Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

288 Do Frailty Assessments Improve Outcomes for Emergency Laparotomy Patients? A Quality Improvement Project

Aim

Our aim of the project is to increase completion rates of frailty assessments in emergency laparotomies to improve patient outcomes.

Method

This QI project focused on completion of the Rockwood Clinical Frailty Score (RCFS), Comprehensive Geriatric Assessment (CGA), Abbreviated Mental Test Score (AMTS), memory screening, place of residence and care level in patients over 65 years undergoing emergency laparotomies. Criteria was generated using British Geriatric Society recommendations and local hospital guidance.

A year was sampled pre-intervention with the criteria, time clerked and grade. Data was assessed for admission and mortality statistics, and re-admission rates. A presentation to surgical juniors relating to frailty, frailty assessments and guidelines was used as an intervention. The data was re-sampled to identify changes post-intervention.

Results

Fifty-four laparotomy patients were sampled. 28% had a completed RCFS, 15% had a CGA, 67% had a place of residence, 41% had level of care documented, 13% had a memory screen and 7% had an AMTS. The small sample size restricted data analysis, however, there was a general decrease in length of admission and time to medically fit with increased frailty score completion.

Post-intervention, completion of the RCFS, CGA, place of residence and care level increased. Completion of memory screening and AMTS decreased. Compliance increased in FY1s, SHOs and registrars.

Conclusions

The intervention had a positive impact: the average number of frailty criteria completed per patient increased by 39%, Foundation Year trainees now have frailty teaching, and the clerking booklet was reviewed. A re-audit is planned to ensure ongoing improvement.

Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial

BACKGROUND

Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site.

METHODS

In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

FINDINGS

Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events.

INTERPRETATION

Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias.

FUNDING

National Institute for Health Research Research for Patient Benefit and Allergan.

Unsuspected radiolucent partial denture impaction in the sigmoid colon mimicking malignancy

We report the case of a 79-year-old male who presented with altered bowel habit. Subsequent endoscopy and radiological investigations suggested the diagnosis of a likely sigmoid colon malignancy. Surgery was performed to remove the suspected tumour and post-surgical histology showed only inflammatory change in an area of underlying sigmoid diverticulosis with an associated impacted dental prosthesis.

Sealing of vessels larger than 7 millimeters using Enseal in porcine aorta

Background:

The Enseal (Ethicon Endo-Surgery, Blue Ash, Ohio) tissue-sealing device has proven efficacy for ligation of vessels <7 mm in diameter, even with significant supraphysiologic bursting pressures. We aimed to evaluate the safety of Enseal in porcine vessels >7 mm.

Materials and Methods:

The lumbar aortas of pigs that were euthanized for unrelated procedures were harvested. A 5- to 6-cm segment of aorta was sealed using the Enseal device. The opposite end was attached to a pressure-testing device to measure pressures at leak or bursting. The bivariate Pearson correlation was used to determine the relationship between diameter and bursting pressure. One-way analysis of variance was used to determine differences between the groups of vessels on the basis of their diameter.

Results:

Ninety samples of 5-cm aorta segments were used to assess bursting pressure. The median diameter was 14 mm (range, 7–18) and bursting pressure was 85 mm Hg (range, 24–650). The Pearson test showed a negative correlation between vessel diameter and bursting pressure (P = .25). One-way analysis of variance did not show any significant difference between vessel diameters grouped by size (P = .517), and neither did the Scheffe post hoc test when comparing diameter with bursting pressure; 31% of specimens failed to seal.

Conclusions:

Bursting pressures are low and inconsistent after tissue sealing with the Enseal device in porcine vessels >7 mm. These vessels also demonstrated a higher rate of failure to seal. The histologic results of the aorta segments (ie, a low collagen-elastin ratio) may be the cause of the low bursting pressures.

A prospective study of in vivo and ex vivo sealing of the human inferior mesenteric artery using an electrothermal bipolar vessel-sealing device

BACKGROUND

Mesenteric vascular ligation is a critical step in minimally invasive colorectal surgery. This study assessed the quality of in vivo and ex vivo sealing of the human inferior mesenteric artery (IMA), as well as the relation of IMA stump and bursting pressure.

PATIENTS AND METHODS

This was a prospective experimental study in a tertiary-care teaching hospital. In total, 25 patients were included in the study. For the main outcome measures, bursting pressures were measured for each specimen. Ten freshly sealed specimens were histologically assessed for seal quality and lateral thermal damage.

RESULTS

We evaluated 54 specimens from 25 patients for bursting pressure, of which 25 were primary sealed vessels (sealed in vivo at surgery) and 29 were secondary sealed vessels (sealed in the laboratory). The mean bursting pressure was 862 mm Hg. The mean diameter was 4 mm (range, 3-5 mm) with a standard deviation of 1 mm. Pearson correlation showed no correlation between diameter and bursting pressure (P=.187) or the length and bursting pressure (P=.247). There was no statistically significant difference in bursting pressures in the four groups of vessels based on length. One calcified vessel had a significantly lower bursting pressure of 89 mm Hg. There was no intraoperative or postoperative bleeding. Ten sealed specimens were sent for histological evaluation, which showed mean lateral thermal damage of 0.57 mm (range, 0-1.75 mm).

CONCLUSIONS

The bursting pressure in IMAs sealed with a bipolar device is significantly higher than physiological pressures; thus, the device can be safely used in sealing the vessel during colorectal surgery. Additionally, the length of the vessel stump does not correlate with the bursting pressures. Care needs to be taken when the vessel is calcified, which can be a potential cause of a weak seal.

Unusual cause of acute abdomen--omental infarction occurring in a child with cyclical neutropenia

Omental infarction is a rare cause of acute abdomen in childhood. We describe a case of omental infarction mimicking acute appendicitis occurring in a child with cyclical neutropenia. Neutropenic enterocolitis, a serious cause of the acute abdomen, has been linked with cyclical neutropenia. In neutropenic patients, omental infarction when diagnosed pre-operatively can be managed conservatively with the focus on improving the neutrophil count. If after imaging the diagnosis is in doubt, there should be a low threshold for laparoscopy. The low incidence of omental infarction will continue to mean that it is a diagnosis made at operation for suspected appendicitis. In these cases, the infarcted tissue may be removed by the laparoscopic or open technique.