Clinical  scenario  1  

You  are  the  ST3  on  call  for  general  surgery  in  a  busy  DGH.  The  on  call  rota  means  that  you  do  a  week  
of  long  days  and  this  is  your  fifth  day  of  seven;  the  consultant  is  also  on  call  with  you  for  the  week  
and  he  is  not  your  usual  consultant  and  this  is  your  first  week  working  with  him.  It  is  5pm  and  you  
are  on  the  surgical  admissions  unit.  

The  next  patient  you  see  is  a  65  year  old  patient  with  a  5  day  history  of  increasing  abdominal  
distension  and  absolute  constipation.  He  has  no  vomiting  and  has  developed  abdominal  pain  over  
the  past  24  hours.  Prior  to  the  acute  illness,  he  has  no  past  surgical  history  but  does  suffer  from  
tablet  controlled  hypertension.  He  has  had  a  3  month  history  of  increasing  diarrhoea.    

When  you  go  to  meet  him,  you  realise  that  you  have  met  him  two  days  ago  when  you  saw  him  on  
the  SAU  and  discharged  him  without  tests  with  a  diagnosis  of  infective  gastroenteritis.  The  patient  
and  his  family  recognise  you  as  being  the  surgical  registrar  who  had  seen  them  previously  but  as  you  
begin  to  take  a  history,  you  glance  through  the  previous  notes  and  see  that  your  previous  
examination  and  history,  which  you  thought  your  SHO  had  recorded,  has  not  been  documented.    

Please  describe  how  you  would  proceed  and  consider  what  clinical  and  management  issues  need  to  
be  addressed.  

Clinical  Scenario  2  

You  are  the  ST3  on  call  for  general  surgery  in  a  rural  DGH.  You  are  on  a  night  on-­‐call  and  these  are  
your  first  nights  on  call  in  this  hospital.  Your  consultant  is  a  colorectal  consultant  and  you  are  on  with  
an  FY1  and  an  FY2  on  the  SHO  tier.  During  the  night,  you  are  phoned  by  the  Emergency  Department  
registrar  that  a  19-­‐year  old  man  has  just  been  admitted  to  the  Department  with  a  stab  wound  to  his  
left  chest.  

Please  describe  your  actions  and  management  and  the  organisational  issues  that  need  to  be  
considered.  

 
  

Clinical  scenario  3  

You  are  the  ST3  on  call  for  general  surgery  in  a  busy  DGH.  A  13  year  old  boy  has  been  admitted  from  
his  school  after  having  been  hit  in  the  abdomen  during  a  rugby  match.  His  teacher  informs  you  that  
he  has  no  past  medical  history  and  the  school  nurse  confirms  this.  He  is  complaining  of  left  upper  
quadrant  pain  and  is  pale.  On  initial  assessment,  he  is  tachycardic  and  hypotensive.  His  abdomen  is  
distended  and  he  is  tender  in  the  left  upper  quadrant.  There  is  no  peritonism.    

After  initial  fluid  resuscitation  with  1  litre  of  crystalloid,  his  pulse  and  blood  pressure  have  improved  
and,  on  talking  to  him,  he  does  not  really  appreciate  the  severity  of  his  injuries  or  seem  able  to  
understand  the  issues  concerned.  He  has  had  an  arterial  blood  gas  done  which  shows  a  
Haemoglobin  of  8.1  g/dL.  As  you  continue  your  treatment,  his  parents  arrive  and  inform  you  that  
they  are  Jehovah’s  Witnesses  and  refuse  blood  transfusion  for  their  son.  

Please  describe  the  clinical  and  organisational  issues  need  to  be  addressed.  

Clinical  scenario  4  

You  are  the  ST3  on  call  for  general  surgery  in  a  busy  DGH.  Though  there  are  separate  vascular  and  
general  surgery  consultants  on  call,  as  the  registrar,  you  cover  both  specialties.  You  are  contacted  by  
the  Emergency  Department  registrar  who  informs  you  that  a  45  year  old  factory  worker  has  been  
admitted  after  having  his  left  lower  limb  crushed  by  a  forklift  truck  which  had  reversed  into  him.  You  
have  not  been  on  call  with  the  vascular  consultant  before  and  it  is  not  your  current  specialty.  

Please  describe  your  initial  and  continuing  management  and  describe  the  clinical  and  organisational  
needs  that  need  to  be  met.  

 
  

Clinical  scenario  5  

You  are  the  new  ST3  on  a  general  and  colorectal  surgery  firm.  You  have  been  in  outpatients’  clinic  all  
morning  which  has  finished  an  hour  late  and  you  have  an  afternoon  operating  list  which  starts  in  ten  
minutes.  The  list  consists  of  two  open  inguinal  hernia  repairs  and  excision  of  a  lipoma  under  local  
anaesthesia.  It  is  an  extra  operating  list  to  reduce  waiting  lists  and  the  patients  have  not  been  seen  
by  you  or  your  consultant  previously  but  have  been  seen  and  listed  by  other  consultants  on  the  unit.  
When  you  look  through  the  letters  for  each  patient,  they  are  all  in  their  mid  forties  and  have  no  past  
medical  or  surgical  history  recorded  and  look  like  uncomplicated  cases.  Your  consultant  has  asked  
you  to  start  the  list.  

Please  talk  through  the  clinical  and  management  needs  that  to  be  addressed.  

Clinical  scenario  6  

You  are  the  ST3  on  call  for  general  surgery  in  a  busy  DGH.  Though  there  is  a  separate  urology  on  
take,  as  the  registrar,  you  cover  both  specialties.  You  have  not  been  on  call  with  this  Urologist  before  
and  prior  to  the  on  call,  had  not  met  him.  During  your  general  surgery  post  take  ward  round  with  the  
general  surgery  consultant,  SHO  and  FY1,  your  SHO  is  bleeped  away  to  the  Urology  ward.  Soon  after,  
you  are  bleeped  about  a  21-­‐year-­‐old  girl  on  the  ward  for  urinary  sepsis  who  has  become  increasingly  
unwell  and  your  SHO  is  worried  that  the  patient  is  becoming  increasingly  septic.  
  

Please  describe  your  initial  management  and  discuss  the  clinical  and  management  needs  that  should  
be  addressed.  

Clinical  Scenario  7  

You  are  the  ST3  on  call  for  general  surgery  and  have  just  started  your  night  shift  with  an  SHO  and  an  
FY1.  There  is  also  a  night  nurse  practitioner  with  you  at  the  handover.  The  consultant  on  call  is  not  
present  at  the  handover  and  is  not  a  consultant  you  have  worked  with  previously.  It  is  8.15pm  and  
you  are  receiving  the  clinical  handover  from  the  day  team.  There  have  been  7  admissions  of  whom  
three  need  a  registrar  review;  the  first  is  a  72  year  old  man  with  severe  epigastric  pain  in  whom  the  
initial  blood  tests  and  x-­‐rays  have  been  performed  but  not  reviewed.  The  second  is  a  45  year  old  
woman  with  right  upper  quadrant  pain,  jaundice  and  rigors  and  the  third  is  a  36  year  old  man  with  
right  groin  pain.  The  day  registrar,  who  is  an  ST7  colleague,  informs  you  that  there  is  also  a  27  year  
old  man  with  classical  signs  of  appendicitis  who  has  been  worked  up  and  booked  and  consented  for  
a  laparoscopic  appendicectomy  that  is  next  on  the  acute  list.  

Please  describe  your  management  and  the  clinical  and  management  issues  that  may  arise.  

Clinical  Scenario  8  

You  are  the  ST3  on  call  for  general  surgery  and  are  asked  to  see  a  56  year  old  man  with  sudden  onset  
epigastric  pain.  Please  talk  through  your  clinical  management.  
  

Clinical  Scenario  9  

You  are  the  ST3  on  call  for  general  surgery  are  have  been  bleeped  on  nights  by  the  medical  SHO  
about  a  65  year  old  woman  with  multiple  sclerosis  who  has  been  admitted  with  abdominal  
distension.  Please  talk  through  your  clinical  management.  

Clinical  management  scenario  1  

You  are  the  ST3  on  call  for  general  surgery  in  a  busy  DGH  and  it  is  1630.  You  are  currently  on  the  SAU  
and  the  on-­‐call  team  consists  of  a  CT2,  an  FY1,  a  general  surgery  consultant  and  a  vascular  surgery  
consultant.  The  consultants  are  not  with  you  on  the  SAU.  You  have  three  patients  to  see  on  the  SAU  
which  is  full  and  4  patients  who  have  been  referred  from  the  Emergency  Department  that  are  
currently  waiting  for  a  bed.  You  have  been  bleeped  twice  by  the  ED  consultant  demanding  that  you  
go  to  the  ED  to  review  the  patients.  You  then  receive  a  bleep  from  the  site  matron  who  informs  you  
that  the  hospital  is  virtually  full  and  that  you  need  to  discharge  patients  as  soon  as  possible.    
There  are  two  patients  waiting  for  acute  surgery;  the  first  is  a  44  year  old  woman  who  has  been  
admitted  (3rd  presentation)  with  biliary  colic  and  has  been  fasting  since  0800  for  a  laparoscopic  
cholecystectomy  and  the  second  is  a  58  year  old  man  who  has  insulin  dependent  diabetes  with  a  
peri-­‐anal  abscess.  He  has  been  fasted  since  1300.  There  is  currently  a  urology  case  in  the  acute  
theatre  (ureteroscopy  and  insertion  of  stent  for  ureteric  colic)  that  has  just  started.  
How  would  you  proceed?  
 
 
 
Clinical  management  scenario  2  
You  are  the  ST3  on  call  for  general  surgery  and  there  are  a  number  of  cases  that  are  on  the  acute  list.  
It  is  0900  and  you  are  meeting  with  the  acute  anaesthetists  (consultant  and  CT2)  and  the  ODP  in  
  

charge  of  acutes  for  the  afternoon  and  beyond.  The  ODP  tells  you  that  there  is  currently  only  enough  
laparoscopic  equipment  for  two  laparoscopic  cases  and  that  there  will  need  to  be  a  45  minute  
turnaround  between  cases  once  the  two  trays  have  been  used.  Please  look  through  the  list  of  
patients  and  determine  an  order  of  operations  and  describe  your  management.  All  the  patients  have  
been  fasted  since  midnight.  
 
Patient  1  –  78  year  old  man  with  left  iliac  fossa  peritonism.  Raised  inflammatory  markers.  PMH  –  
Ischaemic  heart  disease  and  COPD.  Currently  hypotensive  and  tachycardic.  CT  confirms  perforated  
diverticular  disease.  The  anaesthetist  tells  you  that  the  patient  will  require  lines  and  at  least  an  hour  
of  anaesthetic  preparation.  On  the  list  for  a  laparotomy  and  Hartmann’s  procedure.  
 
Patient  2  –  18  year  old  woman  with  right  iliac  fossa  pain.  Negative  pregnancy  test.  Normal  bloods.  
No  other  imaging.  On  the  list  for  a  diagnostic  laparoscopy  
 
Patient  3  –  51  year  old  man  with  insulin  dependent  diabetes  with  fluctuant  perianal  abscess.  
 
Patient  4  –  44  year  old  woman  with  resolving  gallstone  pancreatitis  (this  admission).  On  the  list  for  
laparoscopic  cholecystectomy.  The  anaesthetist  informs  you  that  he  thinks  that  these  operations  are  
an  abuse  of  the  acute  list  and  that  lap  chole  should  be  on  an  elective  list  and  discharged  when  
recovered.  
 
Patient  5  –  23  year  old  man  with  known  ulcerative  colitis.  No  significant  pain  but  slowly  rising  CRP  
after  4  days  of  IV  steroids.  Referred  across  from  gastroenterology  consideration  of  surgery  but  the  
operation  title  has  not  been  written  on  the  booking  form  
 
Clinical  Management  Scenario  3  
You  are  the  ST3  for  colorectal  and  general  surgery  and  are  in  the  outpatients  department  during  a  
morning  clinic  (due  to  finish  at  12pm).  The  doctors  in  the  clinic  are  you,  your  consultant  and  an  SHO.  
You  also  have  two  medical  students  on  the  firm  who  have  come  to  the  clinic  as  well.  The  clinic  is  
overbooked  and  by  1130AM,  there  are  still  10  patients  waiting  to  be  seen.  The  delay  is  over  an  hour  
and  a  half  already.  You  have  an  afternoon  list  which  is  due  to  start  at  1pm  and  has  an  elective  
laparoscopic  cholecystectomy  on  a  patient  with  previous  obstructive  jaundice  (secondary  to  
gallstones)  that  settled  spontaneously  and  a  reversal  of  loop  ileostomy  3  months  after  an  anterior  
resection  for  rectal  cancer  but  you  have  not  seen  these  patients  yourself.  
 
Your  consultant  informs  you  that  he  has  an  important  meeting  in  his  office  and  leaves  the  clinic  
asking  you  to  see  the  patients  on  the  list  at  the  end  of  clinic  and  start  the  team  brief.  The  clinic  sister  
is  increasingly  irate  and  tells  you  that  two  patients  are  increasingly  angry  about  the  delay  and  are  
demanding  to  be  seen  next.  One  of  these  patients  is  also  demanding  to  see  the  consultant.  
 
  

Describe  how  you  would  proceed  and  what  clinical  management  and  organisational  issues  need  to  
be  addressed  
 
 
 
Clinical  Management  Scenario  4  
You  are  the  ST3  registrar  and  are  in  the  middle  of  your  evening  ward  round  when  the  ward  sister  
asks  to  speak  to  you.  She  informs  you  that  the  next  patient  you  are  about  to  see,  who  was  admitted  
with  a  left  axillary  abscess  and  went  to  theatre  on  the  acute  list  earlier  that  afternoon  has  woken  up  
and  is  complaining  that  the  abscess  has  not  been  drained  and  is  still  there.  The  sister  also  tells  you  
that  there  is  a  dressing  over  the  left  lateral  chest  wall,  some  distance  from  the  abscess.  The  SHO  who  
is  with  you  on  the  ward  round  then  speaks  up  and  mentions  that  he  was  in  the  theatre  for  the  case  
(which  was  performed  by  a  registrar  colleague)  but  that  the  patient  had  not  been  examined  pre-­‐
operatively  as  the  registrar  had  been  busy  with  other  on-­‐call  commitments.  On  arrival  to  the  theatre,  
the  patient  was  already  prepped  and  draped  and  they  carried  out  the  operation  as  they  considered  
appropriate.  
Describe  how  you  would  proceed  and  what  clinical  management  and  organisational  issues  need  to  
be  addressed  
 
 
 
 
 
 
 
 
 
 
 
 
Clinical  Management  Scenario  5  
You  are  the  ST3  on  call  (nights)  for  general  and  vascular  surgery  at  a  rural  DGH.  You  are  on  call  as  
part  of  a  Hospital  At  Night  team  and  this  consists  of  two  FY1  doctors,  an  SHO  (who  is  a  post-­‐MRCS  
CT2  trainee)  who  covers  urology,  orthopaedics  and  ENT  as  well  and  two  night  nurse  practitioners.  
There  are  specialty-­‐specific  registrars  on  call  from  home  for  the  other  specialties  though  the  
anaesthetic  registrar  (who  also  covers  obstetrics)  is  resident  on-­‐call  as  well.  
You  are  bleeped  at  midnight,  while  you  are  in  the  comfort  of  the  Doctors’  Mess,  from  the  ST3  
Emergency  Department  registrar.  He  tells  you  that  he  has  been  contacted  by  a  paramedic  crew  and  
that  they  are  bringing  in  the  victims  of  a  car  crash.  All  he  knows  is  that  there  are  three  injured  
patients,  though  one  appears  to  have  walked  out  of  the  car  at  the  scene.  The  other  two  are  alive  but  
  

potentially  seriously  injured.  The  Emergency  Department  registrar  tells  you  that  he  is  very  
inexperienced  and  is  not  sure  what  to  do  in  this  situation  but  has  asked  for  your  help.  
Describe  how  you  would  proceed  and  what  clinical  management  and  organisational  issues  need  to  
be  addressed.  
 
 
 

Teamworking  /  Leadership  Question  1  

You  are  the  new  ST3  on  a  general  surgery  firm  and  during  an  on  call,  you  have  found  it  difficult  to  
organise  management  of  a  patient  with  an  acute  upper  gastrointestinal  bleed.  You  discussed  the  
  

case  with  your  consultant  who  informed  you  that  this  is  a  recurrent  problem  in  your  hospital  as  
there  are  no  local  guidelines  for  upper  GI  bleed  management.  

He  asks  you  to  look  into  the  possibility  of  establishing  some  guidelines.  Discuss  the  management  and  
teamworking  issues  that  might  arise.  

Teamworking  /  Leadership  Question  2  

You  are  the  new  ST3  on  a  general  surgery  firm  in  a  busy  DGH.  During  an  acute  laparoscopic  
appendicectomy,  your  SHO,  who  is  a  core  trainee,  explains  that  he  feels  that  he  is  not  getting  
enough  operative  experience  and  that  he  is  likely  to  complain  to  the  Deanery.  You  mention  this  to  
you  consultant  after  the  case;  he  is  the  consultant  responsible  for  core  trainees  and  asks  you  to  try  
and  organise  a  ‘locals’  list  that  could  be  geared  towards  training  operations  for  the  SHO  tier.  

Discuss  how  you  would  go  about  doing  this  and  the  management  and  teamworking  issues  that  might  
arise.  

Teamworking  /  Leadership  Question  3  

You  are  the  ST3  general  surgery  registrar  on  call.  The  team  on  with  you  includes  an  FY1,  a  CT1,  
a  vascular  surgery  consultant  and  a  GI  surgery  consultant.  At  8.30  pm,  the  GI  consultant  is  on  his  
way  in  to  undertake  a  laparoscopy  with  you  on  a  27  year  old  assault  victim,  who  is  ventilated  on  
ITU  because  of  an  attempted  strangulation  but  who  is  making  poor  progress  and  becoming  
increasingly  unstable  and  acidotic.  A  CT  scan  shows  a  little  free  fluid  in  the  upper  abdomen  and  
little  else  of  note  but  the  ITU  consultant  is  worried  about  potential  bowel  necrosis.  While  waiting  to  
send  for  the  ITU  patient,  you  are  asked  to  see  a  93  year  old  lady  in  atrial  fibrillation  with  acute  limb  
ischaemia  of  10  hours  duration.  She  has  a  reasonable  quality  of  life  and  her  relatives  are  
extremely  anxious  that  something  is  done  to  save  the  leg,  which  is  pale,  pulseless,  paraesthetic  
and  paralysed  but  still  potentially  salvageable.  During  your  examination  of  the  patient  you  receive  
a  telephone  call  from  a  hospital  25  miles  away  referring  you  a  67  year  old,  otherwise  fit  man  
admitted  there  at  3pm  with  presumed  renal  colic.  He  is  haemodynamically  stable  but  has  just  had  
a  CT  showing  a  contained  rupture  of  an  8cm  abdominal  aortic  aneurysm.  You  are  obliged  to  
accept  him  on  the  vascular  emergency  network  rota  and  you  know  his  transfer  will  take  anywhere  
from  90  to  120  minutes.  You  phone  the  vascular  consultant  who  advises  that  the  acutely  ischaemic  
leg  patient  risks  potentially  lethal  reperfusion  injury  the  longer  the  delay  in  revascularisation.  How  
would  you  proceed?  
 
 
 
  

 
Teamworking  /  Leadership  Question  4  
You  are  the  ST3  in  a  busy  DGH  which  is  hoping  to  achieve  Foundation  Trust  status.  There  has  been  a  
recent  audit  that  has  shown  that  less  than  one  third  of  patients  who  might  be  eligible  for  day  case  
surgeries  actually  undergo  a  day  case  admission  as  there  is  no  formal  day  case  unit.  You  have  been  
asked  by  your  consultant  to  investigate  this  in  more  detail  and  see  whether  there  is  a  case  to  be  
made  for  a  capital  project  to  build  a  day  case  unit.  Discuss  the  teamworking  and  leadership  issues  
involved  and  how  you  would  proceed.  
 
 
Teamworking  /  Leadership  Question  5  
You  are  the  ST3  registrar  for  upper  gastrointestinal  and  general  surgery  and  you  are  about  to  start  
your  afternoon  ward  round.  The  team  with  you  are  the  SHO,  the  FY1,  a  ward  nurse  and  a  student  
nurse.  There  is  also  a  final  year  medical  student  on  the  firm  who  is  coming  round  with  you.  Your  
interviewer  will  act  as  the  members  of  the  team  that  you  can  ask  questions  to.  You  had  taken  the  
morning  ward  round  and  left  certain  instructions:  
Patient  1  –  65  year  old  man,  1/52  post  Ivor  Lewis  oesophagectomy.  Clinically  well  but  kept  nil  by  
mouth  until  a  gastrograffin  swallow  which  you  had  asked  to  be  organised  for  today  
Patient  2  –  27  year  woman  with  a  long  history  of  Crohn’s  disease  who  came  in  on  the  acute  take  
with  small  bowel  obstruction.  She  had  a  laparotomy,  ileocaecal  resection  and  primary  anastomosis  5  
days  earlier.  She  had  initially  progressed  well  but  this  morning  had  a  fever.  You  had  asked  for  some  
blood  tests  to  be  done  and  checked.  
Patient  3  –  42  year  old  man  who  had  an  elective  laparoscopic  cholecystectomy  yesterday.  Clinically  
well.  Plan  was  for  discharge  this  morning  after  the  discharge  summary  had  been  completed.  You  are  
surprised  to  see  he  is  still  here.  The  patient  is  angry  and  is  now  saying  that  he  may  not  be  able  to  get  
transport  home  at  this  time  of  the  day.  
Patient  4  –  19  year  old  woman  who  came  in  on  the  acute  take  with  a  short  history  of  right  iliac  fossa  
pain.  You  planned  to  perform  some  tests  and  requested  that  an  ultrasound  be  organised.  
Patient  5  –  A  64  year  old  man  admitted  for  a  planned  gastrectomy  on  the  elective  list  tomorrow.  You  
have  met  him  in  clinic  and  have  got  to  know  him  and  his  family  well  and  they  have  some  questions.  
The  staff  nurse  tells  you  that  he  missed  his  pre-­‐assessment  appointment  earlier  in  the  week  due  to  
bad  weather  preventing  him  getting  into  hospital.  
 
Talk  through  your  management  and  discuss  the  teamworking  and  leadership  issues  that  may  arise.  
 
 
 
 

 
  

Endovascular  aneurysm  repair  versus  open  repair  in  patients  with  abdominal  aortic  aneurysm  
(EVAR  trial  1):  randomised  controlled  trial.  

Lancet.  2005  Jun  25-­‐Jul  1;365(9478):2179-­‐86.  

EVAR  trial  participants.  

BACKGROUND:    

Although  endovascular  aneurysm  repair  (EVAR)  has  a  lower  30-­‐day  operative  mortality  than  open  
repair,  the  long-­‐term  results  of  EVAR  are  uncertain.  We  instigated  EVAR  trial  1  to  compare  these  two  
treatments  in  terms  of  mortality,  durability,  health-­‐related  quality  of  life  (HRQL),  and  costs  for  
patients  with  large  abdominal  aortic  aneurysm  (AAA).  

METHODS:    

We  did  a  randomised  controlled  trial  of  1082  patients  aged  60  years  or  older  who  had  aneurysms  of  
at  least  5.5  cm  in  diameter  and  who  had  been  referred  to  one  of  34  hospitals  proficient  in  the  EVAR  
technique.  We  assigned  patients  who  were  anatomically  suitable  for  EVAR  and  fit  for  an  open  repair  
to  EVAR  (n=543)  or  open  repair  (n=539).  Our  primary  endpoint  was  all-­‐cause  mortality,  with  
secondary  endpoints  of  aneurysm  related  mortality,  HRQL,  postoperative  complications,  and  
hospital  costs.  Analyses  were  by  intention  to  treat.  

FINDINGS:    

94%  (1017  of  1082)  of  patients  complied  with  their  allocated  treatment  and  209  died  by  the  end  of  
follow-­‐up  on  Dec  31,  2004  (53  of  aneurysm-­‐related  causes).  4  years  after  randomisation,  all-­‐cause  
mortality  was  similar  in  the  two  groups  (about  28%;  hazard  ratio  0.90,  95%  CI  0.69-­‐1.18,  p=0.46),  
although  there  was  a  persistent  reduction  in  aneurysm-­‐related  deaths  in  the  EVAR  group  (4%vs  7%;  
0.55,  0.31-­‐0.96,  p=0.04).  The  proportion  of  patients  with  postoperative  complications  within  4  years  
of  randomisation  was  41%  in  the  EVAR  group  and  9%  in  the  open  repair  group  (4.9,  3.5-­‐6.8,  
p<0.0001).  After  12  months  there  was  negligible  difference  in  HRQL  between  the  two  groups.  The  
mean  hospital  costs  per  patient  up  to  4  years  were  UK  pound  sterling  13,257  for  the  EVAR  group  
versus  pound  sterling  9946  for  the  open  repair  group  (mean  difference  pound  sterling  3311,  SE  690).  

INTERPRETATION:    
  

Compared  with  open  repair,  EVAR  offers  no  advantage  with  respect  to  all-­‐cause  mortality  and  HRQL,  
is  more  expensive,  and  leads  to  a  greater  number  of  complications  and  reinterventions.  However,  it  
does  result  in  a  3%  better  aneurysm-­‐related  survival.  The  continuing  need  for  interventions  
mandates  ongoing  surveillance  and  longer  follow-­‐up  of  EVAR  for  detailed  cost-­‐effectiveness  
assessment.  

Preoperative  radiotherapy  versus  selective  postoperative  chemoradiotherapy  in  patients  with  

rectal  cancer  (MRC  CR07  and  NCIC-­‐CTG  C016):  a  multicentre,  randomised  trial.  

Lancet.  2009  Mar  7;373(9666):811-­‐20.  doi:  10.1016/S0140-­‐6736(09)60484-­‐0.  

Sebag-­‐Montefiore  D,  Stephens  RJ,  Steele  R,  Monson  J,  Grieve  R,  Khanna  S,  Quirke  P,  Couture  J,  de  
Metz  C,  Myint  AS,  Bessell  E,  Griffiths  G,  Thompson  LC,  Parmar  M.  

St  James's  University  Hospital,  Leeds,  UK.  

BACKGROUND:    

Preoperative  or  postoperative  radiotherapy  reduces  the  risk  of  local  recurrence  in  patients  with  
operable  rectal  cancer.  However,  improvements  in  surgery  and  histopathological  assessment  mean  
that  the  role  of  radiotherapy  needs  to  be  reassessed.  We  compared  short-­‐course  preoperative  
radiotherapy  versus  initial  surgery  with  selective  postoperative  chemoradiotherapy.  

METHODS:    

We  undertook  a  randomised  trial  in  80  centres  in  four  countries.  1350  patients  with  operable  
adenocarcinoma  of  the  rectum  were  randomly  assigned,  by  a  minimisation  procedure,  to  short-­‐
course  preoperative  radiotherapy  (25  Gy  in  five  fractions;  n=674)  or  to  initial  surgery  with  selective  
postoperative  chemoradiotherapy  (45  Gy  in  25  fractions  with  concurrent  5-­‐fluorouracil)  restricted  to  
patients  with  involvement  of  the  circumferential  resection  margin  (n=676).  The  primary  outcome  
measure  was  local  recurrence.  Analysis  was  by  intention  to  treat.  This  study  is  registered,  number  
ISRCTN  28785842.  

FINDINGS:    

At  the  time  of  analysis,  which  included  all  participants,  330  patients  had  died  (157  preoperative  
radiotherapy  group  vs  173  selective  postoperative  chemoradiotherapy),  and  median  follow-­‐up  of  
  

surviving  patients  was  4  years.  99  patients  had  developed  local  recurrence  (27  preoperative  
radiotherapy  vs  72  selective  postoperative  chemoradiotherapy).  We  noted  a  reduction  of  61%  in  the  
relative  risk  of  local  recurrence  for  patients  receiving  preoperative  radiotherapy  (hazard  ratio  [HR]  
0.39,  95%  CI  0.27-­‐0.58,  p<0.0001),  and  an  absolute  difference  at  3  years  of  6.2%  (95%  CI  5.3-­‐7.1)  
(4.4%  preoperative  radiotherapy  vs  10.6%  selective  postoperative  chemoradiotherapy).  We  
recorded  a  relative  improvement  in  disease-­‐free  survival  of  24%  for  patients  receiving  preoperative  
radiotherapy  (HR  0.76,  95%  CI  0.62-­‐0.94,  p=0.013),  and  an  absolute  difference  at  3  years  of  6.0%  
(95%  CI  5.3-­‐6.8)  (77.5%vs  71.5%).  Overall  survival  did  not  differ  between  the  groups  (HR  0.91,  95%  CI  
0.73-­‐1.13,  p=0.40).  

INTERPRETATION:    

Taken  with  results  from  other  randomised  trials,  our  findings  provide  convincing  and  consistent  
evidence  that  short-­‐course  preoperative  radiotherapy  is  an  effective  treatment  for  patients  with  
operable  rectal  cancer.  

Fast  track  surgery  versus  conventional  recovery  strategies  for  colorectal  surgery.    

Cochrane  Database  Syst  Rev.  2011  Feb  16;(2):CD007635.  doi:  10.1002/14651858.CD007635.pub2.  

Spanjersberg  WR,  Reurings  J,  Keus  F,  van  Laarhoven  CJ.  

Department  of  Surgery,  Radboud  University  Nijmegen  Medical  Center,  PO  Box  9101,  Nijmegen,  
Netherlands,  6500  HB.  

BACKGROUND:    In  recent  years  the  Enhanced  Recovery  after  Surgery  (ERAS)  postoperative  pathway  
in  (ileo-­‐)colorectal  surgery,  aiming  at  improving  perioperative  care  and  decreasing  postoperative  
complications,  has  become  more  common.  OBJECTIVES:    We  investigated  the  effectiveness  and  
safety  of  the  ERAS  multimodal  strategy,  compared  to  conventional  care  after  (ileo-­‐)colorectal  
surgery.  The  primary  research  question  was  whether  ERAS  protocols  lead  to  less  morbidity  and  
secondary  whether  length  of  stay  was  reduced.  SEARCH  STRATEGY:    To  answer  the  research  
question  we  entered  search  strings  containing  keywords  like  "fast  track",  "colorectal  and  surgery"  
and  "enhanced  recovery"  into  major  databases.  We  also  hand  searched  references  in  identified  
reviews  concerning  ERAS.  SELECTION  CRITERIA:    We  included  published  randomised  clinical  trials,  in  
any  language,  comparing  ERAS  to  conventional  treatment  in  patients  with  (ileo-­‐)  colorectal  disease  
requiring  a  resection.  RCT's  including  at  least  7  ERAS  items  in  the  ERAS  group  and  no  more  than  2  in  
the  conventional  arm  were  included.  

DATA  COLLECTION  AND  ANALYSIS:    Data  of  included  trials  were  independently  extracted  by  the  
reviewers.  Analyses  were  performed  using  "REVMAN  5.0.22".  Data  were  pooled  and  rate  differences  
  

as  well  as  weighted  mean  differences  with  their  95%  confidence  intervals  were  calculated  using  
either  fixed  or  random  effects  models,  depending  on  heterogeneity  (I(2)).  

MAIN  RESULTS:    4  RCTs  were  included  and  analysed.  Methodological  quality  of  included  studies  was  
considered  low,  when  scored  according  to  GRADE  methodology.  Total  numbers  of  inclusion  were  
limited.  The  trials  included  in  primary  analysis  reported  237  patients,  (119  ERAS  vs  118  
conventional).  Baseline  characteristics  were  comparable.  The  primary  outcome  measure,  
complications,  showed  a  significant  risk  reduction  for  all  complications  (RR  0.50;  95%  CI  0.35  to  
0.72).  This  difference  was  not  due  to  reduction  in  major  complications.  Length  of  hospital  stay  was  
significantly  reduced  in  the  ERAS  group  (MD  -­‐2.94  days;  95%  CI  -­‐3.69  to  -­‐2.19),  and  readmission  rates  
were  equal  in  both  groups.  Other  outcome  parameters  were  unsuitable  for  meta-­‐analysis,  but  
seemed  to  favour  ERAS.  

AUTHORS'  CONCLUSIONS:    The  quantity  and  especially  quality  of  data  are  low.  Analysis  shows  a  
reduction  in  overall  complications,  but  major  complications  were  not  reduced.  Length  of  stay  was  
reduced  significantly.  We  state  that  ERAS  seems  safe,  but  the  quality  of  trials  and  lack  of  sufficient  
other  outcome  parameters  do  not  justify  implementation  of  ERAS  as  the  standard  of  care.  Within  
ERAS  protocols  included,  no  answer  regarding  the  role  for  minimally  invasive  surgery  (i.e.  
laparoscopy)  was  found.  Furthermore,  protocol  compliance  within  ERAS  programs  has  not  been  
investigated,  while  this  seems  a  known  problem  in  the  field.  Therefore,  more  specific  and  large  RCT's  
are  needed.  

Appendectomy  versus  antibiotic  treatment  for  acute  appendicitis.  

Cochrane  Database  Syst  Rev.  2011  Nov  9;(11):CD008359.  doi:  10.1002/14651858.CD008359.pub2.  

Wilms  IM,  de  Hoog  DE,  de  Visser  DC,  Janzing  HM.  

Department  of  Emergency  Medicine,VieCuri  Medical  Centre  of  Northern  Limburg,  Venlo,  
Netherlands.  

BACKGROUND:    Acute  appendicitis  is  one  of  the  most  common  causes  of  acute  abdominal  pain.  
Present  day  treatment  of  choice  for  acute  appendicitis  is  appendectomy,  however  complications  are  
inherent  to  operative  treatment.  Though  surgical  appendectomy  remains  the  standard  treatment,  
several  investigators  have  investigated  conservative  antibiotic  treatment  of  acute  appendicitis  and  
reported  good  results.  

OBJECTIVES:    Is  antibiotic  treatment  as  effective  as  surgical  appendectomy  (laparoscopic  or  open)  in  
patients  with  acute  appendicitis  on  recovery  within  two  weeks,  without  major  complications  
(including  recurrence)  within  one  year?  

SEARCH  METHODS:    We  searched  the  Cochrane  Central  Register  of  Controlled  Trials  (The  Cochrane  
Library  Issue  6,  2011);  MEDLINE  (until  June  2011);  EMBASE  (until  June  2011);  Prospective  Trial  
Registers  (June  2011)  and  reference  lists  of  articles.  
  

SELECTION  CRITERIA:    Randomised  and  quasi-­‐randomised  clinical  trials  (RCT  and  qRCT)  comparing  
antibiotic  treatment  with  appendectomy  in  patients  with  suspected  appendicitis  were  included.  
Excluded  were  studies  which  primarily  focused  on  the  complications  of  acute  appendicitis.  

DATA  COLLECTION  AND  ANALYSIS:    Two  authors  independently  assessed  trial  quality  and  extracted  
data.  The  review  authors  contacted  the  trial  authors  for  additional  information  if  required.  Statistical  
analysis  was  carried  out  using  Review  Manager  and  MetaAnalyst.  A  non-­‐inferiority  analysis  was  
performed,  comparing  antibiotic  treatment  (ABT)  to  the  gold  standard  (appendectomy).  By  
consensus,  a  20%  margin  of  non-­‐inferiority  was  considered  clinically  relevant.  

MAIN  RESULTS:    Five  RCT's  (901  patients)  were  assessed.  In  total  73.4%  (95%  CI  62.7  to  81.9)  of  
patients  who  were  treated  with  antibiotics  and  97.4  (95%  CI  94.4  to  98.8)  patients  who  directly  got  
an  appendectomy  were  cured  within  two  weeks  without  major  complications  (including  recurrence)  
within  one  year.  The  lower  95%  CI  was  15.2%  below  the  20%  margin  for  the  primary  outcome.  

AUTHORS'  CONCLUSIONS:    The  upper  bound  of  the  95%  CI  of  ABT  for  cure  within  two  weeks  
without  major  complications  crosses  the  20%  margin  of  appendectomy,  so  the  outcome  is  
inconclusive.  Also  the  quality  of  the  studies  was  low  to  moderate,  for  that  reason  the  results  should  
be  interpret  with  caution  and  definite  conclusions  cannot  be  made.  Therefore  we  conclude  that  
appendectomy  remains  the  standard  treatment  for  acute  appendicitis.  Antibiotic  treatment  might  
be  used  as  an  alternative  treatment  in  a  good  quality  RCT  or  in  specific  patients  or  conditions  were  
surgery  is  contraindicated.  

Laparoscopic  versus  open  surgery  for  suspected  appendicitis.  

Cochrane  Database  Syst  Rev.  2010  Oct  6;(10):CD001546.  doi:  10.1002/14651858.CD001546.pub3.  

Sauerland  S,  Jaschinski  T,  Neugebauer  EA.  

Department  of  Non-­‐Drug  Interventions,  Institute  for  Quality  and  Efficiency  in  Health  Care,  
Dillenburger  Str.  27,  Cologne,  Germany,  51105.  

BACKGROUND:    Laparoscopic  surgery  for  acute  appendicitis  has  been  proposed  to  have  advantages  
over  conventional  surgery.  

OBJECTIVES:    To  compare  the  diagnostic  and  therapeutic  effects  of  laparoscopic  and  conventional  
'open'  surgery.  
  

SEARCH  STRATEGY:    We  searched  the  Cochrane  Library,  MEDLINE,  EMBASE,  LILACS,  CNKI,  SciSearch,  
study  registries,  and  the  congress  proceedings  of  endoscopic  surgical  societies.  

SELECTION  CRITERIA:    We  included  randomized  clinical  trials  comparing  laparoscopic  (LA)  versus  
open  appendectomy  (OA)  in  adults  or  children.  Studies  comparing  immediate  OA  versus  diagnostic  
laparoscopy  (followed  by  LA  or  OA  if  necessary)  were  separately  identified.  

DATA  COLLECTION  AND  ANALYSIS:    Two  reviewers  independently  assessed  trial  quality.  Missing  
information  or  data  was  requested  from  the  authors.  We  used  odds  ratios  (OR),  relative  risks  (RR),  
and  95%  confidence  intervals  (CI)  for  analysis.  

MAIN  RESULTS:    We  included  67  studies,  of  which  56  compared  LA  (with  or  without  diagnostic  
laparoscopy)  vs.  OA  in  adults.  Wound  infections  were  less  likely  after  LA  than  after  OA  (OR  0.43;  CI  
0.34  to  0.54),  but  the  incidence  of  intraabdominal  abscesses  was  increased  (OR  1.87;  CI  1.19  to  
2.93).  The  duration  of  surgery  was  10  minutes  (CI  6  to  15)  longer  for  LA.  Pain  on  day  1  after  surgery  
was  reduced  after  LA  by  8  mm  (CI  5  to  11  mm)  on  a  100  mm  visual  analogue  scale.  Hospital  stay  was  
shortened  by  1.1  day  (CI  0.7  to  1.5).  Return  to  normal  activity,  work,  and  sport  occurred  earlier  after  
LA  than  after  OA.  While  the  operation  costs  of  LA  were  significantly  higher,  the  costs  outside  hospital  
were  reduced.  Seven  studies  on  children  were  included,  but  the  results  do  not  seem  to  be  much  
different  when  compared  to  adults.  Diagnostic  laparoscopy  reduced  the  risk  of  a  negative  
appendectomy,  but  this  effect  was  stronger  in  fertile  women  (RR  0.20;  CI  0.11  to  0.34)  as  compared  
to  unselected  adults  (RR  0.37;  CI  0.13  to  1.01).  

AUTHORS'  CONCLUSIONS:  In  those  clinical  settings  where  surgical  expertise  and  equipment  are  
available  and  affordable,  diagnostic  laparoscopy  and  LA  (either  in  combination  or  separately)  seem  
to  have  various  advantages  over  OA.  Some  of  the  clinical  effects  of  LA,  however,  are  small  and  of  
limited  clinical  relevance.  In  spite  of  the  mediocre  quality  of  the  available  research  data,  we  would  
generally  recommend  to  use  laparoscopy  and  LA  in  patients  with  suspected  appendicitis  unless  
laparoscopy  itself  is  contraindicated  or  not  feasible.  Especially  young  female,  obese,  and  employed  
patients  seem  to  benefit  from  LA.  

Endovascular  aneurysm  repair  versus  open  repair  in  patients  with  abdominal  aortic  aneurysm  
(EVAR  trial  1):  randomised  controlled  trial.  

Lancet.  2005  Jun  25-­‐Jul  1;365(9478):2179-­‐86.  

EVAR  trial  participants.  

BACKGROUND:    
  

Although  endovascular  aneurysm  repair  (EVAR)  has  a  lower  30-­‐day  operative  mortality  than  open  
repair,  the  long-­‐term  results  of  EVAR  are  uncertain.  We  instigated  EVAR  trial  1  to  compare  these  two  
treatments  in  terms  of  mortality,  durability,  health-­‐related  quality  of  life  (HRQL),  and  costs  for  
patients  with  large  abdominal  aortic  aneurysm  (AAA).  

METHODS:    

We  did  a  randomised  controlled  trial  of  1082  patients  aged  60  years  or  older  who  had  aneurysms  of  
at  least  5.5  cm  in  diameter  and  who  had  been  referred  to  one  of  34  hospitals  proficient  in  the  EVAR  
technique.  We  assigned  patients  who  were  anatomically  suitable  for  EVAR  and  fit  for  an  open  repair  
to  EVAR  (n=543)  or  open  repair  (n=539).  Our  primary  endpoint  was  all-­‐cause  mortality,  with  
secondary  endpoints  of  aneurysm  related  mortality,  HRQL,  postoperative  complications,  and  
hospital  costs.  Analyses  were  by  intention  to  treat.  

FINDINGS:    

94%  (1017  of  1082)  of  patients  complied  with  their  allocated  treatment  and  209  died  by  the  end  of  
follow-­‐up  on  Dec  31,  2004  (53  of  aneurysm-­‐related  causes).  4  years  after  randomisation,  all-­‐cause  
mortality  was  similar  in  the  two  groups  (about  28%;  hazard  ratio  0.90,  95%  CI  0.69-­‐1.18,  p=0.46),  
although  there  was  a  persistent  reduction  in  aneurysm-­‐related  deaths  in  the  EVAR  group  (4%vs  7%;  
0.55,  0.31-­‐0.96,  p=0.04).  The  proportion  of  patients  with  postoperative  complications  within  4  years  
of  randomisation  was  41%  in  the  EVAR  group  and  9%  in  the  open  repair  group  (4.9,  3.5-­‐6.8,  
p<0.0001).  After  12  months  there  was  negligible  difference  in  HRQL  between  the  two  groups.  The  
mean  hospital  costs  per  patient  up  to  4  years  were  UK  pound  sterling  13,257  for  the  EVAR  group  
versus  pound  sterling  9946  for  the  open  repair  group  (mean  difference  pound  sterling  3311,  SE  690).  

Preoperative  radiotherapy  versus  selective  postoperative  chemoradiotherapy  in  patients  with  

rectal  cancer  (MRC  CR07  and  NCIC-­‐CTG  C016):  a  multicentre,  randomised  trial.  

Lancet.  2009  Mar  7;373(9666):811-­‐20.  doi:  10.1016/S0140-­‐6736(09)60484-­‐0.  

  

Sebag-­‐Montefiore  D,  Stephens  RJ,  Steele  R,  Monson  J,  Grieve  R,  Khanna  S,  Quirke  P,  Couture  J,  de  
Metz  C,  Myint  AS,  Bessell  E,  Griffiths  G,  Thompson  LC,  Parmar  M.  

St  James's  University  Hospital,  Leeds,  UK.  

BACKGROUND:    

Preoperative  or  postoperative  radiotherapy  reduces  the  risk  of  local  recurrence  in  patients  with  
operable  rectal  cancer.  However,  improvements  in  surgery  and  histopathological  assessment  mean  
that  the  role  of  radiotherapy  needs  to  be  reassessed.  We  compared  short-­‐course  preoperative  
radiotherapy  versus  initial  surgery  with  selective  postoperative  chemoradiotherapy.  

METHODS:    

We  undertook  a  randomised  trial  in  80  centres  in  four  countries.  1350  patients  with  operable  
adenocarcinoma  of  the  rectum  were  randomly  assigned,  by  a  minimisation  procedure,  to  short-­‐
course  preoperative  radiotherapy  (25  Gy  in  five  fractions;  n=674)  or  to  initial  surgery  with  selective  
postoperative  chemoradiotherapy  (45  Gy  in  25  fractions  with  concurrent  5-­‐fluorouracil)  restricted  to  
patients  with  involvement  of  the  circumferential  resection  margin  (n=676).  The  primary  outcome  
measure  was  local  recurrence.  Analysis  was  by  intention  to  treat.  This  study  is  registered,  number  
ISRCTN  28785842.  

FINDINGS:    

At  the  time  of  analysis,  which  included  all  participants,  330  patients  had  died  (157  preoperative  
radiotherapy  group  vs  173  selective  postoperative  chemoradiotherapy),  and  median  follow-­‐up  of  
surviving  patients  was  4  years.  99  patients  had  developed  local  recurrence  (27  preoperative  
radiotherapy  vs  72  selective  postoperative  chemoradiotherapy).  We  noted  a  reduction  of  61%  in  the  
relative  risk  of  local  recurrence  for  patients  receiving  preoperative  radiotherapy  (hazard  ratio  [HR]  
0.39,  95%  CI  0.27-­‐0.58,  p<0.0001),  and  an  absolute  difference  at  3  years  of  6.2%  (95%  CI  5.3-­‐7.1)  
(4.4%  preoperative  radiotherapy  vs  10.6%  selective  postoperative  chemoradiotherapy).  We  
recorded  a  relative  improvement  in  disease-­‐free  survival  of  24%  for  patients  receiving  preoperative  
radiotherapy  (HR  0.76,  95%  CI  0.62-­‐0.94,  p=0.013),  and  an  absolute  difference  at  3  years  of  6.0%  
(95%  CI  5.3-­‐6.8)  (77.5%vs  71.5%).  Overall  survival  did  not  differ  between  the  groups  (HR  0.91,  95%  CI  
0.73-­‐1.13,  p=0.40).  

 
  

Fast  track  surgery  versus  conventional  recovery  strategies  for  colorectal  surgery.    

Cochrane  Database  Syst  Rev.  2011  Feb  16;(2):CD007635.  doi:  10.1002/14651858.CD007635.pub2.  

Spanjersberg  WR,  Reurings  J,  Keus  F,  van  Laarhoven  CJ.  

Department  of  Surgery,  Radboud  University  Nijmegen  Medical  Center,  PO  Box  9101,  Nijmegen,  
Netherlands,  6500  HB.  

BACKGROUND:    In  recent  years  the  Enhanced  Recovery  after  Surgery  (ERAS)  postoperative  pathway  
in  (ileo-­‐)colorectal  surgery,  aiming  at  improving  perioperative  care  and  decreasing  postoperative  
complications,  has  become  more  common.  

OBJECTIVES:    We  investigated  the  effectiveness  and  safety  of  the  ERAS  multimodal  strategy,  
compared  to  conventional  care  after  (ileo-­‐)colorectal  surgery.  The  primary  research  question  was  
whether  ERAS  protocols  lead  to  less  morbidity  and  secondary  whether  length  of  stay  was  reduced.  

SEARCH  STRATEGY:    To  answer  the  research  question  we  entered  search  strings  containing  
keywords  like  "fast  track",  "colorectal  and  surgery"  and  "enhanced  recovery"  into  major  databases.  
We  also  hand  searched  references  in  identified  reviews  concerning  ERAS.  

SELECTION  CRITERIA:    We  included  published  randomised  clinical  trials,  in  any  language,  comparing  
ERAS  to  conventional  treatment  in  patients  with  (ileo-­‐)  colorectal  disease  requiring  a  resection.  RCT's  
including  at  least  7  ERAS  items  in  the  ERAS  group  and  no  more  than  2  in  the  conventional  arm  were  
included.  

DATA  COLLECTION  AND  ANALYSIS:    Data  of  included  trials  were  independently  extracted  by  the  
reviewers.  Analyses  were  performed  using  "REVMAN  5.0.22".  Data  were  pooled  and  rate  differences  
as  well  as  weighted  mean  differences  with  their  95%  confidence  intervals  were  calculated  using  
either  fixed  or  random  effects  models,  depending  on  heterogeneity  (I(2)).  

MAIN  RESULTS:    4  RCTs  were  included  and  analysed.  Methodological  quality  of  included  studies  was  
considered  low,  when  scored  according  to  GRADE  methodology.  Total  numbers  of  inclusion  were  
limited.  The  trials  included  in  primary  analysis  reported  237  patients,  (119  ERAS  vs  118  
conventional).  Baseline  characteristics  were  comparable.  The  primary  outcome  measure,  
complications,  showed  a  significant  risk  reduction  for  all  complications  (RR  0.50;  95%  CI  0.35  to  
0.72).  This  difference  was  not  due  to  reduction  in  major  complications.  Length  of  hospital  stay  was  
significantly  reduced  in  the  ERAS  group  (MD  -­‐2.94  days;  95%  CI  -­‐3.69  to  -­‐2.19),  and  readmission  rates  
were  equal  in  both  groups.  Other  outcome  parameters  were  unsuitable  for  meta-­‐analysis,  but  
seemed  to  favour  ERAS.  
  

Appendectomy  versus  antibiotic  treatment  for  acute  appendicitis.  

Cochrane  Database  Syst  Rev.  2011  Nov  9;(11):CD008359.  doi:  10.1002/14651858.CD008359.pub2.  

Wilms  IM,  de  Hoog  DE,  de  Visser  DC,  Janzing  HM.  

Department  of  Emergency  Medicine,VieCuri  Medical  Centre  of  Northern  Limburg,  Venlo,  
Netherlands.  

BACKGROUND:    Acute  appendicitis  is  one  of  the  most  common  causes  of  acute  abdominal  pain.  
Present  day  treatment  of  choice  for  acute  appendicitis  is  appendectomy,  however  complications  are  
inherent  to  operative  treatment.  Though  surgical  appendectomy  remains  the  standard  treatment,  
several  investigators  have  investigated  conservative  antibiotic  treatment  of  acute  appendicitis  and  
reported  good  results.  

OBJECTIVES:    Is  antibiotic  treatment  as  effective  as  surgical  appendectomy  (laparoscopic  or  open)  in  
patients  with  acute  appendicitis  on  recovery  within  two  weeks,  without  major  complications  
(including  recurrence)  within  one  year?  

SEARCH  METHODS:    We  searched  the  Cochrane  Central  Register  of  Controlled  Trials  (The  Cochrane  
Library  Issue  6,  2011);  MEDLINE  (until  June  2011);  EMBASE  (until  June  2011);  Prospective  Trial  
Registers  (June  2011)  and  reference  lists  of  articles.  

SELECTION  CRITERIA:  Randomised  and  quasi-­‐randomised  clinical  trials  (RCT  and  qRCT)  comparing  
antibiotic  treatment  with  appendectomy  in  patients  with  suspected  appendicitis  were  included.  
Excluded  were  studies  which  primarily  focused  on  the  complications  of  acute  appendicitis.  

DATA  COLLECTION  AND  ANALYSIS:  Two  authors  independently  assessed  trial  quality  and  extracted  
data.  The  review  authors  contacted  the  trial  authors  for  additional  information  if  required.  Statistical  
analysis  was  carried  out  using  Review  Manager  and  MetaAnalyst.  A  non-­‐inferiority  analysis  was  
performed,  comparing  antibiotic  treatment  (ABT)  to  the  gold  standard  (appendectomy).  By  
consensus,  a  20%  margin  of  non-­‐inferiority  was  considered  clinically  relevant.  

MAIN  RESULTS:  Five  RCT's  (901  patients)  were  assessed.  In  total  73.4%  (95%  CI  62.7  to  81.9)  of  
patients  who  were  treated  with  antibiotics  and  97.4  (95%  CI  94.4  to  98.8)  patients  who  directly  got  
an  appendectomy  were  cured  within  two  weeks  without  major  complications  (including  recurrence)  
within  one  year.  The  lower  95%  CI  was  15.2%  below  the  20%  margin  for  the  primary  outcome.  

 
  

Laparoscopic  versus  open  surgery  for  suspected  appendicitis.  

Cochrane  Database  Syst  Rev.  2010  Oct  6;(10):CD001546.  doi:  10.1002/14651858.CD001546.pub3.  

Sauerland  S,  Jaschinski  T,  Neugebauer  EA.  

Department  of  Non-­‐Drug  Interventions,  Institute  for  Quality  and  Efficiency  in  Health  Care,  
Dillenburger  Str.  27,  Cologne,  Germany,  51105.  

BACKGROUND:  Laparoscopic  surgery  for  acute  appendicitis  has  been  proposed  to  have  advantages  
over  conventional  surgery.  

OBJECTIVES:  To  compare  the  diagnostic  and  therapeutic  effects  of  laparoscopic  and  conventional  
'open'  surgery.  

SEARCH  STRATEGY:  We  searched  the  Cochrane  Library,  MEDLINE,  EMBASE,  LILACS,  CNKI,  SciSearch,  
study  registries,  and  the  congress  proceedings  of  endoscopic  surgical  societies.  

SELECTION  CRITERIA:  We  included  randomized  clinical  trials  comparing  laparoscopic  (LA)  versus  
open  appendectomy  (OA)  in  adults  or  children.  Studies  comparing  immediate  OA  versus  diagnostic  
laparoscopy  (followed  by  LA  or  OA  if  necessary)  were  separately  identified.  

DATA  COLLECTION  AND  ANALYSIS:    Two  reviewers  independently  assessed  trial  quality.  Missing  
information  or  data  was  requested  from  the  authors.  We  used  odds  ratios  (OR),  relative  risks  (RR),  
and  95%  confidence  intervals  (CI)  for  analysis.  

MAIN  RESULTS:    We  included  67  studies,  of  which  56  compared  LA  (with  or  without  diagnostic  
laparoscopy)  vs.  OA  in  adults.  Wound  infections  were  less  likely  after  LA  than  after  OA  (OR  0.43;  CI  
0.34  to  0.54),  but  the  incidence  of  intraabdominal  abscesses  was  increased  (OR  1.87;  CI  1.19  to  
2.93).  The  duration  of  surgery  was  10  minutes  (CI  6  to  15)  longer  for  LA.  Pain  on  day  1  after  surgery  
was  reduced  after  LA  by  8  mm  (CI  5  to  11  mm)  on  a  100  mm  visual  analogue  scale.  Hospital  stay  was  
  

shortened  by  1.1  day  (CI  0.7  to  1.5).  Return  to  normal  activity,  work,  and  sport  occurred  earlier  after  
LA  than  after  OA.  While  the  operation  costs  of  LA  were  significantly  higher,  the  costs  outside  hospital  
were  reduced.  Seven  studies  on  children  were  included,  but  the  results  do  not  seem  to  be  much  
different  when  compared  to  adults.  Diagnostic  laparoscopy  reduced  the  risk  of  a  negative  
appendectomy,  but  this  effect  was  stronger  in  fertile  women  (RR  0.20;  CI  0.11  to  0.34)  as  compared  
to  unselected  adults  (RR  0.37;  CI  0.13  to  1.01).  

AUDIT  QUESTION  1  

During  a  monthly  M&M  meeting,  you  present  a  case  of  a  patient  who  developed  a  DVT  3  weeks  after  
discharge  from  hospital  following  an  otherwise  uncomplicated  gastric  bypass  procedure  for  morbid  
obesity.  You  are  asked  by  your  consultant  to  look  into  DVT  prophylaxis  on  the  unit.  Describe  how  
you  would  go  about  doing  this.  

AUDIT  QUESTION  2  

During  a  monthly  M&M  meeting,  there  seem  to  be  a  number  of  patients  who  have  developed  
wound  infections  after  laparotomy.  You  are  asked  by  your  consultant  to  look  into  this.  Describe  how  
you  would  go  about  doing  this.  

AUDIT  QUESTION  3  

In  a  colorectal  outpatient  clinic,  you  and  your  consultant  discuss  the  fact  that  the  number  of  2-­‐week-­‐
wait  referrals  seem  to  be  ever  increasing  but  the  symptoms  they  have  do  not  correlate  with  
appropriate  referral  criteria.  He  asks  you  to  audit  this.  Describe  how  you  would  go  about  doing  this.  

AUDIT  QUESTION  4  
  

During  an  HDU  ward  round  with  your  consultant,  you  see  a  patient  who  has  been  transferred  there  
urgently  from  the  ward  overnight.  He  is  6  days  post  uncomplicated  right  hemicolectomy.  He  has  
gone  into  respiratory  failure  secondary  to  pulmonary  oedema.  When  you  look  at  his  fluid  chart,  you  
see  that  he  has  received  four  litres  of  IV  fluids  in  the  preceding  20  hours.  His  blood  panel  shows  that  
he  has  a  hyperchloraemic  acidosis  and  that  3  of  the  4  litres  were  normal  (0.9%)  saline.  Your  
consultant  demands  to  know  why  this  has  happened  and  asks  you  to  make  sure  it  does  not  happen  
again.  Describe  how  you  would  go  about  doing  this.  

AUDIT  QUESTION  5  

The  sister  on  your  vascular  ward  comments  on  the  ward  round  that  a  lot  of  the  patients  are  having  
wound  problems  after  amputation  and  that  “a  couple  have  died  recently”.  Your  consultant  asks  you  
to  audit  the  outcomes  after  amputation.  Describe  how  you  would  go  about  doing  this.  

 
  

 
  

COMMUNICATION  QUESTIONS  

Communication  Skills  Station  1  

You  are  the  ST3  on  call  for  general  surgery  at  a  DGH  with  a  strong  reputation  for  interventional  
radiology.  Just  prior  to  the  morning  handover,  your  consultant  phones  you  and  tells  you  his  car  has  
broken  down  and  he  will  be  half  an  hour  late.  He  has  asked  you  to  take  the  handover  and  go  to  the  
x-­‐ray  department  with  your  SHO  and  FY1  to  discuss  the  patients  with  the  on-­‐call  radiologist  in  the  
acute  x-­‐ray  meeting  and  arrange  the  imaging  that  you  wish  to  organise.  Please  have  a  look  through  
the  following  patient  details  of  all  the  admissions  for  the  past  24  hours  and  discuss  them  with  the  
radiologist,  who  will  be  your  interviewer.  Please  decide  what  tests  you  would  like  and  discuss    
 
Patient  1  –  45  year  old  man  with  multiple  sclerosis  with  soft  abdominal  distension.  Plain  x-­‐rays  have  
been  performed  but  you  have  not  seen  them.  Handover  note  states  that  the  patient  has  no  
significant  pain  and  normal  bloods.  
 
Patient  2  –  67  year  old  woman  who  has  known  diverticular  disease.  PMH  of  ischaemic  heart  disease  
and  hypertension  with  tablet  controlled  diabetes  and  obesity.  Moderate  LIF  tenderness  for  24  hours  
but  no  peritonism.  Febrile  overnight  and  raised  inflammatory  markers  (WCC  19,  CRP  201).  Normal  X-­‐
Rays  
 
Patient  3  –  37  year  old  woman  who  has  been  admitted  with  colicky  upper  abdominal  pain,  jaundice  
and  rigors.  PMH:  Left  inguinal  hernia  repair  1  year  ago,  18/12  post  gastric  bypass  for  obesity.  USS  
organised  yesterday  confirms  gallstones  and  a  dilated  CBD  at  1.1  cms  with  a  stone  in  the  distal  CBD.  
Bilirubin  104  CRP  198  
 
Patient  4  –  18  year  old  man  admitted  with  a  short  history  of  central    right  iliac  fossa  pain.  Raised  
inflammatory  markers  and  right  iliac  fossa  peritonism  
 
Patient  5  –  49  year  old  woman  admitted  with  severe  epigastric  pain  radiating  through  to  the  back  for  
1/7.  Haemodynamically  stable  but  very  tender  in  epigastrium.  Normal  X-­‐Rays.  WCC10  Amylase  981.  
Normal  ABG.  CRP  107.  Other  bloods  normal  range.  
 

 
  

 
 
 
 
 
 
 
 
 
Communication  Skills  Scenario  2  
You  have  been  in  your  new  ST3  post  for  2  weeks.  The  post  is  in  a  hospital  you  have  not  worked  in  
before  and  you  are  just  finding  your  feet.  The  overnight  10pm  to  8am  emergency  cover  team  for  
general  surgery  comprises  an  FY1,  a  CT2  and  the  consultant,  who  is  non-­‐resident  but  covers  
emergencies  24  hours  at  a  time.  You  are  on  emergency  daytime/evening  cover  this  week  and  have  
just  completed  your  shift  at  10.00pm.  You  had  not  previously  worked  with  the  consultant  on  call,  
who  did  a  ward  round  with  you  at  7pm  before  going  home  and  asked  you  to  telephone  at  the  end  of  
your  shift  for  an  update  on  the  emergency  patients.  
You  had  had  a  number  of  admissions,  who  were  seen  by  the  consultant  on  the  7pm  ward  round:  
-­‐  A  24  year  old  male  with  non-­‐specific  central  abdominal  pain  for  observation  

-­‐  A  47  year  old  female  with  cholecystitis  clinically  for  whom  you  were  to  arrange  an  ultrasound  scan  
that  evening  with  a  view  to  possible  cholecystectomy  tomorrow  
-­‐  A  20  year  old  female  with  a  pilonidal  abscess,  which  you  drained  during  the  day  
-­‐  A  24  year  old  male  with  a  stab  wound  to  the  abdomen  which  you  had  explored  under  local  
anaesthetic  and  as  far  as  you  could  tell  did  not  appear  to  enter  the  peritoneal  cavity.  The  consultant  
had  requested  an  abdominal  CT  as  a  precaution  on  the  7pm  ward  round  but  it  had  not  been  done  by  
10pm.  
At  9pm  you  admitted  a  28  year  old  male  who  had  a  3  hour  history  of  upper  abdominal  pain  of  acute  
onset.  He  had  vomited  once  or  twice  with  no  obvious  blood  in  the  vomitus.  He  had  no  other  
significant  medical  history  and  was  on  no  medication  but  did  admit  to  drinking  several  pints  of  beer  
most  nights  a  week.  On  examination  he  had  multiple  tattoos  and  was  irritable.  His  pulse  was  96,  his  
respiratory  rate  26  and  his  temperature  37.4oC.  His  blood  pressure  was  110/70.  His  chest  was  clear.  
He  had  a  midline  laparotomy  scar  which  he  said  was  following  a  road  traffic  accident  3  years  ago.  He  
was  vague  about  the  event  and  did  not  know  what  had  been  done.  He  was  tender  in  his  upper  
abdomen  but  without  obvious  guarding.  His  bowel  sounds  were  present  but  quiet.  The  patient  did  
not  appear  too  unwell  to  you.  The  FY1  had  sent  off  investigations  which  showed:  
Hb  13.8       Na  141         pH  7.35  
WCC  14.2       K  4.3         pCO2  3.2  
Pts  323       Urea  9.2       pO2  15.8  
Creat  82       HCO3  18  
  

Amylase  403       BE  -­‐4  

 
Chest  x-­‐ray:  normal  looking  lungs  and  heart,  no  free  gas  under  the  diaphragm  as  far  as  you  could  see  
Abdominal  x-­‐ray:  No  obvious  abnormality  
You  set  up  an  IVI,  prescribe  analgesia  and  ask  the  nurses  to  let  you  know  if  there  is  any  change  in  his  
observations.  You  then  hand  over  to  the  CT2  who  is  on  overnight.  During  a  quick  ward  round,  the  
admissions  you’d  had  during  the  day  all  seem  quite  well  although  the  24  year  old  man  with  non-­‐
specific  central  abdominal  pain  has  flicked  a  temperature  up  to  37.8oC,  the  patient  with  the  stab  
wound  wants  to  take  his  own  discharge  and  the  nurses  have  had  to  change  the  dressing  for  the  
patient  with  the  pilonidal  abscess  because  of  bleeding.  
 
As  the  consultant  answered  your  call  at  the  end  of  your  shift,  you  remembered  that  you  had  
forgotten  to  organise  the  ultrasound  on  the  patient  with  suspected  cholecystitis.  
 
Communication  Skills  Scenario  3  
You  are  the  ST3  on  call  for  general  surgery  and  at  the  night  handover,  have  been  told  that  there  is  
one  more  lap  appendix  to  do  and  the  consultant  has  insisted  that  it  gets  done  tonight.  You  go  to  
theatres  after  handover  and  speak  to  one  of  the  circulating  team  who  informs  you  that  there  is  a  
gynaecology  case  currently  on  the  table  but  that  it  should  finish  soon.  You  go  to  see  the  rest  of  the  
acute  admissions  and  then  go  back  to  theatre.  It  is  now  0130AM  and  the  gynae  surgeons  have  begun  
closing.  You  ask  to  send  for  the  appendix  and  are  told  bluntly  by  the  anaesthetic  registrar  that  it  is  
too  late  to  do  an  appendix.  Describe  how  you  would  go  about  dealing  with  this  situation.  
 
 
Communication  Skills  Scenario  4  
You  are  the  ST3  for  a  colorectal  firm  and  you  have  just  attended  the  weekly  MDTM  for  colorectal  
cancer.  You  have  presented  a  patient  who  is  currently  an  in-­‐patient  with  abdominal  pain.  He  had  
previously  had  a  right  hemicolectomy  for  Dukes’  C2  disease  3  years  previously.  His  CT  done  
yesterday  shows  widespread  liver  and  peritoneal  metastases  and  the  recommendation  from  the  
MDT  is  that  he  should  be  for  palliative  chemotherapy  only  (if  fit  enough)  or  best  supportive  care.  
Your  consultant  has  to  be  at  a  meeting  for  the  rest  of  the  day  and  he  has  asked  you  to  speak  to  the  
patient.  Describe  how  you  would  go  about  doing  this  and  the  communication  skills  issues  that  may  
arise.  
 
 
Communication  Skills  Scenario  5  
You  are  the  ST3  on  a  general  surgery  firm  in  a  new  Deanery  to  where  you  have  previously  trained.  
You  are  working  for  the  senior  consultant  on  the  firm  and,  other  than  your  introductory  meeting,  
you  have  not  got  to  know  him.  Your  first  clinical  session  together  is  a  half-­‐day  morning  list.  The  first  
case  is  an  open  right  inguinal  hernia  and  he  has  told  you  to  start  without  him  and  have  the  SHO  to  
  

assist.  During  your  dissection,  you  ask  for  a  self-­‐retainer  but  are  instead  given  two  Langenbeck  
retractors  by  the  senior  scrub  nurse  who  informs  you  brusquely  that  your  consultant  “never  uses  a  
self  retainer”.  Describe  how  you  would  approach  and  deal  with  this  scenario  and  the  
communications  skills  issues  that  may  arise.  
Q1  You  are  on  call  and  approaching  the  end  of  your  shift,  the  on  call  consultant  has  asked  you  to  
give  him  a  call  and  run  by  the  admissions  for  that  day.  

1. 46  year  old  female,  known  gallstones,  presenting  with  RUQ  pain,  cholecystitis.    
2. 10  year  old  boy  with  lower  abdo  pain,  normal  inflammatory  markers  and  a  soft  abdomen.  
3. 35  year  alcoholic,  epigastric  pain,  amylase  569  
4. 85  year  old  man  with  lif  pain,  wcc  21  crp  360,  localised  peritonism.  
5. 34  year  old  recently  returned  from  Africa,  sting  bite  on  forearm,  cellulitis,  temp  of  38,  
hypotensive.    
6. 57  year  old  man,  with  severe  central  abdo  pain,  hypotensive    
7. 67  year  old  man,  mild  abdominal  pain,  query  as  to  whether  there  is  free  air  on  the  CXR,  he  
has  a  soft  abdomen,  and  otherwise  is  stable    
8. An  18  year  old  afro  Caribbean  male  with  severe  generalised  abdo  pain.    
9. 72  year  old  known  arteriopath,  with  a  dusky  toe.    
10. 28  year  old  female  recent  diagnosis  of  ulcerative  colitis,  mild  lower  abdominal  pain  and  
raised  inflammatory  markers.      

Example  2:  You  had  to  run  a  clinic  without  your  consultant  who  was  called  to  an  urgent  meeting.  
You  saw  the  following  list  of  patients  and  your  consultant  would  like  you  to  give  him  a  call  at  the  
end  and  run  through  who  you  saw.    

1. 45  year  old,  recent  change  in  bowel  habit,  some  rectal  bleeding,  nothing  to  find  on  
examination  in  clinic.    

2. 34  year  old,  cancer  follow-­‐up.  Right  hemicolectomy  for  Dukes  A  cancer  a  year  ago.    

3. 56  year  old,  small  sided  right  inguinal  hernia.  Otherwise  fit  and  well.  

4. 72  year  old  female,  large  sized  palpable  upper  abdominal  mass,  looks  pale.    

5. 45  year  old  female,  admission  two  months  ago  with  suspected  diverticulitis,  follow  up  in  
clinic.    

6. 21  year  old,  bleeding  2  degree  haemorrhoids  seen  in  clinic.  

  

7. 49  year  old  female,  follow  up  2  months  following  admission  for  ultrasound  proven  
cholecystitis.    

8. 22  year  old  female,  one  year  history  of  loose  stool,  colicky  abdominal  pain  following  meals  

9. A  63  year  old  two  weeks  post  subtotal  colectomy,  with  severe  abdo  pain  and  fevers  and  
nausea  

10. A  53  year  old  smoker  with  short  distance  bilateral  calf  claudication  to  100  yards.    

 
Team  working  and  leadership  

1. You  have  just  joined  a  general  surgical  department  where  the  majority  of  juniors  appear  
very  unhappy  with  their  current  working  conditions,  in  particular  the  on  call  rota.  Morale  is  
at  an  all  time  low,  and  you  have  been  asked  by  your  consultant  to  think  of  ways  to  improve  
the  overall  atmosphere  of  the  department.    
2. You and the other registrars are not happy because of the high number on on-call shifts and
the fact that you are not with the same consultant. What do you do?
 

More  Clinical  Scenarios  

Clinical  scenario  and  management  

1.  you  are  on  call  and  the  gastroenterologists  would  like  you  to  see  a  patient  with  UC  suffering  with  
an  acute  flare  up  that  they  believe  will  need  an  urgent  subtotal  colectomy.  The  consultant  on  call  
with  you  is  a  breast  surgeon.  The  colorectal  consultant  is  not  in  the  building  at  present.  At  the  same  
time,  you  receive  a  call  that  a  suspected  leaking  AAA  is  being  transferred  from  another  hospital  over  
to  you.  Lastly  there  is  a  child  who  is  ten  who  is  due  for  an  appendicectomy,  and  theatres  have  called  
asking  if  you  are  ready  for  them  to  send.  Part  of  your  team  includes  a  CT2  and  an  FY1.  Consider  what  
organisational  and  clinical  issues  need  to  be  addressed.  

2.  You  are  the  st3  on  call.  You  are  called  by  a&e  as  they  would  like  you  to  see  an  elderly  severely  
demented  woman  who  has  sustained  a  head  injury  and  has  a  GCS  of  6.  In  addition,  there  is  an  18  
year  old  female  who  is  hypotensive  with  RIF  pain.  In  addition,  there  is  one  more  patient  who  25  
years  old  who  has  been  involved  in  an  RTA,  he  has  no  obvious  injuries  and  is  haemodynamically  
stable.  Part  of  your  team  includes  a  CT2  and  an  FY1.  Consider  what  organisational  and  clinical  issues  
need  to  be  addressed.  
  

3.  It  is  the  weekend  and  you  are  the  ST3  on  call.  You  receive  a  call  from  a  DGH  –  a  ruptured  
aneurysm  is  due  to  be  transferred  over,  in  addition  you  have  just  seen  a  patient  who  is  peritonitis  
with  a  pneumoperitoneum  on  the  CXR.  Lastly  there  is  a  45  year  old  with  right  sided  abdominal  pain  
who  is  haemodynamically  stable  that  still  has  not  been  seen.  You  have  a  CT2  and  an  FY1  as  part  of  
your  team.  Consider  what  organisational  and  clinical  issues  need  to  be  addressed.  

4.  You  are  the  night  ST3,  and  have  been  handed  over  a  patient  with  peritonitis  that  needs  an  urgent  
laparotomy.  You  disagree  with  the  plan.  In  addition,  you  review  another  admission  due  for  an  
appendicectomy  who  has  a  cough.  There  is  a  phone  call  from  resus  –  a  suspected  ruptured  AAA  has  
just  arrived.  What  do  you  do?  Part  of  your  team  includes  a  CT2  and  an  FY1.  Consider  what  
organisational  and  clinical  issues  need  to  be  addressed.  

5.  A  15  yr  old  boy  is  brought  in  by  his  father  having  fallen  off  his  bike.  He  is  c/o  LUQ  pain.  He  is  pale  
and  peripherally  shut  down.  As  you  take  the  hx  it  is  apparent  the  parents  are  divorced  and  the  son  
normally  lives  with  his  mother.  He  is  intelligent  and  understands  the  situation  fully.  Examination  
confirms  that  he  is  tachycardic  and  hypotensive.  He  has  an  abdomen  that  is  distended  and  tender  
maximally  in  the  LUQ  where  there  is  bruising  from  where  the  bicycle  handlebars  have  caught  him.  
You  suspect  a  ruptured  spleen  Consider  what  organisational  and  clinical  issues  need  to  be  
addressed.