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

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.

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.