The Surgeon

List of editors

2010-10-01

Inside contents list

2010-10-01

Regionalisation of Trauma Services in England & Wales: Implications for Scotland

Jan O. Jansen — 2010-10-01

There are approximately 16,000 injury-related deaths in the UK per year, and around 1000 of these occur in Scotland. Outcomes from major trauma are worse than in comparable health services: Mortality for severely injured patients who are alive when reaching hospital is 40% higher than in the United States, and the likelihood of dying from injury has remained static since 1994, compared with a 25% decrease in North America. Over 30% of in-hospital trauma deaths are considered potentially preventable, and 60% of trauma patients receive a standard of care considered less than good practice. Although these studies were conducted in England, it is unlikely that the situation in Scotland is materially different.

Clinical presentation and waiting time targets do not affect prognosis in patients with pancreatic cancer

Dimitri A. Raptis, Chris Fessas, Peter Belasyse-Smith, Tom R. Kurzawinski — 2010-10-01

Abstract: Introduction: The prognosis of patients with pancreatic cancer remains poor despite recent advances in treatment. It is not known whether delays in referring, diagnosing and treating these patients and the way they present can affect their survival.Aims: In our study we investigated the impact of clinical presentation (jaundice, abdominal pain, weight loss) and delays in management of these patients on their treatment and survival.Methods: Data on all patients with pancreatic cancer referred to the Pancreatic Unit (1997–2002) were collected prospectively and analysed using SPSS 16®. The delay in diagnosis and treatment for each patient was measured by estimating the time from the beginning of symptoms to the date of the referral letter (T1), the time from the referral date to the date of first review at the Unit (T2) and the time from date of review to the date of diagnosis/treatment (T3). Treatments were defined as 1) pancreatic resections, 2) gastric and biliary bypass and 3) biliary stents. The term ‘operability’ was used to describe patients thought to have a potentially removable tumour and had an operation and ‘resectability’ applied to the patients whose tumour was actually removed at the operation. Follow-up time and survival were recorded by reviewing the patient’s notes, hospital electronic databases and by contacting patients General Practitioners.Results: There were a total of 355 patients with pancreatic cancer. Median age at diagnosis was 64 (i.q.r. 56–71) years and median follow-up was 8 (i.q.r. 4–14) months.The overall 1, 3 and 5 years patient’s survival was 26%, 5% and 4% respectively. 1, 3 and 5 years survival of inoperable patients was 24%, 2% and 0% and for operable patients was 35%, 13% and 9% respectively. The median survival time for those patients that underwent operation was significantly higher than those that did not (12 vs 6 months, p < 0.001).The overall median time from initial symptoms to diagnosis/treatment (T1 + T2 + T3) was 102 (i.q.r. 56–182) days, T1 was 65 (i.q.r. 31–143), T2 17 (i.q.r. 8–28) and T3 11 (i.q.r. 6–21) days. The time delay from symptoms to referral (T1) had minimal clinical relevance to survival, with a hazard ratio of only 1.001 (95% CI 0.001–0.002, p = 0.043) per day. Of all 355 patients, 305 (86%) were reviewed and treated within 62 days from the GP referral (T2 + T3). There was no significant difference in operability, resectability and survival of patients that were diagnosed/treated before or after 62 days from referral (T2 + T3) (median months 6.5 and 7.9 respectively, p = 0.134).Patients presenting with jaundice were referred (T1, median 56 vs 103) and diagnosed/treated (T2 + T3, median 96 vs 130) days (p < 0.001) sooner, had a higher operability rate (33% vs 21%, p = 0.035) but not a significantly higher resectability rate of (37% vs 29%) (p = 0.608). Isolated or combined mode of clinical presentation had no significant effect on survival (p = 0.965). On multivariate regression analysis, prognostic factors of survival were a resectable tumour and the time from the beginning of symptoms to referral.Conclusion: This study showed that pre-hospital delays in referring patients to a specialist unit, but not hospital related 62 days target, had an no impact on operability, resectability and survival. Clinical presentation also had no impact on the survival. We confirmed that pancreatic resection is the most important factor in determining the length of survival in patients with pancreatic cancer.Our study implies that the successful implementation of the 62 days National Cancer Waits Target across the UK is unlikely to have an impact on prognosis in patients with pancreatic cancer. Focusing on early referral to specialist Pancreatic Units might be more effective.

2-Week wait referrals in suspected skin cancer: Does an instructional module for general practitioners improve diagnostic accuracy?

Z. Shariff, A. Roshan, A.M. Williams, A.J. Platt — 2010-10-01

Abstract: The two-week wait (2WW) scheme in the United Kingdom for suspected skin cancer has been criticised for having low pick up rates, with a high proportion of clinically benign lesions being referred as suspicious.We studied the referral patterns of skin cancer to our hospital under the 2WW initiative, and aimed to quantify the effect of a targeted continuing medical education (CME) module on improving diagnostic accuracy.All referrals to our hospital (dermatology and plastic surgery) under the 2WW rule were audited between July and September 2006. A targeted CME module was sent to GPs describing and illustrating common lesions. After 11 months, all 2WW referrals were prospectively studied between August and October 2007. The main outcome measure was the percentage of correctly referred squamous cell carcinomas (SCCs) and melanomas.237 referrals were made between July and August 2006, and 223 referrals between August and October 2007. The proportion of appropriately referred skin cancers (SCCs and melanomas) was 23.2% before CME, and 20.6% after CME. There were no differences in pick up rates before and after the CME amongst suspected SCCs (21.1% vs. 29.7%) or melanomas (24.6% vs. 15.1% respectively). Referrals to Plastic Surgery were more likely to be confirmed histologically as melanomas or SCCs (23.6% and 33.7% respectively) than those made to Dermatology (17.5% and 15.3% respectively).The proportion of correctly suspected skin malignancies under the 2WW initiative remains low despite education. A targeted CME module sent to GPs fails to improve pick up rates. There is a need for continuing dermatology training amongst referring physicians.

Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk

2010-10-01

Abstract: Background: Nipple discharge accounts for up to 5% of referrals to breast surgical services. With the vast majority of breast carcinomas originating in the ductal system, symptomatic dysfunction of this system often raises disproportionate clinical concern. The aim of this study is firstly, to evaluate the clinical importance of nipple discharge as an indicator of underlying malignancy and secondly, to assess the diagnostic application of duct cytology in patients presenting with nipple discharge.Study design: We performed a retrospective analysis of all patients presenting with nipple discharge as their primary symptom to the symptomatic breast unit at a tertiary referral center over a 30-month period (n = 313). The Hospital Inpatient Enquiry (HIPE) System and BreastHealth database were used to identify our study cohort. Parameters evaluated included patient demographics, clinical presentation, clinical evaluation, radiological assessment and histological/cytological analysis.Results: Three-hundred and thirteen patients presented with nipple discharge as their primary complaint. Invasive breast carcinoma was diagnosed by Triple Assessment in 5% of patients. 24% of patients presenting with nipple discharge underwent nipple aspiration and cytological analysis. Duct cytology was diagnostic of the underlying breast carcinoma in 50% of triple assessment diagnosed carcinoma. Four risk factors were identified as having a significant association with breast carcinoma, these included (a) age >50 years (p < 0.0001), (b) bloody nipple discharge (p < 0.008), (c) presence of a breast lump (p < 0.0001) and (d) single duct discharge (p < 0.006).Conclusions: Nipple discharge is a poor indicator of an underlying malignancy. Use of nipple aspiration and duct cytology for the assessment of nipple discharge is of limited diagnostic benefit. However, by utilizing the systematic, gold standard approach of Triple Assessment (clinical, radiological and cytological evaluation), the risk of underlying carcinoma can be accurately defined.

Irish (Republic) versus British (North West) orthopaedic trainees: What are the differences?

L.N. Banks, J. Cashman, R. Mohil, S. Morris, J.P. McElwain — 2010-10-01

Abstract: British Trainees have gradually had their working week curtained over the last 8 years. The Republic of Ireland Trainees have not been subjected to the European Working Time Directive prior to 2009 and have therefore worked on average, more hours than their British counterparts. We wanted to see if the differing schemes had an impact on recruiting and training orthopaedic surgeons. We surveyed Republic of Ireland orthopaedic specialist registrars (SpRs) and North West (NW) British SpRs/specialist trainees (ST3 and above) to see if there were any discernable differences in working patterns and subsequent training exposure.A standard proforma was given to Irish Trainees and to NW SpRs/STs at their National or regional teaching (January/February 2009).62% of Irish and 47% of British NW Trainees responded. Irish trainees were more likely to have obtained a post-graduate degree (p = 0.03). The Irish worked more hours per week (p < 0.001) doing more trauma operative lists (p = 0.003) and more total cases per 6 months than the NW British (p = 0.003).This study suggests that more hours worked, equals more operative exposure, without detriment to the academic side of training. Obviously it is not possible to say whether fewer operations make for a poorer surgeon, but the evidence suggests that it may be true.

Up-regulation of signal transducer and activator of transcription-3 is associated with aggravation of ulcerative colitis

Fujun LI, Yiyou ZOU, Xuefeng LI — 2010-10-01

Abstract: Objective: The signal transducers and activators of transcription (STAT) family of proteins are intracellular signal transduction molecules involved in the expression of numerous proinflammatory genes in inflammatory cells. This study was executed to determine the association between the expression pattern of STAT-3 in the colonic mucosa of patients with ulcerative colitis (UC) and the progression of this disease.Methods: We carried out the real-time reverse transcription-polymerase chain reaction (RT-PCR), Western-blot analysis and immunohistochemical staining to examine the expression of STAT-3 at both mRNA and protein levels in 25 patients with UC and 10 normal controls. The association between STAT-3 expression pattern and the severity of the disease was also analyzed.Results: The expression of STAT-3 mRNA and protein in the ulcerated and inflamed colonic mucosa was significantly higher than that in the non-inflamed colonic mucosa (for mRNA: P = 0.001, 0.02 and for protein: P = 0.003, 0.03, respectively), but there was no statistically significant difference in the non-inflamed colonic mucosa of UC patients and normal controls (for mRNA: P = 0.062 and for protein: P = 0.063). Furthermore, immunohistochemical analysis showed that among the inactive, mild ∼ moderate, and severe colonic mucosae of UC patients, the positive rates of STAT-3 expression were 60.0%, 66.7%, and 88.9%, respectively.Conclusion: Our study provides convincing evidence for the first time that the up-regulation of STAT-3 in colonic mucosa may be associated with the progression of human UC and STAT-3 may be a potential therapeutic target for this disease.

Brain-machine interface: The challenge of neuroethics

Andreas K. Demetriades, Christina K. Demetriades, Colin Watts, Keyoumars Ashkan — 2010-10-01

Abstract: The burning question surrounding the use of Brain-Machine Interface (BMI) devices is not merely whether they should be used, but how widely they should be used, especially in view of some ethical implications that arise concerning the social and legal aspects of human life. As technology advances, it can be exploited to affect the quality of life. Since the effects of BMIs can be both positive and negative, it is imperative to address the issue of the ethics surrounding them. This paper presents the ways in which BMIs can be used and focuses on the ethical concerns to which neuroscience is thus exposed. The argument put forward supports the use of BMIs solely for purposes of medical treatment, and invites the legal framing of this.

Short bowel syndrome

Claire L. Donohoe, John V. Reynolds — 2010-10-01

Abstract: The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.

Recent advances in video-assisted thoracoscopic approach to posterior mediastinal tumours

2010-10-01

Abstract: Minimal invasive video-assisted thoracic surgery can be a safe alternative technique in the assessment, diagnosis and surgical resection of posterior mediastinal tumours. Video-assisted thoracic surgery may be particularly suited for the management of posterior mediastinal tumours as most are benign. Surgical technique continues to evolve from the classic 3-port access in order to tackle more complex tumours positioned at the apical and inferior recesses of the posterior mediastinum. The preoperative identification of dumbbell tumours is important to facilitate arrangements for a single-stage combined resection for both the intra-thoracic and intraspinal tumour. Results from Video-assisted thoracic surgery posterior mediastinal tumour resection are comparable with conventional surgical techniques in terms of symptomatic improvement, recurrence and survival. Video-assisted thoracic surgery approach has been shown to result in less post-operative pain, improved cosmesis, shorter hospital stay, and more rapid recovery and return to normal activities. In over a decade, video-assisted thoracic surgery has gradually matured and is now a promising therapeutic alternative to open approach. In certain selected patients, video-assisted thoracic surgery may be considered the standard of care for conditions of the posterior mediastinum. Recent developments in robotic surgery for the management of mediastinal tumours are promising, however, long-term results are pending.

Hyperhidrosis: Evolving concepts and a comprehensive review

Tobias Vorkamp, Fung Joon Foo, Sidra Khan, Jan D. Schmitto, Paul Wilson — 2010-10-01

Abstract: Hyperhidrosis (primary or secondary) describes a disorder of excessive sweating. It has a significant negative impact on quality of life and affects nearly 1% of the population living in the United Kingdom (UK). Axillary involvement is the most common affecting 80% of cases.A common link to these disorders is an extreme non-thermoregulatory sympathetic stimulus of exocrine sweat glands, mostly due to emotional stimuli. Non-surgical treatment involves topical medication, iontophoresis and systemic anti-cholinergics. More recently the use of intradermal botulinum toxin has gained popularity.Surgical treatment reserved for severe cases, not responding to conservative management involves local excision, curettage and thoracoscopic sympathectomy. Evolving concepts for treatment, risks and benefits are discussed in the paper herein.

Skin-sparing mastectomy: A novel method to maximise training opportunities

2010-10-01

Skin-sparing mastectomy (SSM) is an increasingly used technique both in the treatment of breast cancer and in prophylactic surgery This technique involves a standard mastectomy with or without resection of the nipple-areola complex (NAC). The significant difference is the majority of the native skin envelope is preserved during the resection allowing immediate reconstruction with favourable cosmetic results. The exposure of the tissue during the operation is markedly limited, where just a single circum-areolar incision has been made. A reliable technique is necessary to achieve oncological clearance, avoid local recurrence and reduce post-operative complications. In particular, the incidence of skin flap necrosis can occur in up to 25% which can have devastating implications when implants have been used Importantly, the incidence of complications may correlate with surgical experience It is therefore essential that trainees have adequate opportunities to train in SSM.

Liver and pancreatobiliary surgery with liver transplantation

Stephen J. Wigmore — 2010-10-01

This addition to the Oxford Specialist Handbooks in Surgery series covers the subspecialties of HPB surgery and Liver transplantation. It describes itself as being “aimed primarily at trainees in general surgery, hepatology, gastroenterology, radiology and anaesthesia.” While the choice of topics covered is to me logical it does cut across the Intercollegiate Examination in Surgery sub-specialization arrangements which put HPB and Oesophagogastric surgery together and group solid organ transplantation as a separate subspecialty. There is good coverage of a wide breadth of topics and although a ‘bulleted list’ format is used extensively, the book is easily understood. There are a few examples where a more narrative style would convey the nuances of decision making better but on the whole the subject areas are comprehensively covered. The text is illustrated with black and white photographs and line drawings which are good quality and add value to the text. Explanations of investigations and procedures will provide useful reading for those earlier in their career and descriptions of complications and their management are pitched at a more Intercollegiate level.