This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

The effect of the first EBP waned and a second EBP was performed about 42 days later. A larger blood volume (35 ml) was injected, and the patient was maintained in a head-down position for 20 min. Within a couple of hours, he became more alert and there was marked improvement in his social behaviour. This improvement was not as marked as that following the first EBP and lasted for ,1 month. A repeat MRI of the brain did not show any CSF leak. At the request of the neurologist and the family, a third and final EBP was performed about 5 months later. Twenty millilitres of blood were injected into the epidural space. This resulted in improvement of symptoms, both social and cognitive, albeit short-lived. HHB is responsible for the most severe form of apathy. Diagnosis is mainly clinical. The most characteristic features on MRI are brainstem swelling and sagging of the brain in the absence of meningeal enhancement. 2 EBP resolves symptoms in patients with HHB 2 by elevating the epidural and CSF pressures. The most likely mechanism causing symptoms in HHB is spontaneous intracranial hypotension secondary to CSF leak. 3 After consideration of the limited literature with regard to treatment of the condition and the potential benefits of an EBP, we decided to proceed. It was unfortunate that no CSF leak was identified, as it could then have been amenable to radiological or surgical intervention for sustained relief of symptoms. We performed the EBP in the lumbar inter-space, as it is technically easier, safer, and can accommodate a larger volume of blood. The patient required a repeat EBP after a month in view of the non-sustained effect of the previous blood patch. No complications, attributed to the epidural, were seen in our patient during the follow-up.

Immediate perioperative care may have prolonged effects on postoperative survival. Specialized preoperative assessment clinics may reduce mortality after colorectal surgery.

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.