Table 1.
Questions put forward for the first round of prioritisation
| Question number | Question | High-priority ranking (4 or 5) (n) | Low-priority ranking (1 or 2) (n) |
|---|---|---|---|
| General EGS | |||
| 3 | What is the impact of emergency laparotomy on quality of life in frail patients? | 135 | 10 |
| 24 | Which pre- or post-operative interventions improve clinical outcomes in patients with frailty after emergency surgery? | 130 | 4 |
| 25 | What are the best predictors of adverse outcomes and mortality in older adults presenting with emergency general surgery pathology? | 124 | 10 |
| 16 | How can training be improved to meet emergency general surgery demand, including open surgery? | 119 | 13 |
| 4 | What is the value of enhanced recovery after surgery (ERAS) programmes for EGS patients, compared to standard management? | 114 | 12 |
| 26 | What is the optimal method of assessing fitness for surgery in the emergency setting? | 111 | 19 |
| 13 | What are the absolute risks of anastomotic leak following emergency small bowel/large bowel anastomosis, and the relative importance of risk factors? | 111 | 18 |
| 15 | How can we optimise the rate of reversal of Hartmann’s when performed as an emergency and what are the predictive factors in those who are subsequently reversed? | 108 | 15 |
| 19 | How does small bites closure compare to traditional mass closure in the emergency setting (wound infection, fascial dehiscence and incisional hernia rates)? | 101 | 25 |
| 17 | Should patients have extended venous thromboembolism (VTE) prophylaxis after an emergency laparotomy with or without resection? | 100 | 23 |
| 39 | Is there a link between duration of emergency laparotomy (knife to skin to wound closure) and clinical outcomes? Is there a cut-off where all surgeons should perform damage control surgery in the emergency setting? | 95 | 21 |
| 41 | How can technology be incorporated into patient follow-up to aid early detection of post-operative complications? | 95 | 25 |
| 46 | Are outcomes after emergency surgery improved with the laparoscopic approach as compared to the open approach? | 95 | 21 |
| 23 | Does a laparoscopic approach for adhesional small bowel obstruction reduce the risk of recurrence, and how do we identify those who would benefit most from laparoscopic approach? | 93 | 28 |
| 9 | Is non-operative management inferior to the surgical management of uncomplicated appendicitis? | 91 | 31 |
| 18 | How does negative pressure wound therapy affect clinical outcomes after 90 emergency surgery? | 28 | |
| 7 | Which cohort of patients can be safely managed using an ambulatory appendicitis pathway or day-case appendicectomy for acute appendicitis? | 87 | 33 |
| 22 | What is the best diagnostic approach to acute small bowel obstruction, and what is the role of Gastrografin in diagnosis and/or treatment? | 87 | 34 |
| 20 | Is there value in routine computer tomography (CT) imaging in patients presenting with acute abdominal pain? | 86 | 29 |
| 14 | What is the role of the gut microbiome in anastomotic leakage? | 86 | 31 |
| 34 | Non-specific abdominal pain—how do you define, manage and reduce readmissions? | 85 | 40 |
| 31 | Does early parenteral nutrition in small bowel obstruction improve clinical outcomes? | 82 | 27 |
| 1 | What more can be done to help patients with the psychological sequelae of emergency surgery, and which patient-reported outcome measures are most useful? | 82 | 29 |
| 11 | Should we implement a UK wide acute CT service for right iliac fossa pain to reduce the negative appendicectomy rate? | 81 | 35 |
| 5 | Which cohort of EGS patients derive the greatest benefit from post-operative chest physio? | 81 | 31 |
| 35 | Does the early administration of inotropes during the resuscitation of patients with septic shock result in improved clinical outcomes? | 80 | 29 |
| 37 | What is the optimal method of antibiotic stewardship and rationalisation in emergency general surgery? | 80 | 42 |
| 10 | Is there a difference in clinical outcomes between patients with image-proven appendicitis and conventional (clinically guided) appendicitis? | 79 | 40 |
| 45 | Is the use of mesh safe for the repair of a strangulated hernia where there has been small bowel contamination via enterotomy? | 79 | 41 |
| 29 | Which patients are most likely to need parenteral nutrition following emergency surgery? | 75 | 43 |
| 33 | What are the indications for diagnostic laparoscopy in women of reproductive age presenting acutely with lower abdominal pain? | 75 | 49 |
| 6 | Which diagnostic tool is the most sensitive and specific for acute appendicitis? | 73 | 46 |
| 30 | What is the optimal resuscitation fluid for patients undergoing emergency laparotomy? | 70 | 47 |
| 21 | Does point-of-care ultrasound (POCUS) improve clinical outcomes in emergency surgery patients? | 70 | 41 |
| 27 | Is CT-diagnosed sarcopenia useful as a prognostic indicator of poor outcomes in emergency surgical patients? | 66 | 49 |
| 32 | What is the value of nutritional supplements (e.g. Fortisip) to EGS patients? | 63 | 35 |
| 43 | Is there a role for a symptomatic hernia ‘hot list’ and would it improve clinical outcomes in this cohort of patients? | 62 | 46 |
| 44 | What is the optimum timing of hernia repair after successful reduction in cases of acute incarceration? | 60 | 48 |
| 2 | What is the incidence of post-traumatic stress disorder (PTSD) following emergency surgery? | 56 | 44 |
| 28 | How does patient fatigue affect surgical outcomes after emergency surgery? | 53 | 49 |
| 8 | Do outcomes after paediatric appendicectomy vary in a district general hospital setting when compared with a tertiary hospital setting? | 50 | 64 |
| 36 | Is there any benefit to taking a swab of pus when performing incision and drainage of an abscess? | 49 | 74 |
| 42 | Is laparoscopic approach feasible in emergency inguinal hernia? | 47 | 73 |
| 38 | What are the indications for low-pressure peritoneum in emergency abdominal surgery and do we have data on outcomes? | 41 | 69 |
| 12 | Is there a difference in clinical outcomes between methods currently employed to secure the appendix stump during laparoscopic appendicectomy? | 36 | 74 |
| 40 | Is there a role for robotic-assisted surgery in adult patients with emergency surgical conditions? | 24 | 111 |
| Emergency UGI surgery | |||
| 2 | Does a ‘hot gallbladder’ pathway reduce sepsis rates in addition to gallstone-related complications? | 100 | 18 |
| 7 | Which patient cohort derives the greatest clinical benefit from index cholecystectomy for acute cholecystitis? | 100 | 20 |
| 12 | Can mild acute pancreatitis be managed in an ambulatory setting and in which patients is it safe to do so? | 95 | 31 |
| 5 | Should every centre that offers emergency general surgery offer a ‘hot gallbladder’ service? Which model is best and is pre-operative magnetic resonance cholangiopancreatography (MRCP) required? | 93 | 21 |
| 4 | Should management of acute cholecystitis in the geriatric population differ from standard care? | 88 | 19 |
| 8 | Is cholecystostomy adequate in cases of empyema gall bladder in an older adult, unfit patient or is interval cholecystectomy required? | 87 | 26 |
| 11 | Is therapeutic anticoagulation indicated in cases of portal vein thrombus secondary to acute severe pancreatitis? | 85 | 25 |
| 6 | Can the management of acute cholecystitis be safely performed in an ambulatory setting? | 82 | 31 |
| 9 | What is the best immediate severity assessment for acute pancreatitis (i.e. not a score that uses a 48-h window)? | 77 | 40 |
| 3 | Should intra-operative cholangiogram with or without stone retrieval (by common bile duct exploration if necessary) be routine in cholecystectomy for acute cholecystitis? | 60 | 49 |
| 10 | What is the optimal management of alcohol-related pancreatitis? | 55 | 52 |
| Emergency colorectal surgery | |||
| 2 | Does a formal cancer resection improve disease-free and overall survival in perforated or obstructing emergency colorectal cancer resections? | 102 | 15 |
| 6 | Is endoscopic follow-up required in CT-confirmed acute diverticulitis? | 93 | 25 |
| 1 | How do stent, stoma or immediate resection for obstructing colorectal cancers compare? | 92 | 15 |
| 14 | Regarding the various treatment strategies in lower gastrointestinal bleeding (e.g. surgical, endoscopy, interventional radiology, medical systemic treatment), is single or combination treatments superior? | 81 | 30 |
| 9 | Is there a CRP level (or other marker) which could identify cases of diverticulitis which can safely be managed conservatively, i.e. antibiotics versus no antibiotics? | 80 | 33 |
| 12 | What is the incidence and indications/selection criteria for surgical intervention with sigmoid volvulus? | 80 | 20 |
| 8 | Could FiT testing be used to screen for possible colorectal malignancy in diverticulitis patients rather than routine post-admission endoscopy/CT Colonography? | 79 | 30 |
| 5 | What are oncologic results in colon cancer treated in an emergency situation? | 77 | 34 |
| 15 | What is the optimum management of novel oral anticoagulants (NOACs) in patients with PR bleeding? | 75 | 28 |
| 4 | Endoscopic obstructing colorectal tumour: what should we do and what is the best timing for surgical intervention? | 67 | 23 |
| 16 | Should we train surgeons to mark for stomas in the emergency setting and would this affect patient satisfaction with stoma? | 67 | 37 |
| 10 | Should perforated diverticular disease be operated on exclusively by colorectal surgeons to decrease the rate of Hartmann’s procedure? | 61 | 48 |
| 17 | What is the evidence comparing diverting stoma and the use of Flexi-Seal in necrotising perineal and perianal infections? | 60 | 42 |
| 11 | Is there a role and benefit of laparoscopic washout for mild diverticulitis and how does it correlate with the Hinchey scale? | 54 | 51 |
| 3 | What is the best operative strategy to achieve laparoscopic resection in obstructing left sided colorectal cancers? | 53 | 39 |
| 13 | Is there a role for, and what would the indications be, for a laparoscopic Hartmann’s procedure for sigmoid volvulus in older adults? | 46 | 52 |
| 7 | Has the age at time of presentation of acute diverticulitis changed in the last 20 years and why? | 35 | 57 |
| Non-technical questions | |||
| 1 | Which human/organisational factors cause inefficiency in a dedicated emergency theatre? | 103 | 14 |
| 2 | What influences decision-making for emergency surgery for the surgeon, patient and family? | 93 | 13 |
| 3 | How can the informed consent process be optimised for emergency general surgery patients? | 84 | 17 |
| 4 | What are the costs and ethical considerations of randomisation in emergency surgery? | 63 | 40 |
| Health service related | |||
| 12 | Are emergency surgical outcomes improved with peri-operative physician or geriatrician input? | 96 | 15 |
| 1 | Which patients derive the greatest benefit from routine HDU/ITU care after emergency surgery? | 92 | 15 |
| 10 | Is there a volume–outcome relationship for emergency surgery? | 86 | 17 |
| 13 | Are there improved outcomes in patients who are treated on a triaged speciality take? (e.g. pancreatitis to UGI, colon cancer to colorectal) | 85 | 22 |
| 11 | What effect does a fast-track service have on the overall EGS service for patients requiring urgent cholecystectomy, appendicectomy and hernia surgery? | 84 | 17 |
| 14 | Is there a need for an ‘Emergency Surgery’ sub-specialisation? | 82 | 24 |
| 2 | Is there a benefit when a senior decision-maker sees the patient first? | 79 | 32 |
| 3 | Are rapid acute surgical assessment units cost-effective? | 74 | 29 |
| 8 | Would direct access to US and CT imaging for general practitioners affect triage of emergency referrals in NHS? | 66 | 35 |
| 9 | Should surgical emergencies be managed by a specialist or a generalist team? | 65 | 35 |
| 5 | What are the optimum and acceptable extended criteria for referral to surgical ambulatory care for emergency referrals? | 64 | 37 |
| 6 | What is the level of collaboration between dedicated emergency general surgeons and sub-specialists, hepatobiliary (HPB), upper gastrointestinal (UGI) and lower gastrointestinal? | 59 | 46 |
| 4 | What are the reasons for the increase in emergency referrals to secondary care in the UK? | 56 | 46 |
| 7 | Do emergency general surgery consultant surgeons require an elective component within their job plan and should they develop an elective subspecialty? | 55 | 39 |