Staff Publication

Boat propeller transection of hemithorax-successful multidisciplinary surgical reconstruction (2020)

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Type of publication:
Conference abstract

Author(s):
*Cheruvu S.; Oo K.T.M.; Erel E.; Satur C.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 37

Abstract:
A 69 year old man fell into canal and was drawn into the propeller of his canal boat that resulted in transection of the right thoracic cavity and the right upper arm. Emergency helicopter transfer was made to our major trauma centre for multidisciplinary surgical care. Injuries included a full thickness antero-posterior transection from the sternum to beyond the tip of the scapula, and an open right midshaft humeral fracture with wound extending obliquely into the axilla. The entire thoracic cavity was contaminated by canal water. There was severe haemodynamic and cardiorespiratory compromise requiring level 3 intensive care. Following emergency resuscitative management, multidisciplinary surgical care was provided by the cardiothoracic, plastic and orthopaedic surgery teams utilising innovative operative techniques. Multistage operative management of chest wall required initial damage control surgery with debridement and negative pressure therapy. After 4 days of intensive care physiological stabilisation, reconstruction of the thoracic defect was undertaken with specialist thoracic titanium implants and the chest wall was reconstructed. This was a major thoracic trauma case treated successfully using revolutionary surgical techniques at the Royal Stoke Hospital. The subsequent impact on practice for thoracic polytrauma has led to improved survival rates by 75%.

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Assessing the adequacy of radiographs for hip fractures (2020)

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Type of publication:
Conference abstract

Author(s):
*Mulrain J.; *Omar N.; *Burston B.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 138

Abstract:
Aim: Radiographs for the assessment of femoral neck fractures are frequently inadequate for the visualisation of the proximal femur. A low centred radiograph of both hips offers enough information but is rarely achieved.We sought to determine the proportion of hip fractures where initial radiographs adequately visualised the femur to encompass the proposed surgical management.We also sought to find the proportion of patients who required repeat radiographs and whether this was affected by time of presentation. Method(s): A retrospective review of the radiographs of hip fractures presenting to our institution, over a three-month period was undertaken. The timings, number and adequacy of radiographs was assessed. Result(s): Radiographs of 89 patients were reviewed. Most radiographs were taken between 8am and 5pm. Radiographs of 58 patients were centred on the pelvis rather than the hips. Patients presenting overnight were more likely to have adequate radiographs. Despite a duplicate x-ray rate of 48%, most patients (55%) had inadequate visualisation of the proximal femur. The average excess radiation exposure by duplicate radiographs was 2.31mSv per patient. Conclusion(s): The majority of patients had inadequate visualisation of the fractured proximal femur on their radiographs.Many had excessive radiographs performed. This was not improved by increased staffing levels during daylight hours.

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Acute appendicitis-can we shorten the length of hospital stay? (2020)

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Type of publication:
Conference abstract

Author(s):
British Journal of Surgery; Jun 2020; vol. 107 ; p. 197

Citation:
*Jones G.; *Bura K.; *Rink J.

Abstract:
Introduction: Appendicectomy is the most commonly performed emergency general surgical operation in the UK. Hospital episode data revealed that our unit had longer than average length of stay (LOS). We designed a study to examine our length of stay and management of acute appendicitis. Method(s): We performed a retrospective study of consecutive patients undergoing appendicectomy from January to March 2019. Cases were identified from theatre logbooks. Data collection included demographics, pre and post-operative LOS, CT imaging and histology. The data was then examined to see what factors were associated with length of stay and where improvements might be realised. Result(s): 71 patients were identified. Mean LOS was 81 hours, mean time to theatre from admission was 22 hours withmean post-operative LOS at 58 hours. There was a difference between females vs males LOS 95 vs 67 hours. CT scan was obtained in 26 patients and the mean time to theatre in these patients was longer at 27 hours compared to 20 hours in the non- CT group. Patients who took longer to get to theatre had increased LOS. Conclusion(s): Rapid access to CT could shorten time to theatre. Getting patients to theatre quicker might shorten post-operative length of stay.

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Regional experiences of endotracheal intubation during the COVID-19 pandemic in The United Kingdom (2020)

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Type of publication:
Conference abstract

Author(s):
Shuker B.; Smith E.; *Checketts P.; Khan Q.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: In the United Kingdom (UK), consensus guidelines for airway management were published early in the COVID-19 pandemic making recommendations to support clinicians during this potentially challenging intervention (1). Adaptions to existing guidance for airway management in critically ill adults from the Difficult Airway Society (2) included: use of personal protective equipment (PPE), preferential use of the best skilled airway manager to maximise chance of first-pass success, avoidance of aerosol-generating procedures (such as noninvasive ventilation, high flow nasal oxygenation), and use of reliable well practiced techniques (including videolaryngoscopy where appropriate). Objective(s): Areas of the West Midlands were some of the worst affected by the COVID-19 pandemic in the UK (3). We aimed to gain insight into the experiences of clinicians involved with airway management during the COVID-19 pandemic in this region. Method(s): An online survey was distributed to multiple centres within the West Midlands region of the UK. Clinicians who had experience of endotracheal intubation in patients with confirmed, suspected, or unknown COVID-19 status were asked to reflect upon their experience of one patient intubation. Result(s): 127 clinicians from 16 hospitals including 3 large university hospitals responded to the online survey, most were consultant grade (56.7%). Clinicians self-reported an average approximate number of pandemic intubations of 7.35 (range 1-30). When asked to reflect on a single intubation, clinicians reflected on intubations in ICU (42.5%), emergency departments (20.5%), wards (8.7%), and theatre (28.3%). Appropriate PPE was available in 96.1%. The most senior clinician available intubated in 65.4%. Clinicians reported first pass success in 93.7% of responses. Most intubators reported use of videolaryngoscopy (74.8%), however 26% reported not using this equipment regularly and 5.5% did not feel confident with their equipment. Despite a high success rate, difficulties were reported in 15.1%. The most common was desaturation. Other common difficulties included equipment or environment unfamiliarity, lack of skilled support. When asked what advice they would give to colleagues, frequently occurring themes included: ensuring familiarity with equipment, use of a checklist, use of videolaryngoscopy, and availability of a second intubator. Desire for simulation and equipment familiarisation was highlighted in multiple responses, and in one example a clinician attributed their success to a simulation session performed in the week prior. Conclusion(s): Experiences from clinicians in this region highlight the specific challenges encountered involved in airway management of patients with COVID-19, in particular highlighting the importance of advance preparation for intubation when faced with unfamiliar circumstances. Simulation sessions, use of checklists and standard operating procedures for emergency intubation may contribute to maintaining preparedness for intubation in this challenging patient group.

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Intensive care unit (ICU) referrals and admissions at a district general hospital (DGH) in light of the COVID-19 pandemic (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Naughton E.; *Pradhan N.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: The COVID-19 pandemic has led to an increase in ICU referrals and admissions across the UK during 2020 [1]. Intensive care beds are a limited and expensive resource and decisions on patient admission are often very challenging [2]. Proformas help to standardise documentation and decision logging during patient referrals [3]. They provide easily accessible evidence in case of a future referral and allow audit of decision-making processes. A preliminary survey of doctors working in a DGH ICU was undertaken to assess the current referral and admission process in expectation of an increased volume of work.
Objective(s): As a result of the survey, three main areas for improvement were identified: 1. To maintain a record of all ICU referrals and decision-making processes 2. To reduce the time taken for documentation of referrals and admissions 3. To improve the quality and appropriateness of referrals from parent specialities Methods: A proforma was designed for dual use as a referral and admission document. All referrals were recorded on paper and staff received training on how to apply the proforma. After assessment of each referral, irrespective of admission outcome, a completed copy of the proforma was placed in both the patient's notes and a dedicated referrals folder. After one month, a further survey was designed to assess the response postimplementation of the proforma. All referrals made over a threemonth period between April and June 2020 were audited.
Result(s): The initial survey received 12 responses. Prior to the COVID-19 pandemic, documentation of any referral or admission took on average 10-15 minutes. All survey participants felt that referring teams did not have a good understanding of the role of ICU care and estimated that up to 40% of all referrals received were inappropriate. The follow-up survey received 14 responses. Implementation of the proforma reduced the time taken to document a referral or admission on average by 5-10 minutes. Twelve participants found the proforma a useful aid, helping to provide clear documentation and ease communication between ICU team members. Less than 9% of the referrals made between April and June 2020 were admitted to ICU with over 32% of referrals deemed unsuitable for further escalation. Approximately 50% of referrals were made by registrars, with 13% discussed by consultants. The median age of patients referred was 67.5 and the most common reason was for respiratory deterioration.
Conclusion(s): This quality improvement project successfully reduced the time taken to document ICU referrals and admissions. Use of a proforma has provided many benefits, including standardisation of documentation, decision logging and improvement of intra-and inter-team communication. Only a small proportion of patients referred to ICU have been suitable for admission. A teaching session is being designed so that referral information can be fed-back to parent specialties. Referrals will be reaudited after this. Data analysis of this project has been limited by incomplete proforma documentation from participating users.

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A Tidal volume calculator to improve lung protective ventilation in COVID-19 related Acute Respiratory Distress Syndrome (ARDS) (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Hester S.; Baldwin A.; Ali T.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: Routine use of lower tidal volumes (TVs) for the mechanical ventilation of patients with ARDS results in decreased mortality and increases the number of days without ventilator use [1]. Severe COVID-19 pneumonia has been associated with the development of ARDS as characterised by the Berlin definition [2]. A multi-centre preliminary audit was undertaken to identify whether ventilated COVID-19 related ARDS patients were receiving optimal TVs, as recommended by the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) ARDS management guidelines [3]. Objective(s): As a result of the audit, three main areas for improvement were identified. 1. To achieve accurate calculations for ideal body weight (IBW) and target TV 2. To improve documentation of IBW and target TV 3. To achieve TVs no greater than 6 ml/kg Methods: A 'tidal volume calculator' tool was developed using Microsoft Excel, which was simple, colour coded and kept on all Intensive Care Unit (ICU) computer desktops. This tool was designed to use height to calculate IBW and, if the patient's height was unavailable, could also be utilised to calculate height from ulna length. IBW was subsequently used to calculate a target TV. Staff received training on how to apply the tool. Two snapshot audits were carried out in April and May 2020 at two ICUs. The first was conducted prior to the tool's introduction with the second two weeks after its implementation. All patients receiving mechanical ventilation, except those spontaneously breathing, were included. Data was extracted from patient notes, charts and ventilator settings. Result(s): The initial audit included 14 patients. Six patients did not have an IBW documented. Three patients had documented IBWs that were 12 kg, 15 kg and 23 kg greater than the weight calculated using the tool, leading to increased tidal volume targets. Only three patients were achieving TVs of 4-6 ml/kg. Eleven patients were achieving a TV greater than 6 ml/kg, with two of these achieving a TV of greater than 8 ml/kg. The follow-up audit included ten patients. This revealed that all patients had an IBW clearly documented. Moreover, nine patients were achieving TVs within 4-6 ml/kg, with only one patient found to be achieving a TV greater than 6 ml/kg. Conclusion(s): This audit cycle revealed that initially adherence to lung protective ventilation and documentation of IBW was poor. In some instances, documented IBW was vastly different to the calculated IBW, suggesting that in these situations actual body weight may have been used. In a time when clinicians were being redeployed to support ICU, this simple tool was shown to support staff by clearly calculating and displaying IBW and target TV for reference. This directly led to improved adherence to lung protective ventilation and optimisation of patient care. Limitations include that no consideration was made for overall patient outcome, and only a snapshot of achieved TVs from ventilators were recorded; daily/weekly trends were not studied.

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Objective responses to first-line neoadjuvant carboplatin-paclitaxel regimens for ovarian, fallopian tube, or primary peritoneal carcinoma (ICON8): post-hoc exploratory analysis of a randomised, phase 3 trial (2021)

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Type of publication:
Journal article

Author(s):
Morgan R.D.; Jayson G.C.; Clamp A.R.; McNeish I.A.; Krell J.; Cook A.D.; James E.C.; Lord R.; Dark G.; Glasspool R.M.; Parkinson C.; Poole C.J.; Hall M.; Gallardo-Rincon D.; Lockley M.; Essapen S.; Summers J.; Anand A.; *Zachariah A.; Williams S.; Jones R.; Scatchard K.; Walther A.; Kim J.-W.; Sundar S.; Ledermann J.A.

Citation:
The Lancet Oncology; Feb 2021; vol. 22 (no. 2); p. 277-288

Abstract:
Background: Platinum-based neoadjuvant chemotherapy followed by delayed primary surgery (DPS) is an established strategy for women with newly diagnosed, advanced-stage epithelial ovarian cancer. Although this therapeutic approach has been validated in randomised, phase 3 trials, evaluation of response to neoadjuvant chemotherapy using Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST), and cancer antigen 125 (CA125) has not been reported. We describe RECIST and Gynecologic Cancer InterGroup (GCIG) CA125 responses in patients receiving platinum-based neoadjuvant chemotherapy followed by DPS in the ICON8 trial. Method(s): ICON8 was an international, multicentre, randomised, phase 3 trial done across 117 hospitals in the UK, Australia, New Zealand, Mexico, South Korea, and Ireland. The trial included women aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0-2, life expectancy of more than 12 weeks, and newly diagnosed International Federation of Gynecology and Obstetrics (FIGO; 1988) stage IC-IIA high-grade serous, clear cell, or any poorly differentiated or grade 3 histological subtype, or any FIGO (1988) stage IIB-IV epithelial cancer of the ovary, fallopian tube, or primary peritoneum. Patients were randomly assigned (1:1:1) to receive intravenous carboplatin (area under the curve [AUC]5 or AUC6) and intravenous paclitaxel (175 mg/m2 by body surface area) on day 1 of every 21-day cycle (control group; group 1); intravenous carboplatin (AUC5 or AUC6) on day 1 and intravenous dose-fractionated paclitaxel (80 mg/m2 by body surface area) on days 1, 8, and 15 of every 21-day cycle (group 2); or intravenous dose-fractionated carboplatin (AUC2) and intravenous dose-fractionated paclitaxel (80 mg/m2 by body surface area) on days 1, 8, and 15 of every 21-day cycle (group 3). The maximum number of cycles of chemotherapy permitted was six. Randomisation was done with a minimisation method, and patients were stratified according to GCIG group, disease stage, and timing and outcome of cytoreductive surgery. Patients and clinicians were not masked to group allocation. The scheduling of surgery and use of neoadjuvant chemotherapy were determined by local multidisciplinary case review. In this post-hoc exploratory analysis of ICON8, progression-free survival was analysed using the landmark method and defined as the time interval between the date of pre-surgical planning radiological tumour assessment to the date of investigator-assessed clinical or radiological progression or death, whichever occurred first. This definition is different from the intention-to-treat primary progression-free survival analysis of ICON8, which defined progression-free survival as the time from randomisation to the date of first clinical or radiological progression or death, whichever occurred first. We also compared the extent of surgical cytoreduction with RECIST and GCIG CA125 responses. This post-hoc exploratory analysis includes only women recruited to ICON8 who were planned for neoadjuvant chemotherapy followed by DPS and had RECIST and/or GCIG CA125-evaluable disease. ICON8 is closed for enrolment and follow-up, and registered with ClinicalTrials.gov, NCT01654146. Finding(s): Between June 6, 2011, and Nov 28, 2014, 1566 women were enrolled in ICON8, of whom 779 (50%) were planned for neoadjuvant chemotherapy followed by DPS. Median follow-up was 29.5 months (IQR 15.6-54.3) for the neoadjuvant chemotherapy followed by DPS population. Of 564 women who had RECIST-evaluable disease at trial entry, 348 (62%) had a complete or partial response. Of 727 women who were evaluable by GCIG CA125 criteria at the time of diagnosis, 610 (84%) had a CA125 response. Median progression-free survival was 14.4 months (95% CI 9.2-28.0; 297 events) for patients with a RECIST complete or partial response and 13.3 months (8.1-20.1; 171 events) for those with RECIST stable disease. Median progression-free survival for women with a GCIG CA125 response was 13.8 months (95% CI 8.8-23.4; 544 events) and 9.7 months (5.8-14.5; 111 events) for those without a GCIG CA125 response. Complete cytoreduction (R0) was achieved in 187 (56%) of 335 women with a RECIST complete or partial response and 73 (42%) of 172 women with RECIST stable disease. Complete cytoreduction was achieved in 290 (50%) of 576 women with a GCIG CA125 response and 30 (30%) of 101 women without a GCIG CA125 response. Interpretation(s): The RECIST-defined radiological response rate was lower than that frequently quoted to patients in the clinic. RECIST and GCIG CA125 responses to neoadjuvant chemotherapy for epithelial ovarian cancer should not be used as individual predictive markers to stratify patients who are likely to benefit from DPS, but instead used in conjunction with the patient's clinical capacity to undergo cytoreductive surgery. A patient should not be denied surgery based solely on the lack of a RECIST or GCIG CA125 response. Funding(s): Cancer Research UK, UK Medical Research Council, Health Research Board in Ireland, Irish Cancer Society, and Cancer Australia.

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'Daycase parathyroidectomy: Time to change the norm?' (2020)

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Type of publication:
Conference abstract

Author(s):
Chang J.; Neophytou C.; Howard E.; Houghton A.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 37

Abstract:
Introduction: The most recent BAETs audit report of 2017 shows a surprisingly low rate of same-day discharge following parathyroidectomy (10%). In our unit we have developed a simple and safe protocol which allows same day discharge for almost all patients (95%). The 2017 BAETS report has 11,463 patients recorded for primary hyperparathyroidism. Following this simple protocol could save over 9,500 inpatient bed days.
Method(s): Demographics, histology, biochemistry and length of stay were identified for all patients undergoing parathyroidectomy for primary hyperparathyroidism between 01/01/2010 and 31/12/2019. Following surgery all patients were discharged on Calcichew D3 one tablet tds, with arrangements for serum calcium analysis and outpatient appointment at 7 and 10 days Results: We performed 264 parathyroid procedures during the study period. The cohort had a median age of 63 (range 15 – 90). Day-case procedures were carried out in 95% (n=249). 10 patients stayed 24 hours, 4 for 48 hours and 1 patient for 4 days (urgent parathyroidectomy following acute medical admission with symptomatic hypercalcaemia). 1 patient was admitted overnight for observation of bleeding wound (no return to theatre). The remainder were admitted for a mixture of social and anaesthetic reasons. 6 patients (2%) had 30 day morbidity: 2with symptoms of relative hypocalcaemia (not admitted), 1 patient with hypocalcaemia requiring intravenous calcium, 1 seroma, 1 patient presented with an exacerbation of COPD and 1 haematoma.
Conclusion(s): We have shown that same-day discharge after parathyroid surgery is safe and ought to become the norm in other units.

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IMPACT. Operating Department Human Factors Training for the whole team (2020)

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Type of publication:
Conference abstract

Author(s):
Allman T.; Schunke N.; Fenton C.; Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 14

Abstract:
Aims: We identified a gap in effective staff training and developed a novel truly multidisciplinary training day to capture the whole team and expose them to simulation in their usual environment amongst usual peers. Our aim was to maximise the impact factor of multidisciplinary operating department human factors training and utilise high fidelity simulation to expose unknown unknowns and improve theatre safety.
Method(s): Novel human factors training run onsite. On a rotational basis designated theatre lists are blocked for the mandatory training to ensure all members of the theatre teams can attend ranging from porters to consultants and team leaders. Line managers enforce attendance and feedback is collated. Anaesthesia retained oversight and organisation. 3 main sessions run in parallel by teams of multidisciplinary facilitators.

  1. WHO Steps to Safer Surgery: Trust 'STOP THE LINE' video and discussion.
  2. Raising concerns: discussion lead by consultant surgeon.
  3. Theatre simulation & debrief: High fidelity in the operating theatre.

Result(s): The training received exemplary feedback and review from all staff across specialties.Multiple gaps in knowledge, particularly the location of rarely used emergency equipment and drugs was exposed and this allowed for on the spot, high yield training. Candidate feedback revealed the impact of our training was maximised by the facilitation led by consultant surgeons. Conclusion(s): Human factors training is notoriously variable and limited. We've collaborated surgical, anaesthetic and theatre teams to deliver high impact and resourceful training by addressing the human factors that mould our own learning.

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Laparoscopic ligation of inferior mesenteric artery (IMA) for the management of type II endoleak post endovascular aneurysm repair (EVAR) (2020)

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Type of publication:
Conference abstract

Author(s):
*Mashar R.; *Gangwar A.; *McCloud J.; *Shawish E.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 96-97

Abstract:
Aim: Type II endoleaks following EVAR are caused by patent aortic collaterals causing retrograde blood flow, with the IMA being involved in 45-85% of all cases. Transarterial embolization has been described as a management option, but with a high failure rate. We present laparoscopic ligation as an alternative therapeutic strategy, with both technical success and a favourable outcome.
Method(s): An 80-old hypertensive male was diagnosed with a type II endoleak post-EVAR. Shrinkage of the sac was seen initially from 58mm to 52mm on surveillance-computed tomography (CT) of the aorta at 6 months with apersistent type II endoleak involving the IMA and lumbar arteries. Surveillance at 18 months demonstrated a persistent endoleak with enlargement of the sac to 65 mm. After a failed attempt with arterial embolization, he underwent laparoscopic ligation of the IMA Results: The procedure time was 22 minutes and his length of stay was 2 days, with no signs or symptoms of bowel ischaemia. A CT at 2 weeks demonstrated sac shrinkage to 58 mm. Conclusion(s): There have been reports of persistent endoleaks being associated with adverse outcomes, with their primary management remaining controversial. IMA ligation has been associated with sac shrinkage in 65% of patients, an important prognostic factor, and there have been no reported complications thus far. Therefore, it should be strongly considered as an option for management of type II endoleaks in centres with both vascular and general surgical expertise being available

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