Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26–49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1–4] days vs. 3 [2–4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

/pdf/the-management-of-adult-appendicitis-during-the-covid-19-r8xgag9poj.pdf

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.

/pdf/impact-of-the-joint-advisory-group-on-gastrointestinal-2szsomxzo8.pdf

Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond

Introduction The 2017 Joint Advisory Group on Gastrointestinal (GI) Endoscopy (JAG) census highlighted the pressure endoscopy services were under in meeting national targets and the factors behind this In 2019, JAG conducted a further national census of endoscopy services to understand trends in activity, workforce and waiting time targets Methods In April 2019, the census was sent to all eligible JAG-registered services Collated data were analysed through various statistical methods A further comparative dataset was created using available submissions from the 2017 census matched to services in the current census Results There was a 68% response rate (322/471) There has been a 12%–15% increase in activity across all GI procedures with largest increases in bowel cancer screening Fewer services are meeting waiting time targets compared with 2017, with endoscopist, nursing and physical capacity cited as the main reasons Services are striving to improve capacity: 80% of services have an agreed business plan to meet capacity and the number using insourcing has increased from 13% to 20% The workforce has increased, with endoscopist numbers increasing by 15%, nurses and allied health professionals by 14% and clerical staff by 30% Conclusions The 2019 JAG census is the most recent and extensive survey of UK endoscopy services There is a clear trend of increasing activity with fewer services able to meet national waiting time targets than 2 years ago Services have increased their workforce and improved planning to stem the tide but there remains a continued pressure to deliver high quality, safe endoscopy In light of the COVID-19 pandemic, JAG recognises that these pressures will be severely exacerbated and waiting time targets for accreditation will need adjustment and tolerance during the evolution and recovery from the pandemic

https://fg.bmj.com/content/flgastro/12/6/451.full.pdf

National census of UK endoscopy services in 2019.

Introduction Endoscopists are now expected to perform polypectomy routinely. Colonic polypectomy varies in difficulty, depending on polyp morphology, size, location and access. The measurement of the degree of difficulty of polypectomy, based on polyp characteristics, has not previously been described. Objective To define the level of difficulty of polypectomy. Methods Consensus by nine endoscopists regarding parameters that determine the complexity of a polyp was achieved through the Delphi method. The endoscopists then assigned a polyp complexity level to each possible combination of parameters. A scoring system to measure the difficulty level of a polyp was developed and validated by two different expert endoscopists. Results Through two Delphi rounds, four factors for determining the complexity of a polypectomy were identified: size (S), morphology (M), site (S) and access (A). A scoring system was established, based on size (1–9 points), morphology (1–3 points), site (1–2 points) and access (1–3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of scores obtained: level I (4–5), level II (6–9), level III (10–12) and level IV (>12). There was a high degree of interrater reliability for the polyp scores (interclass correlation coefficient of 0.93) and levels (κ=0.888). Conclusions The scoring system is feasible and reliable. Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. This may allow for more efficient service delivery and referral pathways.

https://fg.bmj.com/content/flgastro/4/4/244.full.pdf

A novel method for determining the difficulty of colonoscopic polypectomy

Covid-19 has had a significant impact on all aspects of health care. We aimed to characterise the trends in emergency general surgery at a district general hospital in Scotland. A prospective cohort study was performed from 23/03/20 to 07/05/20. All emergency general surgery patients were included. Demographics, diagnosis and management were recorded along with Covid-19 testing and results. Thirty-day mortality and readmission rates were also noted. Similar data were collected on patients admitted during the same period in 2019 to allow for comparison. A total of 294 patients were included. There was a 58.3 per cent reduction in admissions when comparing 2020 with 2019 (85 vs 209); however, there was no difference in age (53.2 vs 57.2 years, p = 0.169) or length of stay (4.8 vs 3.7 days, p = 0.133). During 2020, the diagnosis of appendicitis increased (4.3 vs 18.8 per cent, p =   grade 1 vs 58.3 per cent > grade 1, p = < 0.05). The proportion of patients undergoing surgery increased (19.1 vs 42.3 per cent, p = < 0.05) as did the mean operating time (102.4 vs 145.7 min, p = < 0.05). Surgery was performed in 1 confirmed and 1 suspected Covid-19 patient. The latter died within 30 days. There were no 30-day readmissions with Covid-19 symptoms. Covid-19 has significantly impacted the number of admissions to emergency general surgery. However, emergency operating continues to be needed at pre-Covid-19 levels and as such provisions need to be made to facilitate this.

/pdf/changes-in-emergency-general-surgery-during-covid-19-in-181gxt9g6v.pdf

Changes in Emergency General Surgery During Covid-19 in Scotland: A Prospective Cohort Study.

Background and aims Endoscopy performance is dependent on the technical ability and experience of the operator. There is anxiety among surgical trainees that certification to perform independent endoscopy to agreed national standards by the date of award of certificate of completion of training is not achievable. The aim of this study was to evaluate the delivery of endoscopy training to UK-based general surgery trainees. Materials and methods An electronic survey of general surgery trainees holding a national training number or in a locum appointment to training post between July and September 2010 was undertaken. Results Two hundred and thirty-three trainees responded from all UK training regions. Stated subspeciality interests included coloproctology (47%), oesophagogastric/bariatric (22%) and hepatobiliary/pancreatic (10%) general surgery. 92% of trainees were training or planned to train in endoscopy, 62% of whom had registered with the Joint Advisory Group (JAG). Thirteen trainees had JAG certification in diagnostic upper GI endoscopy and eight in colonoscopy. There were high rates of dissatisfaction with endoscopy training nationally. Two thirds of trainees had no scheduled training lists. Conflicting elective/emergency commitments, competition and absence of training lists were the most common reasons for a failure to access endoscopy training. Conclusions Higher surgical trainees are failing to achieve national standards for endoscopy practice. There is an urgent need to address the deficiencies in endoscopy training to ensure a competent cohort of surgical endoscopists.

https://fg.bmj.com/content/flgastro/4/1/20.full.pdf

Surgical endoscopy training: the Joint Advisory Group on gastrointestinal endoscopy national review

The HAREM (Had Appendicitis and Resolved/Recurred Emergency Morbidity/Mortality) Study

The joint advisory group on gastrointestinal endoscopy national survey of endoscopy training amongst UK-based higher surgical trainees

/pdf/protocol-letter-multicentre-prospective-cohort-study-of-the-2fkgjyiado.pdf

Protocol letter: multicentre prospective cohort study of the early management of acute pancreatitis in Great Britain and Ireland: PANC Study (Pancreatitis: A National Cohort Study).

After wide consultation with trainees, trainers, employers and other stakeholders, the new General Surgical Curriculum was approved earlier this year and will be implemented from 4 August 2021. It will be outcome based and will be the biggest change in surgical training since 2007. Trainees can progress at their own rate and complete when they have acquired the capabilities of a Day-1 consultant in general surgery with a special interest. The Multiple Consultant Report (MCR) is new and has been developed as the main assessment tool for this outcomes-based curriculum. Assessment in the MCR will be on progress from the ability to only observe at the start of training, to performance at the level of Day-1 consultant in the complex, integrated skills needed for the day-to-day performance of the role in each of the areas of the job (the Capabilities in Practice). The MCR and trainee self assessment will improve feedback and allow specific and bespoke agreed learning objectives to be more easily developed and delivered, and faster but safe training for many. New training pathways have been developed, emphasizing the commonality of emergency general surgery, but also developing special interests reflecting the needs of patients and the service.

The new General Surgical Curriculum and ISCP

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