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8th September - Mortality of emergency abdominal surgery in high-, mid ... (Thread closed)

Welcome to Scalpel's first journal club of the academic year 2016/17!

A link to the paper to be discussed can be found below:

http://onlinelibrary.wiley.com/doi/10.1002/bjs.10151/abstract

The paper is authored by GlobalSurg Collaborative, a collaborative that enables students and doctors of all grades to be involved in research, the paper included data from over 10,000 patients, collected across 58 countries worldwide The discussion will start at 7pm on Thursday 8th September and run for approximately 1 hour.  The link to the discussion room can be found at the following link (you must be logged in):

 http://www.scalpelmanchester.com/new/resources/journal-club/discussion/


About Scalpel journal club:

This is a series of events that helps to educate students on how to critique an academic paper, under the careful supervision of a doctor. No experience of assessing papers or being part of a journal club is necessary! Just come along and learn some skills that will be essential for PEP and your future career!

Scalpel

Please note the next discussion does not start until Thursday 8th September, 7:00pm. The article to be discussed can be found: http://onlinelibrary.wiley.com/doi/10.1002/bjs.10151/abstract

 

nboxall:

9/08 05:41PM

Hi all,

Nick Boxall, Urology SpR at Salford. Looking forward to chairing the discussions a bit later this evening.

 

Nick Ward:

9/08 06:43PM

Hi all, Welcome to journal club and a big thanks to Dr Boxall for joining us tonight! We are looking to kick things off at 6pm, in the mean time if you would like to introduce yourself and leave your email (for a certificate) that would be great.

 

Nick Ward:

9/08 06:44PM

I'm Nick, one of the scalpel committee, i'm a 5th year based at Salford

 

dwang:

9/08 07:02PM

I'm Derek, a final year based at Salford. the email address is haoyu.wang-2@student.manchester.ac.uk

 

nboxall :

9/08 07:02PM

Will wait a couple more minutes for other participants to join before kicking off

 

sinthu0901 :

9/08 07:03PM

Hi I'm Sinthu another 5th year at Salford. sinthuja.naguleswaran@student.manchester,ac.uk

 

sinthu0901 :

9/08 07:03PM

*sinthuja.naguleswaran@student.manchester.ac.uk

 

nboxall :

9/08 07:06PM

We'll crack on then and others can catch up later

 

Nick Ward:

9/08 07:06PM

thanks nick

 

nboxall

9/08 07:08PM

So, what did people think of the topic? Is it relevant? Does it affect our practice?

 

Nick Ward

9/08 07:09PM

I think its an interesting article that due to the number of collaborators allowed data to be gained on an issue that otherwise wouldn't have been possible

 

nboxall

9/08 07:10PM

I agree it's a good number of collaborators. However, does anyone have any thoughts on who the collaborators are and how this may affect the data?

 

Nick Ward

9/08 07:11PM

As to how it would affect our practice i'm not sure?

 

dwang

9/08 07:11PM

I agree. a good global study breaking the borders of the continents

 

dwang

9/08 07:12PM

i think most of the collaborators were junior doctors/med students weren't they?

 

nboxall

9/08 07:12PM

Re: our own practice, it's an important question I think for these forums. If

 

Nick Ward

9/08 07:12PM

i agree with that for the participants derek

 

nboxall

9/08 07:13PM

The more relevant an article, the more it may affect your own practice

 

dwang

9/08 07:13PM

it may affect the practice in low income countries i would think.

 

sinthu0901

9/08 07:13PM

I agree, as in the results it's the low and middle HDI countries that have the highest mortality rate

 

sinthu0901

9/08 07:14PM

and they did comment on the fact that whensafety checklists were used it did reduce it

 

dwang

9/08 07:14PM

good effort for those guys organising this study and writing it up.

 

Nick Ward

9/08 07:14PM

although many confounding factors it may possibly highlight the importance of a surgical checklist in decreassing mortality

 

dwang

9/08 07:14PM

i think the checklist thing could be implemented in low and middle HDI countries

 

dwang

9/08 07:15PM

so that's relevant

 

nboxall

9/08 07:17PM

there is excellent evidence already for the WHO checklist. It's not expensive so is easily implementable. I think the results aren't particularly surprising though with low HDI countries but I think when you take into account as well that the collaborators from these hospitals are likely to be from university hospitals where there is better access to healthcare that things may be worse in the low HDI countries than is actually portrayed

 

Nick Ward

9/08 07:18PM

I fully agree, along with this being a self selected study, could this be a case of selection bias?

 

sinthu0901

9/08 07:19PM

It's also a matter of training staff in using the lists aswell I think. In some of the middle and low HDI countries they were available just not used

 

dwang

9/08 07:19PM

centres with better resources or able to perform these kind of surgeries were selected. definitely a selection bias.

 

sinthu0901

9/08 07:20PM

Yes definitely selection bias

 

Nick Ward

9/08 07:20PM

any ideas on how this bias could have been avoided?

 

dwang

9/08 07:21PM

it's tricky isn't it. i think firstly it's hard to get this project organsied in such global scale. maybe only selecting teaching hospitals in each country?

 

sinthu0901

9/08 07:22PM

I was thinking the same - it needs to compare similar types of hospitals in different countries

 

sinthu0901

9/08 07:23PM

Even in the UK theres in a difference in patients seen in DGHS and specialists centres , if they come through A&E/emergency cases

 

nboxall

9/08 07:24PM

very difficult to do that. Just university hospitals? What about major trauma centres? There are many teaching hospitals where vascular surgery is not available S an example

 

 

Nick Ward

9/08 07:24PM

although it would have massively reduced numbers would it have been more accurate to limit data collection to a single procedure, e.g. emeergency appendectomy?

 

nboxall

9/08 07:25PM

that brings me nicely on to something else I was going to bring up: pathology

 

dwang

9/08 07:25PM

i was pretty glad that they also analysed results after patients who were discharged before 30 days were excluded as they were regarded as alive. otherwise would have been another limitation.

 

sinthu0901

9/08 07:26PM

that could work - it would need to be an emergency procedure that is common globally

 

sinthu0901

9/08 07:26PM

to get enough data on it

 

nboxall

9/08 07:26PM

Certainly appendicectomies are common worldwide by the looks of the data they have!

 

dwang

9/08 07:27PM

but for emergency appendectomy, it's not much difference between countries in terms of the mortality rate as it is relatively a safe procedure isn't it

 

sinthu0901

9/08 07:28PM

It is, but if you think in some areas of low HDI countries there might not be adequate resources or follow up

 

nboxall

9/08 07:28PM

I certainly think trauma should have been excluded. We know that trauma in this country is generally blunt and he traumatic pathology is much more different to that encountered in more economically deprived countries, and more prevalent too

 

sinthu0901

9/08 07:28PM

even if the procedure itself goes well

 

sinthu0901

9/08 07:28PM

I agree

 

dwang

9/08 07:28PM

true that Nick

 

nboxall

9/08 07:31PM

Appendicectomy may be a reasonable procedure. However, in this country we rarely do an open appendix these days. I imagine that's different elsewhere. Laparoscopic vs open could confound things further

 

sinthu0901

9/08 07:32PM

As well as trauma, I think the patients where no disease was identified could have been excluded

 

Nick Ward

9/08 07:32PM

I thought it was remarkable that only 6% of cases in low HDI countries was laproscopic!

 

sinthu0901

9/08 07:33PM

Do you think thats a representable number or could there have been issues with communication/documentation etc? I wasn't sure

 

Nick Ward

9/08 07:34PM

I think that could be true but i'm not sure

 

nboxall

9/08 07:37PM

im not surprised at the low lap rate in low HDI countries

 

nboxall

9/08 07:38PM

a laparoscopic procedure is expensive and the training associated with them is significant

 

nboxall

9/08 07:39PM

I agree about the proposed exclusion of 'pathology unknown' and I'll explain my reasons in a minute unless anyone has any ideas?

 

sinthu0901

9/08 07:40PM

Unknown pathology can account for so many different things

 

dwang

9/08 07:41PM

are you referring to 'other abdominal'?

 

Nick Ward

9/08 07:41PM

I don't really understand the surgeries that could have been performed for no pathology found

 

Nick Ward

9/08 07:41PM

and complication of a previous procedure could span many pathologies also

 

 

 

sinthu0901

9/08 07:41PM

In low HDIs there could be cases where surgery was performed to explore a cause/diagnosis where they don't have high tech diagnostic equipment

 

sinthu0901

9/08 07:42PM

Or at least a limited amount of those resources

 

sinthu0901

9/08 07:42PM

CTs/endoscopes etc? Just a guess!

 

nboxall

9/08 07:43PM

Yes Sinthu, that was exactly my point. Look at how many CTs are performed in higher HDI countries. The prospect of an exploratory laparotomy for

 

nboxall

9/08 07:43PM

is a lot more necessary in the absence of CT

 

nboxall

9/08 07:44PM

Whereas in the UK, we have our 'CT in the hour' for an acute abdomen

 

nboxall

9/08 07:44PM

via the NELA guideline

 

Nick Ward

9/08 07:46PM

I'd never heard of the NELA guideline but it looks quite interesting and something I will definitely read up on thanks

 

sinthu0901

9/08 07:47PM

I haven't come across it before either

 

nboxall

9/08 07:47PM

It's worth a look at and is very relevant to this paper. The website is quite helpful but if anyone wants more info on it am happy to chat after this journal club

 

nboxall

9/08 07:49PM

gallstone disease, 'other abdominal', they're all very different pathologies to appendictomy and trauma

 

nboxall

9/08 07:50PM

I do not think appendicectomy or gallbladder disease are fair comparisons to make between high and low HDI countries because of how prevalent laparoscopic surgery is in high hdi countries

 

Nick Ward

9/08 07:51PM

i agree the 48 vs 6% laproscopic rates could have a major impact upon the outcomes

 

sinthu0901

9/08 07:52PM

yes definitely

 

dwang

9/08 07:52PM

it seems like there is no prefect procedure that could be compared.

 

nboxall

9/08 07:53PM

I think only grossly contaminated faecal peritonitis secondary to perforated hollow viscus could be compared as that's never laparoscopic

 

dwang

9/08 07:54PM

don't know how accessible ultrasound is in low HDI countries. no data on this.

 

sinthu0901

9/08 07:54PM

Yes I agree, along with the fact that what might be a quite straight forward clinical situation in high HDI countries might be quite a serious emergency in lower ones

 

sinthu0901

9/08 07:55PM

ultrasound is also user dependent isn't it? so again training comes into it

 

dwang

9/08 07:55PM

cause it seems like in low HDI countries, there were less gallbladder procedures but then again lifestyle plays a part here.

 

nboxall

9/08 07:57PM

not just lifestyle but also culture, if you co to hospital in the UK with biliary colic or cholecystitis, you expect an operation. Perhaps elsewhere in the world where there is more paternalism, people are more willing to be treated with analgesia or antibiotics

 

sinthu0901

9/08 07:58PM

That's true. probably the cheaper option aswell?

 

nboxall

9/08 07:58PM

right, last few minutes. Seem to have covered a lot, but could go on for longer! Anyone have any closing thoughts or things they wish to discuss?

 

 

 

 

 

Nick Ward

9/08 08:00PM

i think it was a quite general audit undertaken with many limitations but as the paper states the number of collaborators and connections made from this study may build bridges for other more complex audits

 

sinthu0901

9/08 08:00PM

It's a good starting point for this kind of data and analysis. Any global comparison is going to be difficult so they still managed to get quite a lot of good data

 

sinthu0901

9/08 08:01PM

I agree, definitely could be looked into further but possibly narrowing down the selection criteria

 

Nick Ward

9/08 08:02PM

also on behalf of myself and scalpel id like to thank Dr Boxall and everyone for attending and if anyone has any feedback of how future journal clubs could be improved, feel free to email me, any feedback would be much appreciated!

 

dwang

9/08 08:02PM

just looking at their website, they are now narrowing things down a bit. the 2nd project they are looking at SSI

 

dwang

9/08 08:03PM

thanks a lot for organising. i found it useful

 

sinthu0901

9/08 08:03PM

Thanks Nick and Dr Boxall! It's been a good discussion

 

dwang

9/08 08:03PM

Thanks Dr Boxall. Are you an academic surgeon in Salford?

 

sinthu0901

9/08 08:04PM

Oh SSIs could be an interesting one

 

nboxall

9/08 08:05PM

I agree with these points made. Thank you all for your participation and to Scalpel for inviting me to chair this. If anyone wants any help with anything urogical in Salford then they're always welcome. I regularly hold teaching sessions but have no phas II students yet. I'm not an academic surgeon, am a senior clinical fellow in urology, SpR level

 

nboxall

9/08 08:05PM

i have to go now but Nick has my contact details if anyone wants to get in contact. Thank you again!

 

dwang

9/08 08:07PM

Thanks guys