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

Introduction: Four-dimensional computed tomography (4DCT) has emerged as an effective imaging modality to aid parathyroid localisation before surgery. Following a service change in 2018, we evaluated the accuracy of 4DCT to lateralise culprit parathyroid glands causing primary hyperparathyroidism (PHPT) in patients undergoing parathyroid surgery in our centre.

Methods: A total of 117 patients underwent 4DCT before parathyroidectomy for PHPT in NHS Grampian between March 2018 and January 2023, of whom 112 underwent first-time operations. Results of imaging, histopathology and surgery type along with biochemical follow-up were evaluated retrospectively to assess the sensitivity and specificity of 4DCT imaging.

Results: In our centre, 4DCT imaging showed results comparable with those reported previously, with 77.6% sensitivity to lateralise to one side of the neck, 89.1% specificity and an overall accuracy of 83.5%. A total of 58% of patients underwent targeted parathyroidectomy. At three- to six-month follow-up, 94.5% had achieved biochemical cure; 4DCT identified culprit lesions in four out of five patients undergoing reoperation. Age and corrected calcium did not affect accuracy of 4DCT.

Conclusions: 4DCT is an effective first-line imaging modality before first-time parathyroidectomy for PHPT in patients aged >60 years as well as in cases of reoperation. Use as the first-line imaging modality in younger patients may reduce overall radiation exposure by minimising the need for additional imaging, but further study is needed in this age group.

The US National Aeronautics and Space Administration (NASA) will be familiar to most across the world. Leading highly dangerous and innovative space travel, NASA has gone from a blame culture in the 1960s to an environment that keeps safety at the forefront and a top priority. NASA culture aims to ensure that staff work safely through balancing challenges and risks, feel comfortable communicating safety issues and learn from both successes and error. Surgery, and healthcare in general, still has a long way to go to embed a safety culture that values staff and looks at why incidents and errors have happened, and what can be learnt from them, instead of who was to blame. NASA's safety journey is a powerful study in learning from failure, evolving culture and leading with humility. From the Apollo 1, Challenger and Columbia disasters, NASA built a more transparent, accountable and resilient safety system and one that continues to evolve with the frontiers of space exploration. In many ways, surgeons can learn a lot from NASA to improve both patient safety and culture.

Introduction: Right hemicolectomy has evolved from open to minimally invasive approaches. Laparoscopic right hemicolectomy (LRH) is widely adopted, yet challenges persist, particularly in complex dissections. Robotic right hemicolectomy (RRH) offers enhanced precision and ergonomics but remains under scrutiny for its comparative advantages. This study critically evaluates the perioperative outcomes of LRH vs RRH within a single-centre framework.

Methods: A retrospective cohort analysis was carried out at a single tertiary institution, reviewing all RRH cases from January 2021 to December 2024 and comparing them with the most recent LRH cases. Inclusion criteria encompassed adults undergoing elective right hemicolectomy for confirmed malignancy; patients with recurrent disease or emergency indications were excluded. Demographics, tumour characteristics, operative details and short-term outcomes were compared using appropriate statistical tests.

Results: The baseline demographics were comparable between the groups. Transverse colon tumours were more frequent in the RRH group (n = 15, 37.5%) than in the LRH group (n = 2, 5%) (p = 0.003). The mean operative time was comparable in both groups (219.9mi in RRH vs 206.8min in LRH; p = 0.277). RRH demonstrated significantly reduced blood loss (24 vs 50.1 m; p < 0.001), earlier return of bowel function (1.9 vs 2.6 days; p = 0.004), and a reduced hospital stay (3.5 vs 6.1 days; p = 0.001). Lymph node yield was comparable.

Conclusion: RRH offers measurable benefits in recovery and haemostasis as compared with LRH. It offers equivalent short-term oncological outcomes without prolonging the operative time. Our findings suggest RRH may be preferable for anatomically complex cases. Larger, prospective studies with a long-term follow-up period are therefore indicated.

Background: Bone conduction hearing implants (BCHIs) are a valuable alternative option for patients with hearing loss when conventional hearing aids are not effective or a viable option. In the UK, specialist sites offer BCHI services. We aimed to understand whether patients face geographical barriers to accessing this healthcare service.

Methods: A retrospective cohort study was performed at five hospitals in the North West of England over a one-year period (January-December 2023).

Results: In total, 167 primary BCHIs were implanted (median age, 57.7 years; female, n=52 (31.1%)). Patients travelled a median distance of 17.3km from their home to the BCHI site. Of the patients receiving a BCHI, 108 (64.7%) lived in the locality of a BCHI site. The remaining 59 (35.3%) were referred from a non-BCHI centre. The majority of BCHIs were percutaneous (n=154/167, 92.2%) and were performed under local anaesthetic (n=127/167, 76.0%). No correlation between patient age and distance travelled was identified (p=0.22, R=-0.0951).

Conclusions: The findings suggest a greater percentage of all BCHIs that are conducted are seen first at a BCHI centre initially rather than seen elsewhere. This could represent a potential geographical barrier to accessing BCHI services for patients not living in the locality of a non-BCHI providing centre. Future work is required to better understand BCHI service barriers on a national level and to identify methods to ensure equitable access for all.

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.