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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2006 Mar;88(2):233–239. doi: 10.1308/003588406X95138

Publication of Abstracts from the Best Regional Presentations

Editor: Linda de Cossart
PMCID: PMC1964038
Ann R Coll Surg Engl. 2006 Mar;88(2):233. doi: 10.1308/003588406X95138

Falling Circumcision Rates Following Introduction of Topical Steroid for Phimosis

T* Sudhindra 1, P Gopalan 1, SW Hosking 1

Introduction

The usual treatment for phimosis is circumcision, which forms a significant paediatric surgical workload. We have evaluated the outcome of topical betamethasone in treating phimosis and its effect on our circumcision rates.

Patients and Methods

In a prospective design, 66 consecutive boys with phimosis were treated with topical 0.05% betamethasone ointment twice daily for 1 month. Phimosis was graded from 1 (no retractibility) to 6 (full and free retraction). Patients who did not achieve full foreskin retraction were treated for a further month and reviewed 6 months after presentation. Patients with scarred foreskin and balanitis xerotica obliterans (BXO) were excluded. The number of circumcisions carried out for 1 year before steroid treatment was compared to that performed during the subsequent year.

Results

A total of 66 boys, aged 1–13 years (median, 5 years) entered the study. At entry, the median grade of phimosis was 2 (IQ range 2–3). After 1 month, the median grade had improved to 5 (IQ range 4–6) and after 6 months it was 6 (IQ range 5–6). On an intention-to-treat basis, 48 boys (73%) had their phimosis cured by betamethasone. Thirteen patients required surgery and 4 were lost to follow-up. During the year before our practice changed, 48 circumcisions were performed compared to 29 in the following year – a reduction of 40%.

Conclusions

Betamethasone reduced the circumcision workload by 40%. We suggest that topical steroid should be the first line of treatment for non-scarred phimosis.

Ann R Coll Surg Engl. 2006 Mar;88(2):233. doi: 10.1308/003588406X95138

Case-Mix Adjusted Mortality Follows Different Patterns in Rectal and Non-Rectal Cancer Operations: Analysis of Hospital Admission Data

A Jibawi 1, M Ballal 1, Z Swaid 1, S Selva 1, D Cade 1

Introduction

A centre's performance is commonly validated using the workload:mortality relationship. We have shown a significant workload:mortality correlation in upper GI cancer and aortic aneurysm operations. Colorectal cancer operations were found on primary analysis to follow no specific pattern. Case-mix adjustment, however, has not been applied to discriminate different patterns in colorectal cancer operations.

Patients and Methods

Hospital Episode Statistics (HES) data between 1997–2002 were analysed using ICD-10 codes C18.x–C21.x and OPCS codes H04.x–H11.x. Rectal and non-rectal cancer operations with elective versus emergency admission methods were identified as appropriate. Mortality was defined by the method of discharge.

Results

A total of 94,133 operations on colorectal cancer patients were studied in 254 NHS Trust hospitals. Overall, 33,855 rectal cancer operations were performed, 9.8% of which were emergency cases. Increasing workload in both elective and emergency operations did not affect mortality in non-rectal cancer operations. Rectal cancer operations, however, showed a strong significant correlation (CC, −0.71; P < 0.0005) when taking data stratification distribution into account. Regression analysis and logarithmic transformation were used to confirm this correlation and compute the workload thresholds.

Conclusions

HES data analysis suggests operative workload is a significant factor affecting in-hospital mortality for elective and emergency operations in rectal cancer operations. Other factors need to be considered in analysing different performance between different Trusts in non-rectal cases.

Ann R Coll Surg Engl. 2006 Mar;88(2):234. doi: 10.1308/003588406X95138

Learning Curve and Sentinel Node Biopsy Using Blue Dye Only

Yogesh* Jain 1, Duncan Matheson 1, Cerys Burrows 1, Sally Hales 1, Chandeena Roshanlall 1

Introduction

The objective of this study was to assess the feasibility of sentinel node identification in breast cancer patients using Patent Blue V dye only and to initiate a learning curve for breast surgeons.

Patients and Methods

A total of 40 patients with symptomatic breast cancers underwent sentinel node biopsy at our district general hospital. Patent Blue V dye (4 ml) was injected peritumourally and the axilla was explored first. The first visibly blue node was dissected and sent for histology as the sentinel node. Following this, standard axillary dissection was carried out followed by breast operation.

Results

Of the 40 patients, 35 (87.5%) had their sentinel node identified using the blue dye. The time of identification of blue node varied between 5–46 min. We found that the 3 of first 14 patients had failed-identification of sentinel node; however, in the 25 subsequent procedures, all except two had successful sentinel node identification. In 12/35 (34%) of cases, the sentinel node was histologically involved with metastasis. This was the only node involved in 4 out of 12 (33%). The sentinel node was falsely negative in 1 out of 40 cases. The results met the quality criteria set by American Society of Breast Surgeons with a detection rate of > 85% and false negative rate of less than 5%.

Conclusions

Our efforts at Macclesfield District Hospital have demonstrated that there is a surgical learning curve to acquire competency in the sentinel node biopsy technique. We have achieved good results by using Patent Blue V dye only without the use of the additional sophisticated gamma probe.

Ann R Coll Surg Engl. 2006 Mar;88(2):234. doi: 10.1308/003588406X95138

Can You Do the Hip? Quantifying the Decline of Would-Be Surgeons

RS* Ahluwalia 1, ILH Reichert 1, N Slater 1

Introduction

Emergency hip surgery is essential training in orthopaedics. This prospective study investigates the distribution of emergency hip surgery performed by junior trainees and their competence within 1 region after EWTD implementation.

Patients and Methods

We assessed clinical exposure to, and knowledge of, 22 trainees in Basic Surgical Training (BST) orthopaedic posts (August 2004 to January 2005) to fracture neck of femur surgery in the South East Thames Region using a 3-part questionnaire. In addition, they identified the level of competency reached in emergency hip surgery, using The Royal College of Surgeons of England's BST logbook (score 1–4). We contrasted this with similar BST orthopaedic posts, 4 (n = 10), and 12 (n = 3) years ago.

Results

Basic Surgical Trainees participated in 196 emergency hip cases (mean 8.9 of procedures/trainee; n = 22) today, 9.2% (n = 18) as primary surgeon. In 1992 and 2000, trainees were primary surgeon in 43.4% (n = 10/32) and 25.2% (n = 33/131), respectively. Accordingly, today's trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n = 20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n = 2) felt competent without senior supervision (mean orthopaedic BST experience, 15.3 months); whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures.

Conclusions

This study suggests deficiency in operative competence in trainees today due to reduced opportunities. Thus emphasis should be placed on rotas being matched to adequate operative exposure, as trainee emergency hip case numbers have declined in the last 12 years.

Ann R Coll Surg Engl. 2006 Mar;88(2):234–235. doi: 10.1308/003588406X95138

Prediction of Wound Infections After Major Surgery by the Use of Near-Infrared Spectrophotometry

C* Ives 1, D Harrison 2, G Stansby 3

Introduction

The aim of this work was to develop a reliable tool for predicting wound infections after surgery by measuring oxygen saturation (SO2) in tissues using near-infrared spectrophotometry.

Patients and Methods

After gaining ethical approval, patients undergoing major surgery were invited to participate. SO2 of the subcutaneous tissues was recorded at the wound site pre-operatively then 6, 12, 24 and 48 h postoperatively. The patients were classified into two groups, retrospectively: with or without surgical site infection (SSI). SSI was diagnosed using the Control of Diseases Centre definition by personnel blinded to the readings.

Results

Of 28 patients (18 male, 10 female), nine developed SSI. There were no differences between the groups for age, body mass index or arterial oxygen saturation. Pre-operative SO2 in subcutaneous tissues was not different between the two groups; however, there was a significant difference at 12 h, which disappeared at 24 h (12 h: non-infected = 63.2 ± 17.9%; infected = 38.9 ± 17.9%; P = 0.008). A chi-squared test showed that an oxygen saturation below 50% identifies those patients likely to develop SSI (P = 0.014).

Conclusions

Tissue SO2 could be used to predict patients at risk of developing SSI as early as 12 h postoperatively when there is still opportunity for intervention.

Ann R Coll Surg Engl. 2006 Mar;88(2):235. doi: 10.1308/003588406X95138

Senior House Officer Training and the Outlook for Vascular Surgery

JR* Panchmatia 1, DJA Scott 1

Introduction

Training for senior house officers (SHOs) has changed with the introduction of a full shift-working pattern. We studied the vascular operative experience obtained by SHOs nation-wide.

Materials and Methods

This retrospective study analysed the experience of 41 SHOs and correlated this against the Curriculum Framework for the General Professional Practice of Surgery (GPPS) and the VSGBI's index operations.

Results

All results are expressed as a median accompanied by the interquartile range (IQR). The SHOs in this study participated in a total of 4988 vascular procedures.

The GPPS

SHOs typically never achieved the recommended degree of involvement in the treatment of varicose veins (IQR = 5), wound debridement (IQR = 0), femoral embolectomy (IQR = 0) or toe amputation.

VSGBI index operations

On average, SHOs observed or participated in 6 abdominal aortic aneurysm repairs (IQR = 5), 5 carotid endarterectomies (IQR = 6) and 7 femoro-popliteal/crural bypasses (IQR = 10).

Conclusions

Trainees typically observe all of the operations specified in the GPPS and by the VSGBI; however, observation alone is not an indicator of adequate training and the degree of participation regularly fails to reach recommended levels. This will result in a corpus of registrars with inadequate experience in key vascular operations.

Ann R Coll Surg Engl. 2006 Mar;88(2):235. doi: 10.1308/003588406X95138

The Effect of European Working Time Directive Compliance on Surgical Training in a District General Hospital

S* Sloan 1, A Gidwani 1, D Gilpin 1

Introduction

The European Working Time Directive (EWTD) implemented in August 2004 restricts junior doctors to working 58 h per week. Combined with strict rest requirements as per the ‘New Deal’, this limits the exposure of surgical trainees to operation lists, out-patient clinics and ward-based activity. The aim of this study was to assess the effects of working an EWTD-compliant shift rota on operative experience in specialist registrars in one district general hospital.

Materials and Methods

A prospective operation database (FILEMAKER PRO) has been established in this unit since November 2001. In February 2004, the surgical registrar rota changed to an EWTD-compliant shift rota from an on-call rota. A retrospective review of the operation database was performed comparing the total number of general surgical cases, and the caseload of the specialist registrars during two 10-month periods (T1, 1 February to 30 November 2002; T2, 1 February to 30 November 2004).

Results

The total number of general surgical operations performed were T1, n = 1891 and T2, n = 1810. There was an overall 18% reduction in the specialist registrar caseload of general surgical operations performed between the periods studied (T1, n = 629; T2, n = 516; P = 0.019).

Conclusions

Implementation of the EWTD does affect the operative experience of surgical trainees. This has implications for current training methods and the length of surgical training.

Ann R Coll Surg Engl. 2006 Mar;88(2):236. doi: 10.1308/003588406X95138

Who's Got All the Pys? The Reduced Incidence of Ramstedt's Pyloromyotomy

W* Neary 1, A Klidjian 1

Introduction

A reduced number of Ramstedt's pyloromyotomies was noted in a district general hospital over the past 14 years. We wanted to know if this was due to change in referral or a reduction in incidence.

Patients and Methods

All hospitals in the south-west surgical training region were contacted requesting historical numbers of Ramstedt's procedures, on children younger than one year. Barnstable, Bristol Children's', Exeter, Plymouth, Taunton, Truro and Yeovil hospitals replied with data. These figures were compared to Office of Population and Census Survey data to see the number of live births in the region.

Results

Those hospitals that were able to give data from 1990 to 2003 (Exeter, Taunton, Torbay, and Yeovil) showed number of procedures fell – the 60 cases reported in 1990 fell to 5 in 2003 (0.08). For hospitals with 5-year data from 1999 to 2003, the number of procedures fell, from 73 in 1999 to 49 in 2003 (0.67). The total number of live births in the south-west region was 41,090 in 1990, 52,075 in 1999 and 51,476 in 2003.

Conclusions

There is a real reduction in the incidence of this operation, which is not due to a change in referral or population demographics, that may reflect either a reduction in the incidence of pyloric hypertrophy or changing indication for surgery. We wonder if the increased use of histamine receptor antagonists and domperidone over this time is relevant.

Ann R Coll Surg Engl. 2006 Mar;88(2):236. doi: 10.1308/003588406X95138

Laparoscopic Bile Duct Exploration in the Management of Common Bile Duct Stones After Previous ERCP

M* Davies 1, G Chinien 1, S Paulvannan 1, S Caplin 1, TH Brown 1

Introduction

Endoscopic biliary sphincterotomy has an established role in the management of choledocholithiasis with clearance rates of 64–87%. Failure to clear the duct represents a significant clinical problem. Repeat ERCP can still leave 18% of patients with choledocholithiasis. Laparoscopic common bile duct exploration (LCBDE) is an alternative to ERCP for bile duct stones. We report our experience of LCBDE following ERCP. All details of patients undergoing LCBDE are recorded on a database – we have reviewed those whose exploration followed a prior ERCP.

Results

A total of 92 patients underwent LCBDE between November 2000 and March 2005, of whom 27 (10 male, 17 female) had undergone a previous ERCP. The median age of these 27 patients was 77 years (range, 22–89 years). LCBDE was required due to failed stone extraction (n = 11), failed intubation/cannulation (n = 7), complications of ERCP (n = 4) and intra-operative cholangiogram findings (n = 5). The ratio of transcystic versus choledochotomy exploration was 5:22 (ratio almost 50:50 in all LCBDE). Open conversion was required in 5 patients (19%) for impacted stones (7% conversion rate in LCBDE). Complete duct clearance was possible in 22/24 patients (92%); no stones found in 3 patients. There were complications in 4/27 (15%; 2 bile leaks, 1 liver abscess, 1 hernia) and a postoperative ERCP was needed in 5 (1 residual stone, 1 bile leak, 3 removal stent).

Conclusions

LCBDE should be considered in the management of common bile duct stones following unsuccessful ERCP. This group of patients has a higher rate of choledochotomy and a higher conversion rate than in the total group of LCBDE. The duct clearance rate (92%) is better than for repeat ERCP, and the morbidity/mortality rate is less than for open exploration.

Ann R Coll Surg Engl. 2006 Mar;88(2):236–237. doi: 10.1308/003588406X95138

Surgical Endoscopy Training in Wales – Are We on the Right Track?

S Farmer 1, A Miah 1, P Sanjay 1, A Woodward 1, M* Nelson 1

Introduction

In 2004, The Joint Advisory Group for Gastroenterology (JAG) published guidelines on training requirements for a variety of diagnostic and therapeutic endoscopic procedures. Most of the requirements are based on attending approved courses and achieving a sufficient number of cases performed, in particular, under supervision in the initial phases. For instance, the JAG recommends that trainee endoscopists undertake 200 supervised OGDs and 100 colonoscopies within a year prior to supervised independent practice. Our aim was to ascertain whether current surgical SpRs' training fulfils the JAG criteria and identify areas for improvement.

Materials and Methods

A questionnaire was used to survey the SpRs' endoscopic experience in the previous year. Data regarding courses attended, procedures performed and future intentions were collected in addition to training year and subspecialty interest.

Results

In all, 37 SpRs completed questionnaires, representing 72% of the numbered posts in Wales. One SpR had registered as an endoscopic trainee with JAG. Only 11 SpRs had attended a basic endoscopy course and 7 had received formal colonoscopy tuition. Twelve trainees did not keep accurate logbooks of number of cases. Of 28 RITAs, 20 did not examine endoscopy experience at all for that year.

Thirteen SpRs are currently in year 1 and so are excluded from further analysis. Of the 24 remaining trainees, 9 performed no endoscopies at all last year, including four years 4–6 registrars with a declared gastrointestinal interest. A median of 69 endoscopies per trainee (range, 2–345) were logged and about one-third of these were supervised.

We also asked about intentions to perform endoscopies when appointed as a consultant: 80% of trainees with a declared gastrointestinal subspecialty (either upper or lower) anticipated performing both elective and emergency endoscopy, whereas the corresponding figure for breast and vascular trainees was around 50%.

Finally, we found that SpRs had a median of 10 days of unused study leave (range, 0–26 days) at the end of the year of this study.

Conclusions

Endoscopic training for Welsh surgical trainees is inconsistent and does not seem to comply with JAG guidelines at present. Corrective action is necessary to address this before these guidelines become more widely adopted otherwise surgical SpRs may be perceived as under-trained in endoscopic procedures. One possibility is to utilise the unused study leave which most SpRs accrue over the year to provide additional training.

Ann R Coll Surg Engl. 2006 Mar;88(2):237–238. doi: 10.1308/003588406X95138

Para-Aortic Lymphadenectomy in Advanced Testicular Teratoma – The Case for Combined Urological and Vascular Surgical Input

R* McKee 1, B Jenkins 1, RJ Whiston 1

Introduction

In the UK, retroperitoneal lymph node dissection (RPLND) is recommended in cases where significant retroperitoneal lymphadenopathy (nodes greater than 1.5 cm on CT scanning) persists after completion of chemotherapy. As these lymph node masses are in close relation to major vessels and to ureters, it is current practice in this unit for this operation to be performed as a combined procedure involving both a consultant urologist and a consultant vascular surgeon. This audit assesses the appropriateness and effectiveness of such a combined approach.

Patients and Methods

In all, 16 procedures in 14 patients were identified over a 7-year period from theatre records. The case notes were evaluated retrospectively to assess patient demographics, peri-operative findings, investigation and treatment modalities, the relevant skills contributed by each surgeon during the RPLND including management of specific complications, and outcomes, including tumour recurrence and requirements for further surgery.

Results

Patient demographics and peri-operative findings

The average age of presentation was 29 years (range, 19–43 years), with the average age of patients undergoing post chemotherapy RPLND being 31 years. Eleven cases originated from the left testicle, 3 from the right. This is reflected in the sites of retroperitoneal lymphadenopathy, with 11 masses found adherent on or to the left side of the aorta, but only 3 masses intimately involving the IVC (one in a left-sided IVC) and 2 masses between the aorta and the IVC. Two masses were closely associated to the left internal iliac artery. Ureteric stenting was required in 4 cases due to proximity of tumour to the left ureter. In 11 out of the 14 cases, the patients underwent orchidectomy prior to chemotherapy with RPLND for residual post-chemotherapy masses. Orchidectomy was performed as a combined procedure with lymph node dissection after chemotherapy in 2 cases, and in 1 case an orchidectomy was performed after chemotherapy with subsequent RPLND for disease progression.

Complications and requirement for vascular intervention

Six patients had significant intra-operative haemorrhage of up to 4 l of blood, either arterial (from aorta, external iliac artery, or lumbar artery), or venous (from the IVC or renal, adrenal or gonadal veins), all requiring vascular intervention. Reconstruction of the right renal artery using long saphenous vein graft was required in one case. The IVC was ligated in one case due to thrombosis and tumour involvement.

Non-vascular surgical complications

These included one tension pneumothorax following dissection of a right retrocrural tumour mass, and one incisional hernia in a patient who had undergone four different courses of chemotherapy for wide-spread metastatic disease.

Outcomes

Two cases required a second RPLND, one case 14 months after, and the other 7 years after the original RPLND (both after further courses of chemotherapy). All of these cases appear to remain well and tumour-free at time of audit; however, as 10 of these 14 cases were referred from different regions, often with follow-up based in their home region, assessment of postoperative response was difficult.

Conclusions

Given the risk of vascular injury and complications during curative surgery for postchemotherapy retroperitoneal masses in young patients with metastatic testicular teratoma, we recommend this is performed as a combined vascular and urological procedure.

Ann R Coll Surg Engl. 2006 Mar;88(2):238. doi: 10.1308/003588406X95138

Vitamin C Prophylaxis Promotes Oxidative Lipid Damage During Surgical Ischaemia-Reperfusion

S Raman 1, DM Bailey 3, J McEneny 4, G McKeeman 4, IS Young 4, DA Hullin 2, JM McCord 5, B Davies 3, MH Lewis 1

Introduction

Reactive oxygen species (ROS) have been implicated in the cellular membrane damage and postoperative, morbidity associated with vascular surgery requiring obligatory ischaemia due to cross-clamping and subsequent reperfusion. A clinical study was undertaken to evaluate the effects of ascorbate (vitamin C) prophylaxis on ROS in 22 patients undergoing elective abdominal aortic aneurysm (AAA) or infra-inguinal bypass (IIB) repair.

Patients and Methods

Patients were assigned double-blind to receive intravenous sodium ascorbate (2 g vitamin C; n = 10) or placebo (0.9% saline; n = 12) administered 2 h prior to surgery. Blood samples were obtained from the arterial and venous circulation proximal to the respective sites of surgical repair (local) and from an antecubital vein (peripheral) during cross-clamping (ischaemia) and within 30 s of clamp-release (reperfusion).

Results

Ascorbate supplementation increased the veno-arterial concentration difference of lipid hydroperoxides, interleukin (IL)-6 and vascular endothelial growth factor (VEGF) protein during ischaemia. This increased the peripheral concentration of lipid hydroperoxides, total creatine phosphokinase (CPK) and VEGF protein during reperfusion (P < 0.05 versus placebo). Electron paramagnetic resonance (EPR) spectroscopy confirmed that free iron was available for oxidative catalysis in the local ischaemic venous blood of supplemented patients, An increased concentration of the ascorbate radical and aaa-phenyl-tert-butylnitrone adducts assigned as lipid-derived alkoxyl and alkyl species were also detected in the peripheral blood of supplemented patients during reperfusion (P < 0.05 versus ischaemia).

Conclusions

The findings suggest that ascorbate prophylaxis may have promoted iron-induced oxidative lipid damage via a Fenton-type reaction initiated during the ischaemic phase of surgery. The subsequent release of lipid hydroperoxides into the systemic circulation may have catalysed formation of second-generation radicals implicated in the regulation of vascular permeability and angiogenesis.

Ann R Coll Surg Engl. 2006 Mar;88(2):238–239. doi: 10.1308/003588406X95138

The D2 Gastrectomy Learning Curve – Myth or Steep Reality

AN Hopper 1, MR Stephens 1, G Blackshaw 1, J Barry 1, P Edwards 1, I Hodzovic 2, K Harries 1, WG Lewis 1

Introduction

Modified D2 gastrectomy (mD2, preserving pancreas and spleen) has been championed as the operation of choice for Western patients with gastric cancer, although concerns have been raised over the critical workload and experience required for surgical competence. The aim of this study was to determine whether a surgical learning curve existed, as determined by morbidity, mortality, and long-term survival after mD2 gastrectomy in a large UK cancer unit.

Patients and Methods

The outcomes of 100 consecutive R0 mD2 gastrectomies performed by a single specialist upper gastrointestinal surgeon for cancer were studied prospectively. Patients were stratified according to whether they had an early (EGC) or advanced gastric cancer (AGC), and outcomes were analysed in deciles.

Results (see Table)

In a multivariate analysis, only the presence of lymph node metastases was significantly and independently associated with duration of survival (HR 2.9; 95% CI, 2.0–4.4; P < 0,0001).

EGC AGC
Series number 1–60 61–100 1–60 61–100
Number of patients 12 19 48 21
Morbidity (%) 17 11 33* 19*
Operative mortality 17 5 6 0
5-year survival (%) 67 83 33** 68**
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Survival is uncorrected.

*

P = 0.04;

**

P = 0.048.

Conclusions

A significant learning curve emerged, which plateaued after 60 resections had been performed. D2 gastrectomy should be restricted to experienced specialist multidisciplinary teams with large workloads so that adequate training and supervision can be provided during the learning curve.

Ann R Coll Surg Engl. 2006 Mar;88(2):239. doi: 10.1308/003588406X95138

Quality of Lymph Node Retrieval in Colorectal Cancer

MD Evans Sr 1, K Barton 1, A Rees 2, JD Stamatakis 1, SS Karandikar 1

Introduction

NICE has recommended that:1 ‘in patients with colorectal cancer who are treated with curative intent, 12 or more nodes should be examined. If the median number is consistently below 12 the surgeon and the pathologist should discuss their techniques.’ The aims of this study were to:

  1. Evaluate unit lymph node examination in colorectal cancer against NICE recommendations.

  2. Evaluate unit performance against national results using the ACPGBI lymph node harvesting model.2

  3. Evaluate variation between surgeon and pathologist performance within the unit.

Patients and Methods

All patients having surgical resection of colorectal cancer in our unit between April 1999 and October 2004 were identified from the prospectively collected ACPGBI database. The pathology reports of all patients were retrieved from the hospital pathology database. Data recorded were: the surgeon, reporting pathologist, operation type, and use of neo-adjuvant therapy for rectal tumours, Dukes’ stage, and total number of lymph nodes examined. Predicted lymph node yield was calculated from the ACPGBI model for all patients. Observed and expected lymph node harvest was then analysed for individual surgeon and pathologist. Mann-Whitney U-tests were applied to demonstrate any statistical significance between individual's performance.

Results

A total of 381 patients underwent colorectal resection in the study period. One pathology report could not be found, so data on 380 patients were examined. The unit median lymph node retrieval was 13 (range, 0–42; 95% CI, 13.14–14.53) against an ACPGBI predicted median of 9.403. Individual surgeons and pathologists performances are outlined in the Table below.

Surgeons Pathologists
1 (n = 183) 2 (n = 64) 3 (n = 86) Non-GI (n = 47) 1 (n = 200 2 (n = 106 3 (n = 57) 4 (n = 17)
Median LN observed (Range) 12 (1–37) 14 (0–25) 14 (2–42) 14 (1–32) 15 (2–42) 12 (1–32) 11 (0–29) 11 (2–39)
Median predicted
LN count* 9.337 9.281 9.651 9.375 9.356 9.404 9.361 10.402
95% CI 12.48–14.46 11.69–14.59 13.35–16.60 12.02–16.28 14.05–16.03 12.02–14.44 9.69–12.76 7.70–16.89
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*

Predicted from ACPGBI risk-adjusted lymph node harvesting model. LN, lymph node.

Conclusions

The unit performance is in keeping with NICE guidance and is ahead of national performance. There was no significant difference in number of lymph nodes retrieved between the surgeons; however, there was significant difference between the pathologists.

References

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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