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

Introduction: There is a well-documented association between persistent wound drainage and the development of prosthetic joint infections in total hip (THA) and total knee arthroplasty (TKA). Despite this, there are no national clinical guidelines in the United Kingdom on the diagnosis or management of postoperative wound drainage. We aimed to evaluate what variability exists within clinical practice in the recognition and treatment of persistent wound leakage following THA and TKA.

Methods: An anonymous online survey consisting of 12 multiple-choice questions was distributed among hip and knee arthroplasty consultants in the north west of England. Topics covered in the questionnaire included definition, diagnosis, classification, timing and treatment of persistent wound drainage.

Results: Twelve orthopaedic centres across the region participated in data collection. A total of 65 consultants completed the questionnaire. Some 45% of respondents used a definition of persistent wound leakage after arthroplasty, which ranged from drainage beyond 48h to that lasting more than 2 weeks. Only 54% of consultants reported having a monitoring system in place for patients with persistent wound drainage after discharge from hospital. There was wide variation in the preferred timing of initiating both non-operative and surgical management of wound leakage, as well as different treatment modalities used. Most respondents rated C-reactive protein as the most useful serological marker in aiding decision making.

Conclusion: The results demonstrate a lack of concurrence in the recognition and management of postoperative wound drainage. Formal national clinical guidelines are necessary to standardise practice.

Introduction: Every patient admitted to hospital should receive a discharge letter when they leave. Artificial intelligence (AI) has the capability to fulfil this task. Here, we investigate the use of AI to generate discharge letters compared with letters written by a doctor.

Methods: Using an AI tool, ChatGPT, we generated two discharge letters for hypothetical elective tonsillectomy patients. We asked the parents of paediatric tonsillectomy patients to blindly compare the AI letters with two anonymised real discharge letters for tonsillectomy patients, written by two ear, nose and throat (ENT) doctors. Participants were asked to rate the quality of medical information, the ease of reading and the length of each of the four discharge letters. They were also asked to deduce who they thought wrote each discharge letter (AI or a doctor).

Results: Forty-seven parents responded to the survey. Our results demonstrate that the AI letters were reported to contain significantly better medical information (p = 0.0059) and were significantly easier to read than the doctor-written letters (p < 0.0001). Respondents had a 50% sensitivity in correctly identifying the letters written by AI.

Conclusions: AI tools have the potential to write tonsillectomy discharge letters of comparable quality (as perceived by our participant population) to those written by ENT doctors. This study provides preliminary evidence to show that AI-generated discharge letters may be an interesting avenue of further investigation as an application for this tool.

Background: One of the debated indications for paediatric tonsillectomy is unilateral tonsillar enlargement (UTE). The majority of UTE is innocuous in nature; however, concerns exist around a diagnosis of lymphoma, typically found in the presence of other symptoms.

Methods: A retrospective case series analysis of all paediatric tonsillectomy specimens at Bristol Children's Hospital between January 2006 and January 2023 was undertaken.

Results: Four (1.3%) lymphoma diagnoses were identified from the 319 patients who underwent tonsillectomy for UTE. Three patients had localised disease and one patient had systemic infiltration of disease. All patients presented with other signs of malignancy including cervical lymphadenopathy (100%), alteration of appearance of tonsil including colour or visible lesion (75%), snoring (75%), dysphagia (50%), recurrent fever (25%) and weight loss (25%).

Conclusions: We recommend active monitoring of asymptomatic isolated UTE. Diagnostic tonsillectomy should be performed in patients with UTE and cervical lymphadenopathy and/or constitutional symptoms and/or altered tonsillar appearance.

Introduction: We aimed to externally validate the performance of the HAS model (Hajibandeh Index, American Society of Anaesthesiologists status, and sarcopenia) in predicting mortality after emergency laparotomy. We also aimed to compare the HAS model with the Parsimonious NELA (National Emergency Laparotomy Audit) risk score.

Methods: In this retrospective cohort study, we included adult patients who underwent emergency laparotomy between January 2022 and June 2023. The performance of the HAS score and the NELA score in predicting 30-day mortality was compared using receiver operating characteristic (ROC) curve analysis. We performed subgroup analysis for the following age groups: age ≥50, age ≥60, age ≥70, and age ≥80 years.

Findings: We included 117 patients in this study. ROC curve analysis showed that area under the curve (AUC) of the HAS score for 30-day mortality was 0.90 (95% CI 0.83-0.95). Although the AUC of HAS score was higher than the AUC of NELA score for all patients, this was not statistically significant (0.90 vs 0.80, p=0.097). AUC of the HAS score was superior to NELA score in patients aged ≥50 (0.89 vs 0.75, p=0.040), patients aged ≥60 (0.87 vs 0.69, p=0.020), patients aged ≥70 (0.85 vs 0.67, p=0.030), and patients aged ≥80 (0.90 vs 0.66, p<0.001).

Conclusions: The results of the current study support the external validity of the HAS model in predicting 30-day mortality after emergency laparotomy. Prospective studies with larger sample size are required.

Introduction: With increased utilisation of robotics in surgery, the demand for structured training is increasing. This paper presents the safety and efficacy profile of a robotic colorectal fellowship in the United Kingdom.

Methods: This is a retrospective study conducted in a district general hospital between 2019 and 2023. Procedures performed using the Da Vinci robot were divided into two cohorts, those performed by robotic fellows and those performed by consultant surgeons. Each fellowship lasted on average six months and at the end of the fellowship the trainee had completed the mandatory requirements to be certified as a robotic surgeon. The objective of this study is to compare the outcomes of procedures performed by the fellows with those performed by consultants.

Results: Of the 224 robotic procedures recorded, 117 were performed by consultants and 107 by fellows. The median time to complete the procedure was 315min vs 257min for consultants and fellows, respectively. The average postoperative length of stay was 6 and 7 days, the anastomotic leak rate was 4.3% and 5.6% and reoperation rate was 11% and 9% for procedures performed by consultants and fellows, respectively. The median lymph nodal yield was 17 in both groups and the margin positivity rate (R1) resection rate was 7% and 4% (p = 0.4) for procedures performed by consultants and fellows.

Conclusion: It is possible to safely train in robotic colorectal surgery without compromising patient safety, oncological outcomes or adversely affecting theatre efficiency.

Mammary myofibroblastoma (MFB) is a rare benign spindle cell tumour predominantly affecting males, but also observed in postmenopausal females. Its diagnosis remains challenging owing to overlapping histological features with malignant lesions and limited tissue sampling in core biopsies. We present a case of incidentally discovered mammary MFB in a 63-year-old man and review its clinical, radiological and histopathological characteristics. The patient, who had a history of distal pancreatectomy and splenectomy, presented with an incidental left anterior chest wall nodule discovered on computed tomography scan. Clinical examination revealed a benign left retroareolar lump, confirmed by breast ultrasound and mammography. Ultrasound-guided core biopsy demonstrated characteristic spindle cells, prompting immunohistochemical staining confirming the diagnosis of MFB. The lesion was surgically excised with clear margins. Mammary MFB is commonly seen in postmenopausal women and older men, presenting as painless, mobile breast lumps. Imaging findings are nonspecific, resembling fibroadenomas or fat necrosis. Histologically, MFB lacks mammary ducts or lobules and displays characteristic spindle cells with collagenous stroma. Immunohistochemistry aids in differentiating it from other spindle cell tumours. Surgical excision is curative, with no reported cases with recurrence. Mammary MFB should be considered in the differential diagnosis of breast masses in males and postmenopausal women. Despite the challenges in diagnosis, its benign nature and favourable prognosis warrant timely recognition and appropriate management through surgical excision. Further research is needed to establish clear management guidelines and explore its underlying pathogenesis.

Introduction: Robotic-assisted surgery is an alternative approach to minimally invasive surgery for benign upper gastrointestinal (UGI) conditions and abdominal wall hernia - its application in the United Kingdom is still in the initial phases in many National Health Service (NHS) trusts. We detail the experience of Northumbria Healthcare NHS Foundation Trust in implementing a robotic-assisted surgery service for benign UGI procedures and abdominal wall hernia repair.

Methods: The robotic service for benign UGI was established in the trust in February 2022. All theatre staff received online and simulation training before working in the dedicated robotic surgery theatre. Operative timings, surgical outcome measures and patient outcomes including day-case rates were prospectively recorded and analysed to assess the impact of the introduction of this service.

Results: Between February 2022 and June 2023, some 200 robotic-assisted procedures were performed: cholecystectomy (n = 103), hernia repair (n = 74), anti-reflux surgery (n = 9) and Heller's myotomy (n = 14). Median docking times were recorded: cholecystectomy, 9min (4-94min); hernia repair, 10min (4-50min); anti-reflux surgery, 19min (9-37min); and Heller's myotomy, 15min (6-26min). There were no intraoperative complications. Two patients returned to theatre for bile leak following cholecystectomy, presenting on day 2 and day 9 postoperatively.

Discussion: Robotic-assisted benign UGI surgery can be safely performed in a day-case centre and does not impact day-case rates. There were no theatre delays because of prolonged docking times, even in the initial introductory period. There are higher costs associated with robotic-assisted surgery; however, with time and industry development, these are likely to improve.

Introduction: The effective treatment of a patient in a timely manner requires specialist equipment, including in ear, nose and throat (ENT) services, where orifices require careful inspection. Otoscopy, flexible nasendoscopy, peritonsillar abscess drainage and nasal cautery are all common practices and cannot be successfully completed without the necessary equipment. These tasks all require expensive equipment that can easily be misplaced in a busy hospital. A paucity of equipment can delay patient assessment and negatively impact treatment, as well as reduce clinician efficiency and effectiveness. Here, we investigate the impact of equipment loss, and discuss a cost-effective solution to the problem.

Methods: We surveyed ENT departments from 15 different trusts on how equipment loss impacted their patients, staff and their department financially. We also calculated the cost of equipment lost in our department over the course of a year. We subsequently placed trackers on our equipment and calculated the cost of lost equipment after 12 months.

Results: Of the 15 trusts surveyed, 13 responded. Our survey demonstrated the average cost of lost items to be more than £4,900 per department, with concurrent delays in treatment and a reduction in patient-facing time. No equipment was lost after the trackers were placed.

Conclusions: The use of commercially available tracking technology can help reduce the amount of time taken to locate equipment, prevent incurring higher costs and, most importantly, improve patient safety, with an estimated return on investment of more than 3000% and an increase in direct clinical care simultaneously.