OXFORD MEDICAL PUBLICATIONS Current Surgical Guidelines This page intentionally left blank Current Surgical Guidelines Abdullah Jibawi Specialist Registrar in Surgery University Hospitals of Leicester; Visiting Researcher to Oxford University David Cade Medical Director Greater Manchester NHS CATS; Previously Consultant General Surgeon Mid Cheshire Hospitals NHS Foundation Trust 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. 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Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding. v Foreword It is with some trepidation that I began the task of reviewing the contents of this book. My trepidation was based on the fact that, having had a strong interest in guideline production and dissemination myself, I know just how insipid and monotonous guidelines can be. I need not have worried! Indeed, towards the end of my task, I was positively looking forward to reading the next chapter. The authors are to be commended on compiling such a comprehensive collection of contemporary surgical guidelines, and presenting them so clearly that the busy clinician will have no trouble whatsoever in reading and digesting their contents. The sensible use of simple tables makes it straightforward to identify the information relevant to a specifi c clinical problem. I particularly enjoyed the fi rst twenty chapters because they deal with everyday clinical issues that are relevant to surgeons practising in all branches of surgery. I have no doubt that junior doctors who base their day-to-day care of surgical patients on these guidelines will greatly improve the care that they offer. Experienced surgeons will not only fi nd guidelines relevant to their specialist area but can rapidly access contemporary infor- mation from areas of surgical practice outside their immediate expertise. It is for these reasons that this book will be invaluable to all surgeons, be they Foundation year doctors or experienced consultants. The guidelines are UK-based if they are available. Thereafter, the hier- archy is European guidelines followed by North American guidelines. This approach is sensible and pragmatic. In summary, the authors are to be congratulated on compiling and presenting contemporary surgical guide- lines in such a way that they are interesting and immediately relevant to clinical practice. I am certain that I will be referring to my own copy on a very regular basis! Professor Nick London Professor of Surgery University of Leicester vi Preface Documents written for guiding decisions in the diagnosis and management of specifi c diseases have been in use for many thousands of years. Unlike previous approaches that were often based on authority or tradition, modern guidelines refl ect a consensus of expert opinion following a thor- ough and systematic review of currently available scientifi c evidence. Clinical guidelines do not aim to replace the clinical judgement, but to support it. Guideline recommendations attempt to defi ne practices that meet the requirement of most patients in most circumstances, but can give no guarantee of a successful outcome in every individual case. Clinical judgement and decision-making should consider the individual patient’s condition, circumstances and wishes, as well as the quality and availability of expertise in the area where care is provided. In recent years, the number of guidelines produced by national bodies, specialist associations, royal colleges, and others has increased enor- mously and it has become diffi cult for busy clinicians to keep up to date with rapidly changing fi elds. The focus of this handbook is to summarize currently available guidelines in general and vascular surgery in a concise, practical, and friendly way. Neither should it be considered that it includes all acceptable methods of management nor as a standard of clinical care. In short, ‘we summarize the guidelines, you make the decision’. We hope that this book will contribute to the implementation of high quality guidelines in surgical practice. vii General outlines The principles and rules throughout the book are limited in order to provide consistency in summarizing all the scattered guidelines. We have used different search engines to fi nd the most relevant and up-to-date guidelines for each topic. National Library for Guidelines (UK), National Guideline Clearinghouse (US), National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), GoogleTM, and other online portals (e.g. the Association of Surgeons of Great Britain and Ireland, the Royal College of Surgeons of England, and BMJ Clinical Evidence) were accessed and systematically reviewed. Full text guidelines were retrieved, thoroughly evaluated, and summarized. Guidelines written on the same topic and published by dif- ferent authorities were compared and referenced within the summary text as appropriate. Relevant chapters were reviewed independently by the authors and then by appropriate experts in each fi eld. We have integrated friendly statistics within different sections of each chapter to support a realistic decision-making process and allow informed decisions for patients at the point of care. These statistics can be used, for example, to understand the impact of a risk factor on a specifi c disease and allow for better understanding of any recommended screening pro- gramme (e.g. screening for abdominal aortic aneurysm at the age of 65, chapter 46); to realize the limitations of certain investigations in detecting (sensitivity) and confi rming (specifi city) certain pathology or disease severity (e.g. endoscopic ultrasound scan (EUS) in oesophageal cancer staging, chapter 21); and to provide the clinician with the latest fi gures on the effi ciency and safety of different treatment options, and therefore, allow for better communication with patients and evidence-based sup- ported decision-making (e.g. effi cacy of local glyceryl trinitrate (GTN) for anal fi ssure healing, chapter 34). Recommendations for a specifi c investigation, screening, or treatment have been graded as per the original guideline’s grading system, which usually follows the main theme of grading as outlined in chapter 1. Tables have been used extensively within the handbook for summarizing and easy access purposes. The recommended approach for each disease has been outlined using specially designed algorithms which formulate an integral part of each relevant chapter and have to be interpreted within this context. The recommended approach does not include all acceptable methods of diagnosis or management; sound clinical judgment is always required (chapter 1). The audit process has become an integral part of the evaluation of an individual clinician’s performance as well as the hospital internal activities. Audit requires appropriate tools to gather selected information (indica- tors) and compare to standards and guidelines in order to highlight the differences and make changes where appropriate. We have provided the reader with a distinct audit box under the title ‘Know your results’. The audit ideas within the box are there to stimulate the reader’s mind on the practicality of assessing and measuring guidelines in real life. viii GENERAL OUTLINES Some ideas have been derived from published audit work and are refer- enced where appropriate. Finally, we used a quick reference script to allow for rapid and effi cient access to information at the point of care. This style has been adopted based on some constructive feedback we have had during the develop- ment process; the handbook is not to replace the more traditional sur- gical textbooks or handbooks, but to provide the reader with consistent, up-to-date, and sound clinical information. We hope the book will stimulate the reader to read the original documents. Any comments or recommendations are welcomed (please visit our website at: www. surgicalguidelines.co.uk). ix Acknowledgements We would like to record our sincere thanks to our advisors on specifi c sections: Prof. Nick London, Professor of Surgery, University of Leicester and Honorary Consultant Vascular and Endocrine Surgeon, University Hospitals of Leicester NHS Trust; Ms. Linda De Cossart, Vice President of the Royal College of Surgeons of England; Prof Mohan de Silva, University of Sri Jayawardenepura, Colombo, Sri Lanka; Prof. A Ross Naylor, Professor of Vascular Surgery, University Hospitals of Leicester NHS Trust; Prof. Robert Sayers, Professor of Vascular Surgery, University Hospitals of Leicester NHS Trust; Mr. Mark McCarthy, Consultant Vascular Surgeon and Honorary Senior Lecturer, University Hospitals of Leicester NHS Trust; Mr. Martin Dennis, Consultant Vascular Surgeon, University Hospitals of Leicester NHS Trust; Mr. Akhtar Nasim, Consultant Vascular Surgeon, University Hospitals of Leicester NHS Trust; Mr. Sukhbir Ubhi, Consultant Surgeon, University Hospitals of Leicester NHS Trust; Mr. Chris Sutton, Consultant Surgeon, University Hospitals of Leicester NHS Trust; Mr. Roddy Nash, Consultant Surgeon, Derbyshire Royal Infi rmary; Dr Douglas A B Turner, Consultant Anaesthetist and Critical Care, University Hospitals of Leicester NHS Trust; Dr. Sue Povard, Consultant Haematologist and Lecturer at the University of Leicester; Dr. Andrew Swann, Consultant Microbiologist, University Hospitals of Leicester NHS Trust; Ms. Michelle Lapworth, Vascular and Wound Specialist Practice Nurse, University Hospitals of Leicester; Mr. John Jameson, Consultant Surgeon, University Hospitals of Leicester NHS Trust; Mr. Ashley Dennison, Consultant Surgeon, University Hospitals of Leicester NHS Trust; Mr. David Berry, Consultant Surgeon, University Hospitals of Leicester NHS Trust; Mr. David Corless, Consultant Surgeon, the Mid Cheshire Hospitals NHS Trust; Mr. Magdi Hanafy, Consultant Surgeon, the Mid Cheshire Hospitals NHS Trust; Mr. Sulaiman Shoaib, Consultant Surgeon, The North West Wales NHS Trust; Mr. Lloyd Jenkinson, Consultant Surgeon, The North West Wales NHS Trust. We would like also to heartedly appreciate the constructive feedback we had from Prof. Nick London, Professor of Surgery at the University of Leicester (UK), Prof. Murray Brennan, Professor of Surgery at the Memorial Sloan Kettering Cancer Centre (USA), and Prof. Jonathan Meakins, Professor of Surgery at the Nuffi eld Department of Surgery, University of Oxford (UK). Finally, we would like to thank our families, without their support this work would not have been completed ever, and our colleagues for their contributions and feedback: Mohammed Ballal (UK), Chris Mann (UK), Caroline Gjorup (Denmark), Baraa Zuhaili (US), Khalid Osman (UK), and Kee Wong (UK).