The Surgeon

List of editors

2012-02-01

Contents list

2012-02-01

Death within 48 h – Adverse events after general surgical procedures

2011-09-15

Abstract: Background: Comorbidity and emergency intervention are established risk factors for post-operative mortality. This study sought to identify adverse events associated with death within 48 h of general surgical procedures.Methods: All general surgical patients who died within 48 h of operative intervention from 2002–2006 in Scotland underwent retrospective peer review using established Scottish Audit of Surgical Mortality (SASM) methodologies (www.SASM.org).Results: During the 5 years, 1299 patients died within 48 h of surgery, 1134 (87.3%) admitted as an emergency, with a mean age of 71 years; 898 patients (69.1%) were ASA grade 3, 4 or 5; 727 (56.0%) patients had cardiovascular, 398 (30.6%) respiratory and 191 (14.7%) renal comorbidity. Over time exploratory laparotomy (443, 34.1%) was carried out less often (p = 0.004) prior to death due to cardiovascular disease (435, 33.5%), mesenteric ischaemia (264, 20.3%) or multi-organ failure (255, 19.6%). The decision to operate by consultant surgeons rose significantly (p < 0.001). Adverse events were identified in 721 of the 1299 cases; concerns about inappropriate operations (p = 0.018) and poor pre-operative assessment (p = 0.012) decreased significantly.Conclusions: Patients dying within 48 h of surgery are usually elderly, emergency admissions with significant comorbidities who die of cardiovascular events. Timely, appropriate surgery and high quality peri-operative care delivered by consultant staff may prevent early post-operative mortality.

Surgery for perforated small bowel malignancy: A single institution’s experience over 4 years

Ker-Kan Tan, Shieh-Ling Bang, Choon-Kiat Ho — 2011-09-15

Abstract: Introduction: Surgery for perforated small bowel malignancy is associated with dismal morbidity and mortality rates. The aim of the paper was to highlight our institution’s surgical experience in the management of patients with malignant small bowel perforation.Methods: A retrospective review of all patients who underwent operative intervention for malignant small bowel perforation from 2004 to 2007 was performed. The diagnosis was confirmed upon histological evaluation.Results: Emergency surgery was performed in seven patients with perforated small bowel malignancy during the study period. All were above 55 years old, with the majority (6/7) having an ASA score of 3 and above. Pneumoperitoneum on chest radiograph was seen in only one patient while computed tomographic scans demonstrating the pathology were performed in the rest. All patients underwent exploratory laparotomy with resection of the diseased segments within 24 h of admission. Jejunum and the ileum were the sites of perforation in six and one patients, respectively. Three patients had synchronous small bowel tumours. Two patients had stoma created due to extensive peritoneal soilage and haemodynamic instability. Lymphoma was the aetiology in four patients. The other pathologies included leiomyosarcoma (n = 1) and metastatic lung tumours (n = 2). The 30-day peri-operative mortality rate was 42.9% (n = 3). One was discharged to a hospice while another two received chemotherapy upon discharge. These three patients passed away within a year from the surgery. The last patient defaulted follow up.Conclusion: In our small series, patients who were admitted for perforated small bowel malignancy have a high peri-operative mortality rates. For those who survived the initially operation, the long term outlook is still dismal.

A survey of UK surgical trainees and trainers; latest reforms well understood but perceived detrimental to surgical training

Sajid Mehmood, Saima Anwar, Jamil Ahmed, Muhammad Tayyab, David O’Regan — 2011-09-15

Abstract: Introduction: In the United Kingdom, surgical training reforms as part of modernising medical careers (MMC) became fully operational in 2007. This study aims to establish the level of insight and views about MMC based surgical training amongst surgical trainers and trainees working in the National Health Service.Methods: An electronic survey consisting of eight questions was disseminated to surgical trainers and trainees via a web-based link placed on Association of Surgeons in Training website.Results: A total of 138 responses were received. Of those, 77% (n = 107) were from trainees. 92% (n = 127) of respondents understood that the purpose of MMC surgical reforms was to provide structured training. 98% (n = 135) agreed traditional SHO training was poorly structured. Two-thirds (67%, n = 92) believed that MMC will reduce the total time period to complete surgical training. 82% (n = 113) recognised work place assessments as an assessment tool for MMC competencies. 82% (n = 113) were aware that an educational supervisor is assigned to monitor individual training. 70% (n = 96) understood that training is a shared responsibility between trainee, educational supervisor and supervising consultants.However, 69% (n = 95) of respondents believed the standard of surgical training via MMC will deteriorate, 18% (n = 25) anticipated no difference, 8% (n = 11) passed no comments and a mere 5% (n = 7) perceived it as an improvement.Conclusions: This study confirms a generally good level of insight amongst trainers and trainees into the aims and structure of MMC based surgical training. However, the majority believe that ultimately the standard of surgical training is set to fall.

Unplanned overnight admissions in day-case arthroscopic shoulder surgery

J. Sultan, K.Z. Marflow, B. Roy — 2011-09-15

Abstract: The majority of arthroscopic shoulder procedures can be safely performed as day-case surgery. However, despite better pain control and preoperative assessment; some patients end with unplanned overnight admission. The aim of this study was to investigate the reasons behind unplanned admissions of patients undergoing day-case arthroscopic shoulder surgery.A retrospective review of 242 consecutive cases of arthroscopic shoulder surgery performed by the senior author over a period of two years (2007–2008) was carried out. Twenty cases were planned admissions and were therefore excluded. 222 cases were included, of which 40 (18%) were unplanned overnight admissions.Documented causes for overnight stay included abnormal post-operative observations, pain and wound ooze. The age of patients who stayed overnight was significantly higher (p = 0.006). The difference in ASA grade between both groups was less marked but still statistically significant (p = 0.031). More complex procedures, such as rotator cuff repair, were more likely to result in unplanned overnight admission (p < 0.001). The experience of the anaesthetist and administration of interscalene nerve block were not significantly different between the two groups. However, patients anesthetised by less experienced anaesthetists were less likely to receive an interscalene nerve block (p = 0.016).In conclusion; higher patient age, higher ASA grade and more complex arthroscopic procedures are significant risk factors for unplanned overnight admissions in day-case arthroscopic shoulder surgery.

Increased bone mineral density in the non-resurfaced patella after total knee arthroplasty: A clinical and densitometric study

2011-09-15

Abstract: We report the results of a longitudinal study of 40 patients with osteoarthritis who had primary prosthetic replacement without patellar resurfacing, and were followed at 6 months postoperatively with a densitometric study and clinically at a minimum follow-up of 2 years. Densitometric analysis showed a mean preoperative density at the affected knee of 0.69 g/cm2 (CI: 0.62–0.76), compared to 0.86 g/cm2 (CI: 0.79–0.93) for the opposite knee (p = 0.002). In our study population, the return to load and motion to the retained patella led to a significant increase in patellar bone density as measured by densitometry studies. This observation correlated with significant improvement in knee functional score.

The management of soft tissue sarcomas

Steven Cutts, Ferrero Andrea, Raimondo Piana, Richard Haywood — 2011-12-05

Abstract: Background: Soft tissue sarcomas are a rare and heterogeneous group of malignancies that are derived from the mesenchymal cell lines. In the last few decades, the management of these lesions has been improved by the introduction of dedicated Multi Disciplinary Teams (MDTs) where most bone and soft tissue tumours are now treated.Following the recent changes to management outlined by the NICE/IOGs, we believe it is pertinent to review the current thinking on soft tissue tumour management. We also discuss the principles of diagnosis and treatment and the role of adjuvant therapy.Methods: This is a retrospective review. In the preparation of this paper, we have referred to recent NICE guidelines in this field and have performed a Medline search of the existing literature.Results: The key to success is early and appropriate patient referral. Whilst the responsibility for performing surgery has shifted away from the generalist and towards the super-specialist, improvements in survivability can be achieved by promoting basic knowledge within the medical profession as a whole.Conclusions: Both excision and biopsy of a soft tissue sarcoma by a non-specialist surgeon have been shown to increase the risk of tumour recurrence and all invasive procedures should now be performed within the MDT setting.

Review of continent urinary diversion in contemporary urology

S. Bailey, M.H. Kamel, E.A. Eltahawy, N.K. Bissada — 2011-10-17

Abstract: Continent urinary diversion (CUD) continues to be widely accepted by both urologists and patients for urinary reconstruction after cystectomy and some complicated cases of urinary incontinence. Different operative techniques and modifications have been contributed in the last 3 decades. The advantages and disadvantages of each technique have long been debated. Ureterosigmoidostomy is the oldest form of CUD but has lost favor in recent decades. The other 2 broad categories of CUD are cutaneous and orthotopic CUD. This review presents and discusses the current common forms of continent urinary diversions.

Bisphosphonate osteonecrosis of the jaw: A historical and contemporary review

Niall M.H. McLeod, Peter A. Brennan, Salvatore L. Ruggiero — 2011-10-10

Abstract: The use of bisphosphonate drugs has been popularised in the late 20th century for the management of many conditions associated with abnormalities of bone turnover, particularly metastatic and haematogenous malignancy and osteopenia. The increase in indications for the use of bisphosphonates was supported by what was thought to be a very good safety profile. However in 2003 cases of osteonecrosis related to the use of bisphosphonates were first described.The pathogenesis, and with this the explanation of why it only appears to affect the maxillofacial skeleton, and the best way of managing this problem remains unknown.In this review we examine the process of identification of this pathology and the development of guidelines from medical societies and professional bodies on the management of patients before commencing bisphosphonate therapy, requiring dental treatment whilst on therapy, or with a diagnosis of bisphosphonate associated osteonecrosis of the jaws.

Chemoprevention in colorectal cancer - where we stand and what we have learned from twenty year's experience

Shahe Boghossian, Ahmed Hawash — 2011-11-30

Abstract: Introduction: Colorectal chemoprevention is a strategy aimed at preventing tumour progression before irreversible changes to the proteome are in full progress. Chemoprevention is not a new concept. In fact, medical practitioners since the early 19th century have tried various herbal and medicinal products as methods that could prevent tumours. The current understanding of tumourigenesis and cellular signalling focuses on a more targeted approach and paves the way for better understanding of colorectal chemoprevention.Methods: The online databases PubMed, Medline, Medscape Oncology and Scirrus were searched for articles of relevance. The Keyword involved the following words: “Colorectal Cancer Chemoprevention”, “Colorectal Cancer”, “Chemoprevention”, “Adenoma-Carcinoma Sequence” and “Colorectal Polyps”. The search was started from the period of June 1995 until September 2010 inclusive.Results: More than 50 natural and synthetic compounds have been shown to have chemotherapeutic effect but the majority of these agents are still in their early experimental stages and hence far from our subject of discussion. Our discussion will focus on large scale randomised trials on human subjects or established compounds. Within the context of chemoprevention, Non-steroidal anti-inflammatory agents have undergone extensive research and have shown promising results with large scale randomised trials. Additionally, metformin, resveratrol, Histone deacetylase inhibitors, Src kinases as well monoclonal antibodies have shown promising results as well.Conclusion: Colorectal cancer is the fourth most common cancer in the world. In the UK alone the number of cases reported in 2008 was almost 40,000 which make it the third most common tumour nationwide. Curative intent surgery or Colectomy is the treatment of choice for most cases of bowel cancer; however, in a select subpopulation of patients who have been colonoscopically diagnosed to harbour pre-malignant lesions, have a family history of colorectal cancer, or have been genetically diagnosed and treated surgically for colorectal tumours; chemoprevention might play a crucial role in deterring further tumour progression. The very latest studies that are in publication or are just accruing results are giving us encouraging data that might suggest whether mass scale ingestion of a specific medication might deter colorectal tumour progression.

Emerging therapies for thyroid carcinoma

S. Walsh, R. Prichard, A.D.K. Hill — 2012-02-01

Abstract: Thyroid carcinoma is the most commonly diagnosed endocrine malignancy. Its incidence is currently rising worldwide. The discovery of genetic mutations associated with the development of thyroid cancer, such as BRAF and RET, has lead to the development of new drugs which target the pathways which they influence. Despite recent advances, the prognosis of anaplastic thyroid carcinoma is still unfavourable. In this review we look at emerging novel therapies for the treatment of well-differentiated and medullary thyroid carcinoma, and advances and future directions in the management of anaplastic thyroid carcinoma.

Laparoscopic feeding jejunostomy: Description of a modified technique with results

Andrei Ilczyszyn, Faisal El-Medani, Sanjay Gupta — 2011-09-15

We present a safe and easy laparoscopic technique for feeding jejunostomy using readily available suprapubic catheterisation (SPC) kit and percutaneous endoscopic gastrostomy replacement (PEG) kits thus avoiding the problems associated with commercially available jejunostomy kits.

Corrigendum to “Review of colorectal surgery handbook” [The Surgeon9(2011) 235]

2011-12-07

A book review appeared in the above issue of The Surgeon, however several details of the book were inadvertently omitted. Please see here the relevant information. The Publishers apologise for any inconvenience caused.