Approximately 20% of patients diagnosed with colorectal cancer will present with left-sided large bowel obstruction. The optimal management of this cohort of patients remains unclear. We aimed to review international guidelines to see if there was a consensus on the treatment of this surgical emergency. The PubMed and Medline databases were searched for guidelines on the management of left-sided, malignant large bowel obstruction (MBO) between 2010 and 2018. Nineteen guidelines were identified spanning a range of continents. There was no clear consensus on the management of potentially resectable disease. Eight guidelines (42%) suggested primary surgery, two guidelines (11%) suggested stenting as a bridge to surgery and nine guidelines (47%) suggested surgery or stenting could be performed. Primary resection with or without anastomosis was the most frequently recommended procedure (n = 6 35%), but over a third of guidelines gave no operative recommendations. There was very limited detail on the stenting procedure and how long elective surgery should be deferred. In the palliative situation, there was general agreement that stents should be offered in preference to surgery. International guidelines offer limited and contrasting recommendations on the management of left-sided MBO. There is a lack of high-quality evidence to support whether emergency surgery or stenting as a bridge to surgery is the optimal procedure in terms of morbidity, mortality and long-term oncological outcome.

Data from experimental studies have demonstrated that marine omega-3 polyunsaturated fatty acids (O3FAs) have anti-inflammatory and anticancer properties. In the last decade, large-scale randomised controlled trials of pharmacological delivery of O3FAs and prospective cohort studies of dietary O3FA intake have continued to investigate the relationship between O3FA intake and colorectal cancer (CRC) risk and mortality. Clinical data suggest that O3FAs have differential anti-CRC activity depending on several host factors (including pretreatment blood O3FA level, ethnicity and systemic inflammatory response) and tumour characteristics (including location in the colorectum, histological phenotype (eg, conventional adenoma or serrated polyp) and molecular features (eg, microsatellite instability, cyclooxygenase expression)). Recent data also highlight the need for further investigation of the effect of O3FAs on the gut microbiota as a possible anti-CRC mechanism, when used either alone or in combination with other anti-CRC therapies. Overall, these data point towards a precision approach to using O3FAs for optimal prevention and treatment of CRC based on mechanistic understanding of host, tumour and gut microbiota factors that predict anticancer activity of O3FAs.

Background: The relationship between omega-3 polyunsaturated fatty acid (n-3 PUFA) intake and colorectal cancer risk is unclear. Blood n-3 PUFA concentration is a biomarker of dietary n-3 PUFA intake. We examined the relationship between plasma n-3 PUFA concentrations and colorectal cancer risk in UK Biobank (UKBB) participants. Methods: We analyzed the relationship between tertiles (T) of plasma total n-3 PUFAs and n-3 PUFA docosahexaenoic acid (DHA) levels, and overall colorectal cancer (also stratified by tumor location and sex) risk. Cox proportional hazards regression models were adjusted for clinical covariates. Nonlinearity was tested by restricted cubic splines. Results: There were 2,602 incident colorectal cancer cases in 234,598 UKBB participants with baseline plasma fatty acid data (mean follow-up 13.4 years). There was an inverse association between the plasma total n-3 PUFA level [T2 HR = 0.88 (95% confidence interval, 0.80–0.97) compared with the T1 reference; T3 = 0.91 (0.83–1.00)], as well as the plasma DHA concentration [T2 = 0.89 (0.80–0.98); T3 = 0.91 (0.82–1.00)], and colorectal cancer risk. The relationship was nonlinear [P for nonlinearity = 0.14 (total n-3 PUFAs) and 0.008 (DHA)], with a plateau effect at the highest n-3 PUFA concentrations. The relationship was more pronounced for proximal colon cancer [T2 = 0.82 (0.69–0.97); T3 = 0.76 (0.64–0.90) for DHA] and was evident for males [T2 = 0.84 (0.74–0.95); T3 = 0.89 (0.78–1.00)], but not for females. Conclusions: Higher plasma n-3 PUFAs are associated with reduced colorectal cancer risk in the UKBB. Impact: Nonlinearity, as well as tumor site and sex specificities, of the inverse relationship between plasma n-3 PUFA levels and colorectal cancer risk, if confirmed in other diverse populations, has significant implications for nutritional prevention guidelines.

Over the past 50 years the capability of technology to improve surgical care has been realised and while surgical trainees and trainers strive to deliver care and train; the technological ‘solutions’ market continues to expand. However, there remains no coordinated process to assess these technologies. The FOS:TEST Report aimed to (1) define the current, unmet needs in surgical training, (2) assess the current evidence-base of technologies that may be beneficial to training and map these onto both the patient and trainee pathway and (3) make recommendations on the development, assessment, and adoption of novel surgical technologies. The FOS:TEST Commission was formed by the Association of Surgeons in Training (ASiT), The Royal College of Surgeons of England (RCS England) Robotics and Digital Surgery Group and representatives from all trainee specialty associations. Two national datasets provided by Health Education England were used to identify unmet surgical training needs through qualitative analysis against pre-defined coding frameworks. These unmet needs were prioritised at two virtual consensus hackathons and mapped to the patient and trainee pathway and the capabilities in practice (CiPs) framework. The commission received more than 120 evidence submissions from surgeons in training, consultant surgeons and training leaders. Following peer review, 32 were selected that covered a range of innovations. Contributors also highlighted several important key considerations, including the changing pedagogy of surgical training, the ethics and challenges of big data and machine learning, sustainability, and health economics. This summates to 7 Key Recommendations and 51 concluding statements. The FOS:TEST Commission was borne out of what is a pivotal point in the digital transformation of surgical training. Academic expertise and collaboration will be required to evaluate efficacy of any novel training solution. However, this must be coupled with pragmatic assessments of feasibility and cost to ensure that any intervention is scalable for national implementation. Currently, there is no replacement for hands-on operating. However, for future UK and ROI surgeons to stay relevant in a global market, our training methods must adapt. The Future of Surgery: Technology Enhanced Surgical Training Report provides a blueprint for how this can be achieved.

An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England’s Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general surgical operation notes. An annonymised retrospective case note review of general surgical operation notes was undertaken over five separate time periods. The first cycle consisted of periods 1 (prior to EPR implementation), 2 (1 week after EPR) and 3 (4 weeks after EPR). Period 4 was a reaudit 2 weeks after the initial results were presented at the local governance meeting. The cycle was then closed with period 5; 1 year after EPR implementation. A comparison was across all 5 time periods for compliance with the RCS guidelines and with subanalysis of the individual categories. 250 operation notes were reviewed during five time periods. Compliance improved by almost 19% (p=0.0003) between periods 1 and 5. Eleven of the 19 points (57.9%) over the audit period achieved 100% compliance post-EPR compared to 0% prior. Poor compliance were noted in the categories of antibiotic use, venous thromboembolism prophylaxis and estimated blood loss (noting that these are often documented in the anaesthetic record and/or WHO checklist). EPRs do not guarantee compliance with GSP. We propose that GSP standards need to be updated to reflect the modernisation of medical records and a team-based approach with multimodality input sources would achieve better patient records and patient care.

Observational evidence linking dietary n-3 PUFA intake and health outcomes is limited by a lack of robust validation of dietary intake using blood n-3 PUFA levels and potential confounding by fish oil supplement (FOS) use. We investigated the relationship between oily fish intake, FOS use and plasma n-3 PUFA levels in 121 650 UK Biobank (UKBB) participants. Ordinal logistic regression models, adjusted for clinical and lifestyle factors, were used to quantify the contribution of dietary oily fish intake and FOS use to plasma n-3 PUFA levels (measured by NMR spectroscopy). Oily fish intake and FOS use were reported by 38 % and 31 % of participants, respectively. Increasing oily fish intake was associated with a higher likelihood of FOS use (P < 0·001). Oily fish intake ≥ twice a week was the strongest predictor of high total n-3 PUFA (OR 6·7 (95 % CI 6·3, 7·1)) and DHA levels (6·6 (6·3, 7·1). FOS use was an independent predictor of high plasma n-3 PUFA levels (2·0 (2·0, 2·1)) with a similar OR to that associated with eating oily fish < once a week (1·9 (1·8, 2·0)). FOS use was associated with plasma n-3 PUFA levels that were similar to individuals in the next highest oily fish intake category. In conclusion, FOS use is more common in frequent fish consumers and modifies the relationship between oily fish intake and plasma n-3 PUFA levels in UKBB participants. If unaccounted for, FOS use may confound the relationship between dietary n-3 PUFA intake, blood levels of n-3 PUFAs and health outcomes.