BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Oesophageal diverticulae are rare out-pouchings of oesophageal wall with a prevalence of 2/100,000 population/year. Known associations of traction diverticula are causes of mediastinal inflammation including tuberculosis, histoplasmosis, anthracosis, sarcoidosis and rarely systemic lupus erythematosus. Two-thirds of oesophageal diverticula are asymptomatic, and they are a rare cause of dysphagia. Most asymptomatic oesophageal diverticula are managed conservatively with surveillance imaging or endoscopy. Symptomatic patients with diverticula &gt;4cm are usually treated surgically due to the increased risk of aspiration pneumonia and malignancy. In this report, a case of a large mid-oesophageal traction diverticulum in a 66-year-old female with systemic lupus erythematosus has been presented. She was initially managed conservatively with active surveillance for 6 years. When her symptoms progressed, she had repeat endoscopy and computed tomography scan which showed an increase in size of the diverticulum to 6cm in diameter. Her dysphagia had progressively deteriorated, and she was only managing a liquid diet. She therefore proceeded to resection of the diverticulum by right thoracotomy and stapled diverticulectomy. She made an excellent post-operative recovery and at last review, 5 months after the operation, she was back at work, had put on weight, and was tolerating a normal diet. Several surgical/endoscopic treatment options exist for management of oesophageal diverticula, and these must be tailored to every individual case. In this case report, we have compared minimally invasive (laparoscopic/thoracoscopic/robotic assisted) and open (transabdominal/transthoracic) techniques. Patients often have a good symptomatic outcome following surgery. Multi-Disciplinary Team (MDT) involvement with dietetic support is important for optimal recovery of these patients.

Aim Improve clerking of vascular patients at Royal Devon and Exeter (RDE) hospital presenting with acute limb ischaemia (ALI) using standardized electronic proforma. Method Results A total of 65 patients presented to vascular surgery during the 3-month period. Of these 20 patients presented with ‘acute limb ischaemia’. Documentation of rest pain (75%), pulses (Dorsalis paedis in 90%) and exam finding of cold feet (95%) was adequate. However, poor documentation of vascular risk factors such as previous stroke (20%) and atrial fibrillation (15%) was identified. ECG was performed on admission in only 35% patients. Examination like ABPI (10%) and Buerger's test (15%) were also inadequately documented. Conclusions This audit shows inadequate clerking of vascular patients presenting with ALI. The second cycle will include further data collection post-implementation of the electronic proforma to analyse improvements in documentation of the above-mentioned factors at initial clerking.