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

Background

The aim of this study was to analyse the association between use of cement for stem fixation in hip hemiarthroplasty and the outcomes of mobility, mortality, and discharge destination.

Methods

The Irish Hip Fracture Database was examined from 2016 to 2020 to assess for any difference in post op mobility, 7-day, 14-day and inpatient mortality, and discharge destination.

Results

A total of 7109 hemi-arthroplasties were identified from 2016 to 2020. 71.6 % were cemented (n = 5,172), with 28.4 % uncemented (1,937). There was no difference in day 1 post op mobilisation (79.7 % vs 80.9 %) or cumulative ambulatory score on discharge (2.5 vs 2.4). The mortality rate was equivocal at all time points between the cemented and uncemented groups (7 day (.9 % vs 1.2 %), 14 day (1.9 % vs 2.3 %), inpatient (4 % vs 5.1 %)). There was no difference in length of stay (11 vs 12 days) or discharge to home directly (21 % vs 27 %).

Conclusion

The use of cement did not have any significant difference on post op mortality, mobility or discharge destination.

Background

There is a trend for specialist care in breast surgery resulting in fewer primary operative cases for general surgery trainees; and subsequently that trainees performing advanced oncoplastic techniques in breast surgery may negatively impact patient morbidity. We have reviewed the complication rates between Australian general surgery trainees and Breast Consultants.

Methods

A retrospective analysis was performed over a 5-year period (January 2016–December 2021). The key endpoints measured were relative complication rates for consultants compared to trainees, subdivided by surgery type. Surgeries were categorised as either benign, primary breast cancer surgery or re-excision.

Results

A total of 2646 operative cases were performed with the primary operator rate for consultants 58.35 % (n = 1544) and for trainees 41.65 %% (n = 1102). The overall complication rate was 2.83 % (n = 75); the overall rate for the consultants was 2.65 % and 3.08 % for the trainees. The complication rates were not statistically significant (p = 0.59) between the two groups. The mastectomy only complication rate was higher in the consultant group with a result of 7.3 % compared to 2.8 % for the trainees however was not statistically significant (p = 0.18). The most common complication was haematoma formation for both groups.

Conclusions

This study has demonstrated that trainees can safely perform advanced oncoplastic techniques without statistically elevated morbidity. In an era where breast surgery caseloads are increasing, but the exposure to breast surgery during training are decreasing, it is necessary to implement a practice where trainees can perform breast operations under supervision at a specialized unit.

Background

Diabetes foot sepsis (DFS) is the leading cause of amputation of lower extremities. Over 50 % of patients who have had major lower extremity amputation due to DFS are dead within 4 years following the procedure.

Aim

To determine the life expectancy of patients following amputation for DFS at a regional hospital in South Africa.

Methods

We conducted an audit of patients who had DFS and were admitted over a 5-year period. The duration from admission to time of death was recorded in days. Occurrence of death was confirmed from family members of the deceased using structured telephonic interview questionnaires. Categorical findings were summarized using actual counts and percentages and compared using either the Chi-square or Fisher's exact test. We used the mean with standard deviation or median and range to compare parametric and non-parametric continuous data, respectively. The Shapiro-Wilk test was used to test normality of data. Multivariate logistic regression was done to establish factors that were strongly associated with the mortalities. Adjusted survival curves were added to compare the rate of occurrence of mortality between males and females with age as a confounder. Statistical significance was set at a p-value below 0.05.

Results

197 were found of which 100 % of participants had Type 2 diabetes mellitus and 63.5 % were males. Associated comorbidities included hypertension in 73.6 %, obesity in 66 %, alcohol use in 64.5 % and smoking in 58.4 %. 190 participants had an amputation and 19.3 % died.

Conclusion

DFS was more common in males and 96 % of the patients had an amputation. Mortality rate within 4 years following amputation was 19.3 % and was higher in females and individuals with multiple comorbidities.

Background

Hepatectomy is an established treatment for colorectal liver metastasis (CLM) or neuroendocrine liver metastasis. However, its role in non-colorectal non-neuroendocrine liver metastasis (NCNNLM) is controversial. This study aims to compare long-term survival outcomes after hepatectomy between NCNNLM and CLM in a population-based cohort.

Methods

From 2009 to 2018, curative hepatectomy were performed in 964 patients with NCNNLM (n ​= ​133) or CLM (n ​= ​831). Propensity score (PS) matching was performed. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival.

Results

There were 133 patients in the NCNNLM group and 266 patients in the CLM group. The mortality (1.5 ​% vs 1.5 ​%) and morbidity (19.5 ​% vs 20.3 ​%) rates were comparable between the two groups. There was no statistically significant difference in 5-year overall (48.9 ​% vs 39.8 ​%) and recurrence-free (25.1 ​% vs 23.4 ​%) survival rates between NCNNLM and CLM groups. A high pre-operative serum bilirubin level, severe postoperative complications and multiple tumors were independent prognostic factors for poor survival.

Conclusion

Hepatectomy for selected patients with NCNNLM can achieve similar long-term oncological outcomes as those with CLM. High serum bilirubin, severe postoperative complication and multiple tumors are poor prognostic factors for survival.

Introduction

The General Medical Council (GMC) issues annual surveys to all doctors within the United Kingdom (UK) in a formal postgraduate training scheme. This facilitates the monitoring of experiences for quality assurance purposes. Low job satisfaction has been associated with heightened levels of burnout and staff turnover, alongside deteriorating clinical care and productivity levels.

Methods

We gathered and extracted data from the publicly available online GMC reporting tool. Data ranged from 2013 to 2023 and spanned 12 postgraduate surgical training programmes across all 18 indicators available. In total, 198 individual metrics were recorded, in addition to burnout. We conducted trend analysis and yearly average mean scores for individual metrics, burnout and geographical differences for 141 individual training programmes within the 16 training regions.

Results

Of the 198 metrics analysed, 83 (42 ​%) were found to have statistically significant negative trends (P ​< ​0.05), in comparison to 24 (12 ​%) with positive trends. 5 specialities had over 50 ​% of metrics showing a significant negative trend. Overall satisfaction was negative in all 12 programmes, with eight reaching significance (P ​< ​0.05). Of 141 individual training programmes, 29 ​% showed a significantly negative trend in overall satisfaction, with 1 ​% demonstrating a significant positive trend (P ​< ​0.05).

Conclusion

Our study is the first to explore long-term trends in trainee reported surgical training experiences within the UK. Our data have revealed widespread worsening trainee reported experiences and dissatisfaction across multiple specialities and geographical regions, especially in key areas of overall satisfaction, self-development, and clinical supervision.

Background

Transfer of all severe TBI patients to a neurosurgical unit (NSU) has been advocated irrespective of levels of complexity and prognostic factors. Previous publications have suggested that only 50% of severe TBI patients in Ireland were managed in NSUs.

Aims

This study aims to audit severe TBI referrals to the National Neurosurgical Centre, to evaluate reasons for nonacceptance, assess for differences in the transferred and not transferred cohorts and to analyse observed and expected mortality rates.

Methods

Data on all patients with TBI referred in 2021 were prospectively collected using an electronic referral system. Patients with severe TBI (GCS ≤ 8 and AIS ≥ 3) were included and dichotomised into transferred and not transferred cohorts.

Results

Of 118 patients referred with severe TBI, 45 patients (38.1%) were transferred to the neurosurgical centre. Patients in the transferred cohort were significantly younger (p < 0.001), had a higher GCS score (p < 0.001) and a lower proportion of bilaterally unreactive pupils (p < 0.001) compared to the not transferred cohort. 93% (68/73) of those not transferred were either >65 years old, or had bilaterally unreactive pupils, or both. Based on the IMPACT model, the observed to expected mortality ratios in the transferred and not transferred cohorts were 0.65 (95% CI 0.25–1.05) and 0.88 (95% CI 0.65–1.11) respectively.

Conclusion

The observed mortality rate for severe TBI in Ireland was similar to or better than expected mortality rates when adjusted for important prognostic factors. 93% of severe TBI patients not transferred to a neurosurgical centre were either elderly or had bilaterally unreactive pupils or both. These patients have an extremely poor prognosis and recommendation for transfer cannot be made based on current available evidence.

Background

Readmissions following colorectal surgery (CRS) have negative clinical, psychological and financial implications. Identifying patients at risk of readmission remains challenging.

Aims

To determine factors predictive of those likely to require readmission at 40-days following major CRS and to identify novel strategies capable of reducing readmissions.

Methods

Consecutive patients were studied from a prospectively maintained database. All patients were operated on by a single surgeon in a high-volume centre. Where applicable, photography was recorded by patients and emailed directly to the institutional email of the consultant surgeon. Data was recorded and analysed using descriptive statistics.

Results

515 patients were included over a 15-year period (2007-2022). The mean age at surgery was 64 years (18-93). The majority of patients were male (56.9%, n=293) and underwent cancer surgery (58.2%, n=299). Overall, 55 patients were readmitted within 40 days of major CRS (10.7%). Patients with pre-treatment diagnoses of heart failure (P=0.012), ischemic heart disease (P=0.002), renal impairment (P<0.001), atrial fibrillation (P=0.006), hypercholesterolemia (P=0.001), asthma (P=0.013) and hypertension (P=0.001) were more likely to require readmission. The majority of patients were readmitted for definitive management of surgical site issues (SSIs) (43.7% n=24). Other reasons included bowel obstruction (9.1%, n=5), pelvic sepsis (7.3%, n=4) and gastrointestinal upset (7.3%, n=4).

Conclusion

This series demonstrated that patients with cardiopulmonary comorbidities were more likely to be readmitted following major CRS and most readmissions are SSI related. Readmissions for SSIs can be reduced by patients sending photography to the treating surgeon which could reduce readmissions and A&E attendances.

Background

Commercial laparoscopic simulators are costly and with limited accessibility. For this reason, medical students very often do not have an easy access to laparoscopic training important for their practical skills development.

Patients and methods

Using materials available at a standard hardware store we managed to construct a laparoscopic training box with four eye-hand coordination modules that could substitute commercial solutions. In this work we provide a detailed instructions on creating such a training box. Moreover, to evaluate the functionality of our simulator we conducted a survey of students who were provided training using commercial box trainer and our homemade box trainer.

Results

Students considered our homemade laparoscopic training box to be of comparable quality to the commercial solution. All of the surveyed students considered training using a low cost laparoscopic training box to be a positive experience.

Conclusions

Our homemade low cost laparoscopic simulator is relatively easy to construct and was deemed noninferior to the commercial laparoscopic simulator by surveyed students. Such type of laparoscopic simulators could enhance access to laparoscopic training for medical students.

Successful completion of the Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination is mandatory for surgical trainees entering higher specialist training in the United Kingdom. Despite its international reputation, and the value placed on the examination in surgical training, there has been little evidence of its predictive validity until recently. In this review, we present a summary of findings of four recent Intercollegiate studies assessing the predictive validity of the MRCS Part A (written) examination.

Data from all four studies showed statistically significant positive correlations between the MRCS Part A and other written examinations taken by surgical trainees over the course of their education. The studies summarised in this review provide compelling evidence for the predictive validity of this gatekeeping examination. This review will be of interest to trainees, training institutions and the Royal Colleges given the value placed on the examination by surgical training programmes.