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

Background: Early diagnosis, early treatment and long-term follow-up in paediatric patients with Lichen Sclerosus (LS) are mandatory to avoid complications such as urethral meatal stenosis.

Methods: All patients older than five years who underwent circumcision from January 2015 to December 2021 at our centre with positive histology for LS were included. Demographic, preoperative, surgical and postoperative data were analysed. Patients were physically evaluated, and they were asked to fill in two quality of life questionnaires and to perform an uroflowmetry. They were stratified into clusters according to physical and histological examination. Urethral dilatations were investigated to assess the correlation between circumcision and incidence of LS-linked complications.

Results: Among 99 patients included in the study, 95 were finally evaluated. Median age at diagnosis was seven years (range, five to ten years). Median age at surgery was 10.8 years (6-17). Urethral meatus was grade 0 in 47% of cases, grade 1 in 41% and grade 2 in 12%. A total of 19% of circumcised patients with LS had pathological uroflowmetry: the number of patients with pathological uroflowmetry increased as the grade of meatal stenosis increased (13% grade 0, 15% grade 1 and 33% grade 2). Four (4.7%) patients with diagnosis of meatal stenosis underwent meatal dilatations.

Conclusions: By assessing histology of LS it is possible to determine who will develop LS-linked complications such as meatal stenosis. Patients with LS must be followed-up closely and should be treated with corticosteroids for at least for one month to improve their postoperative outcomes.

Introduction: Fragility hip fracture (FHF) care has been revolutionised by the introduction of the best practice tariff and its associated quality assessment domains. However, increasing demands on trauma services, most notably in regional major trauma centres (MTC), have resulted in competing challenges for clinical resources. This study aims to identify whether a dedicated hip fracture unit (HFU) embedded within a trust hosting the regional MTC affords sustained improvements in clinical outcomes for FHFs.

Methods: A 10-year retrospective cohort study was performed using a prospectively collected database that was cross-referenced against contemporary data submitted to the National Hip Fracture Database by a single multicentre National Health Service trust. The study period encompassed a 10-year period covering 5 years before and 5 years after formation of a dedicated HFU. The outcomes evaluated include time to surgery, length of hospital stay, discharge location and mortality.

Results: Some 4,998 patients sustained FHFs: 2,387 patients (2,533 injuries) treated prior to formation of the HFU formation and 2,611 patients (2,813 injuries) treated after. The mean time to surgical intervention was significantly lower in the group treated at the HFU by 3.1 days (p < 0.001). Length of hospital stay was also significantly reduced at the HFU (p < 0.001). More patients were discharged back to their premorbid residence from the HFU (47% vs 40%). The 30- and 365-day mortality rates were significantly reduced at the HFU (p = 0.005 and p = 0.024, respectively).

Conclusion: When embedded within an MTC, the HFU model is a sustainable operational structure in the medium term that provides clear clinical benefits and could be replicated nationally and internationally at similar institutions.

Introduction: Within the past five years there has been a significant increase in the number of international medical graduates (IMGs) joining the United Kingdom's (UK) workforce. Having mentors and supervisors who understand the needs of IMGs and clinical and cultural differences in the workplace can benefit in the transition to working in a new country. Improving knowledge of and understanding differences between general surgical training programmes and grades across different countries could therefore aid in the support of IMGs within the UK.

Methods: Data on general surgical training programmes of the top ten countries for the primary medical qualifications of IMGs in the UK were collected to provide comparison with the UK training programme.

Results: The following countries were included: UK, India, Pakistan, Nigeria, Egypt, Ireland, Sudan, Sri Lanka, Romania, Iraq and South Africa. Training programme lengths ranged from 3 to 10 years. Only some training programmes provide additional training and qualification in sub-specialisation in general surgery. Other differences included a requirement for internship/non specialist training prior to training, differences in lengths of time spent in other surgical specialties and a requirement for research.

Conclusion: Understanding the training programmes of other countries may help UK surgeons to understand the prior experience of IMGs and enable them to provide better training and support.

Introduction: Surgical intervention for medial epicondylitis (ME) is indicated when conservative management fails. This review evaluates different surgical techniques for management of ME in terms of patient-reported outcomes (PROs) and complication rates with a focus on the prognostic implications of preoperative injections and concomitant ulnar neuritis on postoperative outcomes.

Methods: Major medical databases were searched for relevant ME studies published between 2000 and September 2023. Case reports, reviews, abstract-only studies and pre-2000 studies were excluded. Two independent reviewers assessed the databases. A best evidence synthesis using Methodological Index for Non-Randomised Studies (MINORS) criteria summarised findings because of study heterogeneity.

Findings: Seventeen surgical studies (442 patients) met the inclusion criteria; most were retrospective (14 studies). MINORS scores ranged from 3 to 14, indicating variable methodological quality. Weighted means showed significant postoperative PRO improvements (p > 0.05). The overall complication rate was 3.1%, with percutaneous techniques showing 0% complications vs 6.4% for arthroscopic release and 11.1% for ulnar nerve transposition. Median time to surgery was 6 months of failed nonoperative treatment. Two studies found minimal impact of preoperative ulnar neuritis on outcomes. One of four studies assessing preoperative injections found a significant negative correlation with outcomes.

Conclusions: This review highlights a scarcity of high-quality research on surgical ME management. Nevertheless, surgical treatment for recalcitrant cases shows promising outcomes with low complication rates, particularly for percutaneous techniques. The evidence suggests that neither preoperative injections nor pre-existing ulnar neuritis significantly affects postoperative outcomes in patients undergoing surgery for ME.

Introduction: Trapeziectomy and ligament reconstruction tendon interposition (LRTI) is a commonly used procedure in the management of first carpometacarpal osteoarthritis. Debate persists regarding the degree of biomechanical improvement following trapeziectomy and subsequently LRTI. This preliminary, single-centre, in vivo, biomechanical study addresses the biomechanical effect of LRTI following trapeziectomy at the time of surgery, with each participant acting as their own control.

Methods: Trapeziectomy and LRTI were performed under wide-awake local anaesthetic with no tourniquet (WALANT) with a flexor carpi radialis (FCR) donor graft. Key pinch grip was assessed in each participant.

Results: The surgical method that resulted in biomechanically the most significant decrease in grip strength compared with preoperative grip strength was trapeziectomy alone with a mean difference of 4.27kg, which was also statistically significant (Tukey's test p<0.001). Mean post-WALANT key pinch grip strength was 6.4kg (sd 2.61); post LRTI the mean key pinch grip strength was 6.33kg (sd 2.63). Following the surgical procedure (trapeziectomy and LRTI) the mean key pinch grip strength was -0.1kg (95% confidence interval -0.93 to 0.81) (Tukey's test p=1), demonstrating no statistically significant difference between the two values. This indicates that LRTI restores pinch grip strength.

Conclusions: Our preliminary research presents a novel method to evaluate for biomechanical advantages following trapeziectomy and LRTI. This supports the biomechanical advantages of FCR LRTI following trapeziectomy, at the time of surgery. There is scope for this research process to be applied more widely in future.

Introduction: Peripheral arterial disease (PAD) involves atherosclerotic stenosis and occlusion of lower leg arteries, leading to significant disability, high cardiovascular and cerebrovascular morbidity and mortality. Critical limb ischemia (CLI) is the most severe form of PAD. With the UK's aging population set to increase, the prevalence of PAD and the burden on vascular teams are expected to rise. This study evaluates the impact of regular input from the Proactive Care of Older People Undergoing Surgery (POPS) team on vascular surgery outcomes.

Methods: This prospective cohort study examined the impact of Care of the Elderly (CoE) input on predefined parameters, focussing primarily on the length of stay (LoS) over 12 months. Data included baseline demographics, comorbidities, frailty scores (assessed using the Rockwood frailty score), LoS and referrals to medical specialties. A retrospective pilot study of 50 consecutive patients indicated a need for CoE input, showing higher local LoS compared with the national average.

Results: Patients in both pilot and project groups were matched for comorbidities, frailty scores and interventions. Despite higher mean age and a greater proportion of patients aged 75+ years in the project group, the study aimed to reduce LoS. Post-quality improvement project implementation, LoS beyond fit-for-discharge decreased from 11.7 days to 9 days in 6 months and to 6 days after 12 months. Referrals to medical specialties decreased from 77% to 40%, and new diagnoses on discharge increased from 28% to 37%.

Conclusions: CoE team input in vascular surgery patient care significantly improved outcomes, reducing LoS and medical specialty referrals, demonstrating cost-effectiveness and suggesting a feasible multidisciplinary approach for other regions.

Introduction: Carotid endarterectomy (CEA) with patch angioplasty is associated with lower restenosis rates compared with primary closure alone. However, evidence regarding patch-material superiority in the mitigation against neointimal hyperplasia and restenosis is limited. This retrospective observational study investigated medium-term restenosis rates between commercially available biological and synthetic carotid patches.

Methods: All primary CEA with patch angioplasty performed between 2007 and 2019 at a single university hospital were identified from theatre records. Restenosis was defined using the European Society for Vascular Surgery duplex criteria, either moderate (50-69%, PSV >213cm/s) or critical (70-99%, PSV >274cm/s). Chi-square tests and Kaplan-Meier curves were used to compare restenosis rates between biological (bovine pericardium) and synthetic patches (Dacron, PFTE and polyester-urethane).

Results: Overall, 127 CEAs were included in the restenosis analysis. Bovine pericardium was the patch material used most frequently (60%, n=75). Median follow-up with duplex was 40.0 months (range 0-144). Moderate restenosis was detected in 14 CEAs (11%) and critical restenosis in 10 (7.8%). Compared with synthetic material, bovine was significantly associated with >50% restenosis but not >70% (p=0.042 and p=0.197, respectively). However, Kaplan-Meier curves demonstrated similar rates of >50% and >70% restenosis between patch types at five years (p=0.081 and p=0.080, respectively). There was no significant difference in peri-operative complication rates between patch types.

Conclusions: These results indicate medium-term restenosis rates after CEA are similar between biological and synthetic patches. However, well-designed randomised control trials are required to definitively answer the question of which patch material is superior for carotid reconstruction.

Rhabdomyosarcoma (RMS) is a form of soft tissue sarcoma that can arise from muscle or fibrous tissue almost anywhere in the body. The two major subtypes of RMS are alveolar and embryonal, whereas the two rarer subtypes are pleomorphic, which typically occurs in adults, and the spindle cell/sclerosing variant, typically seen in children. RMS usually involves the extremities, the head and neck or the genitourinary system. Although it can arise from anywhere in the body, other sites of involvement are rare and usually present only at an advanced stage owing to a mass effect on surrounding tissues and organs. We present a rare case of a child who presented with the signs and symptoms of an acute abdomen, but intraoperatively was found to have a bleeding necrotic mass arising from the anterior abdominal wall. This was histologically confirmed to be a RMS of the embryonal type.