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

Introduction: The aim of this study was to improve shared and informed decision making regarding real-world mortality rates caused by suprapubic catheter (SPC) insertion.

Methods: We undertook tri-centric, retrospective data collection from all patients identified as having a SPC inserted between 2017 and 2022. Data including demographics, frailty scores, comorbidities, reason for SPC insertion and mortality information were collected and statistically analysed.

Results: Sixty-eight patients were identified and included in this study. Mortality after SPC insertion at 30 days was 1.5%: 18.8% at 1 year and 30.4% at 2 years. Medium-term mortality rates were 45.2% at 3 years, rising to 54.5% at 4 years. Patients aged 71 or older at the time of SPC insertion had an overall mortality of 45.9% compared with 10.3% in those aged under 71 years (p < 0.01). Mortality was 53% in frail patients who underwent SPC insertion (Rockwood Clinical Frailty Score >3). Limits of the study include the small sample size and heterogeneity of the population.

Conclusions: SPC insertion is associated with a significant mortality rate of 18.8% at 1 year rising to 45.2% at 3 years in our study cohort. Patients with increasing age and frailty may also be at a greater risk of mortality after SPC insertion. This information is in keeping with the limited data available in the published literature and should be highlighted to clinicians and patients when considering SPC insertion.

Introduction: Thromboelastography (TEG) is a point-of-care test that provides a quantitative of measure of the dynamic changes in clot strength and viscoelastic properties of a whole blood sample. Although conventional coagulation tests are well established in vascular surgery, they do not identify the hypercoagulable state and response to antiplatelet therapy. The role of TEG in peripheral arterial disease (PAD) is unclear and its application as demonstrated in the literature has undergone limited appraisal. The objectives of our study were to identify whether TEG can inform individualised thromboprophylaxis and predict thrombotic events following re-vascularisation in PAD.

Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a PRISMA checklist was completed. PubMed and Embase databases were searched from inception until October 2024 using the relevant Medical Subject Headings terms. Only full-text articles published in the English language reporting the outcomes in PAD with TEG or TEG with platelet mapping (TEG-PM) were analysed. The protocol was registered on the PROSPERO database (ID:CRD42024580627).

Findings: The analysis included 14 studies. TEG-PM was able to quantify the response to antiplatelet therapy and potentially guide individualised thromboprophylaxis. The parameters maximum amplitude, platelet aggregation and platelet inhibition were able to predict thrombotic events. However, substantial heterogeneity in thromboprophylaxis, surgical procedures and comorbidities was observed in the studies.

Conclusions: TEG-PM could serve as a valuable tool for tailoring antiplatelet therapy and predicting outcomes in patients with PAD. Further studies including randomised controlled trials are needed to validate the findings.

Introduction: Clinical predictor rules are useful heuristics that can inspire confidence in clinicians on the front line to make decisions that are safe and reproducible. Rules such as the Ottawa Ankle Rules can also reduce the number of unnecessary radiographs taken, reducing radiation exposure and cost, as well as improving quality of care.

Methods: A previous Delphi study delineated 11 variables associated with an increased likelihood of finding a mandibular fracture and 14 variables associated with an increased likelihood of finding a zygomatic fracture on plain film radiographs. In the current study, clinicians suspecting a mandibular and/or zygomatic fracture were invited to complete a proforma identifying any of these variables in advance of requesting plain film radiograph(s). An interim analysis was conducted with predictors being cross-tabulated against relevant outcomes using: sensitivity, specificity, Jaccard index, odds ratio (OR) and Fisher's exact probability.

Results: During the period January to October 2022 inclusive, 69 records were inputted into REDCap, of which 20/69 demonstrated a fracture. Fisher's exact test produced several significant results including malocclusion (p<0.0001, OR 31.99), presence of a new open bite (p<0.001, OR undefined) and subconjunctival haemorrhage (p<0.05, OR undefined).

Conclusions: Data collection is continuing and initial interim analysis would suggest a sample size of n=252 will be required, assuming a negative scan rate of 55%, to achieve a specificity of 0.90 within ±0.05. We aim to present finalised data in 2025.

Congenital pelvic deformities, such as pubic diastasis, significantly complicate the surgical planning and execution of total hip arthroplasty (THA), the gold standard for treating degenerative hip disease unresponsive to conservative measures. These challenges are exacerbated in the context of trauma, because of disrupted anatomical landmarks and soft tissue imbalances. THA becomes particularly demanding in cases involving traumatic femoral neck fractures in patients with congenital anomalies of the pelvis. We present a unique case of a 62-year-old man with an acute, post-traumatic left-sided hip fracture, and a history of congenital bladder exstrophy and pubic diastasis, who successfully underwent THA. Meticulous preoperative planning with three-dimensional reconstruction software was essential in overcoming the anatomical challenges posed by this case, enabling our successful outcome.

Background: There is increasing emphasis on day-case hemithyroidectomy in the UK, with the national NHS/Get-it-right-first-time (GIRFT) recommending 30% zero-night stay rate. Buckinghamshire Healthcare Trust currently achieves >70% zero-night stay rate. This study profiles successfully treated day-case patients, evaluates reasons for unplanned admissions, complication rates and patient satisfaction, offering insights for units seeking to expand day-case practice.

Methods: This is a retrospective cohort review from 2020 to 2024 of patients undergoing hemithyroidectomy treated by two surgeons: one with over a decade of day-case experience and one adopting the practice in 2021.

Results: Of 336 patients (mean age 51±15 years, male:female 1:4), 283 (84%) were discharged on the same day with planned overnight admissions (37 patients, 11%) were primarily older (62 versus 50 years, p<0.05), more often American Society of Anesthesiologists (ASA) grade 3 (p=0.05), with a trend towards larger gland size, without correlation in either group to surgeon experience. Reasons for unplanned admissions in 14 patients (4%) were: anaesthetic concerns (n=3), intraoperative bleeding (n=2), large glands (n=2) and combined others, with all stays <48h. There was no correlation between unplanned admissions and patient age, ASA status or surgical indication. No hemithyroidectomy resulted in postoperative neck hemorrhage or return to theatre. More than 80% of patients surveyed would choose same-day discharge hemithyroidectomy over an inpatient stay, with all of respondents reporting adequate pain control.

Conclusions: With robust protocols and appropriate patient selection, high rates of day-case hemithyroidectomy are achievable, in alignment with a high rate of patient satisfaction. Unexpected admissions lack clear predictors.

Introduction: Engaging with patients and the public is essential to design and deliver impactful research. Enhancing the relevance of research and tailoring treatments to align with patients' preferences can facilitate improved clinical care.

Methods: We aimed to identify the research, support and treatment priorities of individuals with kidney stone disease (KSD) using a 25-question survey in inpatient and outpatient urology departments.

Results: Forty-four individuals with KSD responded to our survey; 28 (64%) had experienced multiple KSD episodes and 11 reported 5 or more episodes. Median self-rated quality-of-life (QoL) impact (0 = negligible; 10 = severe) was 7.00 out of 10.00 (interquartile range [IQR]: 5.00-9.00), equivalent in individuals with single and recurrent stone episodes. Pain (n = 34), haematuria (n = 28) and anxiety (n = 22) were the primary factors contributing to QoL impact. Participants prioritised research into preventing recurrence, alleviating pain and slowing stone growth. More than one-third desired more information about KSD. Most (n = 36) felt 'likely' or 'very likely' to take medication to reduce their risk of KSD and 25 would commit to life-long therapy. Daily dosing was acceptable to 13 participants if risk of KSD recurrence was reduced by 50%, rising to 34 respondents if risk of recurrence was reduced by 75%. Most respondents (n = 44) expressed willingness to have genetic testing to facilitate personalised medicine research.

Conclusions: Our findings emphasise symptoms contributing to reduced physical and psychological wellbeing in patients with KSD. We highlight the need for research into developing therapies to prevent stone recurrence, alleviate pain and slow stone growth, and for educational materials. Responses indicate an appetite for personalised medicine and oral medications in KSD.

Introduction: During the COVID-19 pandemic in England, orthopaedic surgery trainees experienced a reduction in training opportunities due to periods of elective surgery suspension. We aimed to explore training opportunities for orthopaedic trainees in trusts with and without access to an elective surgical hub.

Methods: This retrospective analysis of administrative data used eLogbook data for registrars who performed six high-volume, low-complexity orthopaedic procedures in NHS hospitals in England between April 2017 and March 2023. Data included training grade, role in the procedure, trust where the procedure was performed and procedure date. These were linked to Hospital Episodes Statistics (HES) data on the total number of these procedures conducted during the study period and whether the trust hosted or fed into an elective surgical hub at the time of the procedure.

Results: Data were analysed for 1,755 trainees acting as first surgeon in 125,759 procedures. Trusts with access to an elective surgical hub significantly increased the proportion of procedures conducted by a trainee compared with non-hub trusts over the study period. Most of the increase in trainee involvement was associated with more senior trainees (ST6-8). The proportional increase was not enough to offset the decline in the absolute number of procedures conducted by trainees (25,598 (2017-2018), 21,057 (2022-2023)).

Conclusions: Elective surgical hubs have made a positive contribution to training opportunities for orthopaedic trainees but not enough to offset the post-pandemic fall in activity. The number of procedures conducted in NHS hospitals and the rate of training opportunities must be increased.

Introduction: A national practice questionnaire in 2020 collected data from UK breast surgeons on breast localisation device use, and found that wires were used most frequently. The current study aimed to assess the change in device use since the previous questionnaire, impact on logistics and clinician feedback.

Methods: The 2020 national questionnaire was repeated, as well as adding qualitative questions to elicit themes important to clinicians in differentiating between the quality of localisation device experience. The electronic survey was distributed to UK breast surgeons and radiology members of the Association of Breast Surgery and British Society of Breast Radiology. The medians of the satisfaction responses for each device were compared with the median responses for wire.

Results: There were 157 completed questionnaires, with 76 responses from surgeons and 81 from radiologists/radiographers, representing 84 UK breast units (August-December 2022). Localisation device use has changed; from 83% wire and 17% nonwire (5% radio-occult lesion localisation, 2% radioiodine seed and 9% Magseed) in 2020 to 18% wire and 82% nonwire (4% radioiodine seed, 49% Magseed, 6% SAVI SCOUT, 20% Hologic LOCalizer and 3% Sirius Pintuition) by 2022. In 2020 6% of patients had localisation performed before the day of surgery versus 65% by 2022 (p<0.05). Nonwire devices were preferred to wire in six themes for surgeons (p<0.05) and four for radiologists (p<0.05).

Conclusions: UK breast surgery practice is shifting from use of guidewires towards newer localisation devices, with resultant logistical benefits and higher clinician satisfaction.