BRITISH JOURNAL OF SURGERY

ABSTRACTS
Training situational awareness to reduce surgical errors in the operating room
Author: M. Graafland, J. M. C. Schraagen, M. A. Boermeester, W. A. Bemelman, M. P. Schijven
Background
Surgical errors result from faulty decisionmaking, misperceptions and the application of suboptimal problemsolving strategies,
just as often as they result from technical failure. To date, surgical training curricula have focused mainly on the acquisition of
technical skills. The aim of this review was to assess the validity of methods for improving situational awareness in the surgical
theatre.
Methods
A search was conducted in PubMed, Embase, the Cochrane Library and PsycINFO using predefined inclusion criteria, up to
June 2014. All study types were considered eligible. The primary endpoint was validity for improving situational awareness in
the surgical theatre at individual or team level.
Results
Nine articles were considered eligible. These evaluated surgical team crisis training in simulated environments for minimally
invasive surgery (4) and open surgery (3), and training courses focused at training nontechnical skills (2). Two studies showed
that simulationbased surgical team crisis training has construct validity for assessing situational awareness in surgical trainees
in minimally invasive surgery. None of the studies showed effectiveness of surgical crisis training on situational awareness in
open surgery, whereas one showed face validity of a 2day nontechnical skills training course.
Conclusion
To improve safety in the operating theatre, more attention to situational awareness is needed in surgical training. Few
structured curricula have been developed and validation research remains limited. Strategies to improve situational awareness
can be adopted from other industries.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy
Author: S. Huddart, C. J. Peden, M. Swart, B. McCormick, M. Dickinson, M. A. Mohammed, N. Quiney,
Background
Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of
suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidencebased care
bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early
antibiotics, interval between decision and operation less than 6h, goaldirected fluid therapy and postoperative intensive care.
Methods
The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on riskadjusted
mortality. Comparison of case mixadjusted 30day mortality rates before and after carebundle implementation was made
using riskadjusted cumulative sum (CUSUM) plots and a logistic regression model.
Results
Riskadjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 647
in the baseline interval (299 patients included) to 1244 after implementation (427 patients included) (P<0001). The overall
case mixadjusted risk of death decreased from 156 to 96 per cent (risk ratio 0614, 95 per cent c.i. 0451 to 0836; P=0002).
There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient casemix profile as
determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity
risk (0197 and 0223 before and after implementation respectively; P=0395).
Conclusion
Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Primary skin closure after damage control laparotomy

Author: M. J. Pommerening, L. S. Kao, K. J. Sowards, C. E. Wade, J. B. Holcomb, B. A. Cotton
Background
Damage control laparotomy (DCL) is used widely in the management of patients with traumatic injuries but carries significant
morbidity. Surgicalsite infection (SSI) also carries potential morbidity, increased costs and prolonged hospital stay. The aim of
this study was to determine whether primary skin closure after DCL increases the risk of SSI.
Methods

This was a retrospective institutional review of injured patients undergoing DCL between 2004 and 2012. Outcomes of patients
who had primary skin closure at the time of fascial closure were compared with those of patients whose skin wound was left
open to heal by secondary intention. The association between skin closure and SSI was evaluated using propensity score
adjusted multivariable logistic regression.
Results
Of 510 patients who underwent DCL, primary fascial closure was achieved in 301. Among these, 111 (369 per cent) underwent
primary skin closure and in 190 (631 per cent) the skin wound was left open. Fascial closure at the initial takeback surgery was
associated with having skin closure (P<0001), and colonic injury was associated with leaving the skin open (P=0002). On
multivariable analysis, primary skin closure was associated with an increased risk of abdominal SSI (P=0020), but not fascial
dehiscence (P=0446). Of patients receiving skin closure, 856 per cent did not develop abdominal SSI and were spared the
morbidity of managing an open wound at discharge.
Conclusion
Primary skin closure after DCL is appropriate but may be associated with an increased risk of SSI.

Genotypedefined cancer risk in juvenile polyposis syndrome

Author: E. Aytac, B. Sulu, B. Heald, M. O'Malley, L. LaGuardia, F. H. Remzi, M. F. Kalady, C. A. Burke, J. M. Church
Background
Germline mutations in SMAD4 and BMPR1A disrupt the transforming growth factor signal transduction pathway, and are
associated with juvenile polyposis syndrome. The effect of genotype on the pattern of disease in this syndrome is unknown.
This study evaluated the differential impact of SMAD4 and BMPR1A gene mutations on cancer risk and oncological phenotype in
patients with juvenile polyposis syndrome.
Methods
Patients with juvenile polyposis syndrome and germline SMAD4 or BMPR1A mutations were identified from a prospectively
maintained institutional registry. Medical records were reviewed and the clinical patterns of disease were analysed.
Results
Thirtyfive patients had germline mutations in either BMPR1A (8 patients) or SMAD4 (27). Median followup was 11years.
Colonic phenotype was similar between patients with SMAD4 and BMPR1A mutations, whereas SMAD4 mutations were
associated with larger polyp numbers (number of patients with 50 or more gastric polyps: 14 versus 0 respectively). The
numbers of patients with rectal polyps was comparable between BMPR1A and SMAD4 mutation carriers (5 versus 17). No
patient was diagnosed with cancer in the BMPR1A group, whereas four men with a SMAD4 mutation developed gastrointestinal
(3) or extraintestinal (1) cancer. The gastrointestinal cancer risk in patients with juvenile polyposis syndrome and
a SMAD4 mutation was 11 per cent (3 of 27).
Conclusion
The SMAD4 genotype is associated with a more aggressive upper gastrointestinal malignancy risk in juvenile polyposis
syndrome.

Cohort study of corticosteroid use and risk of hospital admission for diverticular disease
Author: F. Hjern, M. W. Mahmood, M. AbrahamNordling, A. Wolk, N. Hkansson
Background
Medication has been suggested as a potential risk factor for diverticular disease. The objective of this study was to investigate
the association between the intake of corticosteroids, indometacin or aspirin and diverticular disease.
Method
This was a prospective populationbased cohort study of middleaged women in the Swedish Mammography Cohort. Use of
corticosteroids (oral or inhaled), indometacin or aspirin in 1997 was determined from questionnaires. Cases of diverticular
disease were identified from the Swedish national registers until the end of 2010. The relative risk (RR) of diverticular disease
requiring hospital admission according to the use of medication was estimated using Cox proportional hazards models, adjusted
for age, body mass index, physical activity, fibre intake, diabetes, hypertension, alcohol, smoking and education.
Results
A total of 36 586 middleaged women in the Swedish Mammography Cohort were included, of whom 674 (18 per cent) were
hospitalized with diverticular disease at least once. Some 72 per cent of women reported intake of oral corticosteroids and 85
per cent use of inhaled corticosteroids. In multivariable analysis, women who reported oral corticosteroid intake had a 37 per
cent (RR 137, 95 per cent c.i. 106 to 178; P=0012) increased risk of diverticular disease compared with those who reported
no intake at all. Use of inhaled corticosteroids was associated with an even more pronounced increase in risk of 71 per cent (RR
171, 136 to 214; P<0001). There was a significant doseresponse relationship, with the risk increasing with longer duration
of inhaled corticosteroids (P for trend<0001). Use of indometacin (25 per cent of women) or aspirin (442 per cent) did not
influence the risk.

Conclusion
There was a significant relationship between corticosteroids (especially inhaled) and diverticular disease requiring hospital
admission.

Biomechanical abdominal wall model applied to hernia repair

Author: M. Lyons, H. Mohan, D. C. Winter, C. K. Simms
Background
Most surgical innovations require extensive preclinical testing before employment in the operative environment. There is
currently no way to develop and test innovations for abdominal wall surgery that is cheap, repeatable and easy to use. In hernia
repair, the required mesh overlap relative to defect size is not established. The aims of this study were to develop a
biomechanical model of the abdominal wall based on invivo pressure measurements, and to apply this to study mesh overlap
in hernia repair.
Methods
An observational study of intraabdominal pressure (IAP) levels throughout abdominal surgery was conducted to identify the
peak perioperative IAP invivo. This was then applied in the development of a surrogate abdominal wall model. An invitro study
of mesh overlap for various defect sizes was then conducted using this clinically relevant surrogate abdomen model.
Results
The mean peak perioperative IAP recorded in the clinical study was 1740Pa, and occurred during awakening from anaesthesia.
This was reproduced in the surrogate abdomen model, which was also able to replicate incisional hernia formation. Using this
model, the mesh overlap necessary to prevent hernia formation up to 20kPa was found, independent of anatomical variations,
to be 2(defect diameter)+25mm.
Conclusion
This study demonstrated that a surgically relevant surrogate abdominal wall model is a useful translational tool in the study of
hernia repair.
This study examined the mesh overlap requirements for hernia repair, evaluated in a biomechanical model of the abdomen.
Currently, mesh size is selected based on empirical evidence and may underpredict the requirement for large meshes.
The study proposes a relationship between the defect size and mesh size to select the appropriate mesh size. Following further
trials and investigations, this could be used in clinical practice to reduce the incidence of hernia recurrence.

Effect of local injection of mesenchymal stem cells on healing of sutured gastric perforation in an experimental model
Author: L. Liu, P. W. Y. Chiu, P. K. Lam, C. C. Y. Poon, C. C. H. Lam, E. K. W. Ng, P. B. S. Lai
Background
Mesenchymal stem cells are proposed to facilitate repair of organ injuries. The aim of this study was to investigate whether
local injection of mesenchymal stem cells could accelerate healing of sutured gastric perforations.
Methods
Sutured gastric perforations in rats were treated either with local injection of mesenchymal stem cells (injected MSC group) or
by topically spraying with fibrin glue containing mesenchymal stem cells (sprayed MSC group). Controls were treated by local
injection of saline or topical spray of fibrin glue without mesenchymal stem cells. Healing of sutured gastric perforations was
assessed on days 3, 5 and 7.
Results
Local injection of mesenchymal stem cells significantly promoted the healing of gastric perforations, with the highest pneumatic
bursting pressure (mean(s.e.m.) 1123(302) mmHg on day 5 versus 712(174) mmHg in saline controls; P=0001), minimal
wound adhesions, and lowest incidence of wound dehiscence (3, 6, 5 and 1 animal on day 5 in control, fibrin, sprayed MSC and
injected MSC groups respectively; n=10 per group) and abdominal abscess (2, 2, 1 and no animals respectively on day 5).
Histological examination showed that gastric perforations in the injected MSC group displayed reduced inflammation, and
increased granulation and reepithelialization. Sutured gastric perforations in the injected MSC group showed decreased
expression of interleukin 6, and increased expression of transforming growth factor 1 and epithelial proliferating cell nuclear
antigen, compared with the other groups.
Conclusion
Local injection of mesenchymal stem cells was more effective than topical application, and enhanced the healing of sutured
gastric perforations by an antiinflammatory process, enhanced cellular proliferation and earlier onset of granulation.
Abnormal healing of gastric perforation may cause morbidity and increase the risk of death. Adipose tissuederived
mesenchymal stem cells have been found to promote the healing of organ injuries through cellular differentiation and secretion
of cytokines that stimulate cellular proliferation and angiogenesis, and suppress inflammation.

This study explored the therapeutic potential of such mesenchymal stem cells for promotion of the healing of sutured gastric
perforations.
Mesenchymal stem cells delivered by local injection significantly enhanced the healing of gastric perforations with reduced
severity of wound adhesion, and a decreased incidence of wound dehiscence and abdominal abscess. The increased expression
of transforming growth factor 1, proliferating cell nuclear antigen and reduced level of interleukin 6 provide evidence for
enhancement of the healing process. Engrafted mesenchymal stem cells expressed smooth muscle actin as a marker of
myofibroblasts.
This preclinical study indicates that local injection of allogeneic adipose tissuederived mesenchymal stem cells may have a
potential therapeutic role in enhancing the healing of peptic ulcer disease and prevention of ulcerrelated complications.

Intraoperative fluorescencebased enhanced reality laparoscopic realtime imaging to assess bowel perfusion at the anastomotic
site in an experimental model
Author: M. Diana, V. Agnus, P. Halvax, Y.Y. Liu, B. Dallemagne, A.I. Schlagowski, B. Geny, P. Diemunsch, V. Lindner, J. Marescaux
Background
Fluorescence videography is a promising technique for assessing bowel perfusion. Fluorescencebased enhanced reality (FLER)
is a novel concept, in which a dynamic perfusion cartogram, generated by computer analysis, is superimposed on to realtime
laparoscopic images. The aim of this experimental study was to assess the accuracy of FLER in detecting differences in
perfusion in a small bowel resectionanastomosis model.
Methods
A small bowel ischaemic segment was created laparoscopically in 13 pigs. Animals were allocated to having anastomoses
performed at either low perfusion (25 per cent; n=7) or high perfusion (75 per cent; n=6), as determined by FLER analysis.
Capillary lactate levels were measured in blood samples obtained by serosal puncturing in the ischaemic area, resection lines
and vascularized areas. Pathological inflammation scoring of the anastomosis was carried out.
Results
Lactate levels in the ischaemic area (mean(s.d.) 56(28) mmol/l) were higher than those in resection lines at 25 per cent
perfusion (37(17) mmol/l; P=0010) and 75 per cent perfusion (29(13) mmol/l; P<0001), and higher than levels in vascular
zones (25(10) mmol/l; P<0001). Lactate levels in resection lines with 75 per cent perfusion were lower than those in lines
with 25 per cent perfusion (P<0001), and similar to those in vascular zones (P=0188). Levels at resection lines with 25 per
cent perfusion were higher than those in vascular zones (P=0001). Mean(s.d.) global inflammation scores were higher in the
25 per cent perfusion group compared with the 75 per cent perfusion group for mucosa/submucosa (21(04) versus 12(04); P
=0003) and serosa (18(04) versus 08(08); P=0014). A ratio of preanastomotic lactate levels in the ischaemic area relative
to the resection lines of 2 or less was predictive of a more severe inflammation score.
Conclusion
In an experimental model, FLER appeared accurate in discriminating bowel perfusion levels.
Clinical assessment has limited accuracy in evaluating bowel perfusion before anastomosis. Fluorescence videography
estimates intestinal perfusion based on the fluorescence intensity of injected fluorophores, which is proportional to bowel
vascularization. However, evaluation of fluorescence intensity remains a static and subjective measure.
Fluorescencebased enhanced reality (FLER) is a dynamic fluorescence videography technique integrating nearinfrared
endoscopy and specific software. The software generates a virtual perfusion cartogram based on time to peak fluorescence,
which can be superimposed on to realtime laparoscopic images. This experimental study demonstrates the accuracy of FLER in
detecting differences in bowel perfusion in a survival model of laparoscopic small bowel resectionanastomosis, based on
biochemical and histopathological data.
It is concluded that realtime imaging of bowel perfusion is easy to use and accurate, and should be translated into clinical use.

Model for risk adjustment of postoperative mortality in patients with colorectal cancer
Author: K. Walker, P. J. Finan, J. H. van der Meulen
Background
A model was developed for risk adjustment of postoperative mortality in patients with colorectal cancer in order to make fair
comparisons between healthcare providers. Previous models were derived in relatively small studies with the use of suboptimal
modelling techniques.
Methods
Data from adults included in a national study of major surgery for colorectal cancer were used to develop and validate a logistic
regression model for 90day mortality. The main risk factors were identified from a review of the literature. The association with
age was modelled as a curved continuous relationship. Bootstrap resampling was used to select interactions between risk
factors.
Results

A model based on data from 62314 adults was developed that was well calibrated (absolute differences between observed and
predicted mortality always smaller than 075 per cent in deciles of predicted risk). It discriminated well between low and high
risk patients (Cindex 0800, 95 per cent c.i. 0793 to 0807). An interaction between age and metastatic disease was included
as metastatic disease was found to increase postoperative risk in young patients aged 50 years (odds ratio 353, 95 per cent
c.i. 266 to 467) far more than in elderly patients aged 80 years (odds ratio 148, 132 to 166).
Conclusion
Use of this model, estimated in the largest number of patients with colorectal cancer to date, is recommended when comparing
postoperative mortality of major colorectal cancer surgery between hospitals, clinical teams or individual surgeons.

Introduction of laparoscopic abdominal aortic aneurysm repair

Author: A. Q. Howard, P. C. Bennett, I. Ahmad, S. A. Choksy, S. I. P. Mackenzie, C. M. Backhouse
Background
The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair.
These patients were compared with patients having elective open AAA repair.
Methods
Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing
laparoscopic or open AAA repair.
Results
A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and
2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 6675) years, and 923 per cent were men.
There was no significant difference in sex distribution, age or VPOSSUM physiology score between laparoscopic and open
repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were
converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals
were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic
repair had significantly fewer postoperative cardiorespiratory and renal complications (P=0017), and were discharged from
hospital sooner (median 5 (i.q.r. 37) versus 8 (611) days; P=0001).
Conclusion
Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable
for EVAR.

Experimental study of survival of pedicled perforator flap with flowthrough and flowend blood supply
Author: Y. Wang, S.Y. Chen, W.Y. Gao, J. Ding, W. Shi, X.L. Feng, X.Y. Tao, L. Wang, D.S. Ling
Background
Flap viability after transfer depends on blood flow from the arterial blood supply below the fascia. This study evaluated survival
of a pedicle flap with a perforator lateral branch and flowthrough blood supply, compared with that of a flap with a flowend
blood supply and perforator terminal branch.
Methods
Forty SpragueDawley rats, 20 in each group, were assigned to transfer of a superficial epigastric artery pedicle island flap with
a flowthrough or flowend configuration of blood supply. Laser Doppler imaging was used to evaluate flap perfusion 2h, 3days
and 5days after surgery. The rats were killed on day5, and lead oxidegelatineenhanced flap angiography and histology with
haematoxylin and eosin staining was performed. Dorsal midline tissue was excised for quantification of vascular endothelial
growth factor by western blot assay.
Results
On day5 after surgery, the flowthrough group exhibited a significantly greater mean(s.d.) flap survival area
(978(35) versus 808(102) per cent; P=0003), microvascular density (303(19) versus 207(41) per mm2; P<0001) and
perfusion (864(014) versus 595(014) perfusion units; P<0001) than the flowend group. The flowthrough group exhibited
more angiosomes connected by dilated vascular anastomoses between the skin and subcutaneous fasciae.
Conclusion
The flowthrough blood supply improved pedicle perforator flap survival.
Perforator flap failure is mainly the result of impaired blood supply, as a flowend blood configuration is nourished only by the
perforator terminal branch of the artery.
This work showed that the flowthrough blood supply nourished by the perforator lateral branch improved flap survival, with
dilatation of collateral vascular anastomoses and increased neoangiogenesis.
The use of a flowthrough configuration improves perforator flap survival and could therefore minimize morbidity resulting from
flap necrosis.

Surgical complications after open and laparoscopic surgery for perforated peptic ulcer in a nationwide cohort
Author: M. Wilhelmsen, M. H. Mller, S. Rosenstock
Background
Surgery for perforated peptic ulcer (PPU) is associated with a risk of complications. The frequency and severity of reoperative
surgery is poorly described. The aims of the present study were to characterize the frequency, procedureassociated risk and
mortality associated with reoperation after surgery for PPU.
Methods
All patients treated surgically for PPU in Denmark between 2011 and 2013 were included. Baseline and clinical data, including
90day mortality and detailed information on reoperative surgery, were collected from the Danish Clinical Register of
Emergency Surgery. Distribution frequencies of reoperation stratified by type of surgical approach (laparoscopy or open) were
reported. The crude and adjusted risk associations between surgical approach and reoperation were assessed by regression
analysis and reported as odds ratio (OR) with 95 per cent c.i. Sensitivity analyses were carried out.
Results
A total of 726 patients were included, of whom 238 (328 per cent) were treated laparoscopically and 178 (245 per cent) had a
laparoscopic procedure converted to laparotomy. Overall, 124 (171 per cent) of 726 patients underwent reoperation. A
persistent leak was the most frequent cause (43 patients, 59 per cent), followed by wound dehiscence (34, 47 per cent). The
crude risk of reoperative surgery was higher in patients who underwent laparotomy and those with procedures converted to
open surgery than in patients who had laparoscopic repair: OR 198 (95 per cent c.i. 119 to 327) and 236 (137 to 408)
respectively. The difference was confirmed when adjusted for age, surgical delay, comorbidity and American Society of
Anesthesiologists fitness grade. However, the intentiontotreat sensitivity analysis (laparoscopy including conversions)
demonstrated no significant difference in risk. The risk of death within 90 days was greater in patients who had reoperation:
crude and adjusted OR 153 (100 to 234) and 106 (065 to 172) respectively.
Conclusion
Reoperation was necessary in almost one in every five patients operated on for PPU. Laparoscopy was associated with lower
risk of reoperation than laparotomy or a converted procedure. However, there was a risk of bias, including confounding by
indication.

Association of hospital structures with mortality from ruptured abdominal aortic aneurysm
Author: B. A. Ozdemir, A. Karthikesalingam, S. Sinha, J. D. Poloniecki, A. VidalDiez, R. J. Hinchliffe, M. M. Thompson, P. J. E. Holt
Background
There is significant variation in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA) admitted to
hospital in England. This study sought to investigate whether modifiable differences in hospital structures and processes were
associated with differences in patient outcome.
Methods
Patients diagnosed with rAAA between 2005 and 2010 were extracted from the Hospital Episode Statistics database. After risk
adjustment, hospitals were grouped into lowmortality outlier, expected mortality and highmortality outlier categories. Hospital
Trustlevel structure and process variables were compared between categories, and tested for an association with riskadjusted
90day mortality and noncorrective treatment (palliation) rate using binary logistic regression models.
Results
There were 9877 patients admitted to 153 English NHS Trusts with an rAAA during the study. The overall combined (operative
and nonoperative) mortality rate was 675 per cent (palliation rate 416 per cent). Seven hospital Trusts (46 per cent) were
highmortality and 15 (98 per cent) were lowmortality outliers. Lowmortality outliers used significantly greater mean
resources per bed (doctors: 0922 versus 0513, P<0001; consultant doctors: 0316 versus 0168, P<0001; nurses:
2341 versus 1770, P<0001; critical care beds: 0045 versus 0019, P<0001; operating theatres: 0027 versus 0019, P=
0002) and performed more fluoroscopies (mean 126 versus 92 per bed; P=0046) than highmortality outlier hospital Trusts.
On multivariable analysis, greater numbers of consultants, nurses and fluoroscopies, teaching status, weekday admission and
rAAA volume were independent predictors of lower mortality and, excluding rAAA volume, a lower rate of palliation.
Conclusion
The variability in rAAA outcome in English National Health Service hospital Trusts is associated with modifiable hospital
resources. Such information should be used to inform any proposed quality improvement programme surrounding rAAA.

Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair
Author: M. W. Christoffersen, E. Brandt, F. Helgstrand, M. Westen, J. Rosenberg, H. Kehlet, P. Strandfelt, T. Bisgaard
Background
The mesh fixation technique in laparoscopic incisional hernia repair may influence the rates of hernia recurrence and chronic
pain. This study investigated the longterm risk of recurrence and chronic pain in patients undergoing laparoscopic incisional
hernia repair with either absorbable or nonabsorbable tacks for mesh fixation.
Methods
This was a nationwide consecutive cohort study based on data collected prospectively concerning perioperative information
and clinical followup. Patients undergoing primary, elective, laparoscopic incisional hernia repair with absorbable or non
absorbable tack fixation during a 4year interval were included. Followup was by a structured questionnaire regarding
recurrence and chronic pain, supplemented by clinical examination, and CT when indicated. Recurrence was defined as either
reoperation for recurrence or clinical/radiological recurrence.
Results
Of 1037 eligible patients, 849 per cent responded to the questionnaire, and 816 were included for analysis. The median
observation time for the cohort was 40 (range 072) months. The cumulative recurrencefree survival rate was 715 and 820
per cent after absorbable and nonabsorbable tack fixation respectively (P = 0007). In multivariable analysis, the use of
absorbable tacks was an independent risk factor for recurrence (hazard ratio 153, 95 per cent c.i. 111 to 209; P = 0008). The
rate of moderate or severe chronic pain was 153 and 161 per cent after absorbable and nonabsorbable tack fixation
respectively (P = 0765).
Conclusion
Absorbable tack fixation of the mesh was associated with a higher risk of recurrence than nonabsorbable tacks for laparoscopic
mesh repair of incisional hernia, but did not influence chronic pain.

Risk stratification by the Appendicitis Inflammatory Response score to guide decisionmaking in patients with suspected
appendicitis
Author: A. J. Scott, S. E. Mason, M. Arunakirinathan, Y. Reissis, J. M. Kinross, J. J. Smith
Background
Current management of suspected appendicitis is hampered by the overadmission of patients with nonspecific abdominal pain
and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory
Response (AIR) score to guide clinical decisionmaking were assessed.
Methods
During this 50week prospective observational study at one institution, the AIR score was calculated for all patients admitted
with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having
nonappendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the
AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations
were quantified.
Results
A total of 464 patients were included, of whom 210 (633 per cent) with nonappendicitis pain were correctly classified as low
risk. However, 13 lowrisk patients had appendicitis. Lowrisk patients accounted for 481 per cent of admissions (223 of 464),
57 per cent of negative explorations (48 of 84) and 507 per cent of imaging requests (149 of 294). An AIR score of 5 or more
(intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced
appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the
majority of patients with appendicitis in the highrisk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound
imaging could not exclude appendicitis in lowrisk patients (negative likelihood ratio (LR) 10) but could rulein the diagnosis in
intermediaterisk patients (positive LR 102). CT could exclude appendicitis in lowrisk patients (negative LR 00) and rulein
appendicitis in the intermediate group (positive LR 109).
Conclusion
Risk stratification of patients with suspected appendicitis by the AIR score could guide decisionmaking to reduce admissions,
optimize utility of diagnostic imaging and prevent negative explorations.

Outcome after surgical resection for duodenal adenocarcinoma in the UK

Author: L. Solaini, N. B. Jamieson, M. Metcalfe, M. Abu Hilal, Z. Soonawalla, B. R. Davidson, C. McKay, H. M. Kocher,
Background
Factors influencing longterm outcome after surgical resection for duodenal adenocarcinoma are unclear.
Methods

A prospectively created database was reviewed for patients undergoing surgery for duodenal adenocarcinoma in six UK
hepatopancreaticobiliary centres from 2000 to 2013. Factors influencing overall survival and diseasefree survival (DFS) were
identified by regression analysis.
Results
Resection with curative intent was performed in 150 (843 per cent) of 178 patients. The postoperative morbidity rate for these
patients was 400 per cent and the inhospital mortality rate was 33 per cent. Patients who underwent resection had a better
median survival than those who had a palliative surgical procedure (84 versus 8 months; P <0001). The 1, 3 and 5year
overall survival rates for patients who underwent resection were 839, 667 and 512 per cent respectively. Median DFS was 53
months, and 1 and 3year DFS rates were 808 and 565 per cent respectively. Multivariable analysis revealed that node status
(hazard ratio 173, 95 per cent c.i. 107 to 279; P = 0006) and lymphovascular invasion (hazard ratio 349, 183 to 664; P =
0003) were associated with overall survival.
Conclusion
Resection of duodenal adenocarcinoma in specialist centres is associated with good longterm survival. Lymphovascular
invasion and nodal metastases are independent prognostic indicators.

Effects of biliopancreatic diversion on diurnal leptin, insulin and free fatty acid levels
Author: M. Raffaelli, A. Iaconelli, G. Nanni, C. Guidone, C. Callari, J. M. Fernandez Real, R. Bellantone, G. Mingrone
Background
Free fatty acid (FFA) levels are raised in obesity as a consequence of increased production and reduced clearance. They may
link obesity with insulin resistance. Bariatric surgery can result in considerable weight loss and reduced insulin resistance, but
the mechanism of action is not well understood. Although drugs such as metformin that lower insulin resistance can contribute
to weight loss, a better understanding of the links between obesity, weight loss and changes in insulin resistance might lead to
new approaches to patient management.
Methods
Variations in circulating levels of leptin, insulin and FFAs over 24h were studied in severely obese (body mass index over 40
kg/m2) women before and 6 months after biliopancreatic diversion (BPD). Body composition was measured by dualenergy X
ray absorptiometry. A euglycaemichyperinsulinaemic clamp was used to assess insulin sensitivity. Levels of insulin, leptin and
FFAs were measured every 20min for 24h. Pulsatile hormone and FFA analyses were performed.
Results
Among eight patients studied, insulin sensitivity more than doubled after BPD, from mean(s.d.) 3978(774) to 9666(2701)
mmol per kg fatfree mass per min, under plasma insulin concentrations of 10229(960) and 9361(995) units/ml respectively.
The secretory patterns of leptin were significantly different from random but not statistically different before and after BPD, with
the exception of the pulse height which was reduced after surgery. Both plasma insulin and FFA levels were significantly higher
throughout the study day before BPD. Based on Granger statistical modelling, lowering of daily FFA levels was linked to
decreased circulating leptin concentrations, which in turn were related to the lowering of daily insulin excursions. Multiple
regression analysis indicated that FFA level was the only predictor of leptin level.
Conclusion
Lowering of circulating levels of FFAs after BPD may be responsible for the reduction in leptin secretion, which in turn can
decrease circulating insulin levels.
Insulin resistance is a common feature of obesity and type II diabetes. These patients are also relatively insensitive to the
biological effects of leptin, a satiety hormone produced mainly in subcutaneous fat.
Biliopancreatic diversion, a malabsorptive bariatric operation that drastically reduces circulating lipid levels, improves insulin
resistance independently of weight loss. The mechanism of action, however, has still to be elucidated.
This study demonstrated that normalization of insulin sensitivity after bariatric surgery was associated with a reduction in 24h
free fatty acid concentrations and changes in the pattern of leptin peaks in plasma. Bariatric surgery improves the metabolic
dysfunction of obesity, and this may be through a reduction in circulating free fatty acids and modification of leptin metabolism.

Identification of microRNAs associated with abdominal aortic aneurysms and peripheral arterial disease
Author: P. W. Stather, N. Sylvius, D. A. Sidloff, N. Dattani, A. Verissimo, J. B. Wild, H. Z. Butt, E. Choke, R. D. Sayers, M. J. Bown
Abstract
Background
MicroRNAs are crucial in the regulation of cardiovascular disease and represent potential therapeutic targets to decrease
abdominal aortic aneurysm (AAA) expansion. The aim of this study was to identify circulating microRNAs associated with AAA.
Methods
Some 754 microRNAs in wholeblood samples from 15 men with an AAA and ten control subjects were quantified using
quantitative reverse transcriptasePCR. MicroRNAs demonstrating a significant association with AAA were validated in

peripheral blood and plasma samples of men in the following groups (40 in each): healthy controls, controls with peripheral
arterial disease (PAD), men with a small AAA (3054mm), those with a large AAA (over 54mm), and those following AAA repair.
MicroRNA expression was also assessed in aortic tissue.
Results
Twentynine differentially expressed microRNAs were identified in the discovery study. Validation study revealed that let7e (fold
change (FC) 180; P = 0001), miR15a (FC 224; P < 0001) and miR196b (FC 226; P < 0001) were downregulated in
peripheral blood from patients with an AAA, and miR411 was upregulated (FC 590; P = 0001). miR196b was also
downregulated in plasma from the same individuals (FC 375; P = 0029). The same miRNAs were similarly expressed
differentially in patients with PAD compared with healthy controls. Validated and predicted microRNA targets identified through
miRWalk revealed that these miRNAs were all regulators of AAArelated genes (vascular cell adhesion molecule 1, intercellular
cell adhesion molecule 1, DAB2 interacting protein, 1antitrypsin, Creactive protein, interleukin 6, osteoprotegerin,
methylenetetrahydrofolate reductase, tumour necrosis factor ).
Conclusion
In this study, circulating levels of let7e, miR15a, miR196b and miR411 were differentially expressed in men with an AAA
compared with healthy controls, but also differentially expressed in men with PAD. Modulation of these miRNAs and their target
genes may represent a new therapeutic pathway to affect the progression of AAA and atherosclerosis.

Protein kinetics in human endotoxaemia and their temporal relation to metabolic, endocrine and proinflammatory cytokine
responses
Author: A. S. A. Khan, J. M. Gibson, G. L. Carlson, O. Rooyackers, J. P. New, M. Soop
Background
Sepsis is associated with profound alterations in protein metabolism. The unpredictable time course of sepsis and the
multiplicity of confounding factors prevent studies of temporal relations between the onset of endocrine and proinflammatory
cytokine responses and the onset of protein catabolism. This study aimed to determine the time course of wholebody protein
catabolism, and relate it to the endocrine, metabolic and cytokine responses in a human endotoxaemia model of early sepsis.
Methods
Six healthy male volunteers were studied twice in random order, before and for 600min after administration of either an
intravenous bolus of Escherichia colilipopolysaccharide (LPS) or sterile saline. Wholebody protein synthesis, breakdown and net
protein breakdown were measured by amino acid tracer infusion, and related to changes in plasma levels of growth hormone,
glucagon, cortisol, insulinlike growth factor (IGF) 1, tumour necrosis factor (TNF) and interleukin (IL) 6.
Results
Protein synthesis, breakdown and net protein breakdown increased and peaked 120min after LPS administration (P <0001),
the alterations persisting for up to 480min. These peaks coincided with peaks in plasma growth hormone, TNF and IL6
concentrations (P = 0049, P < 0001 and P < 0001 for LPS versus saline), whereas plasma cortisol concentration peaked later.
No alterations in plasma insulin or glucagon concentrations, or in the IGF axis were observed during the period of abnormalities
of protein metabolism.
Conclusion
LPS administration induced an early protein catabolic response in young men and this coincided with changes in plasma growth
hormone, TNF and IL6 concentrations, rather than changes in cortisol, glucagon, insulin or the IGF axis.
Sepsis in surgical patients is common and remains associated with substantial mortality. Although sepsis is a heterogeneous
condition and its pathophysiology therefore difficult to study, a universal and profound clinical problem is protein catabolism not
responsive to nutritional support. Human experimental endotoxaemia is a promising model of clinical sepsis that can be used to
elucidate underlying pathophysiology and explore novel therapeutic approaches.
This study demonstrates that human experimental endotoxaemia replicates the changes in wholebody protein turnover seen in
clinical sepsis. Frequent measurements allowed identification of tumour necrosis factor (TNF) , interleukin (IL) 6 and growth
hormone as putative mediators.
Human experimental endotoxaemia is a valid model for further study of mechanisms and putative therapies of catabolism
associated with sepsis. In particular, effects of TNF and IL6 blockade should be evaluated.

Prognostic characteristics of duodenal gastrointestinal stromal tumours

Author: Q. Zhang, C.H. Shou, J.R. Yu, W.L. Yang, X.S. Liu, H. Yu, Y. Gao, Q.Y. Shen, Z.C. Zhao
Background
This study evaluated the clinical characteristics, surgical procedures and prognosis of duodenal gastrointestinal stromal
tumours (GISTs).
Methods

Patients with a diagnosis of primary duodenal GIST treated between January 2000 and December 2012 were analysed. Patients
with gastric and small intestinal GISTs were chosen as control groups according to the following parameters: age, tumour size,
mitotic index and adjuvant imatinib therapy. Operative procedures for patients with duodenal GIST included
pancreaticoduodenectomy or limited resection. Diseasefree survival (DFS) was calculated using KaplanMeier analysis.
Results
Some 71 patients with duodenal, 71 with gastric and 70 with small intestinal GISTs were included in the study. DFS of patients
with duodenal GIST was shorter than that of patients with gastric GIST (3year DFS 84 versus 94 per cent; hazard ratio (HR)
3.67, 95 per cent c.i. 1.21 to 11.16; P=0.014), but was similar to that of patients with small intestinal GIST (3year DFS
84 versus 81 per cent; HR 0.75, 0.37 to 1.51; P=0.491). Patients who underwent pancreaticoduodenectomy were older, and
had larger tumours and a higher mitotic index than patients who had limited resection. The 3year DFS was 93 per cent among
patients who had limited resection compared with 64 per cent for those who underwent PD (HR 0.18, 0.06 to 0.59; P=0.001).
Conclusion
The prognosis of duodenal GISTs is similar to that of small intestinal GISTs.

Surgical treatment of gastrointestinal stromal tumour of the rectum in the era of imatinib
Author: M. J. Wilkinson, J. E. F. Fitzgerald, D. C. Strauss, A. J. Hayes, J. M. Thomas, C. Messiou, C. Fisher, C. Benson, P. P. Tekkis, I.
Judson
Background
Gastrointestinal stromal tumours (GISTs) of the rectum often require radical surgery to achieve complete resection. This study
investigated the management and outcome of surgery for rectal GISTs and the role of imatinib.
Methods
A cohort study was undertaken of patients identified from a database at one tertiary sarcoma referral centre over a continuous
period, from January 2001 to January 2013.
Results
Over 12 years, 19 patients presented with a primary rectal GIST. Median age was 57 (range 3077) years. Neoadjuvant imatinib
was used in 15 patients, significantly reducing mean tumour size from 76 (95 per cent c.i. 61 to 90) to 41 (28 to 53) cm (P <
0001). Nine of these patients underwent surgical resection. Imatinib therapy enabled sphincterpreserving surgery to be
undertaken in seven patients who would otherwise have required abdominoperineal resection or pelvic exenteration for tumour
clearance. Neoadjuvant imatinib treatment also led to a significant reduction in mean(s.d.) tumour mitotic count from 16(16) to
4(9) per 50 highpower fields (P = 0015). Imatinib was used only as adjuvant treatment in two patients. There were three
deaths, all from unrelated causes. Eleven of the 13 patients who underwent resection were alive without evidence of recurrence
at latest followup, with a median diseasefree survival of 38 (range 20129) months and overall survival of 62 (39162)
months.
Conclusion
The use of neoadjuvant imatinib for rectal GISTs significantly decreased both tumour size and mitotic activity, which permitted
less radical sphincterpreserving surgery.

Scoring system to distinguish uncomplicated from complicated acute appendicitis

Author: J. J. Atema, C. C. van Rossem, M. M. Leeuwenburgh, J. Stoker, M. A. Boermeester
Background
Nonoperative management may be an alternative for uncomplicated appendicitis, but preoperative distinction between
uncomplicated and complicated disease is challenging. This study aimed to develop a scoring system based on clinical and
imaging features to distinguish uncomplicated from complicated appendicitis.
Methods
Patients with suspected acute appendicitis based on clinical evaluation and imaging were selected from two prospective
multicentre diagnostic accuracy studies (OPTIMA and OPTIMAP). Features associated with complicated appendicitis were
included in multivariable logistic regression analyses. Separate models were developed for CT and ultrasound imaging,
internally validated and transformed into scoring systems.

Results
A total of 395 patients with suspected acute appendicitis based on clinical evaluation and imaging were identified, of whom 110
(278 per cent) had complicated appendicitis, 239 (605 per cent) had uncomplicated appendicitis and 46 (116 per cent) had
an alternative disease. CT was positive for appendicitis in 284 patients, and ultrasound imaging in 312. Based on clinical and CT
features, a model was created including age, body temperature, duration of symptoms, white blood cell count, Creactive
protein level, and presence of extraluminal free air, periappendiceal fluid and appendicolith. A scoring system was constructed,
with a maximum possible score of 22 points. Of the 284 patients, 150 had a score of 6 points or less, of whom eight (53 per
cent) had complicated appendicitis, giving a negative predictive value (NPV) of 947 per cent. The model based on ultrasound

imaging included the same predictors except for extraluminal free air. The ultrasound score (maximum 19 points) was
calculated for 312 patients; 105 had a score of 5 or less, of whom three (29 per cent) had complicated appendicitis, giving a
NPV of 971 per cent.
Conclusion
With use of novel scoring systems combining clinical and imaging features, 95 per cent of the patients deemed to have
uncomplicated appendicitis were correctly identified as such. The score can aid in selection for nonoperative management in
clinical trials.