, (P > 0.05). The proportion of out-of-hours operating performed in the 17:00–20:00 evening shift was almost 50% (pre-EWTD 48.4%, post-EWTD 48.9%), see Table 1. There was no change between the two time periods, (chi-squared, P > 0.10).

Table 1.

Number of out-of-hours procedures by shift time

Pre-EWTD Post-EWTD
Long day (17:00–20:00) 62 (48.4%) 46 (48.9%)
Night period (20:00–00:00) 54 (47.6%) 37 (47.6%)
After midnight (00:00–08:00) 14 (4%) 11 (3.5%)
Total 128 94
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The number of out-of-hours operations where the consultant was the operating surgeon was 27 (21.1%) compared to 13 (13.8%) post-EWTD. Ninety-six (75.0%) operations out-of-hours were performed by middle-grades compared to 73 (77.7%) post-EWTD.

Conclusions

The proportion of emergency operations performed during the evening shift is unchanged after the introduction of the EWTD. There is no decrease in the amount of middle-grade led operating post-EWTD. It is possible to maintain exposure to emergency surgery whilst working EWTD compliant hours.

Ann R Coll Surg Engl. 2007 May;89(4):452. doi: 10.1308/147870807X160470

Low Rate of Re-Intervention Following Endovascular Abdominal Aortic Aneurysm (AAA) Repair (EVAR): Related to a Strict Selection Protocol

A Abdellaoui 1, M Atwan 1, M Adelekan 1, JS Abraham 1, JM Lavelle 1, TAJ Calvey 1, M Bukhari 1, MA Tomlinson 1, P Wilson 1

Introduction

Since the introduction of EVAR in 1999 in our vascular unit, we have employed a strict selection protocol based on favourable aortic neck and iliac anatomy, which has resulted in a low rate of re-intervention, and consequent morbidity.

Patients and Methods

Patients requiring elective AAA repair were screened for eligibility for EVAR on the following anatomical considerations: aortic neck length > 15 mm, aortic neck diameter < 22 mm, aortic neck angulation < 60°, iliac artery diameter > 9 mm and < 14 mm with minimal tortuosity and calcification. Following EVAR, patients underwent CT at 1, 3, 6, and 12 months, and annually thereafter. We have studied procedure-related mortality, morbidity, surgical conversion rate, endoleaks, aneurysm enlargement and graft patency.

Results

In our vascular unit, 30 patients (25 males and 5 females; median age, 74 years; range, 63–90 years) underwent EVAR between 1999 and 2005, accounting for 25% of all patients requiring non-urgent AAA repair. The median aneurysm diameter was 5.9 cm (range, 5.1–9.0 cm). EVAR was successful in 29 patients (97%). Thirty-day mortality was zero. One patient had early thrombosis of an iliac limb of the stent-graft, and required femoro-femoral cross-over bypass. One patient required immediate open conversion related to failure of stent deployment due to excessive iliac calcification. Endoleak has occurred in 3 patients (10%) in 6 years (median follow-up, 34.5 months; range, 1–72 months). One patient (3%) has required re-intervention to seal an endoleak (type I). Overall, our complication rate was 16% and re-intervention rate was 3%.

Conclusions

Patients selected for EVAR using a strict protocol of anatomical characteristics have low peri-operative morbidity and mortality, and a very low rate of re-intervention.

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England

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