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

Background: Operating theatres significantly impact healthcare's carbon footprint. Surgeons, as key decision-makers, are essential in driving sustainable practices. This study evaluates the attitudes and practices of Irish surgeons towards environmental sustainability, identifies barriers to implementation, and explores opportunities for improvement.

Methodology: A cross-sectional survey was distributed to members and fellows of the Royal College of Surgeons in Ireland (RCSI). The structured questionnaire comprised demographic items, Likert-scale statements, and open-ended questions, addressing awareness of sustainability, waste management behaviours, and individual commitment to sustainable practices.

Results: A total of 177 responses (response rate of 85.9 %) were received; 74 % (n = 131) of respondents were male and 55.4 % (n = 98) were consultant surgeons. While most respondents acknowledged the importance of sustainability in surgery, many reported limited familiarity with the concept. The volume of non-clinical waste generated in surgical settings was frequently underestimated. Reported barriers to implementing sustainable practices included insufficient education and awareness, financial constraints, and dependence on single-use instruments. Concerns regarding sterility and infection prevention also emerged as deterrents to adopting reusable alternatives. In addition to the quantitative findings, open-ended responses were analysed using thematic analysis, which revealed nuanced insights into surgeons' perceptions of sustainability, including underlying concerns, motivations, and system-level barriers.

Conclusions: There is a clear disconnect between the perceived importance of sustainability and its practical application in surgical settings. Barriers exist at multiple levels - individual, institutional, and systemic. These findings underscore the urgent need for targeted educational and policy-driven interventions to embed sustainability into surgical practice.

Background: Peritoneal metastases (PM) are a common site of spread in colorectal cancer (CRC) and are associated with poor survival outcomes. The true burden of disease is difficult to quantify due to limitations in imaging and limited symptoms until advanced disease. Systemic therapy has limited benefits and there is an increasing interest in the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). This narrative review summarises the current literature on epidemiology of PM in CRC and evidence based current management strategies.

Methods: PubMed was search for the terms "Peritoneal Metastases" or "Peritoneal carcinomatosis" and "Colorectal Cancer" from inception to December 2024. Titles of all English language articles were considered and backwards referencing screening was undertaken in key articles. Inclusion criteria included all original articles with a focus on the clinical management of PM and CRC.

Findings: PM occur in 5-10 % of patients with CRC. The current literature likely underestimates the true burden of disease due to reliance on accurate registry data, and little is published on UK data. Systemic therapy has limited benefit in patients with PM. The PRODIGE-7 trial highlighted the benefits of CRS in select patients but raised questions about the benefits of HIPEC. Prophylactic HIPEC remains controversial but the findings of HIPECT4 show promising results.

Conclusion: The true burden of PM and CRC remains unclear particularly in the UK population. CRS has clear benefits in patients that undergo complete cytoreduction. Further work is required to determine the benefits of HIPEC and how to optimise this for patients.

Background: and methods: Robotic-assisted surgery has become a cornerstone of modern surgical innovation, offering enhanced precision, minimal invasiveness, and improved recovery compared with conventional techniques. Its rapid adoption across multiple specialties in Ireland has brought substantial benefits for patients but also challenges regarding surgeon training, programme oversight, and patient safety. Until recently, Ireland lacked a unified national governance framework for robotic surgery. In recognition of this, the Royal College of Surgeons in Ireland (RCSI) established the National Robotic Surgery Leads Group in 2023, tasked with creating national standards for governance, training, and safe practice.

Results: This paper outlines the framework developed by the Leads Group, presenting a model that balances innovation with robust clinical governance. Central to this approach is the establishment of hospital-based Robotic Surgery Governance Committees (RSGCs), responsible for credentialing, training oversight, and monitoring key safety indicators. Training is structured around vendor-led pathways, mentorship, modular component training, and telementoring, with hybrid approaches recommended to optimise safety. Safety monitoring includes key performance indicators such as case volume, console times, transfusion rates, conversion to open surgery, ICU admissions, and morbidity and mortality outcomes. Additional considerations addressed include recognition of surgeon vulnerability during the early learning curve, emergency preparedness, case-mix management, consent processes, and the safe introduction of new robotic platforms.

Conclusion: A national survey of all robotic surgeons in Ireland, with a 76 % response rate, demonstrated overwhelming support for the establishment of RSGCs and KPI monitoring. This framework represents Ireland's first national governance model for robotic surgery and positions the country as a leader in fostering a culture of safety, innovation, and excellence in surgical care.

Background: Clinical documentation is essential for safe and effective patient care but places a considerable clerical burden on clinicians. Ambient artificial intelligence (AI) systems, which capture clinical conversations and generate structured notes in real time, have shown promise in primary and outpatient care but remain underexplored in the inpatient setting. This study examined the impact of an ambient AI scribe on documentation timing, quality, and workload in a simulated orthopaedic inpatient setting.

Methods: Seven postgraduate year one junior doctors participated in simulated orthopaedic ward rounds incorporating an ambient AI scribe (Heidi Health, Melbourne, Australia). A total of 150 clinical documents were generated: 120 progress notes (60 manual, written retrospectively, and 60 produced in real time using ambient AI) and 30 discharge summaries (15 manual and 15 AI-generated). Documentation time was recorded, and quality was assessed using the Physician Documentation Quality Instrument-9 (PDQI-9) for each clinical document. Workload was evaluated using the NASA-TLX instrument.

Results: Ambient AI significantly reduced documentation time for both progress notes (median 27s vs. 128s; P < .0001) and discharge summaries (median 114s vs. 459s; P < .0001). Time savings persisted across all complexity levels. AI-generated progress notes achieved higher overall PDQI-9 scores than manual notes (median 43.5 vs. 41; P = .002), with significant gains in thoroughness, currency, and usefulness, without compromising accuracy. Similarly, AI-generated discharge summaries scored higher (median 40 vs. 33; P < .0001), with improvements in comprehensibility, organisation, internal consistency, and synthesis. Junior doctors reported reduced workload across all NASA-TLX domains, with the largest improvements in frustration (-79 %) and effort (-81 %).

Conclusion: In simulated orthopaedic ward rounds, ambient AI substantially reduced documentation time, improved document quality, and alleviated workload for junior doctors.

Background: Older adults have high rates of morbidity and mortality following traumatic spinal cord injuries (SCI) but are also at increased risk of intraoperative and postoperative complications compared to younger counterparts. This study aims to identify the optimal time to surgical intervention in elderly patients presenting with traumatic SCI.

Methods: A retrospective review was carried out at our centre from 2016 to 2020 to identify geriatric patients (≥65 years old) presenting with a traumatic SCI, managed surgically. Cohorts were categorised and compared for outcomes based on their time from injury to surgery. The different time intervals assessed include: 24 h and 72 h.

Results: 72 patients were identified. 13/72 (18.1 %) underwent surgery within 24 h of their injury and 32/72 (44.4 %) underwent surgery within 72 h of their injury. Overall, the results favoured delayed surgical intervention for both time intervals in terms of high dependency unit (HDU) requirement (p = 0.004 and p = 0.048), intensive care unit (ICU) requirement (p = 0.001 and p = 0.015) and intraoperative complications (p = 0.043 and p = 0.02). Of the patients with preoperative American Spinal Injury Association (ASIA) Impairment Scale (AIS) A grade, those who underwent surgical decompression after 72 h had greater neurological improvement (p = 0.019) and a smaller proportion of HDU (p = 0.006) and ICU (p = 0.047) requirement.

Conclusion: To the authors' knowledge, this is the first study to compare surgical outcomes in geriatric patients with traumatic spinal cord injury (SCI) based on injury-to-surgery time intervals. The findings are hypothesis-generating and suggest a potential benefit to delayed surgical intervention in a subset of these patients. Further prospective research is needed to better define optimal timing and management strategies in this complex and vulnerable population.

Background: Differential attainment (DA), defined as unexplained variation in educational outcomes, persists throughout medical training. This study investigates whether demographic characteristics are associated with differences in the likelihood of receiving a Core Surgical Training (CST) offer during the 2024 UK national selection round.

Methods: A retrospective cross-sectional analysis of anonymised applicant-level data from UK-wide CST recruitment was performed. All applicants with complete demographic and outcome data were included. The primary outcome was the offer of a CST training post. Logistic regression evaluated associations between offer outcomes with gender, ethnicity, nationality, age, country of qualification, and disability status.

Results: Applicants applying directly from FY2 were significantly more likely to receive CST offers than those from other backgrounds (RR = 1.73, 95 % CI: 1.51-2.00). Female applicants had higher odds of receiving an offer compared to male applicants (aOR = 1.44, 95 % CI: 1.19-1.74, p < 0.001). Applicants identifying as Asian (OR = 0.54), black (OR = 0.31), and other/Chinese (OR = 0.67), as well as non-UK nationals (OR = 0.24), non-UK graduates (OR = 0.68), and applicants aged >30 (OR = 0.39) had significantly lower odds of receiving an offer (all p < 0.001). Applicants reporting disabilities had increased odds of success (OR = 3.36, 95 % CI: 1.53-7.38, p = 0.002). No significant difference was observed related to sexual orientation or pregnancy/maternity leave.

Conclusions: Despite structured recruitment processes and individual portfolio scoring, differential attainment persists across multiple demographic groups in CST selection. Targeted early support is essential to improve equity, especially for international medical graduates, older applicants and applicants from minoritised ethnic backgrounds.

Background & aims: Sleeve gastrectomy is a widely performed bariatric surgery, yet its outcomes can vary significantly depending on environmental factors such as high altitude. High altitude, characterized by hypobaric hypoxia, may affect oxygen delivery, recovery, and metabolic processes post-surgery. This study aims to evaluate high altitude as a prognostic factor in sleeve gastrectomy outcomes, focusing on complication rates, weight loss, and recovery duration.

Results: The meta-analysis revealed a significantly higher postoperative complication rate for the high-altitude group, with a relative risk (RR) of 1.45 (95 % CI: 1.35-1.55, p < 0.05) [9, 14]. To address heterogeneity in altitude definitions [6, 9], we performed a sensitivity analysis excluding the study with the highest altitude cutoff (≥2500 m). The results remained consistent (RR: 1.42, 95 % CI: 1.32-1.53) [14, 19], confirming the robustness of our primary finding.

Conclusions: High altitude is a critical factor influencing sleeve gastrectomy outcomes, leading to increased complications and prolonged recovery. Preoperative assessments and postoperative care must address altitude-specific challenges, including enhanced oxygenation strategies, to optimize patient recovery and surgical success. These findings emphasize the need for tailored clinical approaches to improve outcomes for bariatric surgery patients in high-altitude environments.

Background: The National Health Service (NHS) in the UK aims to deliver healthcare services around the clock. Major Trauma Centres (MTCs) are crucial in this operation, requiring continual 24/7 operations. Despite efforts to provide on-site nurseries catering to children aged 3 months to 5 years, there remains a significant gap in childcare provision for on-call workers. This shortfall particularly affects surgeons, nurses and military medical personnel whose shifts extend beyond standard nursery operating hours. This discrepancy raises concerns about the sufficiency of support for healthcare professionals with irregular schedules.

Aims: This study delves into the existing childcare facilities in NHS major trauma centres, aiming to identify challenges faced by on-call workers and propose strategies to bridge this childcare gap. By addressing these issues, the study contributes to discussions on how to best support healthcare professionals working 24/7 while ensuring the well-being of their children.

Methods: The research involved a review of in-house childcare facilities across all 27 MTCs in England. Data from named nurseries affiliated with the MTC official NHS websites were examined, including nursery names, capacity, operating hours, and available services such as weekend placements and emergency out-of-hours cover.

Results: Results showed that out of 27 MTCs, 26 had on-site nurseries. However, only a fraction of these operated beyond standard hours, with none offering emergency or weekend services. This highlighted a significant deficit in comprehensive childcare support. The lack of childcare services tailored to the irregular schedules of NHS workers might impact career choices. This discrepancy sharply contrasts with childcare benefits provided in the private sector and government settings.

Conclusion: The current NHS childcare provision falls short of meeting the demands of a 24/7 service, posing challenges for on-call workers. This underscores the urgent need for 24-h childcare facilities that align with the operational requirements of the NHS. Reforms in this critical area are imperative to address these shortcomings.

Background: Given changing demographics in surgery, this study aimed to assess the representation and diversity of speaker pool in the last decade of Conjoint Scientific Congresses by analysing the participating speakers, both the invited speakers and presenting trainees, in terms of their gender, affiliations and origin.

Methods: This study retrospectively reviewed online program leaflets to collect information on the gender, origin, presentation role, invitation status, and affiliation of speakers. Information on invited speakers were evaluated from 2013 to 2022, and for presenting trainees, from 2015 to 2023, due to data availability.

Results: This study identified 1817 speakers, including invited speakers (2013-2023) and 791 trainees (2015-2023). The percentage of female invited speakers increased significantly from 7.7 % in 2013 to 27.5 % in 2023 (p < 0.05; 95 % CI [0.46, 0.95]). The mean percentage of female trainees was 37.4 % (range 28.7 %-48.7 %), and there was no significant change in this percentage over the years (p = 0.44; 95 % CI). Local speakers increased significantly from 69.2 % in 2013 to 83.8 % in 2022 (p < 0.05; 95 % CI [0.91, 0.99]), associated with a greater involvement from the public sector, from 57.8 % in 2013 to 92.3 % in 2023 (p < 0.05; 95 % CI [0.64, 0.96]).

Conclusion: Over the years, female invited speakers increased, and female trainee participation remained similar, suggesting better representation of surgical community. There was an increasing participation of local speakers, particularly in the public sector, which may lead to potentially less diversity in the speaker pool.

Introduction: Surgical care is an essential, resource-intensive component of healthcare. It contributes a significant carbon footprint and waste production. As part of Ireland's commitment to achieving net-zero emissions by 2050, surgical services have emerged as a critical focus area for sustainability reforms.

Aims: This review explores national policies, research contributions, and the leadership role of institutions in driving sustainable practices.

Discussion: Ireland has made significant strides in incorporating sustainability into its healthcare system, particularly within surgical care. National initiatives and efforts led by institutions are commendable steps toward reducing the environmental footprint of healthcare. The integration of sustainability into education and research is assessed, along with challenges and barriers to systemic change. Significant gaps remain in terms of implementing Ireland's sustainability policies effectively across all hospitals. Issues include the disparity in resources between urban and rural hospitals and patient engagement practices.

Recommendations: Four key findings are recommended. Stronger national policies on sustainability audits and practices are essential. An increased focus on sustainability in research is required. An emphasis on training and teaching sustainable surgical practices is needed. Improving patient education will aid in the goal of increasing surgical sustainability in Ireland.

Conclusions: Ireland continues to focus on enhancing policy frameworks, expanding research, building capacity across the healthcare workforce, and engaging the public in sustainable healthcare practices. Several challenges persist that hinder the scaling and broad implementation of these initiatives. Evidence from global studies supports actionable recommendations for Ireland's future sustainability agenda.