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

Brunner's gland hamartoma (BGH) is a rare, benign tumour composed of mucin-secreting glands within the duodenal submucosa. Lesions typically range from 0.5 to 1.0cm and are usually managed endoscopically, with larger tumours occurring infrequently. This case involves a 74-year-old woman presenting with syncope. Diagnostic investigations revealed a massive BGH with a 10cm pedicle, accompanied by significant iron deficiency anaemia and intussusception. Although there are no formal, universally established guidelines, literature favours endoscopic removal because of reduced bleeding, a shorter hospital stay and lower cost. However, open surgical resection proved more appropriate owing to the lesion's size and complexity. This case highlights the challenges of managing giant BGHs and supports open surgical intervention when standard methods are unsuccessful.

Objective: Major lower limb amputation is often the final treatment for patients with chronic limb-threatening ischaemia. Postoperative weight loss is a common but under-recognised issue that may affect dosing accuracy for weight-dependent anticoagulants such as low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs). This study assessed the extent of postoperative weight change and the frequency of anticoagulant dose adjustment in routine practice.

Methods: A single-centre retrospective cohort study included patients who underwent above- or below-knee amputation between July 2022 and January 2023. Inclusion criteria were documented pre- and postoperative weights and inpatient prescription of LMWH or DOACs. LMWH was prescribed exclusively as dalteparin and DOAC therapy as edoxaban. Doses were reviewed against British National Formulary weight-based recommendations.

Results: Of 39 patients, 17 met inclusion criteria (median age 69 years; 53% male). Procedures were divided evenly between emergency and elective. The mean postoperative weight loss was 7.5%±2.3% of preoperative body weight. Patients undergoing above-knee amputation lost more weight (mean 8.7kg) than those with below-knee amputation (mean 3.8kg). Two patients (11.8%) required dose adjustments - one on edoxaban after falling below 60kg, and one on dalteparin after dropping from 59.5kg to 55.5kg.

Conclusions: Major amputation is associated with clinically relevant postoperative weight loss, yet anticoagulant dose adjustments were uncommon. Routine postoperative weight monitoring and prompt review of weight-based therapy are recommended to improve dosing accuracy and reduce potential anticoagulation risk.

Introduction: Patient education programmes prior to hip and knee arthroplasty reduce anxiety and create realistic expectations. We describe a 'virtual joint school' (VJS) model and analyse patient feedback and environmental impact.

Methods: Eligible patients first viewed online educational videos, and then attended an interactive virtual session during which knowledge was reinforced. Each session was attended by eight to ten patients along with a relative or friend, and was hosted by a multidisciplinary team consisting of nurses, physiotherapists, occupational therapists and a former patient who provided personal insight. Feedback was obtained prospectively using an electronic questionnaire, and travel savings were calculated using Python software.

Results: From July 2022 to February 2023, 267 patients attended the VJS; of whom 117 (44%) responded to the questionnaire. Among them, 87% found the pre-learning videos helpful and comprehensible, 92% felt their concerns were adequately addressed, 96% felt they had sufficient opportunity to ask questions and 96% were happy with the level of confidentiality involved. Although 83% felt they received sufficient support from the health board to access the virtual session, 63% also took support from family/friends to attend it. Only 15% felt they would have preferred a face-to-face format. By having 'virtual' sessions, each patient saved, on average, 38 miles and 62min of travel (10,070 miles and 274h saved for 267 patients). Each VJS session produced 0.32kg of CO₂ compared with 110kg of CO₂ per face-to-face session.

Conclusions: Virtual joint schools are acceptable to patients and reduce the carbon footprint of healthcare. We recommend their implementation at other arthroplasty centres.

Background: Complications can be devastating for patients, but the 'second victim' phenomenon is increasingly being acknowledged, whereby the surgeons involved in the complication are adversely affected by such complications. For trainees, who are early into their surgical careers and are on a learning curve, such events can be formative or pivotal in their careers. Additionally, as temporary rotating members of the departments they work in, there can often be educational, interpersonal or workplace demands that amplify such effects, and a lack of professional ties that allow them to comfortably discuss complications with temporary or new work colleagues.

Methods: An online questionnaire was designed and distributed to UK Trauma and Orthopaedic trainees. Sixty-five trainees responded from across ten deaneries.

Results: There were significant negative effects of complications on trainees, including sadness (77.8%), anxiety (63.5%), guilt (69.8%) and embarrassment (63.5%). A total of 40.3% reported complications affected them outside of work. Only 60.9% felt well supported. Only 22.2% were offered formal support. In addition, 66.7% have witnessed another trainee struggle after a complication. Only 15.6% felt their training programme adequately prepares them to deal with the emotional impact of complications.

Conclusions: Adverse effects of complications on Trauma and Orthopaedic trainees are a prevalent issue. There are no ubiquitous formal structures in place to support trainees affected by complications. Nonblame, informal debrief sessions were cited repeatedly as beneficial.

Introduction: Renal hyperparathyroidism is a common complication of chronic kidney disease, often requiring parathyroidectomy (PTX) when medical therapy fails. Following surgical intervention, recurrence and postoperative complications, in particular hypocalcaemia, are variable. This study compares post-PTX outcomes between two UK centres, focusing on recurrence rates, length of stay (LOS) and factors influencing postoperative intravenous (IV) calcium administration.

Methods: A retrospective cohort study was conducted across two centres from 2008-2022. Demographic, biochemical, and clinical factors were analysed, with primary outcomes being disease recurrence and postoperative IV calcium requirement.

Results: In total, 114 patients were included: 66 from centre A and 48 from centre B. Some 65.2% underwent total parathyroidectomy in centre A vs 60.4% in centre B. The remainder were subtotal parathyroidectomies. Total recurrence was higher in centre A (34.8%) than centre B (20.8%) and a longer LOS was seen in centre A (median 5.5 days vs 3 days, p = 0.007). IV calcium use was higher in centre B (35.4% vs 24.2%, p = 0.194), although not statistically significant. Predictors of recurrence were limited, with preloading with alfacalcidol being protective in a univariate model (hazard ratio [HR] 0.33, p = 0.005). Higher postoperative phosphate, parathyroid hormone and alkaline phosphate levels were significant predictors of postoperative IV calcium in multivariate analysis (p < 0.05).

Conclusions: Significant differences in recurrence and LOS suggest that preoperative disease burden and perioperative management strategies influence outcomes. The higher recurrence at centre A may be linked to disease severity, while the shorter LOS and higher IV calcium use at centre B may reflect different pre- and postoperative care approaches. These findings highlight the need for careful management and identification of factors which may impact outcomes.

Introduction: Most patients with Crohn's disease (CD) have at least one bowel resection during their lifetime. Patients considering surgery will probably look for information online, as is common practice among patients with chronic illnesses. The aim of this systematic review is to assess the quality and readability of web-based patient information on bowel resection for CD.

Methods: Google was searched using predefined search terms, developed with input from patient experts. For each term, results from the first two pages were screened for eligibility. Patient-focused websites on bowel resection for CD were included. The quality of the information was assessed using the DISCERN tool, and the readability with the Flesch-Kincaid ease of readability (FK) score. The accessibility adjustments of websites were also assessed.

Results: Of the 118 sources identified, 91 were excluded and 27 sources were analysed. One-third (n = 10) did not discuss the different types of resections. Ileocolic resection (the most commonly performed resection) was described in eight sources. Discussion of management post-resection (n = 6) and of lifestyle changes (n = 11) was sparse. There were some instances of factually incorrect information. The mean DISCERN score was 3.1 ± 0.80 (range 1-5), indicating moderate quality information. The mean FK score was 51.9 ± 8.70 (corresponding to patients requiring A levels or equivalent to fully understand the text).

Conclusions: The study findings highlighted the limitations of the current online patient information surrounding bowel resection in CD. The involvement of patients, working alongside professional bodies and clinicians, in the development of health-related websites is recommended.