Abstract Background Despite significant changes in healthcare, work practices, and leisure activity, the proposed precipitating factors for abdominal wall hernias have remained largely unchanged for almost two centuries. We aimed to investigate if there have been shifts in these factors over time by examining patients’ perception of precipitating factors for abdominal wall hernia development. This study was conducted in the Royal College of Surgeons In Ireland Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, where patients with abdominal wall hernias completed a questionnaire . Results A total of 277 patients (mean age 55.7; 85.6% male) with abdominal wall hernia completed the questionnaire (66.1% inguinal; 10.8% umbilical; 6.9% paraumbilical; 10.5% epigastric; 3.2% incisional; 1.4% femoral, and 1.1% port-site). One hundred and twenty patients (43.3%) believed their hernia was due to lifting, 71 (25.6%) cited gym activity and 17 (6.1%) cited other sporting activities as the precipitating factor. Traditional factors – chronic cough and constipation - were cumulatively cited only by 11 patients (4.0%), while prostatic obstruction was not cited by any. Conclusion This study suggests that fitness pursuits may be an increasing contributor to the development of abdominal wall hernia. Greater attention should be paid to the proper use of gym equipment to minimise the risk of hernia development.

BACKGROUND:There is currently no consensus on the role, method or frequency of surveillance following curative treatment of oesophageal cancer; re-investigation largely relying on symptom triggers which may delay detection of recurrence and impact survival. We hypothesised that intensive surveillance with endoscopy and imaging was more likely to detect recurrent or new cancer at a curable stage and this study examined the outcomes of this surveillance policy. PATIENTS AND METHODS:A prospective database of curatively treated oesophageal carcinoma patients was interrogated for patients with new or recurrent disease detected on surveillance and amenable to salvage surgery. Surveillance was by clinic visits and endoscopy/biopsy 3-monthly to 3 years, 6-montjhly to 5 years and yearly thereafter while computerised tomography (CT) was performed 6-monthly for the first 3 years, annually to 5 years, and subsequently as indicated. RESULTS:Of 205 patients treated with curative intent, 24 (11.7 %) underwent salvage surgery for 27 incidences of new or recurrent cancer. The median and 5-year survival was 51.8 months and 45.8 %, which was not inferior to the entire cohort of patients treated for cure, which was 30.2 months and 32.6 % respectively (p = 0.498). CONCLUSIONS:Intensive surveillance identified almost 12 % of patients with recurrent or second primary cancer amenable to salvage surgery, with a non-inferior outcome to the remaining cohort. Further studies will refine surveillance intervals, techniques and follow-up duration for oesophageal cancer as for other GI malignancies.

Abstract Background The incidence of esophageal cancer is disproportionately greater in males, but trials of treatments are not gender stratified. It is unclear whether the response or outcome following neoadjuvant chemoradiotherapy (NCR) is gender specific. This study compared the presentation, response to NCR and outcome of female with male patients. (48) Methods A prospectively maintained database of 205 esophageal carcinoma patients treated with curative intent between 1998 and 2019 was interrogated for the impact of gender on presentation, response to NCR treatment and survival. (32 words) Results Of 205 patients, 59 (29%) females were significantly older than males [mean (SD) age 66.1 (10.8) v. 61.6 (11.2) (p=0.008)]. Sixty-six percent of females had squamous cell carcinoma (SCC) while 116 (79.5%) males had adenocarcinoma (AC) (<0.001). Females with SCC had a mean age 66.7 years versus 58.9 years for males (p=0.006). Seventy-eight percent of females had a clinical complete response (cCR), versus 43.8% of males (P<0.001). Sixty-nine percent of females with AC had a cCR versus 39% of males (p=0.04). Controlling for age, diagnostic stage and treatment type, females survived significantly longer than males [HR 0.71 CI 0.52-0.98 (p=0.035)]. (100 words) Conclusion This study found that females were on average a decade older with a significantly greater cCR rate, and a superior survival advantage compared to males. This suggests that randomized trials should stratify for gender. (35 words)

The prognosis of patients with adenocarcinoma of the esophagus and esophagogastric junction (AEG) is poor. From current evidence, it remains unclear to what extent preoperative chemoradiotherapy (CRT) or preoperative and/or perioperative chemotherapy achieve better outcomes than surgery alone. To assess the association of preoperative CRT and preoperative and/or perioperative chemotherapy in patients with AEG with overall survival and other outcomes. Literature search in PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and International Clinical Trials Registry Platform was performed from inception to April 21, 2023. Two blinded reviewers screened for randomized clinical trials comparing preoperative CRT plus surgery with preoperative and/or perioperative chemotherapy plus surgery, 1 intervention with surgery alone, or all 3 treatments. Only data from participants with AEG were included from trials that encompassed mixed histology or gastric cancer. Among 2768 initially identified studies, 17 (0.6%) met the selection criteria. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed for extracting data and assessing data quality by 2 independent extractors. A bayesian network meta-analysis was conducted using the 2-stage approach. Overall and disease-free survival, postoperative morbidity, and mortality. The analyses included 2549 patients (2206 [86.5%] male; mean [SD] age, 61.0 [9.4] years) from 17 trials (conducted from 1989-2016). Both preoperative CRT plus surgery (hazard ratio [HR], 0.75 [95% credible interval (CrI), 0.62-0.90]; 3-year difference, 105 deaths per 1000 patients) and preoperative and/or perioperative chemotherapy plus surgery (HR, 0.78 [95% CrI, 0.64-0.91]; 3-year difference, 90 deaths per 1000 patients) showed longer overall survival than surgery alone. Comparing the 2 modalities yielded similar overall survival (HR, 1.04 [95% CrI], 0.83-1.28]; 3-year difference, 15 deaths per 1000 patients fewer for CRT). Similarly, disease-free survival was longer for both modalities compared with surgery alone. Postoperative morbidity was more frequent after CRT plus surgery (odds ratio [OR], 2.94 [95% CrI, 1.01-8.59]) than surgery alone. Postoperative mortality was not significantly more frequent after CRT plus surgery than surgery alone (OR, 2.50 [95% CrI, 0.66-10.56]) or after chemotherapy plus surgery than CRT plus surgery (OR, 0.44 [95% CrI, 0.08-2.00]). In this meta-analysis of patients with AEG, both preoperative CRT and preoperative and/or perioperative chemotherapy were associated with longer survival without relevant differences between the 2 modalities. Thus, either of the 2 treatments may be recommended to patients.

Importance The prognosis of patients with adenocarcinoma of the esophagus and esophagogastric junction (AEG) is poor. From current evidence, it remains unclear to what extent preoperative chemoradiotherapy (CRT) or preoperative and/or perioperative chemotherapy achieve better outcomes than surgery alone. Objective To assess the association of preoperative CRT and preoperative and/or perioperative chemotherapy in patients with AEG with overall survival and other outcomes. Data Sources Literature search in PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and International Clinical Trials Registry Platform was performed from inception to April 21, 2023. Study Selection Two blinded reviewers screened for randomized clinical trials comparing preoperative CRT plus surgery with preoperative and/or perioperative chemotherapy plus surgery, 1 intervention with surgery alone, or all 3 treatments. Only data from participants with AEG were included from trials that encompassed mixed histology or gastric cancer. Among 2768 initially identified studies, 17 (0.6%) met the selection criteria. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed for extracting data and assessing data quality by 2 independent extractors. A bayesian network meta-analysis was conducted using the 2-stage approach. Main Outcomes and Measures Overall and disease-free survival, postoperative morbidity, and mortality. Results The analyses included 2549 patients (2206 [86.5%] male; mean [SD] age, 61.0 [9.4] years) from 17 trials (conducted from 1989-2016). Both preoperative CRT plus surgery (hazard ratio [HR], 0.75 [95% credible interval (CrI), 0.62-0.90]; 3-year difference, 105 deaths per 1000 patients) and preoperative and/or perioperative chemotherapy plus surgery (HR, 0.78 [95% CrI, 0.64-0.91]; 3-year difference, 90 deaths per 1000 patients) showed longer overall survival than surgery alone. Comparing the 2 modalities yielded similar overall survival (HR, 1.04 [95% CrI], 0.83-1.28]; 3-year difference, 15 deaths per 1000 patients fewer for CRT). Similarly, disease-free survival was longer for both modalities compared with surgery alone. Postoperative morbidity was more frequent after CRT plus surgery (odds ratio [OR], 2.94 [95% CrI, 1.01-8.59]) than surgery alone. Postoperative mortality was not significantly more frequent after CRT plus surgery than surgery alone (OR, 2.50 [95% CrI, 0.66-10.56]) or after chemotherapy plus surgery than CRT plus surgery (OR, 0.44 [95% CrI, 0.08-2.00]). Conclusions and Relevance In this meta-analysis of patients with AEG, both preoperative CRT and preoperative and/or perioperative chemotherapy were associated with longer survival without relevant differences between the 2 modalities. Thus, either of the 2 treatments may be recommended to patients.

Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, ‘real-world’ clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes. This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020–2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days. A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24–46] vs 38 [26–55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6

There is increasing recognition that point-of-care ultrasound (POCUS), performed by the clinician at the bedside, can be a natural extension of the clinical examination—the modern abdominal “stethoscope” and provides an opportunity to expedite the care pathway for patients with acute gallbladder disease. The primary aims of this study were to benchmark the accuracy of surgeon-performed POCUS in suspected acute gallbladder disease against standard radiology or pathology reports and to compare time to POCUS diagnosis with time to definitive imaging. This prospective single-arm observational cohort study was conducted in four hospitals in Ireland, Italy, and Portugal to assess the accuracy of POCUS against standard radiology in patients with suspected acute biliary disease (ClinicalTrials.govIdentifier: NCT02682368). The findings of surgeon-performed POCUS were compared with those on definitive imaging or surgery. Of 100 patients recruited, 89 were suitable for comparative analysis, comparing POCUS with radiological findings in 84 patients and with surgical/histological findings in five. The overall global accuracy of POCUS was 88.7% (95% CI, 80.3–94.4%), with a sensitivity of 94.7% (95% CI, 85.3–98.9%), a specificity of 78.1% (95% CI, 60.03–90.7%), a positive likelihood ratio (LR+) of 4.33 and negative likelihood ratio (LR) of 0.07. The mean time from POCUS to the final radiological report was 11.9 h (range 0.06–54.9). In five patients admitted directly to surgery, the mean time between POCUS and incision was 2.30 h (range 1.5–5), which was significantly shorter than the mean time to formal radiology report. Sixteen patients were discharged from the emergency department, of whom nine did not need follow-up. Our study is one of the very few to demonstrate a high concordance between surgeon-performed POCUS of patients without a priori radiologic diagnosis of gallstone disease and shows that the expedited diagnosis afforded by POCUS can be reliably leveraged to deliver earlier definitive care for patients with acute gallbladder pathology, as the general surgeon skilled in POCUS is uniquely positioned to integrate it into their bedside assessment.

There is no accepted surveillance strategy following curative oesophageal cancer management, with reinvestigation often relying on symptom development. Lack of a surveillance standard may impact on outcome and survival. We hypothesized that strict surveillance was more likely to detect curable recurrent disease. This study compared the outcome for salvage surgery for recurrent disease, detected on a strict surveillance program, with survival of patients that had undergone immediate surgery following an incomplete response to neoadjuvant chemoradiotherapy. A prospective database of oesophageal carcinoma patients who were treated with curative intent (Surgery alone, Neoadjuvant Chemoradiotherapy (NeoCR) plus surgery, Definitive Chemoradiotherapy or Neoadjuvant Chemoradiotherapy with surveillance by choice), was interrogated for patients with recurrent disease amenable to salvage surgery. Surveillance for all consisted of 3-monthly endoscopy and 6-monthly CT scanning for 3 years, followed by 6-monthly endoscopy and yearly CT scanning to 5 years, and both yearly thereafter. If recurrence was diagnosed patients were restaged and, if suitable, underwent salvage surgery. Their outcome was compared with patients undergoing neoadjuvant chemoradiotherapy and having immediate surgery for an incomplete response. Of 205 patients treated with curative intent, 18 (9%) underwent salvage surgery for locoregional recurrence. They had a median survival of 61.6 months (range 10.32 to 136.08) and a 3-year survival of 50%. This compares to 115 patients who underwent surgery following incomplete response to NeoCR, who had a median survival of 38.3 months (range 2.20 to 254.26) and a 3 year survival of 44%, which was statistically insignificant between the groups (p= 0.975). The overall mean survivals were 57.84 months and 57.9 months respectively. Intensive surveillance identified a cohort of patients (9% of total) with recurrence amenable to salvage surgery and with outcomes non-inferior to immediate surgery following NeoCR. As most were asymptomatic, it is suggested that without surveillance the opportunity for curative intervention would have been lost. Even novel treatments will require detection of recurrence before disease becomes unmanageable. It is suggested that surveillance guidelines be updated to standardize interval endoscopy/imaging, as for other GI malignancies.

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The COVID-19 pandemic poses enormous challenges to the delivery of healthcare worldwide. This is paralleled by a reduction in surgical training opportunities. The COVIDSurg research collaborative predicted cancellation of over 28 million elective cases during the first wave of the pandemic in early 2020. As the world combats new waves of infection, and increasingly virulent strains of COVID-19, health services have seen a return to restraints on elective activity similar to those of early 2020. This raises barriers to the traditional model of surgical training. Although vaccines provide hope, the future remains uncertain. It is therefore important to count the cost of this pandemic to trainees and to consider correctives. A recent questionnaire delivered to Irish surgical trainees showed that most respondents believed the pandemic had negatively impacted their access to elective activity. There are few data, however, to quantify that impact or how it is distributed across training grades. An analysis of theatre registry data from a Dublin teaching hospital was performed, comparing activity in the second quarter of 2020 with the same period in 2019 (Table 1). Theatre activity consisted of general and local anaesthetic procedures, as well as emergency and therapeutic endoscopy. Overall, 382 fewer operations were performed during the second quarter of 2020 than in the same period in 2019, representing a 66 per cent decrease in training opportunities. When the impact was correlated with training grade, all grades experienced large decreases in their opportunities as lead operator between the two periods: specialist registrars suffered a greater than 70 per cent decrease to six cases per month per person; service registrars suffered a 66 per cent decrease to five cases per month per registrar; senior house officers on the core surgical training scheme suffered an over 80 per cent decrease to less than two cases per month each; and senior house officers in service positions suffered a 70 per cent decrease to less than two cases per month. Similar reductions in training opportunities as first assistant were also observed across all grades. While operating time has been decimated by the pandemic, trainees have focused their attention on non-technical skill sets. Collaboratives such as the COVIDSurg and Young BJS groups, involving participants from over 60 countries, have allowed trainees to develop team working and academic skills, and training institutions such as the Royal Colleges of Surgeons have embraced video-conferencing technology to facilitate trainee engagement and continued learning. Learning to operate safely, however, remains the bedrock of surgical training. Although the ability to deliver hands-on clinical operative training is impaired, increased use of novel technologies, including online platforms such as TouchSurgery (https://www.touchsurgery.com) and home laparoscopic box kits, have been shown to help in key skill acquisition and may, partially, fill this gap. Future training programmes, however, first need to assess the impact that the pandemic has had on trainee skill sets, as trainees may not be best judges of its impact on their competencies. They will then need to correct any deficit. With bold innovation and leadership, such deficiencies can be corrected. The CholeS study revealed that only 17 per cent of all cholecystectomies were performed by senior trainees, with consultants performing over 80 per cent. This is probably representative of all other major procedures. When current elective surgery restrictions are lifted, consideration must be given to suspending the current ‘efficiency’ model in favour of ensuring that trainees are proctored through these cases to rectify the accumulated training deficit exacerbated by the pandemic. This may help to mitigate the effects of the pandemic and ensure the continued production of Table 1 Comparison of theatre registry data for 2019 and 2020

Background: The COVID-19 pandemic poses unparalleled problems for the safe delivery of surgical care worldwide, initially resulting in the cancellation of all but the most urgent procedures. This has been paralleled by a reduction in surgical training opportunities, with long-term implications for the future delivery of surgical care.

The article is written partially in response to the article by Gustaffson et al on "Out of hours cholecystectomy" and emphasizes the importance of adherence to the Tokyo guidelines in addition to discussing bailout options for the impossible gallbladder promoting Laparascopic aspiration over open conversion when proceeding with the cholecystectomy laparasopically is not safe

BACKGROUND:Laparoscopic cholecystectomy has become the standard approach to gallbladder surgery, but open cholecystectomy retains a role in complex cases. AIMS:The aim of this study was to evaluate exposure of senior trainees in general surgery to open cholecystectomy and their experience and confidence in independent performance. METHODS:General surgical trainees on a higher surgical training programme from surgical training years 5 (ST 5) to 8 (ST8) were invited to partake in an online anonymous survey. Data pertaining to case numbers, whether supervised or independently performed and level of comfort were collated and analyzed. RESULTS:Twenty-six of 40 trainees responded (65%). Twenty-one (81%) had performed over 40 laparoscopic cholecystectomies with their trainer either scrubbed or un-scrubbed in theatre. As to open cholecystectomy experience, 12 trainees had assisted in 5 or fewer cases and only 3 assisted in over 20; 17 (65%) had performed 2 or fewer cases whilst assisted by their trainer while 24 of 26 trainees (92%) had no independent experience of open cholecystectomy. However, 16 felt they would be "somewhat comfortable" and 2 reported feeling "very comfortable" while only 8 reported they were "not comfortable" converting to open cholecystectomy. CONCLUSIONS:This study confirms a steep decline in training opportunities in open cholecystectomy, but also raises concern about a Dunning-Kruger effect as, despite this lack of experience, the majority felt "somewhat comfortable" or "very comfortable" in converting to open surgery. Trainees need first to be familiar with safer alternatives to conversion. Surgical trainers need to consider the assessment of confidence as well as competence as an endpoint of trainee evaluation.

Background: Laparotomies are associated with high rates of morbidity, of which surgical site infections (SSI) are highly prevalent. There is sparse evidence to support routine application of prophylactic negative pressure dressings to closed laparotomy wounds. A randomised controlled trial (RCT) was undertaken to assess whether prophylactic negative pressure dressings reduce the incidence of postoperative SSI after laparotomy.