[306][307][308][309][310][311][312] Audit weeks. This would take the form of a cholecystectomy (and bile duct clearance if necessary) in fit patients and an endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy in the unfit. Indeed the risk of recurrence of acute biliary pancreatitis in the presence of cholelithiasis could be as high as 60% within 6 months. 3Endoscopic sphincterotomy significantly reduces the risk of recurrent acute biliary pancreatitis in unfit patients to 2-5% at 2 years. [4][5][6] In the management of acute cholecystitis, the conventionally adopted approach of conservative treatment and interval cholecystectomy has its distinct disadvantages. Whilst the majority of patients respond to such treatment approach, up to one-fifth of patients fail to do so and require an urgent cholecystectomy. [7][8][9] Moreover, up to one-quarter of patients who have recovered from acute cholecystitis relapse while awaiting an interval cholecystectomy. 7 In a randomised controlled trial of early versus delayed open cholecystectomy for acute cholecystitis some 25 years ago, Lahtinen and colleagues 7 found early surgery to be safe and associated with significantly shorter operating time, and had avoided the complications of failed medical treatment. A number of recent randomised clinical trials have addressed the timing and surgical approach to cholecystectomy in patients with acute cholecystitis, 9-13 and demonstrated that laparoscopic cholecystectomy performed during the index admission with acute cholecystitis was associated with a shorter hospital stay, 9,11-13 quicker recovery, 9 and a reduction in the overall treatment cost when compared with open cholecystectomy during the index admission with acute cholecystitis 12 or interval laparoscopic cholecystectomy. 9,11,13 Moreover, early laparoscopic cholecystectomy was safe, and earlier reports of increased risk of bile duct injuries 14 were not substantiated by more recent experiences. 9,11,13,15 The aims of this study, therefore, were to survey the currently adopted practice of the UK surgeons in the surgical management of acute biliary pancreatitis and acute cholecystitis, to evaluate the impact of various subspecialty interests on the practice adopted, and to suggest pathways towards a better implementation of the guidelines and other evidence-based management approaches. Materials and MethodsThe names and addresses of the practising members of the Association of the Surgeons of Great Britain and Ireland were obtained from the Association's office, and a postal questionnaire was sent to its 1086 current members. The survey included a general questionnaire, as well as a questionnaire that addressed the current practice adopted by each surgeon in relation to the timing and approach to the surgical management of acute biliary pancreatitis and acute cholecystitis (see Appendix). The reply to the questionnaire was anonymous. Statistical analysisThe replies were compiled on a computer database for analysis. Data were analysed using SPS...

Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.

INTRODUCTION: Fast Track Colorectal Clinics are becoming a requirement to meet the government's 10-day rule for patients with suspected cancers to be seen by a specialist. However, such clinics soon tend to get overwhelmed by huge numbers of referrals, many of them inappropriate. The Association of Coloproctology of Great Britain and Ireland has published criteria for appropriate referral. We evaluated the sensitivity of these criteria and attempted to recommend appropriate changes. METHODS: Data of 50 consecutive colorectal cancers from our DGH since January 2000 has been collected in relation to demographics, presenting signs and symptoms, haemoglobin levels as well as treatment. The new Criteria were then applied strictly to these cases and we evaluated whether these patients would have been eligible for fast track referral, if these criteria had been in force since January 2000. RESULTS: Forty-one (82%) of 50 patients would have been eligible for referral as follows: 11 (22%) rectal bleeding with diarrhoea; 8(16%) persistent diarrhoea without bleeding (>60 years), 12 (24%) bleeding without anal symptoms (>60 years), 0 (0%) palpable right sided abdominal mass, 7 (14%) palpable rectal mass, 16 (32%) iron deficiency anaemia (<11 g/dl in men & <10 g/dl in women), 10 (20%) patients qualifying on more than one criterion. However, 9 (18%) patients had presenting features that would have excluded them from a fast track referral as follows: 4 (8%) only abdominal pain + weight loss (48, 54, 72, 75 years old), 2 (4%) change in bowel habit + no rectal bleeding (54, 57 years old), 1 (2%) palpable mass at a site other than the right side of the abdomen. CONCLUSIONS: We feel that this study, although small, highlights the dangers of having very rigid criteria for such clinics. The new criteria though high in specificity have low sensitivity for safety. We recommend some modifications to the criteria as follows: rectal bleeding without anal symptoms >50 years instead of 60 years; patients with a palpable mass anywhere on the abdomen; and the adddition of a new criterion of abdominal pain with weight loss. These modifications would significantly increase the sensitivity from 82% to 94%.

We report a case of an acute strangulated gastric volvulus in a hernia of Bochdalek in an adult female patient that was repaired successfully via the laparoscopic approach. A left-sided diaphragmatic hernia contained a strangulated but viable gastric volvulus and a noncompromised colon. The contents of the hernia were reduced, and the 4-cm congenital diaphragmatic defect was primarily repaired with nonabsorbable sutures. The patient was discharged on the second postoperative day and remained symptom-free at 7 months. Unlike the very few previous reports of elective laparoscopic repair of uncomplicated Bochdalek hernias, this appears to be the first report of an urgent laparoscopic repair of a complicated hernia of this type.

Background Effective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19. Methods This was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients. Results 27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy. Conclusion In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.