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

Introduction: Oral and maxillofacial surgery (OMFS) is a surgical specialty dealing with a broad spectrum of pathology affecting the head and neck. Despite a rising burden of head and neck conditions, exposure to OMFS in the undergraduate medical curriculum remains limited. This has consequences for medical undergraduates' competence and confidence in managing related conditions and their recruitment into this specialty.

Methods: A literature search was conducted in September 2024 on Pubmed, Dynamed, DARE, EMBASE, Cochrane and BMJ electronic databases for articles published between 1970 and 2024. The review was registered with PROSPERO (CRD42024556491).

Results: Ten studies involving 2,499 participants were included. Only 33.1% of students had experience in OMFS, with variations in exposure type ranging from formal teaching sessions to clinical placements. Most exposures were brief, typically less than a week, and often did not extend beyond basic lectures or shadowing. A notable proportion of students expressed a desire for more comprehensive training in OMFS. Only 12.8-37% of participants were considering a career in OMFS. Low interest rates were attributed to dual qualification requirements, cost and duration of training.

Conclusions: The findings highlight a major gap in OMFS education delivered by medical schools. This is concerning given that OMFS in the UK is struggling to fill higher surgical training posts. If interest in the profession remains low, we may encounter a recruitment and workforce crisis. Future strategies must focus on meaningful opportunities to increase OMFS experience in the medical curriculum while addressing other barriers to recruitment and retention.

Introduction: During consent, surgeons discuss surgical and anaesthetic risks with patients. We investigated whether patients also wish to be informed about hospital organisational risks.

Methods: We used a cross-sectional survey. A questionnaire with three real-life scenarios of hospital organisational problems likely to increase the risk of surgery was given to 1,003 patients in neurosurgical departments of three United Kingdom (UK) teaching hospitals. The scenarios were: (1) computer failure in the operating room; (2) lack of surgical equipment; and (3) bed shortage or lack of operating capacity causing postponement of surgery. We quantified how strongly participants wish to be informed about organisational risks, whether this information alters a patient's decision to have surgery, and the desire of patients to discuss these risks further.

Results: In total, 980 of 1,003 (97.7%) questionnaires were returned and 84.3%-88.5% of patients wished to be informed about hospital organisational risks - more women than men (odds ratio [OR] 1.6-1.8, p < 0.05). Knowledge of the hospital organisational risks would influence 69.2%-70.4% of participants' decisions to have surgery; 74.9%-78.3% of participants wished to discuss the organisational risks with surgeons and 50.0%-60.8% with hospital managers before surgery. Some 69.4% of patients were concerned about organisational risks vs 77.1% who were concerned about surgical risks.

Conclusions: Most neurosurgery patients consider hospital organisational risks to be material. To comply with the Montgomery ruling in UK medicolegal case law, neurosurgeons and hospital managers should discuss with patients the organisational risks in addition to the surgical and anaesthetic risks during consent.

Introduction: Oncotype-DX testing has reduced adjuvant chemotherapy use in breast cancer but there is limited evidence on patients with sentinel lymph node micrometastasis (SLNmi). This study aimed to evaluate the real-world use of Oncotype-DX testing on adjuvant chemotherapy decision-making in patients with SLNmi.

Methods: This retrospective cohort analysis included ER-positive, HER2-negative patients with SLNmi treated during 2016-2022 at a tertiary care hospital. A three-member simulated multidisciplinary team (MDT) panel, who were blinded to the Oncotype recurrence score (RS), made chemotherapy recommendations using clinicopathological data and PREDICT scores. The simulated MDT recommendations were then compared with the Oncotype RS. RS≥26 was used to identify patients who would benefit from adjuvant chemotherapy.

Results: A total of 77 patients (median age 58 years) were included. Most (69%) patients underwent breast conservation. Most tumours (71%) were ductal, Grade 2 (68%); 39% had lymphovascular invasion. Median tumour size was 23mm. Median number of SLNs excised was 2; the median Oncotype RS was 16 (range 0-45). Six patients had RS≥26; all were recommended for chemotherapy by the simulated MDT. Of the 71 patients with RS ≤25, the simulated MDT recommended chemotherapy in 19 (27%), a personalised chemotherapy discussion in 35 (49%) and no chemotherapy in 17 (24%). Thus, 76% of these patients had a change in management with Oncotype-DX, avoiding a recommendation or a discussion regarding chemotherapy.

Conclusions: This real-world analysis found that Oncotype-DX aids adjuvant treatment decision making in patients with SLNmi, changing the recommendation to give chemotherapy in up to 76% of the cohort.

Introduction: We aimed to investigate the effect of unplanned conversion to open surgery during laparoscopic pancreaticoduodenectomy on resection margins and complications.

Methods: A systematic review and meta-analysis (proportion and comparison models) with meta-regression using random-effects modelling compliant with PRISMA statement standards was conducted. All studies with a minimum sample size of 15 patients reporting conversion to open surgery in patients undergoing laparoscopic pancreaticoduodenectomy were included. The outcomes included R0 resection, Clavien-Dindo ≥3 complications, and 30-day mortality.

Findings: A total of 44 studies comprising 6,108 patients were included. Conversion occurred in 11.3% (95% confidence interval (CI) 9.1-13.5). The reason for conversion was bleeding in 27.9% (16.3-39.5%), technical difficulties in 46.5% (95% CI 33.7-59.4), oncological concerns in 29.2% (95% CI 18.2-40.2) and iatrogenic injuries in 7.7% (95% CI 3.4-12.1). Multivariable meta-regression analysis showed that conversion did not affect R0 resection (coefficient: -0.228, p=0.307), Clavien-Dindo ≥3 complications (coefficient: 0.129, p=0.609) and 30-day mortality (coefficient: -0.013, p=0.647). The outcomes were not affected by the reasons for conversion. Comparison meta-analysis showed that conversion does not affect R0 resection (risk difference (RD): -0.07, 95% CI -0.17-0.03, p=0.18), Clavien-Dindo ≥3 complications (odds ratio: 2.17, 95% CI 0.67-6.99, p=0.20) and 30-day mortality (RD: 0.02, 95% CI -0.04-0.07, p=0.57).

Conclusions: Unplanned conversion to open surgery, regardless of the reason for conversion, may not affect resection margins and complications in laparoscopic pancreaticoduodenectomy (moderate certainty). Conversion during laparoscopic pancreaticoduodenectomy should not be seen as a failure because it has no negative impact on outcomes; however, not converting when indicated will undoubtedly have negative impact.

Introduction: Abdominal wall reconstruction (AWR) is increasingly recognised as a subspecialty in general surgery, owing to the growing complexity and advancement of hernia repair techniques. Concerns have been raised among UK hernia specialists about current surgical training adequately preparing trainees for both simple and complex hernia procedures.

Methods: A CHERRIES-compliant survey was developed by a panel of hernia experts to evaluate UK training in hernia surgery. The 41-item questionnaire assessed perceived competence and confidence in performing eight types of hernia repair, categorised as simple (primary inguinal, umbilical, laparoscopic inguinal and Rives-Stoppa) or complex (recurrent inguinal, component separation and parastomal hernia repair), along with broader AWR-related topics (open abdomen management, participation in multidisciplinary meetings). The survey was disseminated via social media, targeted chat groups and surgical conferences.

Results: The survey was conducted from 21 January to 27 September 2024. Of approximately 500 possible respondents, 116 completed the survey (47 surgical trainees (ST) 7-8s, 30 clinical fellows and 34 consultants), yielding an estimated 22.2% response rate. Curriculum requirements were met only for open inguinal and umbilical hernia repair. Although there are no formal curriculum requirements for complex repairs, trainee exposure remains limited; two-thirds had performed fewer than ten recurrent inguinal or component separation procedures. For parastomal hernias, confidence was highest with suture repair despite these being associated with poor outcomes. Overall, median confidence scores were highest for simple repairs and lowest for complex ones.

Conclusions: Current UK surgical training provides inadequate exposure to complex AWR, highlighting the need for targeted curriculum improvement.

Partial nephrectomy for small renal masses is well established as the preferred means of surgical treatment for kidney cancer, to preserve renal function. Although minimally invasive techniques are now standard in many countries, open surgery remains an important technique for difficult cases. Partial nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is challenging and not widely reported. We describe the open surgical technique for partial nephrectomy in patients with multicystic kidneys who are not on renal replacement therapy (RRT). We illustrate the technique using three cases of patients with multicystic kidneys and solid renal masses. All had early chronic kidney disease, making partial nephrectomy for suspected kidney cancer the preferred strategy. The patients had stable creatinine and were recurrence-free at last follow-up. Open partial nephrectomy remains an important surgical technique for resection of challenging kidney tumours, such as those in multicystic kidneys. Patients with ADPKD and solid renal masses who are not on RRT should be managed in the same manner as the background population, with nephron-sparing surgery wherever possible.

Introduction: Emergency obstructed hernias pose a significant clinical challenge and can lead to higher complication rates, prolonged recovery, bowel resection and recurrence. Early diagnosis, urgent surgical intervention and appropriate antimicrobial prophylaxis are key. Our study aimed to describe the impact of national lockdowns on emergency obstructed hernia admissions and the effect on patient demographics and compliance with recommendation rates. Should another lockdown be in place in the future this could help us prepare plans for appropriate care and service provision.

Methods: Patient records for those who received emergency surgery on obstructed hernias at a single site during the three COVID-19 lockdown periods in England were reviewed and underwent thematic analysis. A temporal comparison was undertaken, and 105 patients met the inclusion criteria.

Results: There were no significant differences in age, American Society of Anesthesiologists (ASA) grade and length of stay. The mean duration of symptoms was 1,307 ± 1,779 days in the lockdown group vs 215 ± 593 days in the control group (p < 0.005). Long-standing hernias were the primary reason for admission in the lockdown group compared with 'other medical issues' in the control group. Both the 7-day (7.5% vs 4.6%; p < 0.05) and 30-day (10.0% vs 7.7%; p < 0.05) re-admission rates were higher in the lockdown group than the control group.

Conclusions: This study suggests that more patients presented in obstruction and as an emergency with long-standing hernias during the COVID-19 lockdown. We recommend enacting adequate postoperative follow-up to reduce higher rates of re-admission, and better patient education or discussions with primary care to ensure adequate forward referrals of hernias.

Extramedullary plasmacytoma is a rare type of tumour consisting of monoclonal plasma cells found in soft tissues. Breast plasmacytomas account for less than 1% of all breast neoplasms. Breast plasmacytomas are challenging to identify on imaging due to nonspecific features. Their rarity as a cause of breast lump presents a management challenge to breast clinicians. Official guidance on management in the breast is lacking. We report a case of a 100-year-old woman who was diagnosed with multiple extramedullary plasmacytomas after an incidental finding of a right breast mass on a CT scan.