Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (2 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Iain D. Anderson, BSc, MD, FRCS(Eng), FRCS(Gen), FRCS(Glas)
,
Consultant Surgeon, Intestinal Failure Unit, Salford Royal Hospital, Manchester, UK
Emma Barrow, MBChB, MD, FRCS(Gen)
,
Specialist Registrar, Intestinal Failure Unit, Salford Royal Hospital, Manchester, UK
Paul Baskerville, MA, DM, BMBCh, FRCS
,
Consultant Vascular and General Surgeon and Director of Surgical Practice, King's College Hospital, London, UK
Andrew C. de Beaux, MBChB, FRCS, MD
,
Honorary Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh
;
Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK
David E. Beck, MD, FACS, FASCRS
,
Professor and Chairman, Department of Colon and Rectal Surgery, Ochsner Clinic, New Orleans, LA, USA
;
Ochsner Clinical School, University of Queensland School of Medicine, Brisbane, Australia
Kenneth D. Boffard, MBBCh, FRCS, FRCS(Edin), FRCPS(Glas), FCS(SA), FACS
,
Professor and Head, Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
Felicity J. Creamer, BSc(Hons), MBChB, MRCSEd
,
Specialty Registrar, Colorectal Surgery, Western General Hospital, Edinburgh, UK
Dafydd A. Davies, MD, MPhil, FRCSC
,
Fellow, Division of Paediatric and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
Chris Deans, MBChB (Hons), FRCS, MD
,
Part-time Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh
;
Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK
Mark Duxbury, MA, DM, FRCSEd(Gen Surg)
,
Consultant Hepatopancreaticobiliary and General Surgeon, Glasgow Royal Infirmary, Glasgow, UK
R. Michael Grounds, MD, FRCA, FFICM
,
Professor of Critical Care Medicine, St George's University of London
;
Consultant in Anaesthesia and Intensive Care Medicine, St George's Hospital, London, UK
Steven D. Heys, BMedBiol, MD, PhD, FRCS, FRCS(Ed), FRCS(Glasg)
,
Deputy Head of the School of Medicine and Dentistry and Head of Division, University of Aberdeen
;
Honorary Consultant Surgeon, Grampian University Hospitals Trust, Aberdeen, UK
Peter Lamb, MBBS, MD, FRCS(Gen), FRCS(Ed)
,
Honorary Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh
;
Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK
Jacob C. Langer, MD
,
Professor of Surgery, University of Toronto, Robert M. Filler Chair and Chief, Paediatric General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
James Lau, MD
,
Professor of Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong, China
Rhona M. Maclean, MBChB, FRCP, FRCPath
,
Consultant Haematologist, Royal Hallamshire Hospital, Sheffield, UK
Colin J. McKay, MBChB, MD, FRCS
,
Consultant Surgeon, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
B. James Mander, MBBS, BSc, FRCS, MS, FRCS(Gen)
,
Consultant Colorectal Surgeon and Honorary Senior Lecturer, Colorectal Unit, Western General Hospital, Edinburgh, UK
Jonathan A. Michaels, MChir, FRCS
,
Honorary Professor of Clinical Decision Science, School of Health and Related Research, Sheffield University, Sheffield, UK
Enders K.W. Ng, MD, FRCSEd, MBChB
,
Head, Upper GI Division, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Sharath C.V. Paravastu, MBBS, MRCS, PGDip, MD
,
Clinical Lecturer in Vascular Surgery, Academic Vascular Unit, University of Sheffield, Sheffield, UK
Simon Paterson-Brown, MBBS, MPhil, MS, FRCS(Ed), FRCS(Engl), FCS(HK)
,
Honorary Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh
;
Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK
Andrew Rhodes, FRCP, FRCA, FFICM
,
Reader in Critical Care Medicine, St George's University of London
;
Consultant in Anaesthesia and Intensive Care Medicine, St George's Hospital, London, UK
Kathryn A. Rigby, MBChB, MSc, FRCS(GEN)
,
Locum Consultant Oncoplastic Breast Surgeon, York Teaching Hospitals NHS Trust, York, UK
William G. Simpson, MBChB
,
Consultant Chemical Pathologist, Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
Bruce R. Tulloh, MB, MS
,
Honorary Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh
;
Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK
It is now some 17 years since the first edition of the
Companion to Specialist Surgical Practice
series was published. We set ourselves the task of meeting the educational needs of surgeons in the later years of specialist surgical training, as well as consultant surgeons in independent practice who wished for contemporary, evidence-based information on the subspecialist areas relevant to their general surgical practice. The series was never intended to replace the large reference surgical textbooks which, although valuable in their own way, struggle to keep pace with changing surgical practice. This Fifth Edition has also had to take due account of the increasing specialisation in ‘general’ surgery. The rise of minimal access surgery and therapy, and the desire of some subspecialties such as breast and vascular surgery to separate away from ‘general surgery’, may have proved challenging in some countries, but has also served to emphasise the importance of all surgeons being aware of current developments in their surgical field. As in previous editions, there has been increasing emphasis on evidence-based practice and contributors have endeavoured to provide key recommendations within each chapter. The eBook versions of the textbook have also allowed the technophile improved access to key data and content within each chapter.
We remain indebted to the volume editors and all the contributors of this Fifth Edition. We have endeavoured where possible to bring in new blood to freshen content. We are impressed by the enthusiasm, commitment and hard work that our contributors and editorial team have shown and this has ensured a short turnover between editions while maintaining as accurate and up-to-date content as is possible. We remain grateful for the support and encouragement of Laurence Hunter and Lynn Watt at Elsevier Ltd. We trust that our original vision of delivering an up-to-date affordable text has been met and that readers, whether in training or independent practice, will find this Fifth Edition an invaluable resource.
O. James Garden, BSc, MBChB, MD, FRCS(Glas), FRCS(Ed), FRCP(Ed), FRACS(Hon), FRCSC(Hon), FRSE,
Regius Professor of Clinical Surgery, Clinical Surgery School of Clinical Sciences, The University of Edinburgh and Honorary Consultant Surgeon, Royal Infirmary of Edinburgh
Simon Paterson-Brown, MBBS, MPhil, MS, FRCS(Ed), FRCS(Engl), FCS(HK),
Honorary Senior Lecturer, Clinical Surgery School of Clinical Sciences, The University of Edinburgh and Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh
Although surgical sub-specialisation within the specialty of ‘General Surgery’ has progressed rapidly over the last decade or so, most general surgeons on-call, irrespective of their sub-specialty interest, require a core knowledge in both elective and emergency ‘general’ surgery in order to be able to see and treat undifferentiated referrals and conditions outwith their normal everyday elective ‘specialist’ practice. This volume of the
Companion to Specialist Surgical Practice
provides the background information on these key areas of ‘general surgery’ for all practising general surgeons in both the elective and emergency situation. It is the only volume in this series which provides detailed descriptions of evidence-based medicine and how surgical outcomes can be measured, in addition to other important areas common to all of ‘general surgical practice’. These include an overview of day case surgery, abdominal hernias, thrombo-embolic prophylaxis, the management of sepsis and the intensive care patient, the use of scoring systems in patient assessment and surgical nutrition. This volume should be considered complementary to the other more specialist volumes in the series by including all the emergency areas which remain within the remit of the general surgeon on-call. As in everyday practice, there remain emergency patients who, having been resuscitated and a diagnosis reached, might be better served by referral to a colleague or unit with the relevant sub-specialist interest. This volume discusses those conditions which the general surgeon might be expected to deal with and, where appropriate, identifies those which might be better managed by a ‘specialist’. In these cases the reader will be referred on to the relevant specialist volume of this series.
Once again I remain grateful to my long-suffering wife and family for their ongoing support and understanding in the time taken for me to complete the Fifth Edition of this volume of
Core Topics in General and Emergency Surgery
. The success of this volume, as for previous editions, very much lies in the quality of the chapters produced by my co-authors and I am grateful to all of them for the hard work that has obviously gone into writing, or re-writing, each chapter and their timely delivery. The additional workload required in the writing of concise, well-referenced and up-to-date chapters for a book such as this, by busy practising surgeons, should never be under-estimated. I would also like to recognise the support of Elsevier Ltd, as well as the help, enthusiasm and friendship of my co-editor of all five editions of the
Companion to Specialist Surgical Practice
series, James Garden.
Simon Paterson-Brown,
Edinburgh
Critical appraisal for developing evidence-based practice can be obtained from a number of sources, the most reliable being randomised controlled clinical trials, systematic literature reviews, meta-analyses and observational studies. For practical purposes three grades of evidence can be used, analogous to the levels of ‘proof’ required in a court of law:
Beyond all reasonable doubt
. Such evidence is likely to have arisen from high-quality randomised controlled trials, systematic reviews or high-quality synthesised evidence such as decision analysis, cost-effectiveness analysis or large observational datasets. The studies need to be directly applicable to the population of concern and have clear results. The grade is analogous to burden of proof within a criminal court and may be thought of as corresponding to the usual standard of ‘proof’ within the medical literature (i.e.
P
< 0.05).
On the balance of probabilities
. In many cases a high-quality review of literature may fail to reach firm conclusions due to conflicting or inconclusive results, trials of poor methodological quality or the lack of evidence in the population to which the guidelines apply. In such cases it may still be possible to make a statement as to the best treatment on the ‘balance of probabilities’. This is analogous to the decision in a civil court where all the available evidence will be weighed up and the verdict will depend upon the balance of probabilities.
Not proven
. Insufficient evidence upon which to base a decision, or contradictory evidence.
Depending on the information available, three grades of recommendation can be used:
Strong recommendation, which should be followed unless there are compelling reasons to act otherwise.
A recommendation based on evidence of effectiveness, but where there may be other factors to take into account in decision-making, for example the user of the guidelines may be expected to take into account patient preferences, local facilities, local audit results or available resources.
A recommendation made where there is no adequate evidence as to the most effective practice, although there may be reasons for making a recommendation in order to minimise cost or reduce the chance of error through a locally agreed protocol.
Evidence where a conclusion can be reached ‘
beyond all reasonable doubt
’ and therefore where a
strong recommendation
can be given.
This will normally be based on evidence levels:
Ia. Meta-analysis of randomised controlled trials
Ib. Evidence from at least one randomised controlled trial
IIa. Evidence from at least one controlled study without randomisation
IIb. Evidence from at least one other type of quasi-experimental study.
Evidence where a conclusion might be reached ‘
on the balance of probabilities
’ and where there may be other factors involved which influence the recommendation given. This will normally be based on less conclusive evidence than that represented by the double tick icons:
III. Evidence from non-experimental descriptive studies, such as comparative studies and case–control studies
IV. Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both.
Evidence which is associated with either a
strong recommendation
or
expert opinion
is highlighted in the text in panels such as those shown above, and is distinguished by either a double or single tick icon, respectively. The references associated with double-tick evidence are highlighted in the reference lists at the end of each chapter along with a short summary of the paper's conclusions where applicable.
The reader is referred to
Chapter 1
, ‘Evidence-based practice in surgery’, in this volume for a more detailed description of this topic.