A serum lactate of >1.7 mmol/l on day 2 should raise the possibility of a potential AL. Such patients should be selected for more intensive monitoring, optimization and selective gastroscopy.

No abstract

Background: Routine ligation of the thoracic duct during oesophagectomy has been reported to reduce the rate of chyle leak (CL) following oesophagectomy. This study aims to identify risk factors for developing a CL with this approach and review current management. Methods: All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database and their medical records reviewed. Results: A total of 147 oesophagectomies were performed in the period January 2012-December 2014. Eighteen patients with anastomotic leak were excluded. Eleven (8.5%) of the remaining 129 patients developed a CL. Statistically significant predictive factors for CL were squamous cell carcinoma (6/16, 37.5% vs. 5/113, 4.4% in other tumour types, P=0.0005) and high total chest drain volumes on day 2 post operatively measured prior to commencing enteric feeding. Using a threshold of 600 mL on day 2, the sensitivity and specificity for predicting CL are 92% and 82% respectively. Low BMI (mean 24.1 with CL vs. 27.5 without CL) was also associated with a CL, but was not statistically significant. Neither the extent of lymphadenectomy nor the extent of lymph node involvement (N stage) were associated with CL. Six patients with a low volume CL (<600 mL/day) were successfully managed conservatively. The main thoracic duct was never the source of leakage in the 5 patients requiring re-thoracotomy. All 11 patients were successfully discharged home. Conclusions: This study demonstrates squamous cell carcinoma remains a significant risk factor for the development of post-oesophagectomy chylothorax despite the routine ligation of the thoracic duct. In the knowledge that with this approach the main thoracic duct is never the source of CL, patients with a chest drainage of <600 mL/24 h can be successfully treated conservatively. Patients with a chest drain volume of >600 mL/24 h despite conservative management should undergo re-thoracotomy at an early stage.

Purpose – The paper aims to assess the quality (content and legibility) of handwritten operation notes and the reader's interpretation of legibility by clinical seniority. Design/methodology/approach – Consecutive elective and emergency general surgical operations over a six-week period from September 2011 at one hospital were retrospectively collected. Non-retrieval of operation notes, typed notes and endoscopies were excluded. The content of each operation note was assessed against a 26-item checklist. Legibility was assessed by 4 readers (2 Foundation Doctors and 2 Registrars in General Surgery) using an original objective scoring system. Findings – A total of 404 operations were identified; 45 were excluded following review of operation notes. Operation notes were derived from 12 consultants and 11 registrars. Analysis of the content score suggested that time of procedure (1 per cent), ASA grade (1 per cent) and blood loss (5 per cent) were poorly reported. Clinical indication and post-operative instructions were documented in only 52 per cent and 66 per cent of operation notes respectively. Registrar notes had a higher content score compared with consultant notes (15.8 vs 13.5, p<0.001). Legibility scores were reported to be higher for Registrar readers, compared with Foundation Doctor readers (OR 1.95, 95 per cent CI 1.75-2.18, p<0.001). Registrar-written notes had higher legibility scores compared with consultants (OR 19.0, 95 per cent CI 11.6-31.2, p<0.001). Research limitations/implications – The quality of handwritten notes varies. Registrar-written notes are more content-rich and legible. Practical implications – Clinical seniority and specialty training may improve the interpretation of handwritten operation notes. This study adds to growing evidence supporting the widespread adoption of a computerized immediate operation note. Originality/value – An objective scoring system to assess legibility of operation notes written as freehand was used. Also, legibility according to the reader's seniority in clinical training was evaluated.

Background and Aim: Laparoscopic box trainers are valuable in the teaching of basic laparoscopic skills. This study aims to define the impact of formal tuition, supervised practice and feedback on the acquisition of basic laparoscopic skills on a box trainer by novice. Methods: All medical undergraduate attendees of a conference were invited to participate. Participants with previous experience on laparoscopic simulators were excluded. Twenty-eight were randomized to the control group (self-directed learning/practice), 23 to the intervention group (formal tuition/supervised practice/feedback). Baseline and post-intervention performance were assessed using the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded assessors. Results: Both groups showed an overall increase in GOALS score after exposure to the box trainer: control group, 7.79 (SD, 2.23) pre-intervention versus 8.25 (SD 3.04) postintervention; intervention group: 8.43 (SD 2.13) pre-intervention versus 9.35 (SD 2.42) post-intervention (P=0.52). The intervention group showed a greater overall increase in GOALS score compared with the control group, but this was not statistically significant (control mean improvement, + 0.46 [SD 4.08] versus intervention mean improvement + 0.91 [SD 3.84]; P=0.66). A lower performance in depth perception was reported for the control group (mean, À0.07). Conclusions: Box trainers are effective in assisting novices to acquire basic laparoscopic skills. Expert tuition, supervised practice and feedback appear to have an additional positive effect.