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

Introduction: The aim of this study was to chart the natural history of elderly patients with colon cancer who are managed nonoperatively, with the primary outcome being life expectancy from diagnosis to death.

Methods: This was a retrospective analysis of patients aged 80 years and above diagnosed with colon cancer in a tertiary care referral hospital in England between 1 January 2012 and 31 December 2017.

Results: Thirty-two patients were diagnosed with non-metastatic colon cancer and managed non-operatively. The median age of patients in this study was 86 years. The group had a median Charlson Comorbidity Index of 7 (range 6-12) and the median frailty score was 6 (range 3-8). Progression to metastatic disease was identified in two patients; two further patients showed locoregional progression of cancer and therefore required palliative surgical intervention. Survival of these patients ranged from 105 to 1,782 days with a median life expectancy of 586 days. Place of death was identified in 15/31 patients: 4 (27%) died in hospital, 12 (38%) died at home and 15 (47%) died in a nursing or residential home; data were missing for 1 patient (3%).

Conclusions: Nonoperative management of elderly patients with colon cancer yields reasonable life expectancy and a low risk of life-threatening local complications.

Introduction: There is wide variability in the perioperative management of phaeochromocytoma and paraganglioma (PPGL) in different centres. This study aimed to summarise the management of PPGLs as reported in the United Kingdom Registry for Endocrine and Thyroid Surgery (UKRETS) database and to determine current perioperative management of PPGLs by surveying UK clinicians.

Methods: Data recorded on UKRETS from 2005 to 2021 were subjected to descriptive analyses. British Association of Endocrine and Thyroid Surgeons members were invited to participate in an open survey relating to the perioperative management of patients with PPGLs.

Results: A total of 2,007 operations for PPGL from 49 participating centres were included. The median annual workload in each centre was four cases. Operations were performed predominantly laparoscopically (69%). The median length of stay (4 days) was the same in groups of surgeons stratified by volume. The survey had 29 respondents from 22 centres across the UK, and a formal protocol for perioperative management exists in 48% of the centres. Phenoxybenzamine (72%) was preferred for alpha-blockade. The practice of admitting patients for optimisation from 1 to 7 days before the day of surgery was common (62%). Central venous pressure and blood glucose monitoring were mentioned as routine intraoperative adjuncts by 72% of the responders.

Conclusions: There is significant variation in the workload and perioperative management of PPGLs in the UK. This is potentially detrimental to patient outcomes and a consensus document might be beneficial to harmonise practice across the UK.

Introduction: Staging of oesophagogastric (OG) cancers usually involves endoscopy (OGD), and separate visits for contrast enhanced computed tomography (CeCT) and positron emission tomography (PET/CT). At the height of the COVID-19 pandemic, some of our patients underwent single-visit combined staging with PET/CeCT. We compare this novel pathway with standard separate imaging in time to completion of staging, to start of treatment, and cost.

Methods: We identified all patients discussed at our OG multidisciplinary team (MDT) meeting in 2020. Clinical records revealed dates of investigations and treatments. Data were tabulated in Excel, with statistical analysis in SPSS. All patients followed the same MDT process and image reviewing criteria. Costs were compared using prices supplied by finance departments.

Results: A total of 211 new patients were discussed at our MDT in 2020. Of these, 48 patients had combined PET/CeCT staging, and 68 had separate scans. Median time (interquartile range) in days from OGD to final imaging was 9 (6-23) for the combined group versus 21 (16-28) for the separate group (p≤0.001). Median time (days) from OGD to treatment start was 37 (29-52) for combined versus 55 (40-71) for separate (p≤0.001). No combined scans were of insufficient diagnostic quality for the MDT. PET/CeCT had a potential cost saving of £113 per patient.

Conclusions: PET/CeCT allows accurate radiological staging of OG cancers with a single scan. Patients completed staging and started treatment faster, with a potential saving of £10,509 in one year. PET/CeCT has become standard staging at our trust, and we aim to incorporate radiotherapy planning images too.

Both primary and secondary care services in the NHS have been overwhelmed with an increase in referrals on the suspected cancer pathways. The years 2020/2021 saw 551,770 symptomatic breast referrals made in England alone. The Wessex Rapid investigations service in conjunction with the local district general hospital and primary care networks instigated a virtual triage for new breast symptoms. Over the course of a year, 664 people were assessed by either telephone or video using specially trained nurses. Appointments were given within 1-2 working days. The service was highly valued by patients and general practitioners. We were unable to confirm a reduction in referral to secondary care as the evaluation occurred during a postpandemic peak in referrals. We found that 10% of patients with new breast symptoms can safely self-manage. This percentage varied with the experience of the triage clinician. A specialist community face-to-face service could reduce further the need for full secondary care evaluation. Better integration and use of information technology systems would improve the service. The rapid responsiveness and length of consultations is valued by patients. Representation with the same symptoms was rare. This pathway utilises staff outside of the usual primary and secondary care providers and thus reduces the pressure on stretched systems.

Introduction: Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

Methods: This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

Results: Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

Conclusion: A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

CORESS is an independent charity, supported by AXA Health, the MDU and the Kirby Laing Foundation. We are grateful to those who have provided the material for these reports. The online reporting form is available via the CORESS app and on the website (coress.org.uk), which also includes previous Feedback reports. Published cases are acknowledged by a Certificate of Contribution, which may be included in the contributor's record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Contributions from surgeons in training are particularly welcome.

Introduction: Laparoscopic fundoplication remains the standard treatment for patients with severe gastro-oesophageal reflux disease (GORD). Multiple randomised controlled trials (RCTs) have compared the two most commonly performed surgical techniques, total and posterior partial fundoplication (Nissen [NF] and Toupet [TF]), in terms of symptom control and treatment failure in patients without subsequent dysmotility disorders. We aimed to conduct a systematic review and meta-analysis of these two techniques with regard to the long-term effect on reflux control and associated dysphagia.

Methods: The MEDLINE^®, Embase^®, PubMed^® and Cochrane Library databases were searched, and all the relevant published RCTs were shortlisted according to the inclusion criteria. The summated outcomes of long-term results relating to the recurrence of GORD and dysphagia were evaluated in a meta-analysis using RevMan software.

Results: Eight studies (all RCTs) on 1,545 patients undergoing NF or TF were eligible for inclusion in this meta-analysis. There were 799 patients in the NF group and 746 in the TF group. In the random effects model analysis, the incidence of long-term recurrence of GORD was not statistically different between the NF and TF cohorts (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.34-1.41, z=1.01, p=0.31). However, the incidence of long-term dysphagia was statistically lower in the TF group (OR: 2.92, 95% CI: 1.49-5.72, z=3.13, p=0.002) with low between-study heterogeneity (I²=0%).

Conclusions: The findings of this systematic review and meta-analysis on symptomatic GORD appear to be in favour of partial posterior fundoplication (TF) as the optimal treatment. It provides equivalent outcomes in reflux symptom control with a lower risk of postoperative dysphagia compared with total fundoplication (NF).

Background: Patients with an intestinal emergency who do not have surgery are poorly characterised. This study used electronic healthcare records to provide a rapid insight into the number of patients admitted with an intestinal emergency and compare short-term outcomes for non-operative and operative management.

Methods: A single-centre retrospective cohort study was conducted at a tertiary NHS hospital (from 1 December 2013 to 31 January 2020). Patients were identified using diagnosis codes for intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit. Relevant data were extracted from electronic healthcare records (n=3,997).

Results: Nearly half of patients admitted with an intestinal emergency received nonoperative management (43.7%). Of those who underwent surgery, 63.7% were started laparoscopically. The non-operative group had a shorter hospital stay (median: 5.4 days vs 8.2 days [started laparoscopically] or 16.8 days [started open]) and fewer unintended intensive care admissions than the surgical group (2.4% vs 8.7% [started laparoscopically] 21.1% [started open]). However, 30-day mortality for non-operative treatment was double that for surgery (22.4% vs 10.1%). The 30-day mortality rate was found to be even higher for non-operative management (50.3%) compared with surgery (19.5%) in a sub-analysis of patients with admission National Early Warning Score ≥4 (n=683).

Conclusion: The proportion of patients with intestinal emergencies who do not have surgery is greater than expected, and it appears that many respond well to non-operative treatment. However, 30-day mortality for non-operative management was high, and the low number of admissions to intensive care suggests that major invasive treatment was not appropriate for most in this group.

Introduction: Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

Methods: A systematic search of the literature was undertaken using the Medline^®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

Results: A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

Conclusions: This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.