Surgeon-Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland最新文献

Introduction: Hernias following iliac bone grafting are a rare but significant complication, with the earliest case reported in 1945. Repairing these hernias is challenging. Appropriate repair techniques are needed to minimise morbidity and recurrence. We present our experience with three cases of post-iliac graft hernia repair with mesh anchored to titanium mini-plates and a systematic review of current literature.

Method: We conducted a systematic review of the literature in February 2024 on two online databases, PubMed®/MEDLINE and EMBASE, in accordance with PRISMA guidelines. Keywords used were "Hernia," "Iliac," and "Graft." Data on demographics, initial pathology, time to presentation, type of hernia repair, and outcome were collected. Studies not in English and related to other types of hernia were excluded.

Results: We included 30 studies out of 751 results, spanning from 1975 to 2023. There were 40 reported cases of hernias post iliac bone grafting. The age distribution ranged from 37 to 88 years, with a median age of 60. The majority of patients (40 %) presented within one year. Fracture management, accounting for 19 cases (47.5 %), was the main indication for bone grafting. Mesh repair was performed in 31 cases (77.5 %). Seven cases (17.5 %) of recurrence were reported.

Conclusion: Recurrence is a common complication in patients with post-iliac graft hernias. Open mesh repair is the most frequently performed surgery and involves various techniques. While titanium mini-plates as anchors enable a pre-peritoneal plane mesh repair, long-term follow-up and comparative studies are needed to evaluate its efficacy compared to simple mesh.

Background: Multi-ligament knee injury (MLKI) is a complex orthopaedic knee problem, usually following traumatic knee dislocation. Surgical management is preferred and has resulted in better clinical outcomes. However, the optimal surgical treatment protocol is continuously evolving. This study aimed to compare the outcomes of one-stage versus two-stage reconstruction of MLKI.

Materials and methods: This retrospective comparative study was conducted between July 2020 and December 2023 at a government orthopaedic hospital in Nigeria. The inclusion criteria include males and females between 18 and 45 years of age who had one- or two staged knee reconstructions for MLKI and were followed up for a minimum of 12 months. The exclusion criteria were patients below 18 and above 45 years of age, those with previous knee surgery, those associated with femoral or tibia fractures, those with radiological evidence of osteoarthritis, and those with follow-ups less than 12 months. Clinical outcomes using the Lysholm scoring system and complication rate were recorded. The statistical analysis was performed using SPSS version 23.

Results: Fifty-one patients (26 in the OS group and 25 in the TS group) were studied. There was a significant difference between the preoperative and postoperative Lysholm scores in the two groups (p = 0.86 and 0.57 for OS and TS, respectively). However, there was no significant difference between the postoperative Lysholm scores in the two groups (p = 0.918).

Conclusion: One-stage and two-stage reconstruction of chronic MLKI give similar excellent clinical outcomes.

Background: Endovascular aneurysm repair (EVAR) has become the predominant treatment for Abdominal aortic aneurysm (AAA). Racial disparity has been observed in EVAR but Asian Americans have been largely excluded from previous studies. This study aimed to comprehensively evaluate 30-day outcomes of Asian Americans undergoing EVAR for intact infrarenal AAA using a multi-institutional national database.

Methods: Patients who underwent infrarenal EVAR from 2012 to 2022 were identified in the ACS-NSQIP database. Exclusion criteria included age less than 18 years, emergency presentation, and acute intraoperative conversion to open. A 1:3 propensity-score matching was applied to Asian Americans and Caucasians to match their demographics, comorbidities, aneurysm diameter, distant extent of the aneurysm, anesthesia, and concomitant procedures. Thirty-day postoperative outcomes were examined.

Results: Among 16,463 patients who underwent EVAR for non-ruptured infrarenal AAA, 302 (1.83 %) were Asian Americans and 12,373 (75.16 %) were Caucasians. Asian Americans had older age and higher burdens of medical comorbidities. After propensity-score matching, Asian American and Caucasian patients had comparable 30-day outcomes including mortality (1.99 % vs 1.34 %, p = 0.42), cardiac complications (2.32 % vs 1.56 %, p = 0.45), pulmonary complications (2.32 % vs 1.89 %, p = 0.64), and renal complications (1.99 % vs 0.89 %, p = 0.13). However, Asian American patients had a longer operative time (155.80 ± 84.59 vs 136.60 ± 69.60 min, p < 0.01) and length of stay (3.60 ± 6.16 vs 2.71 ± 4.50 days, p = 0.01). All other 30-day outcomes were comparable between Asian American and Caucasian patients.

Conclusion: Asian Americans might be underrepresented in EVAR due to limited healthcare access or a more insidious disease progression. After propensity-score matching, Asian Americans showed similar 30-day outcomes as their Caucasian counterparts. Thus, when given access, EVAR can be as effective and safe for Asian American patients. Future research should investigate the long-term prognosis for Asian Americans after EVAR.

Background & purpose: Cleft Lip and/or Palate, which affects approximately 1:650 live births in Ireland, is a complex congenital condition with lifelong implications. It can affect upper airway function, feeding, hearing, speech development, dental development as well as oral functioning, facial growth and physical appearance. Within cleft surgery, rigorous audit of speech, facial growth and nasolabial aesthetic outcomes is well-established. The importance of including patient-reported outcomes in our routine data-collection is now recognised. The purpose of the current study was to examine patient-reported outcomes (PROs) in a consecutive series of adolescents attending the Dublin Cleft Centre (DCC).

Methods: A validated patient-reported outcome measure (PROM), the CLEFT-Q, was prospectively administered to 156 patients attending the cleft clinic. Results were analysed according to cleft type and compared to those recorded in the CLEFT-Q validation study.

Results: Between (February 2020 and March 2022), the CLEFT-Q was administered to 156 patients with a mean age of 13.5 years (range 10-19 years). Males scored higher satisfaction across all subdomains irrespective of age. Satisfaction was higher in younger age groups compared to older patients in both appearance and quality of life outcomes. Patients with isolated cleft palate scored highest for satisfaction in school, social and psychological function.

Conclusions: PRO data now informs consultations with patients and families at the DCC. This information is also useful in targeting service development to the specific needs of this patient group.

Background: Paraesophageal hernias (PEH), involving abdominal components herniating through the esophageal hiatus, pose serious risks like obstruction and perforation, prompting SAGES to recommend repair upon symptom onset in 2013. Despite surgical advancements, high recurrence rates persist post-PEH repair. Gastropexy, securing the stomach to prevent re-herniation, emerges as a potential solution. However, consensus on its application is lacking. This review aims to map existing research, summarize evidence, and identify gaps guiding future gastropexy research in PEH repair.

Methods: Following PRISMA guidelines, this scoping review conducted a comprehensive literature search using PubMed, Cochrane, and Embase. Eligible studies, including RCTs, observational, and cohort studies, described gastropexy for PEH treatment in adults published in English after 2013. Articles were rigorously screened, with data extracted and organized into tables detailing study characteristics, conditions, and outcomes.

Results: A search yielded 343 studies on gastropexy for PEH, with 17 meeting inclusion criteria. Most were retrospective (47.1 %) or case series (41.2 %). GP, primarily in types III and IV hernias, was mainly performed laparoscopically. Anterior GP was most commonly used (in 64.7 % of included studies), with some studies using additional techniques. Reduced recurrence rates were seen when adjunct procedures such as fundoplication were performed with gastropexy.

Conclusion: This review highlights the varied application of gastropexy in PEH repair, aiming to reconcile differing surgeon opinions. The data suggests gastropexy can be safely utilised across different techniques, offering a viable option for addressing PEH and reducing hernia recurrence, particularly in high-risk cases.

Background: In the last three decades, the worldwide prevalence of obesity has increased by threefold. Using a modified Delphi consensus technique, the Irish Surgical Research Collaborative (ISRC) aimed to formulate consensus guidelines on the peri-operative optimisation of patients with obesity undergoing non-bariatric surgery.

Methods: Subgroups within the ISRC were established to formulate consensus statements using a nominal group technique (NGT) to address the three domains of pre-operative, intra-operative and post-operative care. Three Delphi rounds were circulated nationally to multidisciplinary members of the peri-operative team via electronic survey. Consensus was considered achieved for any statement with >80 % agreement. Data was analysed using Microsoft Excel (Microsoft Corp, Redmond, WA).

Results: Following three Delphi rounds, a total of 94 statements centred around optimising peri-operative care for patients with obesity undergoing non-bariatric surgery reached consensus. Pre-operatively, access to prehabilitation, use of pre-operative risk stratification tools and strategies to reduce obesity-related co-morbidities were all deemed important along with nomination of a hospital obesity lead. Intra-operatively, the prioritised domains were involvement of consultant anaesthetist and surgeon for safe and considered patient positioning, utilisation of minimally invasive surgical techniques, adherence to venous thromboembolism prophylaxis and surgical site infection prevention strategies as well as adoption of multimodal analgesia. Appropriate analgesia prescription, nutritional support, enhanced recovery after surgery and the role of physiotherapy were all deemed essential elements of post-operative care.

Conclusion: As a multidisciplinary peri-operative group, through Delphi consensus, we report agreed perioperative standards to optimise the perioperative care of patients with obesity undergoing non-bariatric surgery. This consensus can be utilised to standardise clinical practice and identify areas for quality improvement.

Background: The epidemiology and management of thyroid cancer has changed radically in the recent past, with rising international incidence of early-stage papillary thyroid cancer (PTC) in particular. In this paper, we review the epidemiology of thyroid cancer in Ireland.

Methods: A retrospective cohort study of National Cancer Registry of Ireland data, 1994-2019.

Results: Records from 4158 patients were analysed. 73 % (n = 3040) were female. The average age was 50.4 years. Patient sex did not change over time (p = 0.662), while age decreased significantly (p < 0.0001). The most common diagnoses were PTC (n = 2,905, 70 %) and follicular thyroid carcinoma (n = 549, 13 %). Incidence rose over threefold (1.8-6.2 cases/100000 person-years). The incidence of T1 PTC rose over twelvefold (0.169-2.1 cases/100000 person-years), while the incidence of stage III and IV disease did not change significantly. Five-year disease-specific survival (DSS) was 85 % and varied significantly by diagnosis - 97 % for PTC versus 5 % for anaplastic thyroid carcinoma. Survival did not change significantly over time. Male sex was a risk factor for more advanced disease (p < 0.0001) but did not independently predict overall survival except in PTC (HR 1.6, p = 0.03). The use of radioactive iodine declined markedly from 49 % to 12.5 %. RAI improved DSS for PTC patients aged over 55 years (p = 0.02) without a notable effect on survival for those under 55 years (p = 0.99).

Conclusion: The epidemiology and management of thyroid cancer in Ireland has changed dramatically in a manner reflective of international trends.