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.

Background Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

A 29-year-old woman elected to terminate her pregnancy at 21 weeks due to severe fetal hydrops. Feticide was carried out, mifepristone (200 mg) was given and 48 h later misoprostol 200 mg was administered per vaginam and repeated 3-hourly until five pessaries had been given. There was no cervical dilatation after the administration of 1,000 mg of misoprostol. The following day, a further five misoprostol 200 mg pessaries were given with still no cervical change. The same regimen was tried orally the next day. Over 3 days, 3,000 mg of misoprostol had been administered, with no cervical change. As the placenta was low lying, rather than attempting an intrauterine installation technique with the risk of haemorrhage, a different prostaglandin was given. Five doses of 1 mg gemeprost were given 3-hourly, yet the cervix remained 2 cm long.An ultrasound revealed an empty, well-contracted upper uterine segment, with a clear midline echo. The pregnancy sac was intact and was markedly distending the lower segment of the uterus. The decision was made to proceed to surgery; a laparotomy and hysterotomy were performed. The findings at operation matched those seen on ultrasound.

An ERP for closure of ileostomy significantly reduces LOS without adverse effects for patients.

INTRODUCTIONColorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment.PRESENTATION OF CASEA 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed.DISCUSSIONIron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia.CONCLUSIONDual pathology raises new difficulties in assessment, investigation and management of colorectal cancer.