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Gut. 2007 November; 56(11): 1614.
PMCID: PMC2095654

JournalScan

Don't get ill in August …

Englesbe MJ, Pelletier SJ, Magee JC, et al. Seasonal variation in surgical outcomes as measured by the American College of Surgeons‐National Surgical Quality Improvement Program (ACS‐NSQIP). Ann Surg 2007;246:456–65.

Fresh concern was raised in the British press recently with regard to the safety of returning to a “mass” change‐over of junior staff in UK hospitals. Change‐over of junior staff had been staggered by grade for many years because of the perception that mortality and morbidity rates were higher in August and February. Similar concerns exist in the US and the authors of this article sought to examine the validity of those concerns.

This observational, multi‐institutional study was conducted by analysis of the National Surgical Quality Improvement Program‐Patient Safety in Surgery Study database. The 30‐day morbidity and mortality rates between two periods of care were compared (early group, 1 July to 30 August and late group, 15 April to 15 June). A prediction model was then constructed via stepwise logistic regression. The results demonstrated an 18% higher risk of postoperative morbidity in the early (n = 9941) vs the late group (n = 10 313) (OR 1.18, 95% CI 1.07 to 1.29, p = 0.0005, c‐index 0.794) and a 41% higher risk for mortality in the early group compared with the late group (OR 1.41, 95% CI 1.11 to 1.80, p = 0.005, c‐index 0.938). The authors are at pains to point out that they have demonstrated a phenomenon suggesting disturbingly higher rates of surgical morbidity and mortality related to the time of year, not a cause. Clearly the change‐over of junior staff may not be related to these seasonal variations in outcomes and to be valid the same trends must be shown to exist in the UK. However, it is a stark reminder of how many of the managed changes to the UK health system lack proper reference to patient care and patient outcome.

Mucosal healing and the natural history of inflammatory bowel disease

Froslie KF, Jahnsen J, Moum BA, et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population‐based cohort. Gastroenterol 2007;133:412–22.

There is increasing interest in mucosal healing as a goal of treatment, in the hope that early and sustained healing will reduce the risk of future complications or surgery. This paper from Norway investigated a large cohort of patients with Crohn's disease and patients with ulcerative colitis diagnosed between 1990 and 1994 and provides valuable evidence about mucosal healing at a time when the main drug treatments were corticosteroids and 5‐aminosalicylates or sulphasalazine. Very few in the cohort received thiopurines and none received biological agents. Patients diagnosed over this 4‐year period received standard follow‐up with colonoscopic evaluation after approximately a year (range 6 months to 2 years) and again at 5 years. Treatment, however, was completely at the discretion of treating physicians. Endoscopic evaluation recorded a simple score of 0 (normal); 1 (light erythema or granularity); or 2 (granularity, friability and bleeding, with or without ulceration). Mucosal healing was defined as grade 0 or 1. Factors at baseline were assessed as predictors of 1‐year mucosal healing, with univariate and multivariate analysis. In the same way, 1‐year mucosal healing was evaluated as predictor of disease activity up to 5 years. Patients with indeterminate or self‐limiting colitis were excluded, as were those who had surgery prior to their 1‐year examination.

There were 354 patients with ulcerative colitis, of whom 50% had mucosal healing at 1‐year. In multivariate analysis, healing was positively associated with more extensive disease at diagnosis and, rather surprisingly, associated with spending more than 12 years in education. Mucosal healing was a significant predictor of subsequent colectomy, although only 13 of 176 without healing at 1‐year later had colectomy, vs 3 of 178 (p = 0.02).

Of the 141 patients with Crohn's disease, 38% had mucosal healing at 1‐year. The baseline factors with significant association on multivariate analysis were fever at diagnosis and a negative association with steroid use. The latter may simply reflect the fact that steroids were used in those with more severe disease but does support the observation that steroids do not cause long‐term mucosal healing in Crohn's disease. It is noteworthy that in the larger cohort with ulcerative colitis steroid use was not negatively associated in this way, which implies that sustained mucosal healing does occur after steroids in ulcerative colitis.

It would be interesting to compare these data with healing rates in the era of thiopurines and biologicals and still leaves open the question whether endoscopic assessment of mucosal healing can be used to target more aggressive treatment for subgroups of patients who don't heal with standard first‐line treatments.

A little something for the weekend Sir?

Clayman RV, Box GN, Abraham JB, et al. Transvaginal single port NOTES nephrectomy: initial laboratory experience. J Endourol 2007;21:640–4.

Can you believe it—it never rains but it pours! After months of careful nurturing and assembly of various sprinkler devices (which always seem to get the bit of the garden you never intended) the lawn finally looked peachy…ready for the visit by the mother‐in‐law who has a keen eye for these things and bases the success of her daughter's husband more on the moss density than anything else. But, in true Sheffield style, I then needed to upgrade the sprinkler to a powered dinghy to get to work a few weeks ago!

The whole affair got me thinking. What can I do on another rainy Sunday evening rather than watch another repeat of Dad's army? The answer is not too far away! Although the article by Clayman and colleagues is essentially a case report, it takes some imaginative thinking to come up with this level of ingenuity and makes you wonder what's round the corner for us all. Why not move out of the lumen and explore pastures new!

The Californian group has performed the first ever trans‐vaginal natural orifice transendoscopic surgery (NOTES) nephrectomy in a porcine model. Using a single 12 mm trocar in the midline followed by an endoscopic trans‐vaginal perforation, renal dissection was performed using an endoscopic needle knife and grasper. Subsequently, the renal artery and vein were ligated using laparoscopic clips prior to the kidney being externalised trans‐vaginally using an EndoPouch retriever—a 300‐minute procedure.

This paper is well worth a read. Is there anywhere we can't go with our trusty ”black snake”? I think a revolution is round the corner. Enjoy it.


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