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

Introduction: Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

Methods: This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

Results: Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

Conclusion: A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

Introduction: Laparoscopic fundoplication remains the standard treatment for patients with severe gastro-oesophageal reflux disease (GORD). Multiple randomised controlled trials (RCTs) have compared the two most commonly performed surgical techniques, total and posterior partial fundoplication (Nissen [NF] and Toupet [TF]), in terms of symptom control and treatment failure in patients without subsequent dysmotility disorders. We aimed to conduct a systematic review and meta-analysis of these two techniques with regard to the long-term effect on reflux control and associated dysphagia.

Methods: The MEDLINE^®, Embase^®, PubMed^® and Cochrane Library databases were searched, and all the relevant published RCTs were shortlisted according to the inclusion criteria. The summated outcomes of long-term results relating to the recurrence of GORD and dysphagia were evaluated in a meta-analysis using RevMan software.

Results: Eight studies (all RCTs) on 1,545 patients undergoing NF or TF were eligible for inclusion in this meta-analysis. There were 799 patients in the NF group and 746 in the TF group. In the random effects model analysis, the incidence of long-term recurrence of GORD was not statistically different between the NF and TF cohorts (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.34-1.41, z=1.01, p=0.31). However, the incidence of long-term dysphagia was statistically lower in the TF group (OR: 2.92, 95% CI: 1.49-5.72, z=3.13, p=0.002) with low between-study heterogeneity (I²=0%).

Conclusions: The findings of this systematic review and meta-analysis on symptomatic GORD appear to be in favour of partial posterior fundoplication (TF) as the optimal treatment. It provides equivalent outcomes in reflux symptom control with a lower risk of postoperative dysphagia compared with total fundoplication (NF).

CORESS is an independent charity, supported by AXA Health, the MDU and the Kirby Laing Foundation. We are grateful to those who have provided the material for these reports. The online reporting form is available via the CORESS app and on the website (coress.org.uk), which also includes previous Feedback reports. Published cases are acknowledged by a Certificate of Contribution, which may be included in the contributor's record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Contributions from surgeons in training are particularly welcome.

Background: Patients with an intestinal emergency who do not have surgery are poorly characterised. This study used electronic healthcare records to provide a rapid insight into the number of patients admitted with an intestinal emergency and compare short-term outcomes for non-operative and operative management.

Methods: A single-centre retrospective cohort study was conducted at a tertiary NHS hospital (from 1 December 2013 to 31 January 2020). Patients were identified using diagnosis codes for intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit. Relevant data were extracted from electronic healthcare records (n=3,997).

Results: Nearly half of patients admitted with an intestinal emergency received nonoperative management (43.7%). Of those who underwent surgery, 63.7% were started laparoscopically. The non-operative group had a shorter hospital stay (median: 5.4 days vs 8.2 days [started laparoscopically] or 16.8 days [started open]) and fewer unintended intensive care admissions than the surgical group (2.4% vs 8.7% [started laparoscopically] 21.1% [started open]). However, 30-day mortality for non-operative treatment was double that for surgery (22.4% vs 10.1%). The 30-day mortality rate was found to be even higher for non-operative management (50.3%) compared with surgery (19.5%) in a sub-analysis of patients with admission National Early Warning Score ≥4 (n=683).

Conclusion: The proportion of patients with intestinal emergencies who do not have surgery is greater than expected, and it appears that many respond well to non-operative treatment. However, 30-day mortality for non-operative management was high, and the low number of admissions to intensive care suggests that major invasive treatment was not appropriate for most in this group.

Introduction: Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

Methods: A systematic search of the literature was undertaken using the Medline^®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

Results: A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

Conclusions: This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Introduction: The aim of this study was to investigate the effect of body mass index (BMI, kg/m²) on outcomes of high-volume low-complexity (HVLC) general surgery procedures and to determine critical values for BMI when selecting patients into HVLC programmes.

Methods: A systematic review was conducted of studies looking at patients in different BMI categories undergoing HVLC general surgery procedures (laparoscopic cholecystectomy, inguinal hernia repair and umbilical or paraumbilical hernia repair), in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A comparison meta-analysis model was constructed to compare the outcomes using random-effects modelling. The QUIPS (Quality In Prognosis Studies) tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) system were used to assess bias.

Results: A total of 26 studies including 486,392 patients were examined. In laparoscopic cholecystectomy, BMI ≥40 was associated with higher conversion to open surgery (odds ratio [OR]: 1.33, p=0.040) but did not affect complications (OR: 0.69, p=0.400) or length of hospital stay (mean difference [MD]: -0.01 days, p=0.900). In inguinal hernia repair, BMI ≥35 was associated with longer operative time (MD: 18.00 minutes, p<0.00001), and higher risk of wound complications (OR: 3.01, p<0.00001) and hospital readmission (OR: 1.46, p=0.0008). In umbilical or paraumbilical hernia repair, BMI ≥30 was associated with higher risk of wound complications (OR: 6.45, p<0.0001) and hospital readmission (OR: 5.56, p<0.00001), and longer operative time (MD: 4.01 minutes, p=0.030).

Conclusions: Obesity was associated with longer operative time (up to 23 minutes) and higher risk of postoperative morbidity (up to 4-fold) in HVLC procedures. BMI <40 (moderate GRADE certainty - laparoscopic cholecystectomy) and BMI <35 (moderate GRADE certainty - inguinal hernia) appear to represent optimal critical values for perioperative safety metrics.

Introduction: Wounds are invariably dressed postoperatively but the evidence for the timing of dressing changes is limited. This meta-analysis evaluated whether the relative risk of wound infection varies depending on when dressings are changed.

Methods: A frequentist random-effects network meta-analysis was conducted on the results of a systematic review of the MEDLINE^®, Ovid^®, Scopus^®, Web of Science™ and PubMed^® databases and the Cochrane Central Register of Controlled Trials performed in May 2023. Evidence quality was graded using the Confidence In Network Meta-Analysis tool.

Results: A total of 4 studies were included with 878 patients. A significant increase in the relative risk of wound infection was found when dressings were left in situ for more than 4.5 days when compared with 48 hours (3.18, 95% confidence interval: 1.22-8.33). There were no significant differences in the relative risk of infection between the other groups. Model heterogeneity and inconsistency were insignificant (Cochran's Q: 0.44, p=0.51). The quality of the evidence was graded as generally very low and risk of bias evaluations showed it to be of high concern for bias.

Conclusions: Late dressing changes significantly increase the risks of wound infection and changes at 48 hours minimise these risks. There was no advantage demonstrated for earlier dressing changes. Ensuring that dressings are changed appropriately can minimise patient harm and health service costs.

Introduction: A multidisciplinary team (MDT) approach to polytrauma patients minimises morbidity and mortality. This project assesses the extent to which British Orthopaedic Association Standards for Trauma guidelines for the management of the frail Orthopaedic patient are currently being met.

Methods: A retrospective analysis was performed of all Trauma and Orthopaedic patients in multiple medical institutions over a 2-week capture period from 1 March 2022 until 14 March 2022 inclusive. Data collected included age, sex, injury, length of stay and dates of speciality input.

Results: A total of 1,050 patients were included from 27 hospitals. The median age was 80 years, with 560 (53.3%) of all fractures being neck of femur fractures. Of the 1,050 patients, 870 (82.9%) were managed operatively. The median number of different speciality involvements was 3; 645 (61.4%) had an orthogeriatric (OG) review. In major trauma centres (MTC), 93.3% had OG input, compared with 66.3% in non-MTC. The speciality with the greatest input was Radiology, with Plastics having the lowest input.

Conclusion: A standardised MDT approach is needed to optimise care and recovery in orthopaedic trauma patients. The difference in results regarding speciality involvement is substantial and needs to be addressed to minimise disparities in care received by this vulnerable cohort of patients.