Annals of the Royal College of Surgeons of England最新文献

Gastric conduit is the preferred reconstruction following oesophagectomy. Patients can develop delayed gastric conduit emptying because of dilatation and poor drainage. We present a novel technique utilising endoscopic suturing to plicate the gastric conduit, improving drainage, reducing sumping and improving quality of life. An 81-year-old man who underwent an oesophagectomy for pT1bN0M0 oesophageal adenocarcinoma presented 6 years later with nutritional failure, body mass index (BMI) 17.5 and recurrent aspiration pneumonia. The gastric conduit had dilated, resulting in significant redundancy and sumping. Endoscopic suture plication of the conduit was performed to avoid the risks of surgical revision. Expertise developed in the practice of endoscopic sleeve gastroplasty was utilised to perform intrathoracic gastric conduit plication, eliminating sumping and reducing conduit redundancy. Following endoscopic gastric conduit plication, contrast swallow demonstrated improved shape and drainage of the conduit. At 6- and 12-month follow-up the patient reported improved diet tolerance, an increased BMI of 24.7 and there had been no hospitalisations for aspiration. EORTC QLQ OG25 scores improved from 60 to 32. Our novel technique for plication of an intrathoracic gastric conduit represents a useful strategy to increase the longevity and function of gastric conduits in oesophageal cancer survivors and those undergoing benign resections where long-term high-quality function of the conduit is important for optimal patient outcomes.

Introduction: Low-risk ankle fractures in children are commonly managed with immobilisation, using options such as supportive bandages, removable boots/braces or casted devices. The aim of this study was to review the literature to determine the optimal treatment for these fractures.

Methods: A systematic review of randomised controlled trials (RCTs) was conducted in November 2024. Comprehensive searches of MEDLINE, Embase and Cochrane CENTRAL were performed. Studies recruiting children (0-18 years) with low-risk, stable or suspected occult ankle fractures managed non-operatively were included, comparing different immobilisation devices. Unscheduled returns to healthcare facilities, patient-reported outcomes, functional outcomes, and complication rates were assessed.

Findings: Seven RCTs involving 503 children were included. Compared with casts, removable boots/braces significantly reduced unscheduled healthcare visits (risk ratio [RR] 0.26; 95% confidence interval [CI] 0.13 to 0.52; p = 0.0001), shortened return to normal activities (mean difference [MD] -6.83 days; 95% CI -11.20 to -2.96; p = 0.0031), and improved functional scores (standardised mean difference [SMD] -0.79; 95% CI -1.03 to -0.55; p < 0.00001). Patient and parent satisfaction was also higher with removable devices. Supportive bandaging reduced missed school days (MD -0.49; 95% CI -0.81 to -0.18; p = 0.002) and accelerated return to baseline activities (14.17 vs 20.19 days; p = 0.0002), although results showed high heterogeneity. No significant differences were found in pain, complications, emotional wellbeing or mobility between groups.

Conclusions: Removable boots or braces offer a favourable alternative to cast immobilisation for low-risk paediatric ankle fractures. However, the necessity of rigid over soft immobilisation remains uncertain. A definitive RCT based on a core outcome set and cost-effective analyses is required to inform treatment recommendations.

Background: Women remain underrepresented in surgery, with dropouts occurring at every stage of training, and women representing under 20% of consultant surgeons. This study explored the relationship between sex, applications for national selection for Higher Specialty Training (ST3), and receipt of an offer.

Methods: This retrospective longitudinal cohort study used data from the UK Medical Education Database. The study population included 1,960 doctors eligible to progress to higher training between 2014 and 2019. The primary outcomes of interest were application for and offer of an ST3 post. Logistic regression analysis was conducted after adjusting for confounders using a directed acyclic graph.

Results: Within the cohort, paediatrics and ear, nose and throat (ENT) had the highest proportion of female applicants (50%), followed by plastic and reconstructive surgery, general surgery (including vascular surgery applicants), urology, and trauma and orthopaedics, with the lowest (22%). Significant (p<0.01) associations were identified between being female and applying for ST3 general, paediatric, and plastic surgery, while applications to orthopaedics favoured men. No association was found between sex and ENT or urology applications. For ST3 offers, significant sex associations favouring women were identified for general surgery and urology. No associations were observed for the other specialties or the cohort as a whole.

Conclusions: Differences exist in the proportion of women applying for ST3 across surgical specialties, with women more likely to obtain a post in general and urological surgery. Recognising these disparities and promoting efforts to cultivate a more diverse and inclusive workforce remains critical.

Introduction: Nationally, in the aftermath of the first COVID-19 lockdown, the waiting list for elective surgery is approximately 7 million. To ameliorate an evolving crisis and improve system resilience, the Royal College of Surgeons of England proposed a 'New Deal for Surgery', promoting COVID-light sites and elective hubs. We evaluate the short-term outcomes, safety and sustainability of the hub model at a large National Health Service trust.

Methods: All major elective colorectal operations performed at the hub between 8 March 2021 and 8 March 2022 were included for analysis. Pertinent data on patient demographics, operative performance and postoperative outcomes were analysed using SPSS 27.

Results: In total, 401 cases were analysed. There was one same-day cancellation because of the unavailability of beds (0.2%). Median distance displacement for patients for their primary surgery was +3.2 miles. Twenty-one patients (5.2%) required postoperative blood transfusion. One patient had nosocomial COVID-19 (0.2%), severe complications of Clavien-Dindo grade ≥3 were observed in 33 patient (8.2%) and transfer-out for higher level care occurred in 34 cases (8.5%). Forty-six 30-day readmissions (11.5%) and two deaths (0.4%) were noted. Median length of stay was 6 days.

Conclusions: The volume of major colorectal surgery at the hub, with acceptable incidence of major complication, transfer-out and minimal patient displacement, attests to the efficacy and safety of the new model.

Background: The role of water-soluble contrast agent (WSCA) as a therapeutic tool in the nonoperative management of adhesional small bowel obstruction (ASBO) remains indeterminate. This survey aimed to understand current surgical practices in WSCA use in the conservative approach to ASBO, and to evaluate key design and feasibility factors to inform a future controlled trial of WSCA in ASBO.

Methods: This study is reported in line with CROSS guidance. The survey consisted of 16 questions organised into three sections: respondent characteristics, current decision-making and WSCA use, and opinions on future trial. Pilot testing was conducted before online distribution to surgeons in the UK delivering Emergency General Surgery. Descriptive analysis was performed.

Results: Of 73 total respondents, 52 (71.2%) were consultants. When treating ASBO conservatively, 80.8% (59/73) reported using WSCA in more than half of cases, but there was wide variation in timings, use and repeat challenges. Between 71.2% and 89.0% of respondents affirmed their willingness to adhere to specific trial protocols. Regarding feasibility, 76.7% (56/73) of respondents agreed or strongly agreed that they would be willing to recruit to a trial and 75.3% (55/73) agreed or strongly agreed that their unit would be able to deliver a trial.

Conclusions: The survey revealed widespread acceptance of WSCA as a therapeutic tool in ASBO among emergency general surgeons. Although practices around its administration varied, there was a clear readiness to adopt standardised protocols. The majority of respondents expressed support for a controlled trial comparing WSCA against a placebo.

Introduction: Reverse shoulder arthroplasty (RSA) is the most common shoulder replacement in the United Kingdom and has traditionally been an inpatient procedure. Advances in anaesthetic and surgical techniques have made day case RSA increasingly popular, yet published data on its outcomes are limited. This study assesses the outcomes of day case RSA using the National Joint Registry (NJR).

Methods: NJR data (April 2012-March 2022) were linked with Hospital Episode Statistics. All patients undergoing RSA for any indication were included. Primary outcomes were revision surgery rates; secondary outcomes included non-revision reoperation, medical complications requiring readmission and patient-reported outcomes for day case vs non-day case patients.

Results: Among 320 day case and 25,748 non-day case RSA patients, day case patients were younger, predominantly male and had lower comorbidity scores. Day case revision rates were 1.45% at 1 year, 1.93% at 3 and 5 years, and 3.96% at 7 years compared with 1.76%, 2.84%, 3.53% and 4.35% for non-day cases. Readmissions for medical complications occurred in 1.56% of day case patients vs 6.34% of non-day cases. Mean Oxford Shoulder Score improvements were 19.83 (±11.32) and 19.16 (±11.80) for day and non-day case groups, respectively.

Conclusion: Day case RSA demonstrates low revision, reoperation and complication rates, with similar patient satisfaction to non-day cases. These findings highlight the safety of day case RSA with careful patient selection and its potential to improve healthcare efficiency from a policy perspective.

Introduction: The importance of non-technical skills (NTS) to surgical performance and patient safety has been increasingly recognised by surgical teams. Inductions for new surgical team members in theatre often provide insufficient, non-standard and 'ad hoc' training in theatre behaviour and etiquette. We conducted a Delphi consensus study among senior surgeons to develop standardised guidance on theatre etiquette for those unfamiliar with the theatre environment, including resident surgical trainees and medical students.

Methods: An international Delphi process of two rounds was conducted. An electronic survey was distributed among senior surgeons, anaesthetists and senior scrub nurses/practitioners, with participants recruited via surgical societies. Participants were asked to rank each statement on a Likert scale of 1 to 5. Consensus was considered if achieved for any statement for which 75% or more indicated agreement. The study was registered with the Open Science Framework.

Results: A total of 261 participants completed the Delphi process; 239 valid responses were included in round 1, with a 23% dropout in round 2. Participants were from 23 countries, 66% were from the UK, 58.2% were male, 51% were from the 30 to 40-year age group, 39% were consultant surgeons and 49% were senior trainees. General surgeons made up 68.6% of respondents, trauma and orthopaedic surgeons 13.4%, healthcare practitioners 2.1% and anaesthetists 1.3%. Thirteen statements were excluded, and 29 reached agreement and were included in the final guidance.

Conclusion: There was agreement among a large international group of surgeons to develop a standardised guidance for theatre etiquette, addressing most of the key aspects of professional conduct and team dynamics. We anticipate that this guidance will serve as a valuable resource for orienting new members of the surgical team, providing a clear framework for maintaining professionalism and fostering effective communication within the theatre environment.

Acute exertional compartment syndrome (AECS) is increasingly recognised as an emergency presentation requiring urgent surgical intervention. This can theoretically affect any myofascial compartment, but is rare around the shoulder, with very limited literature relating to AECS of the supraspinatus muscle. It is vital for the treating medical team to have an index of suspicion for this condition in patients presenting with acute severe shoulder pain secondary to exertion, and act promptly to assess and investigate. Clinical assessment can be combined with important adjunctive investigations including magnetic resonance imaging and compartment pressure measurement, and if the diagnosis is confirmed or strongly suspected, emergency fasciotomy should be performed. We present a case of a patient with AECS of the supraspinatus, treated with emergency fasciotomy, who made a good long-term recovery.

Background: Variation exists in how consultant surgeons identify malnutrition in emergency general surgery (EGS) patients. These relate to differences in surgeon knowledge, understanding, ownership and hospital setting. Little is known regarding how these relate to nonconsultant surgeons, or those with experience of intestinal failure (IF).

Aims: This study aimed to characterise the awareness, practice and training of general surgeons in the identification of malnutrition in the emergency setting.

Methods: The survey focused on three domains: perceptions, current practices and nutrition training. Following piloting, EGS surgeons were invited to complete an online survey. Responses were gathered using Qualtrics. Descriptive analysis and associations with surgeon seniority and IF were performed in SPSSv26. Ethical approval was obtained (UREC 050436). Results are reported with reference to the CHERRIES guidelines.

Results: The completion rate was 52.1% (148/284), of whom 49.7% were nonconsultant surgeons and 46.6% had experience of IF. Surgeons from all UK regions completed the survey. There was strong agreement across participants that malnutrition can affect surgical outcomes and identifying it was an important skill for surgeons. However, only 37.2% (55/148) were confident in doing so. Surgeons with IF experience were significantly more confident than those without (49.3% vs 26.6%). Training was reportedly poor, and local teaching or a short course aimed at surgeons in training was considered most helpful in the future.

Conclusions: Identifying malnutrition in EGS is recognised as an important skill most surgeons feel they are lacking. Support for formal training in this area was high.