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Table 1 Questions put forward for the first round of prioritisation

From: Research priorities in emergency general surgery (EGS): a modified Delphi approach

Question number

Question

High-priority ranking (4 or 5) (n)

Low-priority ranking (1 or 2) (n)

General EGS

   

3

What is the impact of emergency laparotomy on quality of life in frail patients?

135

10

24

Which pre- or post-operative interventions improve clinical outcomes in patients with frailty after emergency surgery?

130

4

25

What are the best predictors of adverse outcomes and mortality in older adults presenting with emergency general surgery pathology?

124

10

16

How can training be improved to meet emergency general surgery demand, including open surgery?

119

13

4

What is the value of enhanced recovery after surgery (ERAS) programmes for EGS patients, compared to standard management?

114

12

26

What is the optimal method of assessing fitness for surgery in the emergency setting?

111

19

13

What are the absolute risks of anastomotic leak following emergency small bowel/large bowel anastomosis, and the relative importance of risk factors?

111

18

15

How can we optimise the rate of reversal of Hartmann’s when performed as an emergency and what are the predictive factors in those who are subsequently reversed?

108

15

19

How does small bites closure compare to traditional mass closure in the emergency setting (wound infection, fascial dehiscence and incisional hernia rates)?

101

25

17

Should patients have extended venous thromboembolism (VTE) prophylaxis after an emergency laparotomy with or without resection?

100

23

39

Is there a link between duration of emergency laparotomy (knife to skin to wound closure) and clinical outcomes? Is there a cut-off where all surgeons should perform damage control surgery in the emergency setting?

95

21

41

How can technology be incorporated into patient follow-up to aid early detection of post-operative complications?

95

25

46

Are outcomes after emergency surgery improved with the laparoscopic approach as compared to the open approach?

95

21

23

Does a laparoscopic approach for adhesional small bowel obstruction reduce the risk of recurrence, and how do we identify those who would benefit most from laparoscopic approach?

93

28

9

Is non-operative management inferior to the surgical management of uncomplicated appendicitis?

91

31

18

How does negative pressure wound therapy affect clinical outcomes after 90 emergency surgery?

28

 

7

Which cohort of patients can be safely managed using an ambulatory appendicitis pathway or day-case appendicectomy for acute appendicitis?

87

33

22

What is the best diagnostic approach to acute small bowel obstruction, and what is the role of Gastrografin in diagnosis and/or treatment?

87

34

20

Is there value in routine computer tomography (CT) imaging in patients presenting with acute abdominal pain?

86

29

14

What is the role of the gut microbiome in anastomotic leakage?

86

31

34

Non-specific abdominal pain—how do you define, manage and reduce readmissions?

85

40

31

Does early parenteral nutrition in small bowel obstruction improve clinical outcomes?

82

27

1

What more can be done to help patients with the psychological sequelae of emergency surgery, and which patient-reported outcome measures are most useful?

82

29

11

Should we implement a UK wide acute CT service for right iliac fossa pain to reduce the negative appendicectomy rate?

81

35

5

Which cohort of EGS patients derive the greatest benefit from post-operative chest physio?

81

31

35

Does the early administration of inotropes during the resuscitation of patients with septic shock result in improved clinical outcomes?

80

29

37

What is the optimal method of antibiotic stewardship and rationalisation in emergency general surgery?

80

42

10

Is there a difference in clinical outcomes between patients with image-proven appendicitis and conventional (clinically guided) appendicitis?

79

40

45

Is the use of mesh safe for the repair of a strangulated hernia where there has been small bowel contamination via enterotomy?

79

41

29

Which patients are most likely to need parenteral nutrition following emergency surgery?

75

43

33

What are the indications for diagnostic laparoscopy in women of reproductive age presenting acutely with lower abdominal pain?

75

49

6

Which diagnostic tool is the most sensitive and specific for acute appendicitis?

73

46

30

What is the optimal resuscitation fluid for patients undergoing emergency laparotomy?

70

47

21

Does point-of-care ultrasound (POCUS) improve clinical outcomes in emergency surgery patients?

70

41

27

Is CT-diagnosed sarcopenia useful as a prognostic indicator of poor outcomes in emergency surgical patients?

66

49

32

What is the value of nutritional supplements (e.g. Fortisip) to EGS patients?

63

35

43

Is there a role for a symptomatic hernia ‘hot list’ and would it improve clinical outcomes in this cohort of patients?

62

46

44

What is the optimum timing of hernia repair after successful reduction in cases of acute incarceration?

60

48

2

What is the incidence of post-traumatic stress disorder (PTSD) following emergency surgery?

56

44

28

How does patient fatigue affect surgical outcomes after emergency surgery?

53

49

8

Do outcomes after paediatric appendicectomy vary in a district general hospital setting when compared with a tertiary hospital setting?

50

64

36

Is there any benefit to taking a swab of pus when performing incision and drainage of an abscess?

49

74

42

Is laparoscopic approach feasible in emergency inguinal hernia?

47

73

38

What are the indications for low-pressure peritoneum in emergency abdominal surgery and do we have data on outcomes?

41

69

12

Is there a difference in clinical outcomes between methods currently employed to secure the appendix stump during laparoscopic appendicectomy?

36

74

40

Is there a role for robotic-assisted surgery in adult patients with emergency surgical conditions?

24

111

Emergency UGI surgery

   

2

Does a ‘hot gallbladder’ pathway reduce sepsis rates in addition to gallstone-related complications?

100

18

7

Which patient cohort derives the greatest clinical benefit from index cholecystectomy for acute cholecystitis?

100

20

12

Can mild acute pancreatitis be managed in an ambulatory setting and in which patients is it safe to do so?

95

31

5

Should every centre that offers emergency general surgery offer a ‘hot gallbladder’ service? Which model is best and is pre-operative magnetic resonance cholangiopancreatography (MRCP) required?

93

21

4

Should management of acute cholecystitis in the geriatric population differ from standard care?

88

19

8

Is cholecystostomy adequate in cases of empyema gall bladder in an older adult, unfit patient or is interval cholecystectomy required?

87

26

11

Is therapeutic anticoagulation indicated in cases of portal vein thrombus secondary to acute severe pancreatitis?

85

25

6

Can the management of acute cholecystitis be safely performed in an ambulatory setting?

82

31

9

What is the best immediate severity assessment for acute pancreatitis (i.e. not a score that uses a 48-h window)?

77

40

3

Should intra-operative cholangiogram with or without stone retrieval (by common bile duct exploration if necessary) be routine in cholecystectomy for acute cholecystitis?

60

49

10

What is the optimal management of alcohol-related pancreatitis?

55

52

Emergency colorectal surgery

   

2

Does a formal cancer resection improve disease-free and overall survival in perforated or obstructing emergency colorectal cancer resections?

102

15

6

Is endoscopic follow-up required in CT-confirmed acute diverticulitis?

93

25

1

How do stent, stoma or immediate resection for obstructing colorectal cancers compare?

92

15

14

Regarding the various treatment strategies in lower gastrointestinal bleeding (e.g. surgical, endoscopy, interventional radiology, medical systemic treatment), is single or combination treatments superior?

81

30

9

Is there a CRP level (or other marker) which could identify cases of diverticulitis which can safely be managed conservatively, i.e. antibiotics versus no antibiotics?

80

33

12

What is the incidence and indications/selection criteria for surgical intervention with sigmoid volvulus?

80

20

8

Could FiT testing be used to screen for possible colorectal malignancy in diverticulitis patients rather than routine post-admission endoscopy/CT Colonography?

79

30

5

What are oncologic results in colon cancer treated in an emergency situation?

77

34

15

What is the optimum management of novel oral anticoagulants (NOACs) in patients with PR bleeding?

75

28

4

Endoscopic obstructing colorectal tumour: what should we do and what is the best timing for surgical intervention?

67

23

16

Should we train surgeons to mark for stomas in the emergency setting and would this affect patient satisfaction with stoma?

67

37

10

Should perforated diverticular disease be operated on exclusively by colorectal surgeons to decrease the rate of Hartmann’s procedure?

61

48

17

What is the evidence comparing diverting stoma and the use of Flexi-Seal in necrotising perineal and perianal infections?

60

42

11

Is there a role and benefit of laparoscopic washout for mild diverticulitis and how does it correlate with the Hinchey scale?

54

51

3

What is the best operative strategy to achieve laparoscopic resection in obstructing left sided colorectal cancers?

53

39

13

Is there a role for, and what would the indications be, for a laparoscopic Hartmann’s procedure for sigmoid volvulus in older adults?

46

52

7

Has the age at time of presentation of acute diverticulitis changed in the last 20 years and why?

35

57

Non-technical questions

   

1

Which human/organisational factors cause inefficiency in a dedicated emergency theatre?

103

14

2

What influences decision-making for emergency surgery for the surgeon, patient and family?

93

13

3

How can the informed consent process be optimised for emergency general surgery patients?

84

17

4

What are the costs and ethical considerations of randomisation in emergency surgery?

63

40

Health service related

   

12

Are emergency surgical outcomes improved with peri-operative physician or geriatrician input?

96

15

1

Which patients derive the greatest benefit from routine HDU/ITU care after emergency surgery?

92

15

10

Is there a volume–outcome relationship for emergency surgery?

86

17

13

Are there improved outcomes in patients who are treated on a triaged speciality take? (e.g. pancreatitis to UGI, colon cancer to colorectal)

85

22

11

What effect does a fast-track service have on the overall EGS service for patients requiring urgent cholecystectomy, appendicectomy and hernia surgery?

84

17

14

Is there a need for an ‘Emergency Surgery’ sub-specialisation?

82

24

2

Is there a benefit when a senior decision-maker sees the patient first?

79

32

3

Are rapid acute surgical assessment units cost-effective?

74

29

8

Would direct access to US and CT imaging for general practitioners affect triage of emergency referrals in NHS?

66

35

9

Should surgical emergencies be managed by a specialist or a generalist team?

65

35

5

What are the optimum and acceptable extended criteria for referral to surgical ambulatory care for emergency referrals?

64

37

6

What is the level of collaboration between dedicated emergency general surgeons and sub-specialists, hepatobiliary (HPB), upper gastrointestinal (UGI) and lower gastrointestinal?

59

46

4

What are the reasons for the increase in emergency referrals to secondary care in the UK?

56

46

7

Do emergency general surgery consultant surgeons require an elective component within their job plan and should they develop an elective subspecialty?

55

39