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

Introduction: Routine chest radiograph (CXR) following chest tube removal is a common practice, yet the optimal timing of CXR in detecting recurrent pneumothorax (RPTX) remains unknown. This study reviewed the incidence of RPTX and its relationship to the timing of the detection of CXR.

Methods: A prospective study was conducted over a 24-month period on patients with thoracic stab wounds who underwent CXR following chest tube removal at a major trauma centre in South Africa.

Results: One hundred and sixty-three patients were included (91% male, mean age: 25 years). Eleven patients (7%) had RPTX, one (9%) of whom required reinsertion of a chest tube. No patients were readmitted following discharge. The timing of the CXR was: <2h (11%), 2-4h (21%), 4-6h (28%), 6-8h (31%) and >8h (9%). Of the 11 RPTX, 55% were detected on CXR at <2h, 36% at 2-4h, 9% at 4-6h, 0% at 6-8h (0%) and 0% at >8h. All RPTX were detected within <6h of chest tube removal. There was no re-presentation of any patients following discharge.

Conclusion: RPTX following chest tube removal is uncommon, and the need for reintervention is low. All patients with RPTX were detected on CXR obtained within 6h of removal. It would appear that routinely delaying CXR anytime beyond 6 hours is unnecessary.

Background: Ischial tuberosity avulsion fracture (ITAF) is a rare injury affecting predominantly adolescent athletes yet lacks standardised management protocols. This study aims to investigate the diverse management preferences among hip surgeons regarding ITAF and share our preferred surgical technique and management.

Methods: In a cross-sectional study, 237 British Hip Society members were surveyed regarding various aspects of ITAF management, including preferences for operative versus non-operative approaches, surgical techniques and postoperative rehabilitation regimens. Sixty-two surgeons responded, yielding a 26% response rate.

Results: Thirty-six surgeons (58.1%) favoured conservative treatment, while 26 (41.9%) preferred surgery based on the degree of displacement. Among those advocating for surgery, 16 (61.5%) deemed displacement ≥20mm as significant, with 5 (19.2%) considering ≥15mm significant and another 19.2% regarding any displacement as significant. Prone theatre positioning was overwhelmingly preferred by 96.2%, with a majority (65.4%) favouring the transverse gluteal crease approach. Postoperatively, 11.5% preferred immediate full weight bearing, while 88.5% opted for six weeks of non-weight-bearing following surgery. Among conservative management advocates, 29% allowed unrestricted weight-bearing post-injury, 11.3% preferred weight-bearing until further review and 59.7% opted for partial weight-bearing for at least six weeks.

Conclusions: This study highlights the absence of a consensus on ITAF management. We present our preferred approach through a case analysis involving an ITAF patient treated at our department to enhance understanding of this rare injury and potentially improve management strategies.

Purpose: Epididymal leiomyomas (LM) are rare benign tumours. Bilateral LM are even more uncommon and there are no management guidelines on LM. We performed a systematic review to update the number of epididymal LM cases reported, and to summarise how these tumours have been managed at different centres with a description of our own experience.

Method: The systematic review was performed according to the PRISMA guidelines. The PubMed database was searched for articles on epididymal LM. Data extracted included patients' age, presenting complaint, diagnostic tests, management and follow-up. In addition, a case from our own institution was presented.

Results: The systematic search identified 120 articles of which 29 articles including 32 patients were analysed. There were 27 (84.4%) unilateral cases and 5 (15.6%) bilateral cases. Surgical treatments included lesion excision, n = 14 (43.8%); orchidectomy, n = 10 (31.3%); partial epididymectomy, n = 5 (15.6%); and total epididymectomy, n = 3 (9.4%). Final histology revealed 21 LM (65.6%) and 11 leiomyoadenomatoid tumours (34.4%). At a median (interquartile range) follow-up of 14 (8-12) months, there were no cases of recurrence. Our patient, a 53-year-old man, presented with bilateral epididymal lesions for over 1 year and underwent ultrasound scan and positron emission tomography imaging. The imaging findings were indeterminate, hence an excisional biopsy on one side was performed which revealed an epididymal LM. Because LM are benign, further surgery on the contralateral side was not performed.

Conclusion: Testis-sparing surgery appears to be feasible and safe, limiting the morbidity of radical orchidectomy. Because epididymal LM are rare, a multidisciplinary assessment and management are advised.

Introduction: Patients with recurrent respiratory papillomatosis (RRP) require frequent surgical removal of benign growths in the airway to maintain patency. This study aimed to investigate the impact of the COVID-19 pandemic on these patients, by monitoring their care and outcomes before and after the pandemic.

Methods: Participants were children or adults diagnosed with RRP, receiving treatment within an acute National Health Service hospital in the United Kingdom, registered with the Airway Intervention Registry. Data were captured between 1 April 2018 and 31 March 2022 (2 years pre- and post-COVID-19). Records for a subgroup of patients treated in England were linked to routine administrative data (Hospital Episode Statistics) for additional follow-up. Frequency of hospital visits, method of admission, type of surgical intervention, complications, disease severity (Derkay score) and voice quality were monitored.

Results: There was a reduction in RRP surgery frequency post COVID-19. The reporting clinician noted an intervention delay caused by COVID-19 in 11.8% of cases, and in half of those the treating clinician noted that the delay had resulted in worse symptoms. Despite this, disease severity remained relatively stable in both children and adults, as demonstrated by the Derkay and voice quality scores.

Conclusions: Patients with RRP experienced a reduction in surgical intervention post COVID-19. Although disease severity appeared overall stable within the study period, the long-term impact of changing surgical management of RRP patients in terms of voice quality and quality of life remain uncertain.

Introduction: Informed consent is fundamental to oncological surgery, but communication is often hindered by medical terminology, inconsistent explanations and variation in patient understanding. Large language models may improve accessibility by generating simplified consent information. This study assessed whether four leading artificial intelligence (AI) chatbots, ChatGPT (GPT-4), Gemini (2.5 Flash), DeepSeek (R1) and Grok (3) could generate information understandable to patients and comprehensive enough to support informed consent for six common oncological operations.

Methods: Standardised patient-style prompts were applied, and chatbot outputs were evaluated for readability using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) and Gunning Fog Index (GF). Quality and completeness, including coverage of procedure details, risks, benefits, alternatives and consequences of no treatment, were assessed by three consultant surgeons using a modified DISCERN instrument.

Results: Gemini produced the highest quality information (mean DISCERN 72.3 ± 3.0), followed by Grok (63.0 ± 1.8), whereas ChatGPT (48.0 ± 4.7) and DeepSeek (47.1 ± 1.8) performed less well. DeepSeek generated the most readable content (FKGL 9.7; GF 10.8), although no model achieved the recommended sixth-grade level. Common limitations included the lack of systematic referencing (except Gemini), occasional factual inaccuracies, reliance on predominantly US-based resources, and failure to assess patient understanding.

Conclusion: Overall, AI chatbots can provide structured, accessible information to support surgical consent, but current limitations restrict their use as standalone tools. Gemini demonstrated the strongest balance of readability and quality, yet all models require refinement to improve reliability, equity, and patient safety. At present, AI should complement, rather than replace, clinician-led consent discussions.

Introduction: This study evaluated the efficacy and safety of Foley catheter balloon tamponade (FCBT) for actively bleeding penetrating neck injuries (PNI), focusing on rates of haemostatic success, subsequent surgical exploration, morbidity and mortality associated with FCBT in PNI.

Methods: A systematic search of Medline/PubMed, Embase, CINAHL and the Cochrane Library was conducted to 29 May 2025. Observational studies reporting FCBT outcomes in actively bleeding PNI were included. Pooled proportions were calculated with random effects models using Freeman-Tukey double-arcsine transformation; heterogeneity was explored with subgroup analysis and meta-regression. Study quality was assessed using the ROBINS-I tool.

Findings: Nine studies (1,658 participants) were included. FCBT was deployed in 236 cases, yielding a pooled rate of use of 27.85% (95% confidence interval [CI] 2.27 to 64.60, I² = 97%, p < 0.01). Primary haemostasis was achieved in 62.50% to 100% across studies, with most series reporting success rates exceeding 80.00%. In total, 53.47% (95% CI 16.97 to 88.27, I² = 61%, p = 0.0360) underwent surgical exploration, most often for major vascular injury or rebleeding at removal. Pooled morbidity and mortality were 11.70% (95% CI 0.00 to 50.47) and 6.30% (95% CI 0.00 to 19.97), respectively.

Conclusions: FCBT is a simple, rapid technique that achieves temporary haemorrhage control in PNI, providing a bridge to definitive surgical control, and may be effective as definitive treatment in selected venous injuries. However, pooled data are limited by heterogeneity in catheter size, balloon inflation and dwell time, restricting interpretability. Standardised multicentre prospective studies are needed to refine indications, optimise technique, and quantify complications.

Introduction: The UK Foundation Programme bridges the gap between medical school and specialty training and should be designed to provide opportunities that make Foundation Doctors (FDs) competitive. These opportunities are afforded in part through study leave. Health Education England (HEE) guidelines detail study leave allowances, but the specifics of what study leave can be used for differs regionally. We investigated differences in study leave across Foundation Schools by comparing individually published guidelines.

Methods: FDs in each Foundation School were used to identify the 2024-2025 study leave guidelines in their respective Foundation School and completed a survey. These data were then independently verified by two authors.

Results: Every Foundation School was compliant with minimum HEE guidelines on study leave. Some Schools allowed twice as many taster days (five versus ten). Every School allowed leave for specialty exams, conferences and courses in Foundation Year 2 (FY2), but limited Schools allowed this in FY1. Most Schools had an undefined study budget, but London allowed up to £1,000, whereas Yorkshire and Humber provided funding only in exceptional circumstances.

Conclusions: Every Foundation School complies with HEE outline guidance for study leave utilisation. However, large geographical discrepancies remain in the level of funding provided to FDs and the majority of leave is limited to FY2, leaving only 106 days for this to be useful towards specialty applications. This highlights a shortfall in the opportunities provided to early career doctors and may impact their ability to make successful applications postfoundation training.

Optilume is a novel drug-coated balloon (DCB) that combines mechanical urethral dilatation with localised delivery of paclitaxel, an anti-proliferative agent aimed at reducing stricture recurrence. We report a rare complication in a 49-year-old man who had a urethral stricture treated with buccal mucosal graft urethroplasty abroad 6 years ago, followed by recurrence of ∼3cm mid-bulbar urethral stricture managed at another hospital with Optilume balloon dilatation. Post-procedure, he developed recurrent episodes of significant urethral bleeding needing multiple visits to the emergency unit. Subsequently, a computed tomography angiogram revealed an active arterial haemorrhage in the base of the penis, most likely arising from the left internal pudendal artery. The bleeding was successfully managed with super-selective embolisation using microcoils, preserving surrounding vascular structures. This case highlights the potential for serious vascular injury with DCB use and underscores the importance of preoperative counselling, careful technique and close postoperative monitoring. It further emphasises the role of microcoil embolisation as a targeted and effective approach for controlling complex urethral bleeding.