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

Rhabdomyosarcoma (RMS) is a form of soft tissue sarcoma that can arise from muscle or fibrous tissue almost anywhere in the body. The two major subtypes of RMS are alveolar and embryonal, whereas the two rarer subtypes are pleomorphic, which typically occurs in adults, and the spindle cell/sclerosing variant, typically seen in children. RMS usually involves the extremities, the head and neck or the genitourinary system. Although it can arise from anywhere in the body, other sites of involvement are rare and usually present only at an advanced stage owing to a mass effect on surrounding tissues and organs. We present a rare case of a child who presented with the signs and symptoms of an acute abdomen, but intraoperatively was found to have a bleeding necrotic mass arising from the anterior abdominal wall. This was histologically confirmed to be a RMS of the embryonal type.

Introduction: The number of bariatric operations is increasing each year. Sleeve gastrectomy is the most popular procedure; however, it often requires revision surgery because of insufficient weight loss, weight regain or gastro-oesophageal reflux disease (GORD). The most popular revisional procedures are Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB). The primary outcome of this meta-analysis was weight loss after revisional surgery following laparoscopic sleeve gastrectomy and the secondary outcomes were gastro-oesophageal reflux, BMI difference, operative time, bleeding and anastomotic leak.

Methods: A systematic electronic search was undertaken using PubMed, MEDLINE, Ovid, Cochrane Library and Google Scholar following PRISMA guidelines. The initial search identified 2,546 articles. After screening, seven papers met the inclusion criteria: six retrospective studies and one randomised controlled trial.

Results: In total, 802 patients met the inclusion criteria: 390 had an OAGB and a further 412 had an RYBG. All patients previously had a sleeve gastrectomy for weight loss. The length of follow-up was 12 months for our primary outcome. We found no statistically significant difference in excess weight loss (%EWL) between OAGB and RYGB (p = 0.11). The incidence of postoperative reflux was statistically significantly higher in the OAGB group (16% vs 10.1%, p < 0.003). Operative time was statistically significantly lower in the OAGB group (p = 0.04).

Conclusions: This meta-analysis showed no statistically significant difference between the two revision bariatric surgery procedures for %EWL. RYGB was superior to OAGB in reducing the incidence of symptomatic GORD, whereas OAGB had a significant shorter operative time.

Our aim was to investigate the effectiveness of navigated transcranial magnetic stimulation (nTMS) brain mapping to characterise preoperative motor impairment caused by an intradural extramedullary (IDEM) tumour and postoperative cortical functional reorganisation. Preoperative and 1-year follow-up clinical, radiological and nTMS data from a case of thoracic spinal meningioma that underwent surgical resection of the lesion were collected and compared. A 67-year-old patient presented with severe progressive thoracic myelopathy (hypertonic paraparesis, clonus, insensate urinary retention) secondary to an IDEM tumour. Initial nTMS assessment showed bilateral upper limb representation with no positive responses for both lower limbs. He underwent successful surgical resection for his IDEM (meningioma WHO grade 1). At 1-year follow-up, the patient's gait was improved and his bladder function normalised. nTMS documented positive responses for both upper and lower limbs and a decrease in the area (right side: 1.01 vs 0.39cm²; left side: 1.92 vs 0.81cm²) and volume (right side: 344.2 vs 42.4uVcm²; left side: 467.1 vs 119uVcm²) of cortical activation for both upper limbs, suggesting a functional reorganisation of the motor areas after tumour resection. nTMS motor mapping and derived metrics can characterise preoperative motor deficit and cortical plasticity during follow-up after IDEM resection.

Introduction: Time-to-theatre (TTT) is a key performance indicator of theatre efficiency and delayed TTT incurs significant costs and poor clinical outcomes. An increasing Irish population in conjunction with an ageing population puts increasing pressure on emergency surgical services across Ireland. We examined our institution's experience with introducing a second emergency theatre and semi-elective theatre lists for acute surgical patients.

Methods: A retrospective review of electronic, prospectively maintained databases was performed between 1 February 2018 and 31 January 2020. A cost analysis was conducted to assess the economic impact of delayed TTT. The cost-saving benefit of introducing a second emergency theatre and semi-elective Kaizen lists was then calculated and compared with 2012-2014 figures from our institution.

Results: In total, 6,679 procedures were performed. Overall mean TTT was 16h, 10h shorter than before the introduction of a second emergency theatre and Kaizen theatre lists (p < 0.001). Patients aged >65 years, who are historically a significantly disadvantaged group, had a shorter TTT following the introduction of a second emergency theatre. The economic advantage of a second emergency theatre resulted in a cost saving of €3,674,538 over 24 months.

Conclusion: Investment in emergency surgical services resulted in more efficient access to emergency theatres. There was a reduction in out-of-hours operating across all specialties and across the more at-risk groups such as those over the age of 65, who had an overall reduction in TTT. This had significant financial benefits and likely reduced the clinical risk associated with delayed TTT and out-of-hours operating.

Introduction: Postoperative surgical hypoparathyroidism (PoSH) following thyroid surgery is an established complication. Several predictive factors have been identified including perioperative parathyroid hormone (PTH) levels. The aim of the study is to compare the drop in perioperative PTH to postoperative day 1 PTH in predicting hypocalcaemia and hypoparathyroidism.

Methods: Records of consecutive patients who had either total or completion thyroidectomy with or without central neck dissection in a 3-year period in a single thyroid surgery unit were accessed to retrieve data on demographics, pathology, surgery, perioperative biochemistry and management.

Results: Of 295 included patients, there were 227 (76.9%) females. Forty-five (15.3%) had completion thyroidectomy, and the rest had total thyroidectomy. Seventy-eight (26.4%) had concomitant central neck dissection. Sixty-four (21.7%) had hypocalcaemia on the day after surgery. Hypoparathyroidism persisted in 10.5% of patients at 6 months. Both day 1 PTH and a drop in PTH predicted day 1 hypocalcaemia (p < 0.001) and 6-month hypoparathyroidism (p < 0.001). The area under the receiver operating characteristic (ROC) curves for day 1 PTH and drop in PTH for the prediction of day 1 hypocalcaemia (0.729 vs 0.726, respectively) and for 6-month hypoparathyroidism (0.964 vs 0.958, respectively) were similar, albeit slightly better for day 1 PTH.

Conclusions: Day 1 PTH is equivalent to (if not better than) drop in PTH in predicting short- and long-term PoSH. Preoperative PTH measurements may not be needed in the detection and/or management of PoSH after thyroid surgery.

Introduction: Total duct excision (TDE) is performed for the diagnosis and management of nipple discharge. The Association of Breast Surgery's recent guidelines recommend considering diagnostic surgery for single-duct, blood-stained or clear nipple discharge, and for symptomatic management.

Methods: We retrospectively reviewed the diagnostic and surgical outcomes of all cases of TDE between January 2013 and November 2019.

Results: In total, 259 TDEs were carried out: 219 for nipple discharge, 29 for recurrent mastitis, 3 for screening abnormalities and 8 for breast lumps. Of the nipple discharge group, 121 had blood-stained discharge. Mean patient age was 52 years (range 19-81). Median follow-up time was 45 months (interquartile range 24-63). The following cases were identified on histopathology: 236 benign breast changes, 10 atypical ductal hyperplasia, 4 lobular carcinoma in situ, 2 low-grade ductal carcinoma in situ (DCIS), 3 intermediate-grade DCIS, 2 high-grade DCIS and 2 invasive ductal carcinomas. In total, 3.5% of patients who underwent TDE had a diagnosis of DCIS or invasive carcinoma. Blood-stained discharge was associated with a significant increase in risk of DCIS or carcinoma compared with other nipple discharge colours (p = 0.043). The most common complications of TDE were infection, poor wound healing and haematoma. Nipple discharge recurred in 14.2% of cases.

Conclusions: TDE can be considered for the diagnostics and management of nipple discharge. Blood-stained nipple discharge increases the risk of DCIS or malignancy, but the majority of the time TDE reveals benign breast pathology.

Introduction: Faecal immunochemical testing (FIT) has been adopted to identify patients requiring further investigations on the colorectal cancer (CRC) referral pathway. We aimed to investigate the effect of antiplatelet and anticoagulant drugs on the accuracy of FIT results.

Methods: This observational study categorised patients with suspected CRC symptoms, who completed both FIT and colonic investigations, into two groups (control and exposed) based on their use of antiplatelet and anticoagulant drugs. Two-by-two tables and receiver operating characteristic (ROC) curve analysis were used to determine accuracy.

Results: A total of 928 patients were divided into a control (n=683) and an exposed group (n=245). A nonsignificant higher proportion of patients tested positive in the exposed group (24.1% vs 18.4%, p=0.063). For detection of CRC, improved sensitivity of 87% vs 81.2%, specificity of 84.8% vs 79.9% and negative predictive value of 99.2% vs 98.3% was calculated in the control vs exposed groups, respectively. The positive predictive value was comparable between the two groups (21.4% vs 22% in the control and exposed groups, respectively). In ROC analysis, there was no difference between the groups (AUC 90% vs 87%, p=0.56). The use of antiplatelet and anticoagulant drugs did not increase the risk of positive FIT results on multivariate logistic regression analysis.

Conclusions: FIT accuracy for CRC detection remained unaffected despite more patients testing positive in the exposed group. FIT should be considered a supplementary tool for triage. Antiplatelet and anticoagulant drugs do not need to be discontinued before collection of FIT.

Introduction: Healthcare contributes more than 1% of all domestic waste in the United Kingdom (UK), with operating theatre waste alone accounting for approximately 50% of all hospital waste. In November 2022, the UK Surgical Royal Colleges issued an Intercollegiate Climate Emergency Declaration and called for urgent action. We review waste production and the recyclability of surgical instrument packaging used in a common ear, nose and throat procedure (thyroidectomy) and suggest strategies to make this surgery more sustainable,. These strategies can be generalised to other surgeries.

Methods: We prospectively audited packaging waste from 20 thyroidectomies performed at the Royal Marsden Hospital in the UK between July and December 2022. All packaging was weighed, categorised and analysed after the operation.

Results: On average, each thyroidectomy produced packaging waste comprising 183g (34%) of plain paper/cardboard, 167g (31%) of soft plastic film, 142g (26%) of laminated paper, 37g (7%) of hard plastic and 11g (2%) of metal foil. Of all the packaging collected, only one item had a recycling label. When extrapolated to the 7,851 thyroidectomies performed in the National Health Service during the fiscal year 2021/2022, the estimated total weight of packaging waste would be 4.2 tonnes, of which only 31.4kg would be indicated as recyclable. When converted to an estimated carbon footprint, total carbon emissions would be 1,048kg CO₂e, equivalent to three round trips from London to Edinburgh in a petrol car.

Conclusion: This audit demonstrates the different categories and vast amount of packaging waste from a common operation. Manufacturers should place clear recyclability labels on packaging, and switch to recyclable materials and a digital information booklet where possible. Local waste audit and analysis can be simple first steps towards making surgery more sustainable.

The Foley catheter is one of the most commonly used devices in modern surgical practice. Developed for draining the urinary bladder, this humble catheter has been employed for many other purposes ranging from urine output monitoring to complex urological investigations. Over time, it has evolved into being applied in more complex and innovative ways in various other specialties apart from urology. In this review article, we describe some of the common and novel uses of this deceptively simple device, and discuss the scope of its application in modern medicine.

Tension pneumocephalus (TP) after spinal surgery is very rare with only a few cases reported in the English literature. Most cases of TP occur rapidly after spinal surgery. Traditionally, TP is managed using burr holes to relieve intracranial pressure. However, our case highlights a rare delayed presentation of TP and pneumorrhacis 1 month after routine cervical spine surgery. It is to our knowledge the first case of TP after spinal surgery to be treated using dural repair and supportive care. A 75-year-old woman presented with TP after having routine cervical decompression and stabilisation for cervical myelopathy. She re-presented 1 month after her initial operation with a leaking wound and altered mental status, which deteriorated rapidly shortly after admission. This, in combination with her radiographic features, influenced the decision to explore her surgical wound emergently. She made a full recovery and was discharged after 2 weeks in hospital. We hope to emphasise the need for a high index of suspicion for cerebrospinal fluid leaks and the low threshold to return to theatre to repair a potential dural defect, as well as illustrate that TP after spinal surgery can be treated successfully without burr holes.