Although no clear guidance exists for the use of LCS in PVD, the majority of respondents continue to use it. Indications and outcomes are documented in this study of UK and Irish vascular surgical practice.

BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

The asplenic patient is at risk of overwhelming post-splenectomy infection (OPSI) due to encapsulated bacteria, namely pneumococcus, haemophilus influenza B and meningococcal C pathogens. The lifetime risk is 1-2% with the estimated mortality being in the region of 40-70% (Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:657-60). Preventative measures include appropriate prophylactic vaccination, long term antibiotics and patient education. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996, with a revised edition published in 2002. There are a number of permutations of these guidelines published by a number of professional bodies and consequently this has led to variable adherence rates to such guidelines. We review the perioperative administration of prophylactic vaccinations.

Natural orifice translumenal endoscopic surgery (N.O.T.E.S) is a technique that allows access to the peritoneal cavity through natural orifices (oral, rectal, vaginal, vesical) without passing through the anterior abdominal wall. Rapid strides have been made in developing this technique, especially in animal models. Majority of research work in this field is originating from USA, while human clinical trials are being reported from India and Southern America. Morbidly obese patients and ITU patients are two target groups where N.O.T.E.S if implemented, will have the highest potential and bearing. With increasing evidence of safe practice in human models, questions on indications and feasibility of practice need to be addressed by rigorous research, strong evidence and collaboration between surgical centers worldwide.

The risk of pelvic nerve injury is not frequently stated, which is more common in women and the elderly. Overall, only 36% of patients were consented for pelvic nerve injury, while only 5% of women were consented. Is this professional discretion, or evidence that surgeons are not being assiduous enough when obtaining consent, which may leave them vulnerable to medicolegal claims? Introduction of procedure-specific consent forms would be a method to address this issue.