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

Introduction: The global increase in life expectancy is likely to lead to a higher number of older patients undergoing colorectal resections. This is an understudied cohort, with available data concentrating on generic surgical outcomes such as postoperative complications and mortality rates. Few studies have explored quality of life and return to baseline in this cohort.

Methods: Inpatient outcome data on all patients aged 75 years and over who underwent colorectal resection in our region between 2018 and 2023 were collected prospectively. Patient characteristics, complication rates, functional decline and mortality data were documented. These data were supplemented with a subsequent review of death, readmission, and admission to a non-own home environment post-surgery.

Results: Of 408 colorectal surgery patients, 303 were elective and 105 were emergency cases. Of these cases, 59.4% (n = 180) of elective cases and 71.4% (n = 75) of emergency patients experienced a postoperative complication. In total, 35.5% of patients experienced a functional decline with reduced mobility or ability to perform independent care. Emergency patients (n = 21, 20%) demonstrated a higher mortality rate at 1 year than elective cases (n = 25, 8.3%).

Conclusion: Colorectal surgery in patients aged 75 years and older presents significant risks, particularly in emergencies. This study documents high rates of functional decline, complications and mortality in elderly patients. It highlights the need for individualised surgical care planning and enhanced perioperative counselling, and helps quantify this functional deterioration.

Introduction: Ménière's disease (MD) is a rare condition whose diagnosis can be challenging. The American Academy of Otorhinolaryngology-Head and Neck Surgeons (AAO-HNS) has published new guidance to facilitate the diagnosis of MD. We surveyed ear, nose and throat (ENT) consultants in the United Kingdom (UK) to assess their confidence in diagnosing MD, their use of the AAO-HNS guidance and current diagnostic and treatment approaches.

Methods: An online questionnaire was distributed. It asked respondents to anonymously rank their confidence in diagnosing MD, identify the minimum investigations required to make a diagnosis, describe their use of the AAO-HNS criteria, share their preferred treatment for acute attacks and state first- and second-line preventative treatment options.

Results: A total of 86 responses were collected. In total, 88% of respondents reported high levels of confidence in diagnosing MD. Most respondents (29.1%) stated the minimum tests required were 'history', 'otoscopy', 'pure tone audiometry' and 'MRI' (magnetic resonance imaging), although some chose as few as one test (3.49%) and others up to seven (1.2%). Regarding use of the AAO-HNS criteria, responses ranged from 'always' (34.9%) to 'never' (20.9%). Prochlorperazine was the first-line treatment for acute attacks for 81.4% of respondents. Betahistine (38.4%) and dietary restrictions (37.2%) were recommended almost equally as first-line preventative measures. The most popular second-line measure was intratympanic steroids (34.9%), followed by betahistine (24.4%).

Conclusion: Our survey revealed wide disparities in the diagnosis and management of MD by ENT consultants in the UK, and AAO-HNS guidelines were not universally used. We propose developing greater consensus and intend to conduct a similar international survey to gather a broader perspective.

Introduction: The purpose of this quality improvement project (QIP) was to identify factors contributing to mental and physical fatigue in major abdominal surgery and to attempt to mitigate the same by incorporating mini hydration breaks with targeted muscle stretches at regular intervals.

Methods: This prospective QIP was conducted in the Peritoneal Malignancy Unit of a national referral centre for peritoneal malignancy-related diseases between February and April 2022. Only procedures lasting longer than four hours were included and all theatre personnel were invited to participate. A baseline survey was conducted to ascertain the impact of mental and physical fatigue. Subsequently, a cross-over study design was utilised; for the first four weeks the procedure was performed with no breaks. This was followed with four weeks of intervention (hydration breaks and muscle stretches). Validated questionnaires (pain scores, occupational fatigue inventory and surgical task load measurement) were used to measure perceived physical and mental fatigue.

Results: Over half (58%) of the 34 participants felt that surgical discomfort affected their stamina, posture and ability to concentrate. Work-life balance was affected in 44%, and 17% felt that it affected their sleep pattern with a minority considering shortening their careers. A reduction in the mean pain score at the end of the day in the group who had breaks (2.61 vs 2.16) was noted. There was global improvement in situational stress, distractibility, temporal and mental demands in the group who had regular breaks, amounting to improvements in self-perceived fatigue levels.

Conclusions: Theatre personnel involved in major surgery experience mental and physical stress that adversely affects work-life balance. Regular, short hydration breaks with muscle stretches can help improve mental and physical wellbeing of theatre personnel involved in major abdominal surgery.

Gallium 68-DOTATATE positron emission tomography scanning is the cornerstone of nuclear medicine imaging for neuroendocrine tumours. Previous reports have demonstrated the potential for vertebral haemangiomata to mimic neuroendocrine skeletal metastases. We present the case of a 42-year-old man with a history of well-differentiated neuroendocrine tumour of the appendix, identified incidentally following emergency appendicectomy. Postoperative ⁶⁸Ga-DOTATATE positron emission tomography/computed tomography scanning revealed an intensely gallium-avid retroperitoneal lesion adjacent to the right psoas muscle. Surgical excision of this lesion was recommended following multidisciplinary team discussion. Histological evaluation of the resected lesion revealed an intravascular capillary haemangioma. Haemangiomas can mimic residual or recurrent neuroendocrine tumour based on gallium avidity, and this should be considered in atypical cases.

Introduction: The National Consultant Information Programme (NCIP) tool provides a platform for NHS consultants to benchmark their practice and for trusts to have a purview of the range, variation and outcomes of surgical procedures. Surgery remains an effective strategy for the treatment of inflammatory bowel disease (IBD) despite advances in medical therapy. This study leverages the NCIP data to assess the current trends of colectomies for IBD and the impact of COVID-19.

Methods: Pseudonymised data (demographics, number and types of colectomy per provider, resection approach and stoma formation) were collected from the NCIP for IBD Dashboard and analysed against outcomes such as readmission, length of hospital stay and mortality.

Results: A total of 132 providers performed 3,907 colectomies for Crohn's and 1,942 colectomies for ulcerative colitis (UC), with 76 (57.58%) performing more than 20 cases over the four-year period. More cases were performed laparoscopically, 55.46% and 61.17% for Crohn's and UC, respectively. Transverse colectomy had the highest readmission rate (29%) for Crohn's, whereas ileoanal anastomosis was highest at 29.37% for UC. Mortality rate was 0.23% and 0.82% for Crohn's and UC, respectively. Length of hospital stay was increased significantly in both Crohn's disease and UC by open procedure and stoma creation.

Conclusions: This study showed significant variation in practice across centres, with the volume of procedures performed in each centre being an influencing factor in the variation, especially when considering the incidence of stoma creation and surgical approach. This achieved the aim of the NCIP to keep a benchmark of standardisation across NHS practice.

Introduction: The COVID-19 pandemic caused a significant disruption to the delivery of surgical services. Guidance prioritising life-saving and cancer surgery was issued. Inflammatory bowel disease (IBD) often requires considered, timely surgery, which may have not been feasible under the conditions imposed by the pandemic. This systematic review aims to quantify the impact of COVID-19 on IBD surgery and assess the safety of performing such surgery.

Methods: A systematic review of MEDLINE, Embase and Web of Science was performed. Studies that included a prepandemic and a pandemic cohort for comparison and reported on numbers of IBD surgeries or postoperative outcomes following IBD surgery were included. Heterogeneity of included studies precluded any meta-analyses.

Findings: In total, 1,220 titles were screened and 13 were included in the final review. All were cohort studies other than one case-control study. A total of 1,673,282 and 1,445,971 patients were included in the prepandemic and pandemic cohorts, respectively. Rates of elective surgery during the pandemic varied from a 66% reduction to a 9.66% increase and emergency surgery varied from no difference to an 18% reduction. Urgent surgery in IBD inpatients appears to be unaffected. Postoperative outcomes were not shown to be negatively impacted by resource limitations.

Conclusions: The COVID-19 pandemic affected IBD surgical services considerably; however, those who did undergo surgery during this period do not appear to have been at an increased risk of adverse outcomes. Further work is required to describe the long-term impacts of these cancellations on IBD services and patient morbidity.

Health inequalities are systematic and potentially remediable differences in health across populations. Understanding the origins of these discrepancies, the healthcare consequences and the manifestations of related diseases can help improve the outcomes of underserved communities. Here I discuss how social factors may be used to help identify particular at-risk populations with regards to urological malignancies, and how these can be potentially used as biomarkers that inform cancer screening targets.

Ampullary lesions, including adenomas and early-stage carcinomas, pose a diagnostic and therapeutic challenge because of their location and proximity to the pancreatic and bile ducts. Transduodenal ampullectomy offers a targeted approach for the resection of these lesions while preserving the integrity of the pancreaticobiliary system. Moreover, transduodenal ampullectomy is associated with favourable postoperative outcomes, including low rates of morbidity and mortality, as well as preservation of pancreatic and biliary function. However, potential complications such as ascending cholangitis pancreatic leakage, bleeding and duodenal stenosis can occur, which would impact the postoperative quality of life. Addressing these outcomes might require either endoscopic procedures or surgical interventions. We present an exceedingly uncommon case of recurrent ascending cholangitis resulting from reflux of food particles into the common bile duct that was treated successfully with a Roux-en-Y hepaticojejunostomy and gastroenterostomy.

Introduction: Changes to the medical curriculum have been advocated to improve knowledge on fluid and electrolytes. We aimed to determine the contemporary level of knowledge of trainee doctors on different aspects of fluid and electrolyte prescribing.

Methods: An online survey was distributed to Foundation Year doctors working throughout the United Kingdom. The first part determined demographic information, where participants studied and currently work, and probed their perceptions of their knowledge on fluid and electrolytes. The second part tested knowledge on a wide variety of aspects of fluid and electrolyte management using 20 multiple-choice questions.

Results: In total, 190 responses were received. Trainee doctors remain responsible for much of the fluid and electrolyte management of patients, and often practise independently. Overall, the average 'score' of each respondent was suboptimal (52%), with no significant difference found between doctors in the first or second year of postgraduate medical practice. Many participants were unable to correctly identify the components of common intravenous fluid products. Understanding of daily electrolyte requirements was also demonstrated poorly, although most showed a good understanding of the daily requirements of water and glucose. The amount of time in medical school allocated to the topic remains low, as do doctors' confidences in their abilities to prescribe fluid and electrolytes.

Conclusions: Knowledge surrounding fluid and electrolyte prescribing remains suboptimal, and Foundation Year doctors are frequently undertaking this responsibility independently. These findings reflect previous research performed over the past 20 years, and little improvement appears to have been made.