Recent Submissions

  • Mastitis and Mammary Abscess Management Audit (MAMMA) in the UK and Ireland.

    Parks, Ruth (British Journal of Surgery, 2024-01)
    Background: The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention. Methods: This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical). Results: A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays. Conclusions: Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.
  • A Review and Comparison of the Efficacy of Prophylactic Interventional Radiological Arterial Occlusions in Placenta Accreta Spectrum Patients: A Meta-analysis

    Akbari, Amir R
    Rationale and objectives: Placenta accreta spectrum (PAS) disorders are increasingly common and associated with significant maternal and neonatal morbidity and mortality due to the associated risk of massive haemorrhage. Currently prophylactic interventional radiology (IR) arterial occlusion is being performed occluding either the internal iliac artery (IIA), abdominal aorta (AA) or uterine artery (UA) in order to prevent this blood loss. The aim of this meta-analysis is to identify whether these IR procedures are effective in reducing estimated blood loss (EBL) and hysterectomy rates and if so which method achieves the optimal results METHODS: A literature search was conducted to acquire case-control studies assessing EBL and hysterectomies performed following IR arterial occlusion in PAS patients, yielding 16 results. Studies were analyzed together and later split into groups dependent on the artery occluded. The results of these were then inputted into forest plots to identify their overall estimated effect with confidence intervals. Results: Prophylactic IR arterial occlusion was proven to reduce both EBL and hysterectomies. When separated by artery, IIA achieved the worst outcomes with no proven effect on EBL and a minimal reduction in hysterectomies. UA scored in the middle with a modest reduction in both outcomes, whilst AA occlusion had the most significant reduction in both EBL and hysterectomies. Conclusion: Prophylactic IR arterial occlusion should be routinely considered in PAS patients to reduce both EBL and rates of hysterectomies. Current literature promotes the use of IIA occlusion; however the findings of this analysis propose that AA and UA occlusion should be favoured.
  • Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

    Watson, Nicholas; Gercek, Yuksel; Guy, Kramer; Holden, Douglas; Whysall, Karen (BJS, 2019-01)
    Background: The Clavien-Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien-Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods: This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien-Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results: A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien-Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion: Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.
  • Turning 'waiting lists' for elective surgery into 'preparation lists'

    Selwyn, David (2021-01)
    Waiting lists for surgery are an integral part of the UK National Health Service (NHS); they are used as a construct to ration surgery and to reduce costs, whilst simultaneously attempting to distribute limited health resources in an equitable manner. 1 They are a feature of health services that have central funding, financed mainly through general taxation, and are present in several other European countries including Italy, Greece, and Spain, where there is a need to manage the dynamics of capacity and demand. Waiting lists are rarer in countries that rely on private healthcare provision (including insurance) or rely on funding through social security (e.g. USA, Austria, Germany, and France). 2 Nevertheless, independent of the healthcare system, there is an inevitable period of time between diagnosis of an illness that may be amenable to surgery and admission for elective surgery. It is now acknowledged that this time can be better spent in preparing patients for surgery in order to improve the patients' experience of healthcare (including quality outcomes and satisfaction), improve population/public health, and reduce the per capita costs of healthcare.
  • A safe method to evacuate pneumoperitoneum during laparoscopic surgery in suspected COVID-19 patients.

    Hanbali, N.; Herrod, Philip; Patterson, Jane (http://www.rcseng.ac.uk/publications/annals/, 2020-05)
    The COVID-19 pandemic has introduced new challenges to surgery and protection of staff in the operating theatre. Aerosol and surface viability of the virus has been shown to last at least hours, with viability lasting days on certain surfaces.[ 1] Uncontrolled evacuation of pneumoperitoneum during laparoscopy may pose an increased risk to staff and other patients. This has led to recent intercollegiate guidance advising against the use of laparoscopy unless there is a clear mortality benefit from laparoscopy over open surgery.[ 2] Several solutions have been proposed including gas filters, traps, or careful deflation.[ 2],[ 3] Here, we offer a more efficient method.
  • What is CPOC and why now?

    Selwyn, David (2019-12)
    Clearly almost all organisations and healthcare systems are under pressure and something needs to change. For this reason, in May this year, the Centre for Perioperative Care (CPOC) was created and hosted by the Royal College of Anaesthetists (RCoA). This is a joint venture with the Royal College of Physicians (RCP), the Royal College of Surgeons of England, the Royal College of Nursing, the Royal College of General Practitioners and the Association of Anaesthetists, with a mandate to deliver transformation change across our surgical pathways. I am incredibly proud to have been appointed as CPOC’s inaugural director and believe working together, across our different specialties, we can make real improvements for our patients on their surgical journey and for ourselves in our organisation of traditional surgical pathways.
  • An assessment of ultrasound guided foam sclerotherapy (UGFS) using the Aberdeen Varicose Vein Questionnaire (AVVQ).

    Makhdoomi, Khalid R (2013-10)
    Aims: The effectiveness of ultrasound guided foam sclerotherapy (UGFS) on health-related quality of life (HRQL) in varicose vein treatment is unknown. We evaluated this using the Aberdeen Varicose Vein Questionnaire (AVVQ). Methods: 146 patients with venous disease of clinical severity class 1-6 completed the AVVQ prior to and 6-weeks after UGFS. Paired t-test analysis was performed. Results: Following UGFS there was a significant improvement in HRQL, assessed by AVVQ scoring: mean 20.1 ± SD 11.5 versus 15.3 ± SD 12.1 (p< 0.02). Improvements in pain in the right leg (0.58 vs. 0.31, p< 0.02) and left leg (0.64 vs. 0.4, p=0.007) and ability to perform daily activities (0.7 vs. 0.4, p<0.0001) were evident postoperatively. There was a significant reduction in pruritis bilaterally: right leg (1.3 vs. 0.5, p< 0.0001); left leg (1.0 vs. 0.6, p<0.008). Treatment led to a reduced concern over cosmetic appearance (2.88 vs. 1.91, p=0.0002) and choice of clothing (2.13 vs. 1.91, p=0.02). A significant reduction of analgesic usage, ankle swelling or stocking use was not demonstrated. Conclusion: UGFS is associated with significant improved functional performance and HRQL. A randomised control trial is indicated to compare the long-term clinical outcomes of UGFS with conventional techniques.
  • Preoperative fasting: a clinical audit.

    Roberts, Stuart (2013-01)
    This clinical audit examines the adherence to guidelines suggested by the Royal College of Nursing (2005); the results uphold previous studies of a preoperative starving period for patients undergoing elective surgical procedures. Patients excessively starved of food or fluids report problems relating to their health. These include hunger, distress and complaints of nausea.
  • Use of a venting PEG tube in the management of recurrent acute gastric dilatation associated with Prader-Willi syndrome

    Mohammed, Ahmed M.A. (2016-01)
    A patient with Prader-Willi Syndrome was admitted to the ICU with features of recurrent acute gastric dilatation, aspiration pneumonia and a massive pulmonary embolus. He was initially managed with intubation, assisted ventilation, intravenous fluids and anticoagulation. Decompression of the stomach was achieved with a nasogastric tube. After ventilator weaning, he did not tolerate the nasogastric intubation that led to a further episode of aspiration pneumonia as a result of non-resolving gastric dilatation. He required readmission to intensive care for a further period of ventilatory support. While the patient was sedated and ventilated, a venting percutaneous endoscopic gastrostomy (PEG) with a jejunal feeding extension was placed, permitting both continued decompression of the stomach and enteral feeding. The patient tolerated the PEG-J well and his nutritional needs were successfully addressed. Oral intake was slowly re-established with ongoing decompression of the stomach with the PEG. He was discharged from hospital with the PEG in place.
  • Spontaneous rupture of the spleen as a result of primary splenic lymphoma

    Mohammed, Ahmed M.A.; Majid, Zulqarnain I.; Villatoro, Eduardo A. (2016-01)
    Spontaneous rupture of the spleen is a true surgical emergency that requires immediate management to prevent rapid exsanguination. It occurs mostly as a result of splenic infiltration by infectious or haematological diseases. We present a case of a 79-year-old male who was admitted to our emergency department with 3 days history of feeling unwell, abdominal pain, and dizziness, with no history of trauma. He was hypotensive, but all other observations were within normal limits. Examination revealed abdominal tenderness, mainly on the left side, with no palpable organs or masses. Computed tomography scan showed an abnormal spleen with signs of intraabdominal bleeding; emergency splenectomy was performed successfully. Histological examination showed infiltration of the spleen by diffuse large B cell lymphoma, which was later confirmed to be primary. The patient went through an uneventful post-operative recovery, and remains disease free so far.
  • Small bowel obstruction 5 years following the ingestion of serrated scissors

    Limb, Richard; Karam, Edward (2016-05)
    Ingested foreign bodies are common in the cohort of psychiatric patients, however clinical quiescence in this group is rare. We present a case of a 45-year-old female with emotionally unstable personality disorder (borderline type) presenting with partial intestinal obstruction 5 years after the known ingestion of serrated metallic scissors. In the asymptomatic interim a conservative approach of tracking the blades radiologically was taken. Following discussion, we conclude the following: early surgical intervention is encouraged if natural passage does not occur within 3 days following ingestion, and that any concurrent surgical needs should be addressed at this time.