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

Introduction: The purpose of this review was to evaluate sustainable interventions in breast surgery that reduce carbon dioxide equivalent (CO₂e) emissions and financial costs, supporting the National Health Service (NHS) goal of net zero carbon emissions by 2040.

Methods: A literature search was conducted using MEDLINE via PubMed up to 2024, targeting studies on sustainability in breast surgery. Search terms included sustainability-related and breast surgery-specific keywords. Owing to limited evidence, a narrative review was performed, incorporating findings from published literature, local audits and environmental impact assessments. Interventions were analysed across the perioperative pathway.

Findings: Only one study specifically addressed sustainability in breast surgery, highlighting a significant evidence gap. However, multiple practical interventions were identified. The use of total intravenous anaesthesia reduced CO₂e emissions by more than 90% compared with inhalational agents. Reusable surgical gowns and drapes offered a lower CO₂e (0.44kg vs 0.77kg per gown) and were cost effective. Switching from intravenous to oral paracetamol saved 47kg CO₂e annually and reduced costs (£0.02 vs £0.49 per dose). Other sustainable practices included waste segregation, minimising unused equipment and implementing electronic documentation. Local audits revealed that 7.5% of opened sutures were unused, highlighting opportunities to reduce waste.

Conclusions: Simple, sustainable changes in breast surgery can significantly reduce both environmental and financial costs. Despite a lack of robust data, practical measures already in use show clear benefits. Future research should focus on whole lifecycle analyses of sustainable interventions, providing evidence to support sustainable practices. Incorporating these interventions across surgical disciplines can meaningfully contribute to achieving NHS net zero goals.

Introduction: Amputation is an uncommon but potentially life-changing complication of burns. No studies of amputation among UK burns patients currently exist.

Methods: A 10-year review of burns patients with amputations at the Queen Elizabeth Hospital Birmingham was conducted. Descriptive analysis was undertaken to identify patient characteristics. Statistical analysis was conducted to identify relationships between patient and injury details and the number of amputations, and relationships between the number of amputations and patient outcomes.

Results: Thirty-five adult burns patients (mean age 48.1 years, 65.7% male) were identified, 62.9% of whom suffered flame burns. The median total body surface area (TBSA) burned was 24%. The amputation risk among admitted burns patients was 1.2%. Major burns patients (≥25% TBSA burned) underwent more minor (p=0.018) and upper limb amputations (p=0.035) compared with minor burns patients. Median length of hospital stay was 67.5 days. Length of stay was positively correlated with the number of total (p=0.001), minor (p=0.004) and upper limb (p=0.002) amputations. In total, 67.6% of amputees underwent revisional procedures. The number of revisions was positively correlated with the number of major (p=0.010) and lower limb (p=0.001) amputations.

Conclusions: A minority of adult burns patients underwent amputations. Patient and injury information may predict a greater number of amputations, which in turn may predict longer hospital stays and a requirement for more revisional procedures. This information could be used to better counsel patients about their likely outcomes. A multicentre case-control study is required to clarify risk factors for amputation in burns.

The cancer journey of a young patient who presented with an obstructing metastatic (Stage 4) colon cancer is described. The addition of bevacizumab to an established chemotherapy regimen of 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX) ameliorated their chemotherapy-associated liver injury (CALI). This improvement in liver quality was demonstrated non-invasively with multi-parametric magnetic resonance imaging (mpMRI). Both the response to chemotherapy and the improvement in liver quality provided by additional bevacizumab allowed this patient with initially unresectable synchronous colorectal liver metastases to undergo resection of their bowel primary, followed by an extended liver resection, uncomplicated by post-hepatectomy liver failure (PHLF). They had subsequent planned ablative therapy with stereotactic ablative radiotherapy (SABR) to a residual central metastasis, and are currently disease free. This case illlustrates the importance of a multi-modal, multidisciplinary and individualised approach to patients' cancer care.

Introduction: Robotic-assisted total knee arthroplasty (RA-TKA) is associated with a higher carbon footprint compared with manual TKA. This review sought to reduce the carbon and financial costs associated with MAKO RA-TKA by 'leaning' surgical trays.

Methods: Surgeons routinely performing MAKO RA-TKA were consulted, and a consensus was reached on items from the standard knee instrument trays that were redundant and could be removed. Two new 'lean trays' were then introduced for MAKO RA-TKA. Carbon and financial savings were calculated based on the reduction in the number of trays requiring decontamination, sterilisation and repackaging.

Results: Implementing lean methodology has reduced the tray count by one, by removing 36 out of 152 instruments per case. In five months, the use of lean trays resulted in saving 115 trays being opened, reprocessed and sterilised. This project has resulted in numerous benefits, including a total carbon saving of 220.85kgCO2e (carbon dioxide equivalent) due to reduced use of sterilisation processes (176kgCO2e) and tray wraps (44.85kgCO2). Staff feedback was positive, noting the ability to count instruments more quickly, increased space in theatre and reduced learning curve for new staff. Additionally, there was a financial saving of approximately £5,750 due to reduced burden on sterilisation services.

Conclusions: It is imperative that innovative technologies are implemented with sustainability in mind and that any potential environmental harm is mitigated wherever possible. In this regard, the implementation of 'lean' surgical instrument trays should be considered to minimise the environmental impact of surgery while also improving efficiency and lowering costs.

Introduction: Self-inflicted harm is a complex behavioural phenomenon and a manifestation of a variety of underlying factors. Penetrating trauma is increasingly common, with rising knife crimes, gun violence and terrorism-related ballistics in the civilian arena. The study aims to review the changing patterns of penetrating neck injury (PNI) over a period of six years in our major trauma service (MTS).

Methods: This was a retrospective review of all cases of adult patients presenting with PNI to Aintree University Hospital (AUH) between January 2017 and January 2023. Cases were identified through medical coding and review of electronic medical records.

Results: A total of 71 cases of PNIs were identified from January 2017 to January 2023, marking a 13% increase in comparison with previous reports. Presentations due to deliberate self-harm (DSH) rose from 27% to 51%, representing an increase of 89% between the two time frames (p=0.0008), peaking at 77% of total presentations during the first wave of COVID-19. The prevalence of mental health disorders increased by 65% during the six years, reaching peak levels at 92% in the year 2020.

Conclusions: This study highlights the rise of self-inflicted PNI in the context of increasing prevalence of psychiatric disorders, demonstrating the importance of reallocation of healthcare resources for health promotion, prevention and treatment in mental health services.

Background: Musculoskeletal (MSK) conditions affect over 20 million people in the UK. Follow-up appointments account for nearly two-thirds of all outpatient activity. Patient-initiated follow-up (PIFU) allows patients to request follow-up appointments based on clinical need, aiming to reduce unnecessary reviews and optimise service use. This study evaluated the impact and utilisation of PIFU in a secondary care Elective Upper Limb (Shoulder and Elbow) Clinic, focusing on patient engagement, re-presentation rates, and suitability across common upper limb conditions.

Methods: A retrospective service evaluation was conducted over 18 months. Patients discharged under the PIFU pathway were included if they had at least six months' follow-up opportunity. Data collected included diagnosis, treatments received, re-presentation rates and outcomes. Descriptive analysis was used to assess patterns and clinical implications.

Results: Out of 353 consultations, 81 patients (23%) were discharged to PIFU. Among these, 62% were first-time referrals discharged at their initial appointment. Conditions most suitable were rotator cuff-related pain (33%), early glenohumeral arthritis (19%) and adhesive capsulitis (10%). Within six months, only 18% of PIFU patients re-accessed care - just 4.2% of the total cohort. One-third of returning patients required surgery, while the remainder were managed nonoperatively and re-entered the PIFU pathway. PIFU freed approximately 20% of follow-up slots.

Conclusions: PIFU is a safe and effective follow-up model for stable or early-stage shoulder and elbow conditions, reducing outpatient burden, supporting patient autonomy and preserving clinic capacity without compromising care quality. Broader implementation, supported by patient education and structured feedback, may enhance sustainable delivery of orthopaedic services.

Introduction: Balloon sinuplasty is an established technique for treating chronic rhinosinusitis and its role in managing complicated acute rhinosinusitis (ARS) is emerging. Complicated ARS is a potentially life-threatening condition and balloon sinuplasty is not currently a competency required by UK otolaryngology trainees. To our knowledge, we are the first to investigate whether a balloon sinuplasty model simulator was able to improve trainee self-perceived competence.

Methods: A prospective, qualitative-based study was carried out including all candidates attending a national paediatric course rotating through our balloon sinuplasty model simulator station. Candidates returned a questionnaire to evaluate their experience.

Results: Twenty feedback forms were returned. Candidates ranged from core trainees to consultants, with the majority being registrar or senior clinical fellow level (89.4%). Three candidates had previously performed balloon sinuplasty in adults and none in children. The number of candidates rating their understanding of how to perform balloon sinuplasty as ≥7 increased after the simulator experience from 9 of 20 (45%) to 20 of 20 (100%). Following the model simulator experience, 45% felt confident in performing balloon sinuplasty in adult patients and 25% in children. In all, 40% of candidates were confident in using balloon sinuplasty electively and 35% felt they would be able to use it in an emergency procedure.

Conclusions: Surgical confidence in performing balloon sinuplasty is generally low, especially among trainees. A balloon sinuplasty model simulator is able to improve this but further training and hands-on experience is required to facilitate translation of simulation acquired surgical skills to the operating theatre.