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

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: There remains great variation in the use of perioperative feeding adjuncts following oesophagogastric cancer resections with unknown clinical benefit. The aim of this study was to examine which preoperative clinicopathological factors were associated with prolonged use of adjuvant nutritional support after oesophagogastric cancer surgery and to evaluate the associated costs.

Methods: A cohort study of 518 patients undergoing oesophagogastric resection and receiving perioperative parenteral nutrition was undertaken. Preoperative clinicopathological characteristics were evaluated using multivariable logistic regression, providing odds ratios (OR) with 95% confidence intervals (CI) and predictive factors for prolonged parenteral nutrition compared using receiver operator characteristic (ROC) analysis. An economic model was developed using complication rates related to parenteral nutrition and 2021 UK National Health Service tariffs.

Results: Predictive factors for prolonged parenteral nutrition use included: age >65 vs ≤65 years (OR 1.83, 95% CI 1.22-2.76), >10% preoperative weight loss (OR 2.20, 95% CI 1.03-4.70), open vs minimally invasive surgery (OR 1.64, 95% CI 1.03-2.62) and neck vs abdominal anastomosis (OR 2.54, 95% CI 1.35-4.79). ROC analysis provided an area under the curve of 0.72. The projected annual unit savings were £75,912 if parenteral nutrition was reserved for high-risk patients.

Conclusions: This study identified factors associated with prolonged nutritional support after oesophagogastric surgery. As practice evolves towards minimally invasive surgery and enhanced recovery protocols with low complication rates, short-course adjuvant feeding may not be necessary for patients who progress promptly to appropriate oral intake. A tailored treatment pathway, excluding routine use of perioperative feeding adjuncts for low-risk patients may lead to considerable cost savings.

Introduction: Sore throat is one of the most common reasons for an acute ear, nose and throat (ENT) admission. Recurrent tonsillitis can be treated definitively by tonsillectomy, but patients must fulfil Scottish Intercollegiate Guideline Network (SIGN) guidelines to be eligible. The aim of this audit was to assess the throat morbidity of patients admitted with 'sore throat' to ENT wards across Scotland.

Methods: A multicentre prospective audit was conducted across six Scottish ENT units over 4 months to assess demographics, risk factors and episode history in patients admitted with sore throat.

Results: Some 279 patients were included: 63.9% were for admitted for tonsillitis, 35.7% for quinsy and 0.4% for deep neck infection. The mean age was 30.1 years (range 6-73 years). Most had reported 0-1 episodes of tonsillitis in the previous 4 years (58.5%-76.6%), with 41.3%-66.2% reporting no antibiotic treatment for sore throats in that time. Prior to admission, 48.7% had been prescribed antibiotics by a general practitioner (GP), and 16.1% had a history of hospital admission for tonsillitis. Only 25.6% of tonsillitis admissions met SIGN tonsillectomy criteria.

Conclusions: Most patients admitted with sore throat in Scotland had low numbers of previous throat complaints. Fewer than half had received antibiotics from a GP before admission. One-quarter met SIGN criteria for tonsillectomy.

Brunner's gland hamartoma (BGH) is a rare, benign tumour composed of mucin-secreting glands within the duodenal submucosa. Lesions typically range from 0.5 to 1.0cm and are usually managed endoscopically, with larger tumours occurring infrequently. This case involves a 74-year-old woman presenting with syncope. Diagnostic investigations revealed a massive BGH with a 10cm pedicle, accompanied by significant iron deficiency anaemia and intussusception. Although there are no formal, universally established guidelines, literature favours endoscopic removal because of reduced bleeding, a shorter hospital stay and lower cost. However, open surgical resection proved more appropriate owing to the lesion's size and complexity. This case highlights the challenges of managing giant BGHs and supports open surgical intervention when standard methods are unsuccessful.

Objective: Major lower limb amputation is often the final treatment for patients with chronic limb-threatening ischaemia. Postoperative weight loss is a common but under-recognised issue that may affect dosing accuracy for weight-dependent anticoagulants such as low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs). This study assessed the extent of postoperative weight change and the frequency of anticoagulant dose adjustment in routine practice.

Methods: A single-centre retrospective cohort study included patients who underwent above- or below-knee amputation between July 2022 and January 2023. Inclusion criteria were documented pre- and postoperative weights and inpatient prescription of LMWH or DOACs. LMWH was prescribed exclusively as dalteparin and DOAC therapy as edoxaban. Doses were reviewed against British National Formulary weight-based recommendations.

Results: Of 39 patients, 17 met inclusion criteria (median age 69 years; 53% male). Procedures were divided evenly between emergency and elective. The mean postoperative weight loss was 7.5%±2.3% of preoperative body weight. Patients undergoing above-knee amputation lost more weight (mean 8.7kg) than those with below-knee amputation (mean 3.8kg). Two patients (11.8%) required dose adjustments - one on edoxaban after falling below 60kg, and one on dalteparin after dropping from 59.5kg to 55.5kg.

Conclusions: Major amputation is associated with clinically relevant postoperative weight loss, yet anticoagulant dose adjustments were uncommon. Routine postoperative weight monitoring and prompt review of weight-based therapy are recommended to improve dosing accuracy and reduce potential anticoagulation risk.

Introduction: Patient education programmes prior to hip and knee arthroplasty reduce anxiety and create realistic expectations. We describe a 'virtual joint school' (VJS) model and analyse patient feedback and environmental impact.

Methods: Eligible patients first viewed online educational videos, and then attended an interactive virtual session during which knowledge was reinforced. Each session was attended by eight to ten patients along with a relative or friend, and was hosted by a multidisciplinary team consisting of nurses, physiotherapists, occupational therapists and a former patient who provided personal insight. Feedback was obtained prospectively using an electronic questionnaire, and travel savings were calculated using Python software.

Results: From July 2022 to February 2023, 267 patients attended the VJS; of whom 117 (44%) responded to the questionnaire. Among them, 87% found the pre-learning videos helpful and comprehensible, 92% felt their concerns were adequately addressed, 96% felt they had sufficient opportunity to ask questions and 96% were happy with the level of confidentiality involved. Although 83% felt they received sufficient support from the health board to access the virtual session, 63% also took support from family/friends to attend it. Only 15% felt they would have preferred a face-to-face format. By having 'virtual' sessions, each patient saved, on average, 38 miles and 62min of travel (10,070 miles and 274h saved for 267 patients). Each VJS session produced 0.32kg of CO₂ compared with 110kg of CO₂ per face-to-face session.

Conclusions: Virtual joint schools are acceptable to patients and reduce the carbon footprint of healthcare. We recommend their implementation at other arthroplasty centres.