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

Clavicle fractures are common in children, comprising up to 15% of fractures presenting to the emergency department. Typically, mid-shaft clavicle fracture in the paediatric population is managed conservatively, with surgery recommended in a select few. A 12-year-old boy presented with a depressed mid-shaft clavicle fracture with an ipsilateral cervical rib exhibiting features of venous congestion. This case was managed conservatively using a sling and the patient was admitted for overnight observation with early mobilisation encouraged. His recovery was complicated by a re-fracture 4 weeks later, which was managed conservatively with a good clinical outcome. This is the first report of such a fracture associated with an ipsilateral cervical rib. This case highlights that such injuries with vascular concerns could be managed conservatively with good outcomes.

Introduction: Ultrasound-guided thermal ablation has progressively emerged in the treatment of benign thyroid nodules. More recently, thermal ablation has also been proposed as a promising treatment alternative for papillary thyroid microcarcinoma (PTMC). This systematic review evaluates the efficacy and safety of ultrasound-guided radiofrequency ablation (RFA) and microwave ablation (MWA) for the treatment of PTMC.

Methods: The PubMed and Cochrane databases were searched for relevant studies up to December 2023 following PRISMA guidelines. Volume reduction rate (VRR), complete disappearance rate (CDR), and associated complications following RFA and MWA were analysed.

Findings: A total of 33 articles were included. Follow-up time ranged from 11 to 130 months. The efficacy of both MWA and RFA on PTMC was remarkable, with VRR reaching up to 99% at 12-month follow-up in the vast majority of patients, while CDR exceeded 80% in most studies. Following ablation, temporary complications at relatively low rates were reported including regional discomfort, voice change and haematoma, except for only one case with permanent recurrent laryngeal nerve injury.

Conclusions: Ultrasound-guided thermal ablation of PTMC is a promising therapeutic approach for patients who are ineligible for, or refuse, surgery. Current research suggests that RFA and MWA provide favourable, low-cost outcomes, but larger multicentre, randomised studies are required to confirm the feasibility and safety of this new treatment modality.

Introduction: Climate change is a significant threat to human health, and surgical care is a major contributor to the carbon footprint of hospital medicine. There is wide variation in perioperative group and save (G&S) blood testing that lacks an evidence base. Eliminating low-value clinical investigations in surgical pathways such as the G&S could lead to significant carbon and cost savings.

Methods: All operations within the trust over a 6-month period and all packed red cell requests made within the same timeframe were analysed retrospectively. Patients were categorised by operation and cross-referenced with transfusion data to determine the transfusion rate of each procedure. The carbon footprint (g CO₂e) of a single G&S was calculated using a bottom-up approach.

Results: Overall, 15,293 operations and 637 red cell requests were included for analysis. Most transfusions across all operation types occurred after the operation day, and only 36 elective cases required intraoperative transfusions. The carbon footprint of the G&S was calculated at 0.43kg CO₂e for an inpatient sample, and 7kg CO₂e for an outpatient sample. Eliminating the second G&S in elective cases with a transfusion rate <1% could save 9 tonnes of CO₂e per year, the equivalent of 24,000 miles in a passenger vehicle.

Conclusions: Transfusion requirements vary significantly for different operation types. Guidelines surrounding perioperative G&S testing should reflect this, which could save avoidable carbon emissions, cost and resources.

Introduction: Omission of closed suction drains in women undergoing simple mastectomy has become the standard in the United Kingdom (UK) with studies demonstrating no difference in symptomatic seroma rates or complications. A theoretical concern is that a large-volume seroma distorts the skin envelope, potentially resulting in inferior long-term postoperative aesthetic appearance and patient satisfaction. Furthermore, the seroma may lead to a delay in adjuvant treatment, in particular, chest wall radiotherapy. There is currently no objective scoring system to evaluate the postoperative appearance after simple mastectomy.

Methods: Patients who had undergone a drainless unilateral simple mastectomy at the Royal Marsden Hospital attending for annual surveillance contralateral mammography between October 2016 and July 2017 were invited to complete a BREAST-Q questionnaire and attend medical photography for panel assessment of aesthetic outcome. Patient satisfaction in this cohort was compared with results from the UK National Mastectomy and Breast Reconstruction Audit (NMBRA) 2011, which was conducted at a time when surgical drains were routinely placed.

Results: The proportion of patients satisfied with their appearance was similar to that of NMBRA 2011. BREAST-Q results were in line with the published literature. A panel assessment scoring system for simple mastectomies was developed. There was no difference in delays to adjuvant treatment between the study and NMBRA cohort.

Conclusions: Omission of drains in women undergoing simple mastectomy did not result in inferior aesthetic outcomes or lower patient satisfaction, nor did it result in delay to adjuvant treatment. BREAST-Q results were in line with the literature. A panel assessment scoring system for simple mastectomy was developed.

Introduction: In response to pressures from the COVID-19 pandemic, a local anaesthetic (LA) biopsy service for patients with suspected head and neck cancer was set up at our centre.

Methods: This study was a prospective audit of patients referred for LA biopsy of head and neck lesions over a 2-year period at an adult United Kingdom tertiary head and neck centre.

Results: In total, 202 patients had LA biopsy during the audit period. Most common types of biopsies were transoral (n = 65, 32.3%) and transnasal endoscopy and biopsy (n = 59, 29.2%). Some 72.8% (n = 147) of lesions were benign, whereas 25.7% (n = 52) of lesions were malignant. One specimen did not arrive at the laboratory and two specimens did not survive transportation/processing, necessitating repeat biopsies. Five patients required repeat biopsy following initial non-malignant histology result (2.47%), three of which required biopsy performed under general anaesthetic (1.49%). There were no identified post-procedure complications.

Conclusions: LA biopsy including transnasal oesophagoscopy/endoscopy is safe, well tolerated and can be used to assess patients with suspected head and neck cancer. Advantages include avoiding the risks of general anaesthesia and freeing up theatre capacity for more complex cases. We estimate savings of £900,000 over 2 years. Faced with limited theatre capacity and growing waiting lists, LA biopsy can also improve time to diagnosis and treatment for head and neck malignancies. We demonstrate the benefits of LA biopsy and highlight the role of transnasal oesophagoscopy/endoscopy in the recovery of surgical services in otolaryngology departments across the world in the post-pandemic era.

Introduction: The literature speaks to the impact of the COVID-19 pandemic having a profound effect on surgical training. Our objective in this study was to quantify the effect of the COVID-19 pandemic on neurosurgical training and to test whether an effect on the quality of neurosurgical training can be inferred from a quantitative methodology.

Methods: Surgical training episodes logged by neurosurgical trainees with a National Training Number were provided by e-logbook for the period January 2019 to December 2023. This was crosslinked with trainee data provided by the Intercollegiate Surgical Curriculum Programme and compared with data from the Capse Healthcare Knowledge System, which records operative spells in English neurosurgical units, over the same period.

Results: Some 24,416 surgical training episodes were logged by trainees in 2023 compared with 32,033 in 2019. The ratio of surgical training episodes logged to operative spells recorded increased from 0.74 to 0.84 between 2019 and 2021, but fell to 0.72 by 2023. When filtered for elective cranial surgical training episodes logged compared with operative spells, the data show a significant drop from 67% to 60%. However, spinal surgical training episodes logged have risen from 58% to 70% of operative spells, although the number of surgical training episodes logged has declined by 1,118. The average number of surgical training episodes logged per year per trainee in 2019-2020 was 132, and this has risen every year and stands at 173 in 2022-2023.

Conclusions: The primary findings of this study are that the recording of training events is below pre-pandemic levels. In total, 4,617 fewer cases were logged in 2023 than in 2019 and the proportion of elective cranial cases logged compared with operative spells fell from 67% in 2019 to 60% in 2023. This study suggests further efforts are needed to safeguard training opportunities and maintain a high quality of training.

Introduction: Infantile hypertrophic pyloric stenosis (IHPS) often presents with significant metabolic derangement requiring preoperative fluid resuscitation. Conventional fluid therapy (CFT) is widely used, but bolus fluid therapy (BFT), guided by serum chloride levels, may allow faster correction and improved outcomes. This study compared the safety and efficiency of BFT vs CFT in infants with IHPS.

Methods: A single-centre randomised controlled trial was conducted over 30 months at a tertiary paediatric surgical unit in Pakistan. Infants aged 2-12 weeks with confirmed IHPS were randomly assigned to receive either CFT or BFT. CFT involved maintenance fluids with potassium supplementation and 6-hourly monitoring. BFT comprised 20ml/kg saline boluses tailored by initial chloride and bicarbonate levels, based on the Dalton algorithm, with monitoring before and after each bolus. Primary outcomes included time to biochemical optimisation, hospital stay, and number of laboratory tests.

Results: One hundred infants were enrolled (n = 50 per group). The BFT group achieved faster correction (7.1 ± 2.2h vs 71.5 ± 10.3h; p = 0.001), shorter hospital stay (118.6 ± 29.9h vs 154.5 ± 37.3h; p = 0.001), and fewer laboratory tests (3.2 ± 0.9 vs 4.8 ± 1.1; p = 0.02). No complications occurred.

Conclusions: Chloride-guided BFT is a safe, efficient alternative to CFT for IHPS. It reduces time to correction, length of stay and investigation burden. Early discharge may also reduce nosocomial risk, offering particular benefit in resource-limited settings.

Introduction: Multicentre clinical research collaboratives collect large, generalisable data sets. However, data are often collected by trainees who may lack clinical or academic experience, raising concerns about data quality and potential reporting bias. Validation practices in such studies are variable. This study outlines the methods, feasibility, and outcomes of internal data validation using the CONGRESS database.

Methods: The multicentre CONGRESS data set of early oesophagogastric cancer was assessed. A random 20% sample of patients was selected to meet a >15% target validation size. Patient, disease and outcome data were re-abstracted from medical records and entered into a validation data set, which was compared with the original database. Cohen's kappa coefficient (κ) and Pearsons corelation (r) were calculated to express the strength of agreement between categorical and continuous variables, respectively.

Results: In total, 302 patients (18.1%) from the original CONGRESS database were included in the validation data set and 3,320 data points were compared between data sets (6,640 total). The percentage of exact agreement for variables ranged from 82.5% to 98.7% (median 92.3%, interquartile range 86.3%-95.7%). Nine variables (1,645 of 2,946, 55.8% data points) showed 'almost perfect' agreement (κ or r > 0.8), and five (1,301 of 2,946, 44.2%) showed substantial agreement (κ > 0.6). None showed weak or poor agreement.

Conclusion: This study proposes a reproducible framework and benchmarks for validating large collaborative clinical data sets, using the national CONGRESS data set as an example. This approach offers a standard for ensuring reliable, high-quality research outcomes across multicentre databases.