The Surgeon - Articles in Press

A practical review of the Glasgow Coma Scale and Score - Corrected Proof

Philip Barlow — 2012-02-02

Abstract: Since the Glasgow Coma Scale was introduced in 1974, it has become the most common method of describing a patient’s level of consciousness. However, despite its almost universal use, there remain a number of misunderstandings, particularly regarding the appropriate situations in which to use the Glasgow Coma Score rather than the Scale, and also in the correct way to elicit and record the motor responses. This article, aimed at non-neurosurgeons, addresses these problems, and provides a reference for those wishing to learn or teach the Glasgow Coma Scale and Score.

Advances in the understanding of the aetiology of Dupuytren’s disease - Corrected Proof

Natasha E. Picardo, Wasim S. Khan — 2012-02-01

Abstract: Dupuytren’s disease is a fibroproliferative disease of the palmar fascia which has been described for centuries, yet the aetiology and pathophysiology remain poorly understood. Surgery and collagenase injections comprise the main therapeutic options but disease recurrence is common. We explore the evidence underlying the current disease theories and outline other potential therapeutic options.

A clinical and radiological assessment of incisional hernias following closure of temporary stomas - Corrected Proof

2012-01-30

Abstract: Aims: The rate of incisional hernia at stoma closure sites is unclear. This study aimed to describe this rate in patients with closed stomas who had definitive post-operative imaging of their abdominal wall.Methods: A retrospective review of patients who had undergone stoma reversal and had a CT or MRI scan of the abdomen ≥2 months following reversal was performed. A radiologist, blinded to the original radiological report and clinical results, reviewed all scans for abdominal wall herniation. This was correlated to documented clinical findings.Results: Fifty-nine patients were included: 49 loop ileostomy and 10 end colostomy reversals. CT scans were performed for 57 patients and MRI for two. The median time from closure to imaging was 10 months (range 3–32 months). The combined clinical and radiological hernia rate was 34% (20/59). Imaging alone produced a rate of 31% (18/59). The clinical rate of hernia detection was 14% (8/59). Using the rate of clinical herniation as the detection standard, imaging had a low positive predictive value (33%, 6/18) but a high negative predictive value (95%, 39/41). Four patients required surgical repair of their stoma site hernia (20%, 4/20).Conclusions: One in three patients undergoing stoma closure developed an incisional hernia. One in five of those with a hernia underwent surgical repair. Definitive imaging may provide an early surrogate marker for late clinically relevant hernias. Consideration of methods to prevent stoma closure site hernias should be considered.

Clinical and histopathological factors affecting failed sentinel node localization in axillary staging for breast cancer - Corrected Proof

2012-01-27

Abstract: Background: Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients.Aims: To analyze reasons for failure of SLN localization by means of a multivariate analysis of clinical and histopathological factors.Methods: We performed a review of 164 consecutive breast cancer patients who underwent SLNB. A superficial injection technique was used.Results: 9/164 patients failed to show nodes. In 7/9 patients no evidence of radioactivity or blue dye was observed. Age and nodal status were the only statistically significant factors (p < 0.05). For every unit increase in age there was a 9% reduced chance of failed SLN localization. Patients with negative nodal status have 90% reduced risk of failed sentinel node localization than patients with macro or extra capsular nodal invasion.Discussion: The results suggest that altered lymphatic dynamics secondary to tumour burden may play a role in failed sentinel node localization. We showed that in all failed localizations the radiocolloid persisted around the injection site, showing limited local diffusion only. While clinical and histopathological data may provide some clues as to why sentinel node localization fails, we further hypothesize that integrity of peri-areolar lymphatics is important for successful localization.By means of a multivariate analysis of clinical, biochemical and histopathological parameters, we review reasons for failure of localization of sentinel nodes in axillary staging for breast cancer and compare it with recent reports in the literature.

Pancreatectomy with synchronous vascular resection – An argument in favour - Corrected Proof

Gabriele Marangoni, Adrian O’Sullivan, Walid Faraj, Nigel Heaton, Mohamed Rela — 2012-01-03

Abstract: Background: The first case-series of pancreatectomy with synchronous en-bloc vascular resection with the aim to improve pancreatic cancer survival was published in 1977. Advances in surgical techniques, intensive care management and teaching centers with high volume cases have dramatically reduced mortality and morbidity of major pancreatic resections. This has led to a progressively wider use of venous and/or arterial resections during pancreatic surgery in selected patients to achieve negative resection margins.Methods: We review the current literature and discuss our experience in pancreatectomies with en-bloc vascular resections.Results: Survival of patients with pancreatic cancer who undergo an R0 resection with venous reconstruction is comparable to those who have a standard pancreaticoduodenectomy with no added mortality or morbidity. Conversely, arterial resection is associated with a higher morbidity, mortality and overall poorer survival, perhaps reflecting more advanced disease.Conclusions: Since the need for vascular resection may not be always apparent on pre-operative imaging, surgeons who perform major pancreatic surgery should be familiar with vascular resection and reconstruction techniques in order to offer to these patients the best chance to prolong survival.

Resection of focally progressive gastrointestinal stromal tumours resistant to imatinib therapy - Corrected Proof

G.H. Tse, E.H.C. Wong, P.J. O’Dwyer — 2011-11-28

Abstract: Aims: To analyse the outcome of patients with gastrointestinal stromal tumour (GIST) who receive imatinib therapy and undergo subsequent resection of focally progressive disease.Methods: We reviewed the records of all cases of GIST discussed at the West of Scotland Sarcoma regional multi-disciplinary team meeting between January 2002 and December 2009 inclusive. We analysed all patients who had undergone surgery for progressive disease on imatinib therapy. Focally progressive disease was diagnosed on computated tomography (CT) and positron-emission tomography-CT and was defined by a GIST lesion initially responsive to imatinib therapy but then underwent growth with evidence of metabolic activity. All procedures were undertaken in a university teaching hospital by a single surgeon.Results: Nine patients were identified who underwent ten resections of focally progressive GIST. Six had previously undergone resection of their primary tumour while three had presented with un-resectable disease. Nine operations were for resection of a solitary progression while one operation was for three foci of progression. Five patients underwent liver resection which was confined to the segments were there was focal progression of GIST; of these one patient had multiple liver metastases and portal hypertension with a mass at the porta hepatis.The absolute survival for patients after resection was 18.4±13.7 months (mean±standard deviation), with progression free survival of 14.1±13.5 months equating to 56% at 1-year. Four patients had been switched from imatinib to sunitinib, for further multi-focal progression.Conclusions: Surgical resection of focally progressive GIST may prolong survival and a second or third resection is a feasible option in selected patients.

The use of weekly departmental review of all orthopaedic intra-operative radiographs in order to improve quality, due to standardized peer expectations and the “Hawthorne effect” - Corrected Proof

2011-11-28

Abstract: Introduction: Clinical governance highlights risk management, clinical effectiveness and use of evidence based practice as key elements in the provision of a quality service. A change in the method of quality control in our orthopaedic trauma unit allowed us the opportunity to study if the quality of operative outcomes had changed as a result. The Hawthorne effect refers to phenomenon whereby employees work quality improves by virtue of their awareness that their labour is being assessed.Methods: A new outcome appraisal forum was introduced in our department in 2009. This forum involved a weekly whole department review of all the previous week’s intraoperative radiographs. We used the tip apex distance (TAD) of the dynamic hip screw (DHS) procedures in hip fracture patients as a surrogate marker, of any objective change in the quality and consistency of intra-operative radiographs, in the year prior to and after the introduction of this review system.Results: We found that the mean TAD and the number of TAD measurements over 25 mm decreased significantly in the year after the new quality control mechanism was introduced.Conclusion: We would recommend the use of a weekly quality control meeting scrutinizing every intraoperative radiograph as a simple, cost effective method of incorporating many aspects of clinical governance, as well as fostering a culture of quality.

Serotonin: A double-edged sword for the liver? - Corrected Proof

M. Lesurtel, C. Soll, B. Humar, P-A. Clavien — 2011-11-28

Abstract: Since the discovery of the impact of serotonin in liver regeneration, this molecule has gained considerable attention in liver physio-pathology. Platelet-derived serotonin initiates liver regeneration after partial hepatectomy in various rodent models. Serotonin agonism stabilizes the hepatic microcirculation and prevents small-for-size liver graft failure. Similarly, serotonin receptor agonists improve the sinusoidal perfusion of aged liver and restore the deficient liver regeneration in old mice through a pathway dependent on vascular endothelial growth factor. Beside hepatocyte proliferation, cholangiocytes have been shown to be able to deploy serotonin as an autocrine/paracrine signal to regulate regeneration of the biliary tree.Increasing evidence indicates that serotonin is involved in many pathological conditions of the liver. For example, serotonin promotes tissue repair after ischemia/reperfusion injury. Reactive oxygen species generated by serotonin degradation contribute to steatohepatitis in rodent models. Serotonin aggravates viral hepatitis, again through vasoactive effects on the microcirculation, and plays a crucial role in the progression of hepatic fibrosis. Finally, serotonin may facilitate tumor growth of primary liver carcinoma like cholangiocarcinoma and hepatocellular carcinoma. These findings make serotonin both friend and foe for the liver. Whichever, these new data emphasize the potential of serotonin as a pharmacological target in liver disease.

Remnant closure after distal pancreatectomy: Current state and future perspectives - Corrected Proof

Thilo Hackert, Markus W. Büchler — 2011-11-24

Abstract: Remnant closure after distal pancreatectomy remains a surgical challenge and is still associated with a fistula rate of about 30%. Despite numerous technical modifications including the use of stapling devices, artificial patches and glue components, no important progress has been made concerning this topic within the last decade. Although tissue texture, co-morbidities and the type of resection may influence fistula rate, substantial improvement can probably be reached by further technical modifications. In addition to the avoidance of fistula development, the recognition and management of this complication is essential to achieve good postoperative outcome.The present review summarizes the currently available data on technical approaches, incidence and risk factors for failure of remnant closure, fistula-associated complications and management as well as the future perspectives in this field of surgery.

Hip artroplasty: A transient reason not to be pregnant - Corrected Proof

Nicola Maffulli, Angelo Del Buono, Vincenzo Denaro — 2011-11-21

Abstract: Metal implants corrode and release metal ions, cobalt and chromium, which, in turn, may cause systemic toxicity, mostly in the first few months from implantation of metal-on-metal hip arthroplasty. At the time of delivery, the placenta reduces the passage of cobalt and chromium ions released from metal-on-metal prosthesis. From a biomechanical view point, hip replacement should not be considered a contraindication for pregnancy or for spontaneous delivery, and does not seem to have any negative effects in terms of risk of dislocation, loosening, fracture, or revision surgery, neither negative effects on clinical and functional outcomes. The long-term biological consequences of exposure to Co–Cr particles and ions remain largely unknown.

Changing practices in the surgical management of hyperparathyroidism – A 10-year review - Corrected Proof

T. McVeigh, A.J. Lowery, D.S. Quill, M.J. Kerin — 2011-11-21

Abstract: Aim: Parathyroid surgery has undergone a paradigm shift over the last decade, with a move from traditional bilateral neck exploration to minimally invasive parathyroidectomy (MIP), and increasing reliance on pre- and intra-operative localization of overactive glands. We aimed to assess changing surgical practices and their impact on the management of parathyroid disease in a tertiary referral centre in the West of Ireland.Methods: A retrospective cohort analysis of those patients undergoing a surgical intervention for parathyroid disease in the period between 1999 and 2009 in our centre was carried out. Data was analysed using PASW (v18) software.Results: 248 procedures were performed, increasing from an annual rate of 6 in 1999 to 45 in 2009. 129 procedures were completed by minimally invasive means, following the introduction of MIP in 2003. Single-gland disease accounted for 87% of cases (n = 216) with carcinomas in 2 patients (0.8%). Pre-operative localization had disappointing diagnostic value, with high false negative rates for both ultrasound (37.3%) and Sestamibi Scanning (35.81%). Intra-operative adjuncts were more helpful, with intra-operative Parathyroid hormone monitoring facilitating curative resection of adenomas in 94.03% at 10 min. Median length of post-operative stay has significantly decreased from 6 days in 1999 to 1 night only in 2009 (p < 0.01, ANOVA). Those patients undergoing MIP had shorter stay than the open group (1.71 days -v-4.73, p = 0.003,t-test).Conclusion: The practice in our centre has shifted to a less invasive approach. Increased utilisation of intra-operative adjuncts has facilitated this change, and resulted in favourable changes in length of stay, extent of dissection, and number of patients treated.

Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE) - Corrected Proof

R.S.J. Dalton, N.J. Smart, T.J. Edwards, I. Chandler, I.R. Daniels — 2011-11-16

Abstract: Background: Many studies report that low rectal cancer treated with abdomino-perineal excision (APE) have higher rates of CRM involvement with associated local recurrence and worse survival when compared to low anterior resection. We present a single surgeon’s short-term outcomes using the prone perineal extra-levator (elAPE) approach.Methods: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent. Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality.Results: Mean distance of tumour from anal verge was 3.63 ± SD 1.52 cm. 14 patients had pre-operative chemo-radiotherapy. The involved circumferential resection margin rate was 3.2%. Median follow-up was 20 (0–45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%.Conclusions: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation.

Corrected Proof

Paul Banaszkiewicz — 2011-11-14

This is a new edition to the Oxford handbook series. Written by specialists in orthopaedics from Oxford, Bristol and Stanmore, the book provides a basic introduction to orthopaedics for junior doctors, medical students and allied health professionals. It is pocket sized, concise, and written.

Wet or dry bandages for plaster back-slabs? - Corrected Proof

Santosh Baliga, D. Finlayson — 2011-11-14

Abstract: Cotton crêpe and stretch bandages are commonly used in back-slabs and casts in orthopaedic practice. In theory they allow swelling to occur after injury while splinting the fracture.The application of a wet bandage prevents the Plaster-of-Paris (POP) setting too rapidly, giving time to apply a mould or attain correct limb position. However, we hypothesised that a wet bandage contracts upon drying and may cause constriction of the splint.This study aimed at determining whether there was any significant change in length of commonly used bandages when wet as well as any further change when left to dry again. Two types of bandage were evaluated.250 mm strips of bandage were dipped into water, gently squeezed and laid flat on a bench. The bandage was then immediately measured in length. The strips were then left to dry and re-measured.This experimental study shows that both cotton crepe and cling significantly shrink by around 7% when wet. This phenomenon has the potential to significantly increase the pressure exerted on the limb by a back-slab. We speculate that the application of wet bandages is why some back-slabs may need released. It is therefore recommended that bandages should be applied only in the dry form.

Malignant otitis externa: An Australian case series - Corrected Proof

Ronald Chin, Phoebe Roche, Elizabeth Sigston, Neil Valance — 2011-10-28

Abstract: Objectives: To establish a clinicopathological profile of malignant otitis externa (MOE) in an Australian tertiary referral institution.Study Design: Retrospective cohort outcomes study.Methods: 24 patients were identified with MOE between January 1998 and July 2007. Patients were classified into Radiological Grades I–IV. Laboratory investigations Including C–reactive protein (CRP), white cell count (WCC), glycosylated haemoglobin (HBA1c) and average glucose level over admission were recorded.Results: Radiological Grade was significantly associated with duration of therapy (rank correlation 0.57, p = 0.004). CRP was a useful indicator confirming disease resolution. Diabetics with MOE had elevated average blood sugar levels during their Hospital admission (p < 0.001) and had poor overall glycaemic control represented by Elevated HBA1c scores (p < 0.001).Conclusions: Malignant otitis externa is a rare disease, which is best managed in a multidisciplinary team setting. This practical grading system can be used to predict the duration of therapy at time of diagnosis, which enables the efficient utilisation of Hospital resources. Poorly controlled diabetics are more susceptible to developing.MOE than diabetics with satisfactory glycaemic control and may represent a subgroup of more brittle diabetics. CRP combined with appropriate clinical and radiological investigations is useful in assessing disease resolution.

Approaches to the hip for Total Hip Arthroplasty (THA) - Corrected Proof

I.H. Abdulkareem — 2011-10-13

Edmunds and Boscainos made comparison between the anterolateral and posterior approaches to Total Hip Arthroplasty (THA), using Harris hip scores and Trendelenburg’s test by looking at pre-operative results and comparing them to post-operative results. They also mentioned that the two most commonly used and described approaches to Total Hip Arthroplasty (THA) are the anterolateral and the posterior approach. They failed to look at the different variations of the anterolateral approach.

A review of major trauma admissions to a tertiary adult referral hospital over a ten year period: Fewer patients, similar survival - Corrected Proof

J.G. Solon, P. Houlihan, D.F. O’Brien, S. Connolly, D. O’Toole, D.A. McNamara — 2011-10-10

Abstract: Background: Trauma is an important cause for presentation to the emergency department, representing a significant number of emergency surgical admissions. Societal changes result in alterations in the epidemiology of trauma.Objectives: This study aimed to review patients admitted to a tertiary referral hospital as a result of traumatic injuries, assessing for changes in admission epidemiology.Methods: Trauma admissions over two year-long periods a decade apart were reviewed. The Trauma Audit and Research Network (TARN) audit system identified admissions and transfers between June 2006 and May 2007. The Hospital In-Patient Enquiry (HIPE) system identified those fulfilling TARN criteria a decade earlier. Comparative analysis was performed on the dataset.Results: There were 367 trauma admissions between June 2006 and May 2007: 88 road traffic accidents (RTAs), 201 falls and 77 other injuries, with 627 admissions a decade earlier: 286 RTAs, 247 falls and 94 others. Males comprised 72% and 69% of RTA admissions in both periods respectively. Firearm-related injuries increased significantly (p = 0.015). Neurosurgical transfers decreased from 256 to 150 with a slight increase in unadjusted overall mortality from 8.5% to 10.9%. Admissions of patients aged less than 19 reduced from 150 to 59 (p = 0.0031) with a similar trend in those aged between 20 and 29 years from 149 to 78.Conclusion: Admissions resulting from RTAs and of patients aged under 30 reduced significantly, however, young males remain the most affected sub-group. Firearm injuries increased significantly, a worrying trend in view of the severity of injury sustained by these victims.

A comparison of the teamwork attitudes and knowledge of Irish surgeons and U.S Naval aviators - Corrected Proof

Paul O’Connor, Stephen Ryan, Ivan Keogh — 2011-10-05

Abstract: Poor teamwork skills are contributors to poor performance and mishaps in high risk work settings, including the operating theatre. A questionnaire was used to assess the attitudes towards, and knowledge of, Irish surgeons (n = 72) towards the human factors that contribute to mishaps and poor teamwork in high risk environments. The responses were compared to those obtained from U.S. Naval aviators (n = 552 for the attitude questions, and n = 172 for the knowledge test). U.S. Naval aviators were found to be significantly more knowledgeable, and held attitudes that were significantly more positive towards effective teamworking than the surgeons. Moreover, 78.9% of Senior House Officers and Registrars stated that junior personnel were frequently afraid to speak-up (compared with 31.3% of Consultants). Only 7.3% of surgeons stated that an adequate pre-operative brief team brief was frequently conducted, and only 15% stated that an adequate post-operative team brief was frequently conducted. It is suggested that the human factors training currently provided to surgeons in Ireland is a positive first step. However, there is a need to stress the importance of assertiveness in juniors, listening in seniors, and more reinforcement of good teamworking behaviours in the operating theatre.

Expert practical operative skills teaching in Trauma and Orthopaedics at a nominal cost - Corrected Proof

J Davies, R Pilling, R Dimri, G Chakrabarty — 2011-09-23

Abstract: Background and purpose: The AO Foundation Operative Fracture Management course is the gold standard in training courses currently available for trainees at ST3 level. We have devised a low cost operative skills course comprising instructional lectures, demonstrations and practical dry bone workshops. To assess the quality of teaching, candidates’ feedback was analysed in two cohorts for the running of the course over two consecutive years: 2008 and 2009.Methods: Trainees were given short instructional lectures by consultant surgeons followed by workshops, with a trainer to candidate ratio of 1:4. A trauma inventory was provided by Stryker Trauma UK, ensuring a nominal fee for each candidate (£50). Feedback was anonymously collected according to a Likert scale and analysed using non-parametric methods appropriate for ranked data.Main findings: Twenty one of 22 (95%) candidates gave feedback in 2008 and 18 out of 18 candidates (100%) in 2009. The teaching provided was highly rated consistently for both years, apart from an informal session on theatre tips and tricks in 2008. This was not repeated in 2009 to allow more practical time. Only one session, an intramedullary nailing lecture, had a significant difference in scores between the 2 years (p = 0.044) because of improved scores in 2009.Conclusions: Due to changes in training, trainees have reduced exposure in theatre and this has implications for the early stages of acquiring practical operative skills. As an adjunct to the AO course, practical skills teaching by consultants in the format of a low cost skills workshop outside of a theatre environment can be achieved with support from a trauma implant supplier.

Laparoscopic adrenalectomy: Auditing the 10 year experience of a single centre - Corrected Proof

2011-09-19

Abstract: Background: Laparoscopic adrenalectomy (LA) is the gold standard for benign adrenal resection, and has been performed at our centre since 2000. We present a retrospective audit of our ten-year experience, and discuss the learning curve.Methods: Creating a retrospective database, clinical and outcome data were collected for all resections performed over a ten-year period (2000–2010). Patients were chronologically divided into an ‘early’ (first 40 cases) and ‘late’ (subsequent cases) group to provide an insight into the learning curve.Results: Over this period, 134 laparoscopic resections were performed, predominantly for benign adenomas (80.3%), with 48% of patients having primary hyperaldosteronism. There was almost equal sex distribution and mean age was 50.2 years, with a median BMI of 28.2. The mean operating time for left and right procedures were 127 and 124 min respectively, with 56.7% of resections being left sided. Our rate of conversion to open was 3.9%. Median length of stay was 4 days post-operatively. There was no mortality and 8.7% patients experienced a surgical complication. Analysis of the grouped data demonstrated a statistically significant reduction in open conversion rate (p = 0.017) and operative time (p = 0.011) in the ‘late’ group. Among the two groups there was no statistically significant difference in the length of stay and surgical complication rate. All results were comparable to published series in the literature.Conclusion: LA has proven to be a safe procedure with a low complication rate at our centre. Our data provide evidence that operative time and conversion rate improves with experience.

Combined laparoscopic anterior resection and right hemicolectomy for synchronous colorectal tumours: How to retrieve both specimens at the same time through a transverse incision - Corrected Proof

Wah-Siew Tan, Hak-Mien Quah, Kong-Weng Eu — 2011-09-15

We describe the technique for concurrent laparoscopic right hemicolectomy and anterior resection in a patient with synchronous tumours in the ascending colon and upper rectum. The sequence of dissection and technique for multiple specimen extractions through a single incision, without need for multiple reconstitution of pneumoperitoneum, is discussed.

Assessment of calf volume in congenital talipes equinovarus by computer analysed digital photography - Corrected Proof

Simon L. Barker, Martin Downing, David J. Chesney, Nicola Maffulli — 2011-09-15

Abstract: The development of evidence-based approaches to the Congenital Talipes Equinovarus (CTEV) is impaired by the diversity of assessment techniques available, many of which have not been validated. Highly objective evaluation techniques that reflect the deformity and permit comparison between studies may lack the necessary link to functional features that are paramount to the patient, namely pain and mobility. Calf wasting is an acknowledged but little investigated component of the pathology. The rapid evolution of digital photography and computerised analytical techniques has yielded an opportunity to explore their role in the assessment of this common paediatric Orthopaedic pathology. This study presents the use of a cost-effective digital photographic assessment technique of maximal calf circumference and calf volume. These indices reflect the muscular development in the calf and therefore have significance in the functional assessment of CTEV and may represent an index of severity. Subjectivity has been limited by computerisation of the analysis process. The technique could easily be adapted to other volumetric analyses.

Perioperative multimodal optimisation in patients undergoing surgery for fractured neck of femur - Corrected Proof

David Macfie, Reza Arsalani Zadeh, Mark Andrews, Jonathan Crowson, John Macfie — 2011-09-15

Abstract: Introduction: Enhanced Recovery after Surgery protocols are associated with reduced length of stay and morbidity in patients undergoing major surgery. The aim of this audit was to assess the impact of a multimodal optimisation protocol in patients admitted with fractured neck of femur.Patients and methods: A multimodal optimisation protocol was introduced for the care of patients with proximal femoral fractures. The short-term effects of the optimised perioperative care programme was assessed and compared with the conventional perioperative care before the intervention.Results: A total of 232 patients were included in this audit, 117 optimised care and 115 conventional care. Patients were similar with regards to age, gender, domicile, mental status and the type of operation. The optimised group suffered from fewer post-operative complications (36 out of 117 vs 48 out of 115, P = 0.04, Chi square test). There was no significant difference between two groups with regards to the length of hospital stay and 30-day mortality.Conclusion: Multimodal optimisation may be associated with a decline in post-operative morbidity in patients with proximal hip fracture. It does not have any significant impact on the length of hospital stay and 30-day mortality.

Imaging the spine for tumour and trauma – A national audit of practice in Irish hospitals - Corrected Proof

J.C. Kelly, D.E. O’Briain, G.A. Kelly, J.P. Mc Cabe — 2011-09-15

Abstract: Background and purpose: The provision of appropriate spinal imaging in cases of acute injury as a consequence of trauma or tumour is becoming ever more challenging. This study assessed the use of multimodal radiological investigations in the management of spinal cord compression as a result of trauma and metastatic cancer in all major Irish hospitals.Methods: We conducted a questionnaire of thirty four hospitals in an effort to assess the provision of these services to patients with possible spinal cord compromise.In all public hospitals the Emergency Department and/or the Orthopaedic Registrars were contacted and asked a series of questions relating to spinal clearance, spinal clearance protocols, CT and MRI scanning facilities and on site orthopaedic services.Results: All centres participated in the study. 67.64% of centres routinely used a protocol in spinal clearance. In 87% of hospitals the Emergency department were responsible for clearing the spine. 85.3% of hospitals had CT availability during normal working hours (9–5) dropping to 47% availability after hours. MRI was available in 50% of hospitals, with surprisingly just two centres providing out of hours MRI imaging services.Conclusion: The provision of radiological services in the management of suspected spinal injuries in Irish hospitals is inadequate in comparison to international best practice. This is most marked in relation to CT and MRI.

The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients - Corrected Proof

J.C. Kelly, D.E. O’Briain, R. Walls, S.I. Lee, A. O’Rourke, J.P. Mc Cabe — 2011-09-15

Abstract: Background: MRSA is a major economic and health issue internationally and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial.Materials and methods: This study was a review of a prospectively maintained database from our unit over three time points from 2005 to 2007. At each time point a new infection control measure was implemented in an effort to reduce MRSA infections. Total rates of MRSA infection and colonisation in all orthopaedic patients were recorded, before and after separation of trauma and elective services, and after the introduction of a screening pre assessment clinic.Results: 12259 orthopaedic patients were reviewed over the three years. The mean age of MRSA infected patients was 71. A higher proportion of female patients were infected than male patients. The mean length of stay for infected patients was 23.4 days. The rate of infection dropped from 0.49% in 2005 to 0.24%in 2007. After the introduction of these measures there was a substantial reduction in organ space and deep tissue infections.Conclusion: The separation of emergency and elective orthopaedic services coupled with effective pre-operative screening has resulted in a significant reduction in MRSA infection despite an ever increasing prevalance.

Liver resection as part of multi-modality treatment of late relapse of germ cell cancer following high dose chemotherapy - Corrected Proof

D.E. McIntosh, J. Harrington, J.D. White, G. Baxter, O.J. Garden — 2011-09-15

Current opinion regarding the best management of patients relapsing post high dose chemotherapy (HDCT) is divided with no established standard chemotherapy regimen. There are very few long term survivors in this group and surgical therapy seems vital to achieve this. Therefore, the most important strategy is a multi-modality approach to these patients leading to resection of residual masses. The most frequent site of surgical resection is the retroperitoneum. However, more unusual sites require specialist surgical approaches in a small number of cases.

The role of sentinel lymph node biopsy in patients with thick melanoma. A single centre experience - Corrected Proof

J. Kelly, H.P. Redmond — 2011-09-15

Abstract: Aims: To evaluate the role, if any, of sentinel lymph node mapping (SLNM) with biopsy (SLNB) in patients with thick cutaneous melanoma.Methods: Consecutive patients with thick (Breslow ≥4 mm) cutaneous melanoma, undergoing SLNB were identified from a departmental database comprising 550 patients in total from 2000 to 2010. Factors examined included demographic data, histological subtype, site and depth of lesion, percentage of positive SLNs, regional recurrence in the setting of a negative SLNB result (false-negative rate), complications, further lymphadenectomy, and follow-up (disease free and overall survival), where available.Results: Sixty-four eligible patients (37 men, 27 women) underwent primary excision and SLNM. Median patient age was 59 years (range 8–82 years). Mean Breslow depth was 7 mm (range 4–19 mm). Thirty melanomas were located on the limbs, 19 on the head and neck and 15 on the trunk. Twenty-three (35%) were ulcerated. Of the 57 patients who had a sentinel node identified, 18 (31%) had metastatic melanoma identified. The mean survival time for patients with a negative SLN was 79 months versus 18 months for those with a positive node. Patients with a negative SLN have a 5 year disease free survival of 79% versus 11% (p < 0.001) and an overall 5 year survival rate of 85% versus 32% when compared to node positive patients.Conclusions: The status of the SLN is predictive of disease recurrence and overall survival in patients with a thick primary cutaneous melanoma. This modality should be employed, where applicable, in this cohort of patients.

Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy - Corrected Proof

2011-09-15

Abstract: Introduction: Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain. The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure.Aims: To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and standard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain.Methods: Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study. The patients were randomly allocated to two groups (group A and group B). In group A (n = 50), low pressure pneumoperitoneum (8 mm Hg) and in group B (n = 50), standard pressure pneumoperitoneum (14 mm Hg) was generated during laparoscopic cholecystectomy. Postoperative shoulder tip pain was assessed at 4, 8 and 24 h after operation by the Visual Analogue Scale of Pain.Results: 14 patients (28%) in group B complained of post operative shoulder tip pain as compared to only 5 patients (10%) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4, 8 and 24 h was less in group A as compared to group B, although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B.Conclusion: Low pressure laparoscopic cholecystectomy (LPLC) significantly decreases the frequency and intensity of postoperative shoulder tip pain. LPLC decreases the demand for postoperative analgesics, decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation.

Raman spectroscopy – A potential new method for the intra-operative assessment of axillary lymph nodes - Corrected Proof

2011-09-15

Abstract: Sentinel Lymph Node Biopsy has become the standard surgical procedure for the sampling of axillary lymph nodes in breast cancer. Intra-operative node assessment of these nodes would allow definitive axillary surgery to take place immediately with associated benefits for patient management. Our experimental study aims to demonstrate that a Raman spectroscopy probe system could overcome many of the disadvantages of current intra-operative methods.59 axillary lymph nodes, 43 negative and 16 positive from 58 patients undergoing breast surgery at our district general hospital were mapped using Raman micro-spectroscopy. These maps were then used to model the effect of using a Raman spectroscopic probe by selecting 5 and 10 probe points across the mapped images and evaluating the impact on disease detection.Results demonstrated sensitivities of up to 81% and specificities of up to 97% when differentiating between positive and negative lymph nodes, dependent on the number of probe points included. The results would have concurred with histopathology assessment in 89% and 91% of cases in the 5 and 10 point models respectively. Using Raman spectroscopy in this way could allow lymph node assessment within a time-frame suitable for intra-operative use.

Is pancreaticoduodenectomy justified in elderly patients? - Corrected Proof

A.W.C. Kow, N.A. Sadayan, A. Ernest, B. Wang, C.Y. Chan, C.K. Ho, K.H. Liau — 2011-09-15

Abstract: Background: Although mortality & morbidity for pancreaticoduodenectomy (PD) have improved significantly over the last two decades, the concern for elderly undergoing PD remains. This study examines the outcome of the elderly patients who had pancreaticoduodenectomy in our institution.Methods: A prospective database comprising 69 patients who underwent pancreaticoduodenectomy between 2001 and May 2008 was analyzed. Using WHO definition, elderly patient is defined as age 65 and above in this study. Two groups of patients were compared [Group 1: Age ≤65 & Group 2: Age >65].Results: The mean age of our patients was 62 ± 11 years. There were 37 (54%) patients in Group 1 and 32 (46%) patients in Group 2. There was no statistical difference between the two groups in terms of gender and race. However, there were more patients in the Group 2 with >2 comorbidities (p = 0.03).The median duration of operation was significantly longer in Group 2 (550 min vs 471 min, p = 0.04). Morbidity rate in Group 2 was higher (56% vs 44%, p = 0.04). There was higher proportion of post-operative pancreatic fistula (POPF) in the elderly group (37.5% vs 16.7%, p = 0.05). Majority of them are Grade A POPF according to the ISG definition.The median post-operative length-of-stay (LOS) in hospital was 9 days longer in Group 2 (p = 0.01). Mortality rate between the 2 groups of patients was comparable (0% vs 3%, p = 0.28).Conclusion: Elderly patients are at increased risk of morbidity in pancreatocoduodenectomy, in particular POPF. However, morbidity and mortality rates are acceptable. It is therefore justified to offer PD to elderly patients who do not have significant cardiopulmonary comorbidities.

Endoscopic screening for colorectal cancer? - Corrected Proof

R.J.C. Steele — 2011-09-15

Until recently, all the evidence around the efficacy of screening for colorectal cancer has been based on faecal occult blood testing (FOBT). As a result, in the United Kingdom, Ireland and in many other countries throughout the world, FOBT screening is in place or in the process of being rolled out. However, recent evidence has emerged which has made the screening community think again. A multi-centre randomised trial of once only flexible sigmoidoscopy between the ages of 55 and 65 years has recently been reported and the results are impressive. Not only is there a reduction in mortality from colorectal cancer, there is also a reduction in incidence which is maintained for up to 12 years after the examination. Interestingly, although the trial mandated colonoscopy for everyone with a significant polyp or cancer found at flexible sigmoidoscopy, the intervention had no effect on incidence of right-sided cancer. However, having a flexible sigmoidoscopy almost abolished the risk of developing a left-sided cancer owing to the removal of adenomatous polyps.

Exsanguinators and tourniquets: Do we need to change our practice? - Corrected Proof

2011-09-15

Abstract: Purpose: Exsanguinators and tourniquets are regularly used in orthopaedic theatres. A good understanding of their application and contraindications must be ensured to prevent injury to limb or life. However, the level of staff understanding is not well documented. The aims of this study were to assess knowledge of their use between theatre personnel and assess their sterility at our institution.Methods: A previously published questionnaire was distributed to various orthopaedic theatre personnel responsible for exsanguinator and tourniquet application. Microbiology culture and sensitivity swabs were also taken.Results: Mean questionnaire score for all participants was 30.9%. None of the 74 participants scored more than 49% in the questionnaire. Exsanguinators grew more positive cultures than the tourniquets.Conclusions: Exsanguinators and tourniquets are used widely in the field of orthopaedics. Lack of their understanding amongst operating theatre personnel involved with their use strongly supports the need for providing and ensuring adequate education to provide the best patient care. In consideration of our findings, we propose a solution addressing these issues.

An inconvenient truth: Treatment of displaced paediatric supracondylar humeral fractures - Corrected Proof

M. Donnelly, C. Green, I.P. Kelly — 2011-09-15

Abstract: The need for emergent management of displaced paediatric supracondylar humeral fractures is being questioned in the literature. Open reduction rates of up to 46% have been reported in the non-emergent management of these injuries. At our institution these fractures are managed as operative emergencies by senior personnel. To examine the ongoing need for this policy we reviewed our results. All patients managed over a five year period with Gartland type IIB or III paeditric supracondylar humeral fractures were identified and a comprehensive chart and radiographic review undertaken. The mean time from injury to fracture reduction and stabilization was 6.6 h. Consultants performed or supervised 90% of cases. Open reduction was necessary in 5% of cases. Complications included a perioperative nerve injury rate of 6% and a superficial pin site infection rate of 3%. This study suggests that, despite the challenge to trauma on-call rostering, the emergency management of these injuries is advantageous to patients in units of our size. Based on the data presented here we continue our practice of emergent management. We suggest that units of a similar size to our own would show a benefit from an analogous policy albeit an inconvenient truth.

Platelet plasma rich products in musculoskeletal medicine: Any evidence? - Corrected Proof

Nicola Maffulli, Angelo Del Buono — 2011-09-15

Abstract: Platelet Reach Plasma (PRP) is considered to accelerate muscle and tendon healing and allow early return to elite competition, and it is often recommend as best practice for management of musculoskeletal injuries. Even though several growth factors abundant in PRPs have been extensively studied in tissue regeneration, the key factors are yet unknown. Given our rudimentary knowledge of the mechanism of action of the PRPs, it is challenging to use this technology to promote early healing, and produce improved and accelerated functional recovery. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up.

When should we operate on elderly patients with a hip fracture? It’s about time! - Corrected Proof

Sukhmeet S. Panesar, Nicole Simunovic, Mohit Bhandari — 2011-09-15

Abstract: Demographic predictions indicate the annual incidence of hip fractures will rise to 100,000 per annum in 2020. The annual costs to the NHS are approximately two billion pounds. Despite significant advances in the operating technique and management of these fractures, controversies still exist. One such matter for debate is the ideal timing for hip fracture surgery. There are arguments for and against early stabilization, yet all this evidence comes from observational studies. We present data from an often overlooked source, the largest patient safety reporting system in the world housed at the National Patient Safety Agency. Since 2003, 4325/4521 (96%) patients suffered some harm due to their operation being delayed. The issue of the ideal timing for hip surgery warrants an answer. This could be in the form of a controlled trial. A randomized trial comparing early surgery versus standard of care (site dependent) in hip fracture repair may provide some future guidance. In the meantime, current evidence suggests that we should stratify the elderly according to their medical morbidities; both new and old; optimize patient’s who develop hypovolemia, accelerated hypertension, untreated infection, symptomatic arrhythmia or cardiopulmonary dysfunction; and attempt to bring patient’s suffering from chronic diseases as close to their baseline level of functioning as normal. Hip fracture repair should then occur as soon as possible.

Painful swollen limb caused by pelvic granuloma in a patient with total hip replacement - Corrected Proof

2011-09-15

A 78-year-old lady presented with swollen ipsilateral lower limb more than a decade following an un-cemented right total hip replacement (THR). Her symptoms were treated medically; in sequence, for lymphoedema, cellulitis, and trochanteric bursitis, with little benefit. A venous Doppler scan ruled out deep venous thrombosis, and a plain radiograph of pelvis demonstrated evidence of polyethylene liner wear in the THR prosthesis (). Later, a mass became palpable in the right groin/iliac fossa, suspicious of bowel cancer. It was associated with onset of pain in the swollen limb. A CT scan revealed a large soft tissue density lesion in right iliacus muscle, measuring 8.3 × 6.0 cm, and displacing right pelvic vessels medially (a and b). The case was discussed in a sarcoma multidisciplinary team meeting, and after an MRI scan, malignancy was ruled out. The mass was considered benign and the patient was referred to Orthopaedics.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting - Corrected Proof

2011-09-15

Abstract: Background: Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria.Methods: From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43–88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis.Results: Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies.Conclusion: Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

The United Kingdom and Ireland Trauma & Orthopaedic eLogbook—An evidence base for enhancing training - Corrected Proof

2011-09-15

Abstract: The United Kingdom and Ireland Trauma and Orthopaedic (T&O) eLogbook was originally conceived over ten years ago in order to provide individual surgeon support and allow national analysis of surgical training experience. Since 2003 every trainee in T&O has been required to submit data recording their operative experience throughout the six years of higher specialist training. We describe how orthopaedic surgeons are using the evidence from the eLogbook to improve training, set operative standards and support consultant (post-specialist registration) revalidation.

Minimally invasive video-assisted parathyroidectomy is a safe procedure to treat primary hyperparathyroidism - Corrected Proof

V Garimella, S Yeluri, A Alabi, AK Samy — 2011-09-15

Abstract: Introduction: Cervical exploration to identify the four parathyroid glands was considered to be the gold standard for management of primary hyperparathyroidism. In recent years, advances in preoperative localizing techniques have led to the use of more targeted, minimally invasive procedures to remove parathyroid glands. We present our series of patients who underwent Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) procedures and our results in treating primary hyperparathyroidism.Methods: Patients who underwent video-assisted parathyroidectomy were identified from a prospectively maintained database. Clinico-pathological data including indications for surgery, complications, conversion to open procedure and success of surgery were obtained from clinical notes.Results: A total of 56 patients underwent MIVAP between 2002 and 2010 at a district general hospital setup. The clinical indication was diagnosed primary hyperparathyroidism. Preoperative localization was attempted in all patients by sestamibi and high resolution ultrasound scans. The median age of patients was 65 years (32–82) and the median operating time was 78 min (20–168). Conversion to open procedure was done in 8/56 (14%) cases. The reason for conversion was failed exploration in 5 patients, inability to retrieve a very large friable adenoma in one patient, lipo-adenoma in one patient and very small parathyroid adenoma in one patient. Postoperative complications happened in one patient (2%) who developed postoperative sepsis resulting in temporary recurrent laryngeal nerve (RLN) palsy. All but 5 patients became normo-calcaemic following surgery.Conclusion: MIVAP is a safe and effective procedure for treating patients with primary hyperparathyroidism. It also allows classical 4 gland exploration, whenever necessary.

Node positive melanoma – A positive note? - Corrected Proof

Justin Kelly, M.J. Kerin — 2011-09-15

Vast concentrated efforts have been made over the past decade in an effort to unearth novel efficacious therapies to improve the disease-free and overall survival of patients with node positive melanoma. With a worldwide increase in incidence, in addition to a mortality rate rising faster than most other cancers, the need for more effective treatment modalities is greater than ever. We briefly discuss 2 of these recent strategies below.

An alternative method for predicting size of femoral component of Oxford partial knee replacement - Corrected Proof

S. Sawalha, C. Pasapula, N. Coleman — 2011-09-15

Abstract: Background: No direct intra-operative measurement to determine the ideal size of the femoral component of Oxford unicompartmental knee replacement (UKR) is currently present. The aim of this study is to assess the accuracy of patients’ shoe size as a predictor of femoral component size.Methods: A retrospective study was conducted to identify the correlation between patients’ shoe size (British system) and the femoral component size. After excluding patients who died (n = 2) and patients in whom the implanted femoral component size was inaccurate (n = 13), the remaining cases (93 UKR in 88 patients) formed the study sample. Postoperative radiographs were reviewed to determine femoral component fit.Results: We found positive correlation between shoe size and femoral component size. In females; a shoe size from 2.5 to 6 predicted a small femoral component and shoe size from 6.5 to 8.0 predicted a medium femoral component. In males, a shoe size from 6 to 9.5 predicted a medium femoral component and a shoe size from 10 to 13 predicted a large femoral component. This relation predicted the femoral component size accurately in 80% of cases. A subgroup analysis, after excluding patients who changed their shoe size during adulthood after foot surgery or pathology (n = 20), showed an accuracy rate of 81%.Conclusion: Shoe size is a simple method that predicts femoral component size more accurately than other methods currently used such as templating, tibial component size and height based on gender.Highlights: ► We assess if patients’ shoe size predicts femoral component size of Oxford knee replacement (UKR). ► Positive correlation was found in 93 Oxford UKR cases studied. ► Shoe size predicted the femoral component size accurately in 80% of cases. ► Changing shoe size during adulthood did not affect the accuracy rate.

The value of whole colonic imaging - Corrected Proof

M. Chaudery, D. Edwards — 2011-09-15

Sir, We are grateful to have the opportunity to respond to the article by Bhangu et al stating that flexible sigmoidoscopy (FS) would have missed 15% of proximal colorectal cancers (CRC) in patients presenting with symptoms alone. We would recommend that the majority of patients referred under the 2 week wait (2WW) criteria should receive whole colonic imaging (WCI). Our preference would be colonoscopy as we believe that this is the most effective way of reaching a diagnosis without missing proximal pathology.

Laparoscopic vs. open liver resection for malignant liver disease. A systematic review - Corrected Proof

Ahsan Rao, Ghaus Rao, Irfan Ahmed — 2011-09-15

Abstract: Introduction: Since the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups.Methods: All the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0).Results: There were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI −261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI −6.33, −2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters.Conclusion: The laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions.

Surgical techniques: Use of arthroscopic “Alligator” forceps for the removal of excess cement in unicompartmental knee arthroplasty - Corrected Proof

Paul D. Sturch, Daniel Marsland, Ian W. Barlow — 2011-09-15

During minimally invasive cemented unicompartmental knee arthroplasty (UKA), the removal of excess cement from the posterior aspect of the joint following insertion of the prosthesis may be technically difficult due to limited surgical exposure (). Retained cement following UKA is a well recognised complication which may require further surgery as a consequence of loose body formation or impingement. The use of the arthroscopic Alligator grasping forceps (Acufex, UK) () facilitates easy access and retrieval of cement following component insertion (). The senior author has used this simple technique successfully in 200 UKAs.