2017

"Door to knife time" for emergency admissions (2017)

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Type of publication:
Conference abstract

Author(s):
*Quraishi M.; Tayyab M.; Badger I.

Citation:
International Journal of Surgery; Nov 2017; vol. 47

Abstract:
The NCEPOD has formed the foundation of local trust guidelines in the triage of surgical patients requiring surgery. Delays in surgical intervention lead to significant morbidity and mortality. Reviewing the reasons for delay to theatre is therefore important in improving service provision and patient outcomes. Method: A retrospective collection of data on 62 (eligible) from 90 consecutive patients that were taken to emergency theatre were reviewed in February 2016. Result: of 62 patients 44 were admitted under general surgery, 6 under urology and 14 under other specialities. There were 37 males and 26 females. Median age was 47 years. As per local guidelines, 3 patients belonged to category III(septic shock), 16 in category V(sepsis without organ dysfunction) and 43 in category VI(infected source without sepsis). This translates into three CEPOD 1 (immediate) and 59 CEPOD 2 (urgent) patients. Two delays were identified, a patient requiring cardiovascular stabilisation prior to surgical intervention and another patient due to lack of perioperative resources. Conclusion: This review has highlighted good compliance with local guidelines and, the importance of the need for clarification of categorisation of surgical urgency. Our local categorisation offers more detail on specific emergencies, but still has significant lapses.

Anaemia and upper GI bleeding: A local experience (2017)

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Type of publication:
Conference abstract

Author(s):
*Ding M.; *Prawiradiradja R.; *Arastu Z.; *Sabri H.; *Smith M.

Citation:
United European Gastroenterology Journal; Oct 2017; vol. 5 (no. 5)

Abstract:
Introduction: There has been significant research recently on the use of blood transfusions in upper GI bleeding (UGIB) [1] with recent evidence advocating a restrictive approach to blood transfusions as well as the use of iron therapy[2] for anaemia post UGIB. Our team conducted a local retrospective analysis on patients admitted with UGIB over a six month period and analysed the use of blood transfusions at our trust which consists of two District General Hospitals. Patient data over a period of up to 12 months post discharge was collected to monitor their anaemia. Aims & Methods: Our aim was to monitor the appropriateness of transfusions in Upper GI Bleeding as well as monitoring the response to iron therapy following discharge. All inpatients that had an Upper GI endoscopy for UGIB were analysed. Electronic patient records were obtained from our endoscopy software and hospital database. Patients were selected over a time period of six months from 1/ 6/2015 to 31/12/2015. A Student's T-Test was used to compare the average increase in haemoglobin (Hb) for patients discharged with iron therapy against those who were not. Results: There were 148 patients, 81 male and 67 female. The mean age was 69.3, minimum 20 and maximum of 98. The average Hb on admission was 103 g/L (min=32 g/L, max=178 g/L). 78 out of 148 (52.7%) patients presenting with UGIB received a blood transfusion. The mean amount of blood received for those transfused was 3.7 units. 48 out of 78 (61.5%) of blood transfusions were given when Hb was below 70 g/L. 30 of 78 (38.5%) were transfused above a Hb of 70 g/L. (36.7%, n=11) of those who were transfused with Hb above 70 had cardiac risk factors. The mortality rate in those transfused above Hb of 70 was 13.3% (n=4) vs 10.4% (n=5) 41.5% (n=44) patients who were anaemic post-UGIB were discharged with iron therapy. The average rise in Hb was 26.5% for those discharged on iron vs 12.1% for those who did not. There was a statistically significant rise in Hb for those discharged with iron therapy (p<0.005) on follow-up versus those who did not receive it (n=62). The anaemia related readmission rates were similar for patients discharged on iron or not (9.1% n=4 vs 9.7% n=6). Conclusion: The data obtained supports a restrictive transfusion policy (mortality rate of 13.3% vs 10.4%). 58.5% of patients who were anaemic on discharge did not receive any iron therapy. On follow up, there was a statistically significant rise in Hb level in the group discharged on iron. Our data affirms recent evidence favouring iron therapy post UGIB. Further education is needed to improve outcome in patients presented with GI bleed.

Suture-assisted punctoplasty (2017)

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Type of publication:
Journal article

Author(s):
*Sachdev A.; *Sagili S.R.

Citation:
Digital journal of ophthalmology : DJO; 2017; vol. 23 (no. 3); p. 60-62

Abstract:
Purpose: To describe a surgical technique in which a suture, instead of forceps, is used to improve access for the introduction of scissors and more easily achieve an appropriately-sized punctoplasty.Materials and Methods: In this technique, a new modification of the 2-snip punctoplasty, a 6-0 polyglactin 910 suture is passed through the posterior wall of the punctum to apply traction. A video of the technique is provided.Results: This technique improves the surgical field of view and eases access for introduction of Vannas scissors into the punctum to perform the punctoplasty.Conclusions: This simple and practical modification of the 2-snip punctoplasty improves instrument access so that an appropriately-sized punctoplasty can be performed with ease.

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A rare mandibular presentation in multiple myeloma (2017)

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Type of publication:
Conference abstract

Author(s):
*Mihalache G.; *MacBean A.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2017; vol. 55 (no. 10)

Abstract:
Introduction: Multiple myeloma(MM)is a relatively rare malignant haematological disease, a monoclonal malignant proliferation of plasma cells that causes osteolytic lesions in the vertebrae, ribs, pelvic bone, skull and jaw. This rare disease develops mainly in men aged 50 to 80 years (mean age, 60 years). Materials: We report on a clinical case of a 45-year-old female patient who presented with spinal and long bones pain to the hospital and she was diagnosed with multiple myeloma. In order to start her treatment (radiotherapy/ chemotherapy/ bisphosphonates) conform our hospital protocol, she came for a full oral and dental assessment. No intraorally abnormalities were seen. However the orthopantomogram showed multiple rounded lesions of various sizes which have little, if any, circumferential osteosclerotic bone reaction. Results: Patient was diagnosed with multiple myeloma with mandibular involvement. She will be followed up by our team and her dentist for monitoring the oral health. Conclusions: The clear and rare multilocular image of myeloma on the orthopantomogram makes our case unique. Knowledge about the maxillofacial manifestations of multiple myeloma is important for the diagnosis of the disease and treatment, also the follow up of these patients regarding their oral manifestations. In the clinical case presented here, we highlight the interdisciplinarity needed to obtain a diagnosis and treatment of multiple myeloma.

Recurrent laryngeal nerve function after central neck dissection (2017)

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Type of publication:
Conference abstract

Author(s):
*Fussey J.; *El-Shunnar S.; *Spinou C.; *Hughes R.; *Ahsan F.

Citation:
European Journal of Surgical Oncology; Dec 2017; vol. 43 (no. 12); p. 2388-2389

Abstract:
It is generally accepted that central compartment neck dissection (CCND) improves locoregional recurrence rates in cases of known central compartment lymph node involvement, however the practice of prophylactic CCND is somewhat more controversial. It is often quoted anecdotally that the risk of damage to the recurrent laryngeal nerve is higher during CND than in thyroidectomy only. The aim of this study was to evaluate recurrent laryngeal nerve injury rates following CND in thyroid cancer patients. Prospectively collected data from three head and neck cancer centres was retrospectively analysed to identify patients who underwent CND with or without concurrent thyroid surgery over a three-year period. Fifty-eight patients underwent CND, 35 of which were bilateral. There were therefore 92 recurrent laryngeal nerves at risk. The temporary recurrent laryngeal nerve palsy rate was 2.2%, and the permanent palsy rate was 3.3%. All cases of permanent recurrent laryngeal palsy occurred in patients undergoing CND and total thyroidectomy for pT4 disease. Many factors can affect recurrent laryngeal nerve palsy rate following CND, including surgeon experience, tumour characteristics and extent of dissection. Our experience suggests that the risk to the nerve in CND is no higher than in standard thyroid surgery.

Incidence of recurrent laryngeal nerve palsy and hypocalcaemia following thyroidectomy in a district general hospital setting by a single surgeon (2017)

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Type of publication:
Conference abstract

Author(s):
*McNamara K.; *Albuidair A.; *Ahsan F.

Citation:
European Journal of Surgical Oncology; Dec 2017; vol. 43 (no. 12); p. 2389

Abstract:
Background: The British Association of Endocrine and Thyroid Surgeons' (BAETS) set a standard of permanent recurrent laryngeal nerve (RLN) palsy of 1-2% and risk of permanent hypocalcaemia of 5-10%. Aim: To establish ates of permanent recurrent laryngeal nerve palsy and post-operative hypocalcaemia from thyroidectomy by a single surgeon in a District General Hospital Setting. Methods: Patient demographics, rates of permanent recurrent laryngeal nerve palsy and postoperative hypocalcaemia were obtained from all hemithyroidectomy, completion thyroidectomy and total thyroidectomy procedures performed between June 2012 and January 2017. Data was collected from the online Clinical Portal. All cases of RLN palsy and hypocalcaemia had been documented in patient's clinical letters. Results: 245 thyroidectomy procedures were performed during this time. This included 179 hemithyroidectomy, 41 completion thyroidectomy and 16 total thyroidectomy procedures. 1/245 (0.4%) patient suffered with permanent recurrent laryngeal nerve palsy in this patient group. 1/57 patients (2%) developed postoperative hypocalcaemia following completion or total thyroidectomy. Conclusion: This study reveals a lower incidence of RLN palsy and hypocalcaemia than is set by standards. Careful preoperative evaluation helps in achieving a satisfactory outcome in thyroid surgery. Thyroid surgery is safe to be done in a District General Hospital in the hands of a Head and Neck surgeon with a subspecialist fellowship training in thyroid.

The novel use of dental suction tubing in the decompression of large dental cysts (2017)

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Type of publication:
Conference abstract

Author(s):
*Otukoya R.; *Mihalache G.; *Castling B.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2017; vol. 55 (no. 10)

Abstract:
Introduction: Dental suction tubing is widely available in OMFS Units. It has a metal radiopaque marker and can easily be cut to the desired length with scissors. It is relatively inexpensive and has a reinforced lumen that makes easy access for saline irrigation.We have used this tubing now in 3 large odontogenic cysts of the jaws and present this as an aid to effective and simple cyst decompression. Materials/Methods: Large odontogenic cysts present a surgical challenge in terms of recurrence prevention, protection of the inferior dental nerve and teeth and avoidance of mandibular fracture. We have effectively managed 3 such cases with the insertion of a segment of dental suction tubing as a decompression grommet at the same time as local anaesthetic biopsy of the cyst lining. The tube rigidity maintains patency and it is robust enough to allow easy self-irrigation by the patient. The position of the tubing can be assessed radiographically. Results: We allowed decompression over a 3 to 6 month period prior to formal cyst enucleation. There were no complications or failures of the tube patency. The benefits of decompression were clear as a demonstrable bony infilling and reduction in cyst size. Additionally the cyst lining became markedly thicker and easier to enucleate intact, an advantage in odontogenic kearatocysts. Conclusions:We would like to commend this dental suction tube grommet technique as an effective way to manage large odontogenic cysts of the jaws.

Sex differences in the splenic flexure (2017)

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Type of publication:
Journal article

Author(s):
Brookes A.F.; Macano C.; Meecham L.; *Stone T.; *Cheetham M.

Citation:
Annals of the Royal College of Surgeons of England; Jul 2017; vol. 99 (no. 6); p. 456-458

Abstract:
INTRODUCTION Anecdotally, surgeons claim splenic flexure mobilisation is more difficult in male patients. There have been no scientific studies to confirm or disprove this hypothesis. The implications in colorectal surgery could be profound. The aim of this study was to assess quantitatively whether there is an anatomical difference in the position of the splenic flexure between men and women using computed tomography (CT). METHODS Portal venous phase CT performed for preoperative assessment of colorectal malignancy was analysed using the hospital picture archiving and communication system. The splenic flexure was compared between men and women using two variables: anatomical height corresponding to the adjacent vertebral level (converted to ordinal values between 1 and 17) and distance from the midline. RESULTS In total, 100 CT images were analysed. Sex distribution was even. The mean ages of the male and female patients were 68.1 years and 66.7 years respectively (p=0.630). The mean vertebral level for men was 8.88, equating to the inferior half of the T11 vertebral body (range: 1-17 [superior half of T9 to inferior half of L2]), and 11.36 for women, equating to the inferior half of the T12 vertebral body (range: 4-16 [superior half of T10 to superior half of L2]). This difference was statistically significant (p=0.0001) and is equivalent to one whole vertebra. The mean distance from the midline was 160.8mm (range: 124-203mm) for men and 138.2mm (range: 107-185mm) for women (p<0.0001). CONCLUSIONS The splenic flexure is both higher and further from the midline in men than in women. This provides one theory as to why mobilising the splenic flexure may be more difficult in male patients.

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