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

The use of radiotherapy has increased in recent years, especially for pelvic neoplasms, and this can result in long-term complications such as recurrent haemorrhagic radiation cystitis (RHC). A 73-year-old male patient presented to a hospital emergency department multiple times with visible haematuria and clots leading to urinary clot retention; he was finally diagnosed with RHC. During the last presentation, the bladder was irrigated continuously with saline using a three-way catheter. During hospitalisation, a cystourethroscopy was performed for bladder evaluation and clot evacuation. Multiple bleeding ulcers were recognised on the bladder wall, biopsies were taken for histopathology, and the ulcers cauterised. Packed red blood cell transfusions were required, and sodium hyaluronate (CystiStat^®) bladder instillations were tried. There was no clinical improvement following any of these interventions. In light of the patient's deteriorating condition, cystoscopic application of PuraStat^® 3ml was administered, which led to remission of the urinary bleeding in the short term. We continue to monitor the effects in the medium and long term. Based on current data, PuraStat^® haemostatic agent therapy may be considered for RHC, when traditional treatments are ineffective or infeasible, potentially eliminating the need for more aggressive therapy such as cystectomy.

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: Unstable abdominal trauma patients should be treated with emergent laparotomy. However, few studies have evaluated the association between time to surgery and survival in these patients. We aimed to assess the influence of time to laparotomy on outcomes in blunt and penetrating unstable abdominal trauma patients.

Methods: This retrospective study includes patients with abdominal injuries, systolic blood pressure <90mmHg on arrival, admitted in Israel during 2000-2018. Data regarding patients' characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), time to surgery, length of hospital stay and mortality were collected via The Israeli National Trauma Registry.

Results: Overall, 69 blunt and 127 penetrating injury patients were included in the study. For blunt and penetrating trauma patients with ISS ≤14, no differences in outcome were found between patients who underwent laparotomy within 60min of admission and those who underwent laparotomy within 60-120min of admission. In patients with blunt trauma, ISS ≥16, and GCS <15, mortality was higher in the immediate laparotomy group (p = 0.004 and 0.049, respectively).

Conclusions: In patients with a penetrating injury, no differences in mortality between immediate and expedient laparotomy were demonstrated. In patients with a blunt injury, with ISS ≥16 and GCS <15, mortality was higher among the immediate laparotomy group.

Introduction: The annual dose limit for radiation exposure to the eye has been reduced recently; the eye is widely recognised as one of the most radiosensitive tissues in the body. There is minimal good quality research as to the radiation dose that the eye receives during endourological surgery and this study aimed to address this.

Methods: A prospective study was performed over an 8-month period at a single large teaching hospital in the UK. Three index procedures were included: ureteric stent insertion, ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL). Surgeons wore a dosimeter on the glabella with fluoroscopy time (FT) and dose area product (DAP) recorded for each case.

Results: A total of 404 procedures were included (247 URSs, 150 ureteric stent insertions and 7 PCNLs). Dosimeters were worn by ten surgeons. Mean FTs (URS 20.56s; ureteric stent 18.96s; PCNL 360.67s) and mean DAP (URS 100.82cGy/m², ureteric stent 119.82cGy/m² and PCNL 1121.62cGy/m²) were identified with significant intersurgeon variability. No surgeon had a total dosimeter dose >0.00mSv.

Conclusions: The International Commission on Radiological Protection recently reduced the yearly eye dose limit from 150 to 20mSv. Cataractogenesis is no longer considered a typical deterministic effect, with a threshold level below which no effect occurs. Even in higher volume centres, these annual limits are unlikely to be reached. Lead glasses may be considered for surgeons and radiologists with the highest exposure but, for the majority, ocular radiation exposure is negligible.

Introduction: Experience accumulated over the last decades suggests nonoperative management (NOM) of civilian gunshot liver injuries can be safely applied in selected cases. This study aims to compare the outcomes of selective NOM versus operative management (OM) of patients sustaining gunshot wounds (GSW) to the liver.

Methods: A registry-based retrospective cohort analysis was performed for the period of 2008 to 2016 in a Brazilian trauma referral. Patients aged 16-80 years sustaining civilian GSW to right-sided abdominal quadrants and liver injury were included. Baseline data, vital signs, grade of liver injury, associated injuries, injury severity scores, blood transfusion requirements, liver- and non-liver-related complications, length-of-stay (LOS), and mortality were retrieved from individual registries.

Results: A total of 54 patients were eligible for analysis, of which 37 underwent NOM and 17 underwent OM. The median age was 25 years and all were male. No statistically significant differences were observed between groups regarding patients' demographics, injury scores, grade of liver injury and associated lesions. NOM patients tended to sustain higher-grade injuries (86.5% vs 64.7%; p = 0.08), and failure of conservative management was recorded in two (5.4%) cases. The rate of complications was 48% with no between-group statistically significant difference. Blood transfusion requirements were significantly higher in the OM group (58.8% vs 21.6%; p = 0.012). The median LOS was seven days. No deaths were recorded.

Conclusion: Patients with liver GSW who are haemodynamically stable and without peritonitis are candidates for NOM. In this study, NOM was safe and effective even in high-grade injuries.

Introduction: Treatment of preoperative asymptomatic bacteriuria (ASB) before endoscopic surgery is recommended by European Association of Urology (EAU) guidelines. United Kingdom (UK) practice varies, however, owing to the historical nature of the evidence behind the guidelines, risk of increased antimicrobial resistance, the paradoxical view that treatment of ASB leads to increased infection and inefficiencies in rescheduling. We do not routinely treat ASB in our practice before holmium enucleation of the prostate (HoLEP). To determine the safety of this, we examined our experience focusing on the infective complications.

Methods: Retrospective data collection was performed on consecutive patients undergoing HoLEP between 2015 and 2020. Indication, preoperative urine cultures and infective complications were recorded. No patients were pretreated with oral antibiotics. All patients received intravenous antibiotics on induction and routine postoperative oral antibiotics at the surgeon's discretion.

Results: Some 443 patients were studied. No urosepsis occurred in the 125 patients with ASB compared with 2 of 318 patients (0.6%) with no growth on preoperative urine culture. Twenty-nine (7%) patients were treated with oral antibiotics for symptomatic postoperative complications (urinary tract infection without fever, epididymitis and haematuria). ASB did not predict for infective complications (urosepsis odds ratio [OR]: 0.50 p=0.66; oral antibiotics OR: 0.97 p=0.93).

Conclusion: Not treating ASB before a HoLEP procedure is safe. This supports the judicious use of antimicrobials preoperatively. Other modalities of endoscopic surgery should be similarly assessed.

Metastatic melanoma of the gallbladder is a rare entity that is often diagnosed late, leading to a poor prognosis. The disease may present insidiously as acute cholecystitis or remain asymptomatic. Optimal management remains unclear but surgical resection is considered the mainstay of treatment for this condition. We report the case of a 47-year-old man who suffered a protracted course of generalised abdominal symptoms eventually culminating in a diagnosis of acute cholecystitis. Following an emergency laparoscopic cholecystectomy, the histology revealed a melanoma with an unknown primary. Subsequently this was traced to the nasopharynx. Because of the presence of concurrent liver metastasis, systemic immunotherapy with palliative intent was commenced following a multidisciplinary team discussion. This case highlights the importance of sending clinical specimens for histological analysis. We argue against selectively choosing which specimens to send for histology because radiological and/or intraoperative macroscopic inspection of resected tissue alone can result in a missed diagnosis.

Objectives: Insertions of nasal and oral foreign bodies (FB) are common presentations in the emergency department, with coins frequently implicated among paediatric populations. Contactless payments were first introduced in the UK in 2007, and cash payments significantly declined from 2012. This study aims to explore the potential implications of increasing contactless payments on FB ingestion.

Methods: UK Hospital Episode Statistics (HES) were reviewed between 2000 and 2022. All FB retrieval procedures involving the alimentary tract, respiratory tract and nasal cavity were included. Regression analysis was performed to assess trends in the incidence of FB ingestion before and following the transition to cashless payments in 2012.

Results: Following the decline in cash payments in 2012, the frequency of alimentary tract FB removal procedures decreased significantly by 27.78 procedures per year (p < 0.001). Similarly, respiratory FB removal procedure decreased by 4.83 per year (p = 0.009) and nasal cavity FB removal procedures decreased by 52.82 per year (p < 0.001).

Conclusions: This study suggests a statistically significant decline in the number of procedures for removal of FB performed in the UK from 2012. Although this relationship is multifactorial, our data suggest an association between the introduction of contactless payments and a reduction in the number of FB retrieval procedures from the of upper aerodigestive tract.