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

Background: Complications can be devastating for patients, but the 'second victim' phenomenon is increasingly being acknowledged, whereby the surgeons involved in the complication are adversely affected by such complications. For trainees, who are early into their surgical careers and are on a learning curve, such events can be formative or pivotal in their careers. Additionally, as temporary rotating members of the departments they work in, there can often be educational, interpersonal or workplace demands that amplify such effects, and a lack of professional ties that allow them to comfortably discuss complications with temporary or new work colleagues.

Methods: An online questionnaire was designed and distributed to UK Trauma and Orthopaedic trainees. Sixty-five trainees responded from across ten deaneries.

Results: There were significant negative effects of complications on trainees, including sadness (77.8%), anxiety (63.5%), guilt (69.8%) and embarrassment (63.5%). A total of 40.3% reported complications affected them outside of work. Only 60.9% felt well supported. Only 22.2% were offered formal support. In addition, 66.7% have witnessed another trainee struggle after a complication. Only 15.6% felt their training programme adequately prepares them to deal with the emotional impact of complications.

Conclusions: Adverse effects of complications on Trauma and Orthopaedic trainees are a prevalent issue. There are no ubiquitous formal structures in place to support trainees affected by complications. Nonblame, informal debrief sessions were cited repeatedly as beneficial.

Introduction: Renal hyperparathyroidism is a common complication of chronic kidney disease, often requiring parathyroidectomy (PTX) when medical therapy fails. Following surgical intervention, recurrence and postoperative complications, in particular hypocalcaemia, are variable. This study compares post-PTX outcomes between two UK centres, focusing on recurrence rates, length of stay (LOS) and factors influencing postoperative intravenous (IV) calcium administration.

Methods: A retrospective cohort study was conducted across two centres from 2008-2022. Demographic, biochemical, and clinical factors were analysed, with primary outcomes being disease recurrence and postoperative IV calcium requirement.

Results: In total, 114 patients were included: 66 from centre A and 48 from centre B. Some 65.2% underwent total parathyroidectomy in centre A vs 60.4% in centre B. The remainder were subtotal parathyroidectomies. Total recurrence was higher in centre A (34.8%) than centre B (20.8%) and a longer LOS was seen in centre A (median 5.5 days vs 3 days, p = 0.007). IV calcium use was higher in centre B (35.4% vs 24.2%, p = 0.194), although not statistically significant. Predictors of recurrence were limited, with preloading with alfacalcidol being protective in a univariate model (hazard ratio [HR] 0.33, p = 0.005). Higher postoperative phosphate, parathyroid hormone and alkaline phosphate levels were significant predictors of postoperative IV calcium in multivariate analysis (p < 0.05).

Conclusions: Significant differences in recurrence and LOS suggest that preoperative disease burden and perioperative management strategies influence outcomes. The higher recurrence at centre A may be linked to disease severity, while the shorter LOS and higher IV calcium use at centre B may reflect different pre- and postoperative care approaches. These findings highlight the need for careful management and identification of factors which may impact outcomes.

Introduction: Most patients with Crohn's disease (CD) have at least one bowel resection during their lifetime. Patients considering surgery will probably look for information online, as is common practice among patients with chronic illnesses. The aim of this systematic review is to assess the quality and readability of web-based patient information on bowel resection for CD.

Methods: Google was searched using predefined search terms, developed with input from patient experts. For each term, results from the first two pages were screened for eligibility. Patient-focused websites on bowel resection for CD were included. The quality of the information was assessed using the DISCERN tool, and the readability with the Flesch-Kincaid ease of readability (FK) score. The accessibility adjustments of websites were also assessed.

Results: Of the 118 sources identified, 91 were excluded and 27 sources were analysed. One-third (n = 10) did not discuss the different types of resections. Ileocolic resection (the most commonly performed resection) was described in eight sources. Discussion of management post-resection (n = 6) and of lifestyle changes (n = 11) was sparse. There were some instances of factually incorrect information. The mean DISCERN score was 3.1 ± 0.80 (range 1-5), indicating moderate quality information. The mean FK score was 51.9 ± 8.70 (corresponding to patients requiring A levels or equivalent to fully understand the text).

Conclusions: The study findings highlighted the limitations of the current online patient information surrounding bowel resection in CD. The involvement of patients, working alongside professional bodies and clinicians, in the development of health-related websites is recommended.

Introduction: Morbidity and mortality are significant risks associated with emergency laparotomies. A risk calculation tool facilitates the identification of high-risk patients and provides clinicians with information to help them make informed decisions. In search of an ideal scoring system that yields accurate results, we compared 30-day mortality predictions using the National Emergency Laparotomy Audit (NELA), the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), and the Surgical Outcome Risk Tool (SORT) risk calculators.

Methods: This retrospective study analysed data collected from adult patients who underwent emergency laparotomies between July 2018 to October 2019 at Maidstone and Tunbridge Wells NHS Trust. Each patient's median preoperative mortality risk was calculated using the four risk calculators: NELA, P-POSSUM, ACS-NSQIP and SORT.

Results: During the study period, 227 patients were eligible for inclusion, with a mean (sd) age of 65 (±16) years and a median American Society of Anesthesiologists score of 2. NELA and P-POSSUM identified 11 patients (sensitivity 73.3%) who died in the high-risk group, which was higher than the identification rates of ACS-NSQIP (53.3%) and SORT (40.0%). The average 30-day mortality risk for the 15 patients who died was 25.8% for NELA, 39.6% for P-POSSUM, 17.9% for ACS-NSQIP and 15.7% for SORT. NELA and ACS-NSQIP had the highest area under the curve at 0.869 and 0.877, respectively. Although NELA exhibited higher sensitivity (73.3%), ACS-NSQIP demonstrated greater specificity (88.7%).

Conclusions: Overall, the NELA score demonstrated the highest performance in predicting mortality in emergency laparotomy.

Introduction: Infected aortic fields are among the most complex surgical challenges, often requiring urgent intervention and associated with a high risk of morbidity and mortality. Bovine pericardium offers a customisable, off-the-shelf option for in situ reconstruction using biological material. We evaluate long-term outcomes following emergency bovine pericardium neo-aorta reconstruction in infected aortic fields.

Methods: Prospectively collected data for all patients treated with bovine pericardium neo-aorta reconstructions from 2018 to date were analysed. The surgical approach included resection of the infected aortic segment, explantation of previous grafts and/or stents, and reconstruction of the neo-aorta using a bovine pericardium sheet. Data collected included patient demographics, comorbidities, clinical presentation, previous interventions, blood tests, complications, length of antibiotic treatment and long-term survival. All neo-aortas were enrolled in an annual ultrasound surveillance programme to monitor for aneurysmal degeneration.

Results: Fifteen aortic reconstructions were performed. The most common indication was aorto-enteric fistulas (n = 7), followed by infected aortic grafts (n = 4), mycotic aneurysms (n = 3) and one contaminated field due to emergency colectomy. Median follow-up was 34 months (range 9-84). Thirty-day mortality was 7%, with another 7% at 10 weeks. Antibiotic-free survival rate was 86%. One patient (7%) required long-term antibiotics post-partial endovascular aneurysm repair explant. Complications included one graft occlusion with limb loss and one case of end-stage renal failure. No aneurysmal degeneration was identified during follow-up.

Conclusion: Bovine pericardial neo-aorta reconstructions have shown excellent long-term resistance to infections and very good durability. Our data add to growing evidence supporting off-the-shelf use of bovine pericardium in emergency aortic reconstruction. Larger numbers through multicentre studies or special registries would help support more regular use.

Eagle's syndrome describes the elongation of the styloid process. The condition has been recognised for over 90 years and causes a wide range of symptoms depending on the level of compression. Compression of the internal carotid artery by the styloid process is referred to in the literature as 'stylocarotid syndrome' or 'vascular Eagle's syndrome' (VES), presenting most commonly as arterial dissection and cerebrovascular events. We present the case of a 53-year-old patient who presented with multiple cerebrovascular events over a six-month period. Computed tomography angiography (CTA) suggested VES; however, magnetic resonance imaging (MRI) of the neck revealed no arterial wall abnormalities, including dissection. Despite the escalation of medical therapy, the patient continued to experience multiple transient ischaemic attacks. Following multidisciplinary team discussion and exclusion of other sources of emboli, a transcervical styloidectomy was performed freeing compression of the carotid artery, resulting in the complete resolution of symptoms. VES should be considered in patients with recurrent or unexplained cerebrovascular or cervical neurogenic symptoms even in the absence of arterial injury. We recommend early styloidectomy when there is a strong clinical suspicion of VES to achieve definitive symptom resolution.

Introduction: The aim of this study was to determine the learning derived from postoperative complications to reduce the risk of avoidable harm.

Methods: A retrospective review of a prospectively maintained local hospital registry of readmissions for complications was undertaken at a single district general hospital over a 10-year period (November 2014-November 2024). Learning points policy changes were monitored prospectively using audit to determine influence on clinical practice.

Results: There were 316 elective complications from 22,658 cases (1.4%) and 251 trauma complications from 15,862 cases (1.6%). There were 293 deaths out of the 38,520 total cases (0.76% mortality rate); of these, 16 occurred in elective surgery (0.07% mortality rate) and 241 trauma cases out of 15,852 (rate of 1.6%). The total number of elective cases requiring reoperation was 374. The cases from different hospitals accounted for 41%; there were 251 local trauma cases that required reoperation. The most frequent complication was implant dislocation in 201 cases, which was avoidable in one-third of cases due to technical issues. Most periprosthetic fractures were a late complication secondary to osteoporosis. Discussion of the care of complex cases enabled improved training packages and pathways to manage wound care, infection and the technical aspects of prosthetic joint implantation and fracture fixation for trainee surgeons.

Conclusions: There is a significant resource implication for managing complications that originate from other hospitals. Monitoring complications and mortality helps improve practice and enable reproducible outcomes.

We present a rare case of a 23-year-old woman with congenitally absent bilateral common iliac arteries, identified incidentally during a computed tomography scan of the abdomen. Imaging revealed occlusion of the aorta below the renal arteries with flow to the lower limbs provided by hypertrophied collaterals. Despite initial conservative management, the patient experienced worsening claudication and functional limitations, prompting surgical revascularisation. An aorto-bifemoral bypass using an axillary-bifemoral graft was performed with successful recovery - the first documented case of surgical repair of this anatomical abnormality, and a novel use of the Gore heparin-bonded graft. Two years post-surgery, the patient was symptom-free. This case highlights the rarity of common iliac artery agenesis, the compensatory role of collateral circulation, and the potential for successful surgical intervention.