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Preventing recurrent Crohn’s Disease after surgery: the Kono-S anastomosis
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Can recurrent diverticulitis be predicted?
Lucia Sobrinoa, Marta Climent, Clara Santanach, Sebastiano Biondo
Diverticular disease is a common disorder, and recent guidelines report on new treatment strategies such as non-antibiotic management. Patients with diverticular disease are increasingly being treated as outpatients. In addition, fewer patients are undergoing emergency surgery whereas there is an increase in the use of elective and laparoscopic surgery in the management of diverticulitis. However, several aspects are still controversial. Strong evidence still lacks for the therapeutic management of patients with recurrent episodes of acute diverticulitis or patients with persistent abdominal symptoms after acute attacks. The European Society of Coloproctology (ESCP) guideline committee reviewed the literature and developed the European guidelines for the management of diverticular disease of the colon in 2020. In spite of the existence of several different classifications for diverticulitis, the committee decided neither to create another classification nor to endorse any of the existing ones. Nevertheless, phlegmonous diverticulitis, considered as uncomplicated by most of the classifications, is a matter of concern since it includes about 70% of the patients with acute diverticulitis. This group of patients may be clinically heterogeneous in terms of characteristics or disease evolution, which in some cases might be complicated. Patients at risk that belong to initially uncomplicated stage need to be identified in order to prevent complications and receive the most appropriate medical/surgical treatment. Classically, colonic resection after the second episode of acute diverticulitis has been supported, since any following episodes will respond insufficiently to medical treatment and with higher morbidity and mortality2. Recently, it was reported that 6.8-27.7%3,4 of patients with acute diverticulitis treated conservatively may require surgical intervention due to complicated diverticulitis or persistent symptoms, most of them during the first year of follow-up. In addition, elective sigmoidectomy seems to be related with a better quality of life (QOL) compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints5,6. Nowadays, the main reason to perform elective sigmoid colectomy (Fig 1) in patients with recurrent disease or with ongoing symptoms after an acute episode of diverticulitis is to improve their QOL. In fact, there are many patients in whom initial antibiotic treatment fails, leading to sub-acute / chronic diverticulitis. In these patients the differentiation between sub-acute ongoing diverticulitis which never resolved, i.e. persisting disease, and a true recurrence is very difficult7. Chronic diverticulitis (Fig 1), considered as a true condition for the first time by the ESCP group, occurs when there is colonic wall thickening or chronic inflammation of the mucosa1. It can appear when an acute diverticulitis does not resolve completely, and it can have an important impact on QOL of the patients, causing persistent abdominal symptoms (abdominal pain, bloating) and changes in bowel habit. However, the uncertainty of the evolution of the disease and the lack of clear signs to identify which patients will develop a chronic condition, make the selection of patients and the best moment to advise surgical resection difficult. Colonic resection has been shown to effectively reduce the number of recurrences, but it should be kept in mind that it is a major surgery with potential severe complications1. The distinction between Irritable Bowel Syndrome (IBS) and symptoms related to chronic diverticulitis after an episode of diverticulitis is of utmost importance, because IBS is a functional disorder and should not be treated surgically8. Endoscopy could help in those cases where differential diagnosis is difficult5. It should be noted that after sigmoidectomy, 25% of patients persist with functional symptoms and abdominal pain9.
Widening participation in cardiothoracic healthcare: INSINC Insight
Kirstie Kirkley, Georgia R. Layton, Javeria Tariq, Heen Shamaz, Mostin Hu, Alana Atkinson, Deborah Harrington, Elizabeth Belcher, Jason Ali, Narain Moorjani, Farah Bhatti, Karen Booth
Equality, diversity and inclusion (EDI) within surgery is important.1 The recent Kennedy Review on Diversity and Inclusion, commissioned by the Royal College of Surgeons of England, made 16 recommendations to improve EDI in the surgical workforce.2 Cardiothoracic surgery in the UK lacks diversity, exemplified with only 13% of the consultant workforce being female, despite females accounting for 49% of UK doctors.3 One method of improving EDI in the specialty, is to focus on widening participation (WP) activities.
In the UK, WP activities and government policies aim to increase representation of lower socio-economic groups in higher education. Published schemes focus on peer-to-peer mentorship from medical to school students. The King’s College London scheme is a monthly seminar series offered to WP school students, publishing a 50% success rate of translation to successful application to medical school.4
Resident selection in surgery
Kristine Hagelsteen, MD PhD, Chris Mathieu
There is a global interest in and growing knowledge about how best to select residents in surgery. In 2010, Paice et al claimed that selection was “the missing link in patient safety work”1. The starting point for collegial discussions on the matter and opinions about selection are things we know and have experience of; and we know that there is a spectrum running from excellent to unsuitable surgeons. Some continue to ask, are surgeons “born or made”, i.e., is it innate talent, or their training that matters? Is competence-based education better than the apprenticeship model?2,3. Further, it is well-established that all facets of competence matter for patient outcomes, not only technical skill4-6. The detrimental effect a less competent or even dysfunctional colleague can have on patients and the workplace environment is also widely recognised7. Attrition from surgical residency programs has been reported to be up to 20%, reflecting bad investments of resources8. Another challenge is that surgery accounts for most adverse events in health care, and that up to 15 % of patients in elective surgery suffer a treatment-related injury9,10. We all want the next generation to be better than us. Selection is thus a foundational factor in raising the standard level of treatment and care, reducing adverse events, improving workplace collaboration and heightening the reputation of the profession.
Some characteristics have been found important for surgeons to be successful, such as having a strong academic background and commitment to lifelong learning; possessing sufficient manual dexterity and fine motor skills to reach proficiency; displaying emotional stability; extroversion and conscientiousness; good communication skills and ability to work in teams; critical thinking ability; situational awareness; robust decision-making and problem-solving skills11-14. A more recent addition to the list is “technical orientation”, i.e. willingness and ability to work in a technology-based environment15.
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