Staff Publication

Childbirth-related pelvic floor trauma in women at-risk: A survey of the current obstetric management of short stature primigravid women (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Rachaneni S.; Freeman R.

Citation:
International Urogynecology Journal; September 2019; vol. 30 (no. 1 Supplement)

Abstract:
Objective: To assess the antenatal and intrapartum management of short statured primigravid women in relation to the awareness of the increased risk of long-term pelvic floor morbidity from childbirth, by Obstetricians and Gynaecologists in the UK. Method(s):We carried out a questionnaire survey with 15 questions about the antenatal and intrapartum management of short statured primigravid women with a clinically large fetus, their timing and mode of delivery and discussion with the women about their risk of long-term pelvic floor morbidity following spontaneous and instrumental vaginal deliveries, their choice of instruments and episiotomy. Result(s): The survey was completed by 424 Members and Fellows of Royal College of Obstetricians and Gynaecologists (UK). We created a scenario of a short stature primigravid woman who presented with a clinically large baby around 38 weeks gestation. Sixty five percent of the responders stated that they would scan for estimated fetal weight, 48% would offer induction of labo-r at 40 weeks gestation and 13% would offer an elective caesarean section at 39-40 weeks. Only 59% of the responders said that would discuss the risks of obstructed labo-r, shoulder dystocia, instrumental delivery and Obstetric anal sphincter injury. Seventy percent of the responders said they would not discuss the long term risks of urinary, fecal incontinence and prolapse during antenatal or intrapartum management. For intrapartum management with failure to progress in the second stage of labo-r, 69% would attempt a rotational instrumental delivery, and only 5% would offer an emergency caesarean section. Manual rotation followed by 'straight' forceps application (59%) was the most frequent rotational delivery offered followed by Ventouse (40%) and Keillands forceps rotation. Thirty four percent stated that do not routinely perform an episiotomy in this scenario. The choice of instrument was not based on the long-term risk of pelvic floor dysfunction in 73% of the responses. Conclusion(s): The survey reveals a poor level of counselling of primigravid women of short stature who are known to be at higher risk of long-term pelvic floor trauma and consequent incontinence and prolapse.

Role of flavonoids in the management of acutely symptomatic haemorrhoids: A systematic review and meta-analysis of randomized, controlled trials (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Rehman S.; Miles W.; Sains P.; Sajid M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5, p. 110

Abstract:
Aims: The objective of this article is to assess the role of role of flavonoids in the management of acutely
symptomatic haemorrhoids.
Method(s): The data retrieved from the published randomized, controlled trials (RCT) regarding the role of flavonoids in the management of acutely symptomatic haemorrhoids was analysed using the principles of metaanalysis. The summated outcome of dichotomous variables was expressed in odds ratio (OR).
Result(s): Ten RCTs on 1478 patients comparing the surgical outcomes in patients having clinically and endoscopically diagnosed acute symptomatic haemorrhoids after using flavonoids versus placebo preparation were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the symptomatic relief (OR, 0.48; 95% CI, 0.16, 1.3928; z = 1.36; P = 0.18), satisfaction on pain relief (OR, 0.30; 95% CI, 0.08, 1.07; z = 1.86; P = 0.06), recurrence (OR, 0.48; 95% CI, 0.14, 1.63; z = 1.17; P = 0.24) and complications rate (OR, 1.31; 95% CI, 0.49, 3.54; z = 0.54; P = 0.59) were statistically similar in both groups. However, symptomatic haemorrhoidal bleeding control rate was higher in flavonoids group (OR, 0.33; 95% CI, 0.13, 0.84; z = 2.33; P = 0.02).
Conclusion(s): Use of flavonoids to treat symptomatic acute haemorrhoids failed to demonstrate better effectiveness over traditional placebo remedies except better bleeding control.

Link to full-text [NHS OpenAthens account required]

Is it Necessary to do Colonoscopy after Appendicectomy in Patients Over the Age of 50 Years? (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Chakrabarty A.; *Vardhrajan V.; *Cheetham M

Citation:
British Journal of Surgery; Sep 2019; vol. 106 S5; p. 70

Abstract:
Aim: In the United Kingdom 1 in 13 people are affected by appendicitis. The commonest age group is between
10 to 20 years. Appendicitis is relatively uncommon in adults over 50 years. There is a belief that appendicitis
may be precipitated or mimicked by colorectal cancer and hence some surgeons recommend that patients over the age of 50 should undergo a post-operative colonoscopy.
Method(s): We identified patients over the age of 50 years who had appendicectomies in our hospital between
2013 and 2017 usingHES data. Detailed data was collected for all the patients from radiology and endoscopy
data bases. We calculated the cost of post-operative colonoscopy to the health system using PBR tariff.
Result(s): 396 patients aged over 50 underwent emergency appendicectomy during the study period. Of these
284 (72%) had had pre-operative C T scans. 88 (22%) out of the 396 patients underwent a colonoscopy within 3 months of their appendicectomy. Of these 88 patients, 62 had pre-operative CT scans. No cancers were found on post-operative colonoscopy. The cost of performing post-operative colonoscopy in this cohort was 35, 464.
Conclusion(s): In an era of liberal preoperative CT scanning for patients over 50 with right iliac fossa pain, it is
not necessary to perform a colonoscopy after appendicectomy. We recommend that for patients who have a
preoperative CT scan, a post-operative colonoscopy is only needed if there are specific imaging abnormalities.

Link to full-text [NHS OpenAthens account required]

Better safe than total; experience of laparoscopic subtotal cholecystectomy in a specialist Upper GI and Bariatric surgery unit and literature review (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Rehman S.; *Abayomi S.; *Jahangir B.; *Maciejewski M.; *Qassem M. ; *Kirby G.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5; p. 117

Abstract:
Aims: NICE/AUGIS guidelines suggest performing cholecystectomies while 'hot' (within a week). There is a
significant risk of biliary injury and/or open procedure in severely inflamed gallbladders and subtotal
cholecystectomies have been suggested to prevent these. The objective of this article is to present short and
medium term outcomes of laparoscopic subtotal cholecystectomy (LSC) in a specialist upper GI and bariatric
unit.
Method(s): This study included all consecutive patients who underwent LSC between August 2014 and August
2018. Clinical notes were retrospectively analysed. Assessed parameters included demographics, urgency of
operation, method of stump closure, length of inpatient stay, biliary injury, post-op incidence of intervention or
re-operation and post-op complications.
Result(s): 20 patients underwent LSC comprising around 0.7% of all the gallbladder operations performed in
our unit during this period. Median age was 67.1 years. 15 (75%) of these operations were carried out as
elective. Stump was closed by absorbable sutures in 18 (90%) of these patients while endoloop was used in one. Median length of stay was 6.2 days. None of the patients had biliary injury on later follow up and 7 (35%)
patients required ERCP. Post-op complications included chronic abdominal pain, wound infection and bile leak
in 2 (10%), 1 (5%) and 1 (5%) patient respectively.
Conclusion(s): Laparoscopic subtotal cholecystectomy proved to have an acceptable profile of safety and
outcomes in our unit and data is comparable with already published literature. Increased incidence of LSC in
elective patients may highlight the significance of establishing a hot gallbladder service.

Link to full-text [NHS OpenAthens account required]

Haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography: a meta-analysis of randomized, controlled trials (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Rehman S.; Miles W.; Sains P.; Sajid M.; Baig M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5; p. 27-28

Abstract:
Aims: The objective of this article is to compare the surgical outcomes following haemorrhoidal artery ligation
and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography.
Method(s): The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical
outcomes following haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal disease with or
without the use of Doppler ultrasonography (DUS) was analysed using the principles of meta-analysis. The
summated outcome of dichotomous variables was expressed in risk ratio (RR) and continuous data was
presented in standardised mean difference (SMD).
Result(s): Four RCTs on 270 patients comparing the surgical outcomes following haemorrhoidal artery ligation
and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography were
analysed using the statistical software Review Manager 5.3. In the random effects model analysis no-DUS
group had shorter procedure time (SMD, 3.69; 95% CI, 2.73, 4.64; z = 7.56; P = 0.00001), better symptomatic
relief rate (RR, 1.95; 95% CI, 1.07, 3.56; z = 2.19; P = 0.03) and lower risk of short or long term haemorrhoidal
bleed (RR, 2.27; 95% CI, 1.25, 4.11; z = 2.70; P = 0.0007). The recurrence rate (RR, 1.87; 95% CI, 0.66, 5.30; z =
1.18; P = 0.24), post-operative pain score and complication rate were similar in both groups.
Conclusion(s): The use of DUS in haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal
disease is not mandatory and better clinical outcomes may be achieved without its use.

Link to full-text [NHS OpenAthens account required]

Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes (2021)

Posted on by

Type of publication:
Journal article

Author(s):
*Donati-Bourne J.; *Mohamed W.G.E.; *Pillai P.; *O'Dair J.; Kasmani Z.; Bhatt R.I.

Citation:
Journal of Clinical Urology; 2021, Volume: 14 issue: 2, page(s): 78-84

Abstract:
Objectives: To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.
Material(s) and Method(s): Comprehensive literature review via PubMed, MEDLINE and Google Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.
Result(s): Pre-operative considerations: – urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury; – assessing for chronic constipation and distended bowel; and – considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Perioperative considerations: – adequate theatre staffing for safe patient transfer; and – planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations: – ensuring attending medical staff are trained to recognise autonomic dysreflexia; – early remobilisation with physiotherapists experienced in treating spinal cord injury; and – attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections
Conclusion(s): Patients with long-term spinal cord injury pose significant potential challenges in the pre-, periand post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.
Level of Evidence: Not applicable for this multicentre audit.

Duplication of the Gallbladder and its Surgical Challenges (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Tamvakeras P.; *Riera M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S6; p. 28

Abstract:
Aims: Duplication of the gallbladder is a rare congenital anomaly. However, awareness of this anatomical variation is crucial when treating gallstone disease. We present the case of a patient with two gallbladders, incidentally found during laparoscopic cholecystectomy. We review the literature and discuss the associated surgical challenges.
Methods: Case presentation and literature review of the classification, clinical presentation, radiological diagnosis and management of gallbladder duplication.
Results: A 37 year old healthy man presented with a two year history of post prandial right upper quadrant abdominal pain. Routine blood investigations were normal and ultrasonography (US) demonstrated gallstones with normal biliary ducts. During laparoscopy he was found to have gallbladder duplication with a Y-shaped type cystic duct, this consisted of two ducts joining together to form a main cystic duct which drained into an otherwise normal common bile duct. No cholangiogram was performed. After meticulous dissection and demonstration of the anatomy, the cholecystectomy was performed. The patient recovered uneventfully and was discharged the next day. Histology showed gallstones and chronic inflammation in both
gallbladders.
Conclusions: A duplicate gallbladder is a rare congenital variation. Preoperative diagnosis can be challenging. Understanding its classification based on the relational anatomy to the biliary tree is essential to avoid biliary injuries. Imaging modalities such as US and computed tomography (CT) may not be sensitive enough. MRCP may demonstrate the biliary tree more clearly. Laparoscopic cholecystectomy can be safely performed, in the presence of symptomatic gallstone disease.

Link to full-text [NHS OpenAthens account required]

The diabetic foot: Get your patient on the right antibiotics! (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Lefroy R.; Summerour V.; *McMullen K.; Corfield L.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5, p. 165

Abstract:
Aim: The National Institute for Clinical Excellence has established evidence-based guidelines for the
management of diabetic foot infection. These follow basic principles of treating infections with broad spectrum
antibiotics until cultures provide more accurate guidance for antibiotic treatment. This audit aimed to assess
the practice of a tertiary vascular centre against this guideline, to bring in measures to improve practice and
then to re-examine this practice.
Method(s): Data was collected retrospectively for all patients who underwent an emergency operative
intervention for a diabetic foot infection under the care of vascular surgery (n=122). Data collection focused on
microbiological samples sent and antibiotics prescribed. The results were shared with the surgical unit and the
guidelines reiterated. A proforma was trialled and one month of patients with diabetic foot infection admitted
as emergencies were prospectively reviewed.
Result(s): Initially, we showed that only 36% had microbiological samples sent at the time of their procedure. Of these, almost half were on antimicrobial therapy not tailored to sensitivities. Following education and
instigation of our proforma, we demonstrated that 77% of patients had samples and improving rates of
appropriate antibiotic prescriptions.
Conclusion(s): Our data demonstrates significant improvement in these patients management. Doctors must
check sensitivities of samples to ensure antibiotic stewardship.

Link to full-text [NHS OpenAthens account required]

Intraoperative Infiltration of Local Anaesthetic with Adrenaline In Sliding Hip Screw Surgery: Does It Reduce the Need for Transfusion? A Comparison of Practice Over Two Hospital Sites (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*T. Banks, *P. Jayawardena, *D. Ford

Citation:
British Journal of Surgery, Sep 2019; vol. 106, S6, p. 108

Abstract:
Aim: Post-operative blood transfusion is frequently required in patients undergoing Sliding Hip Screw (SHS) surgery. This is associated with transfusion related complications, increased cost and length of stay in hospital. We compared practice between two hospitals; pre-incision infiltration of local anaesthetic with adrenaline (LAAd) versus LA without adrenaline prior to wound closure, to evaluate if there was a difference in postoperative haemoglobin drop and the need for postoperative transfusion following SHS surgery.
Method: A retrospective service evaluation was performed using National Hip Fracture Database (NHFD) data in a cohort of 248 patients who underwent SHS surgery between 2017 and 2018; 110 patients had LAAd. Pre and post-operative haemoglobin, postoperative transfusion and local infiltration was recorded from the trust online patient databases. Relationships between groups was determined using z-testing on Excel.
Results: There was no significant difference in postoperative haemoglobin drop between the two cohorts (p=0.119). 32.7% of patients who had LAAd received blood transfusion in contrast with 20.3% without adrenaline.
Conclusion: Whilst surgeons using LAAd may report less bleeding from skin edges and vastus lataralis intra-operatively, and optimised regional anaesthesia, there was no significant difference in haemoglobin drop between the two cohorts. A difference in threshold for transfusion was identified between the
two hospitals.

Link to full-text [NHS OpenAthens account required]

A Rare Case of Cavernous Haemangioma of the Larynx Presenting as Dyspnoea – A Case Report (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
Teo X.Y.; *Rafie A.; Thompson S.; Jolly K.; Darr A.

Citation:
British Journal of Surgery, 2019, Volume 106, Issue S6, p. 72

Abstract:
Introduction: Haemangiomas are a rare entity and seldom observed within the cavern e.g. larynx. The rarity and nature of these lesions can result in clinical unpredictability and mortality. According to literature, laryngeal cavernous haemangiomas often present as dysphonia. However, we have documented a rare case of cavernous haemangioma presenting as dyspnoea. Case presentation: A 71-year old gentleman presented to the A&E with progressive breathlessness and a history of un-investigated intermittent dysphonia. Medical therapy for suspected heart failure and COPD was ineffective, with worsening stridor identified. Assessment by the Otolaryngology team elicited a pedunculated lesion of the vocal cord. An awake fibre-optic intubation was undertaken, under sedation while spontaneously respiring. The patient subsequently underwent urgent microlaryngoscopy to have the lesion resected. Discussion: Cavernous haemangiomas are relatively rare findings with less than 10 cases being documented in the literature. However, in this case, breathlessness was the main presenting complaint. Histological examination of cavernous haemangiomas demonstrated polypoid tissue surfaced by reactive squamous epithelium and underlying stroma containing large dilated vascular channels.
Conclusion: Laryngeal cavernous haemangiomas in adults are uncommon and rarely seen on the vocal cords. Although benign, their course can be unpredictable and airway obstruction can occur rapidly, warranting urgent
excision.

Link to full-text [NHS OpenAthens account required]