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Background: There have been numerous techniques used in laparoscopic appendectomy (LA) to divide the mesoappendix, including LigaSure, Harmonic scalpel, clips, endoloop ligatures, Endo GIA staplers, and bipolar coagulation. However, few studies have investigated monopolar diathermy for mesoappendix division. Therefore, this study aimed to assess both its safety and efficacy in LA. Method(s): In this prospective non-randomized study, patients (n = 87) who underwent LA for acute appendicitis were included. The bipolar electrocautery was used for mesoappendix division in the first 33 patients (BC group), while the monopolar electrocautery was used in the next 54 patients (MC group). Result(s): The median operative time was significantly shorter in the MC group (42 min. vs 47 min. in BE group, p = 0.01). One patient converted to open surgery in the MC group due to uncontrollable bleeding. There were no significant differences between both groups regarding postoperative complications and hospital stay (p = 0.91, p = 0.13, respectively). Conclusion(s): Monopolar electrocautery is safe and effective for mesoappendix division in LP in comparison to bipolar electrocautery. However, larger and multicentric studies are required to validate our results.Copyright © 2023 The Authors
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Background: The COVID-19 pandemic affects all aspects of life all over the world;general surgeons are highly affected along with other healthcare personnel. A gloomy course of the disease makes it hazardous till now;its impact and ways of protection should be of concern for us so that we can keep on our works. Method(s): A survey was carried out at our hospital among general surgeons and surgeons of other specialties of the course with junior doctors and residents. A questionnaire was answered by them concerning their work with the impact of the virus, collecting data from the statistical unit electronically. Iraq has started lockdown for a period of 24 months from March 2020 to March 2022. Result(s): This study is a cross-sectional study using Google Forms and spread over surgical teams of different specialties at the Imemein Kadhumein Medical City Center. From about 248 responses, 118 responses were taken from the survey. Out of the 50 surgeons, 40 (80%) were infected and out of the 68 residents 62 (91.1%) were infected in our hospital (open and laparoscopic). About 20% of the doctors completely stopped attending outpatient clinics, until vaccination started on March 2021, an overall decrease of 60%. A drop of >75% of income was noticed by 45% of them;and 25% of them feel <75% of the income was received. But others have no change or increase in income as patients shift toward private hospitals because the government ones become loaded with COVID patients. Information about the illness and its sequelae was found through the net to be about 81% and through television to be 16%, whereas others were through national and institutional announcements. Conclusion(s): Standardized measures in detection, treatment, and/or vaccination should be taken into consideration based on the solid scientific facts to have a road map for surgeries during this or subsequent pandemics, getting the best outcome for doctors and patients.Copyright © 2022 Nile, Hamdawi, Khiro, licensee HBKU Press
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Background: Mammographic screening programmes reduce breast cancer mortality, but detect many small tumours with favourable biological features which may not progress during a woman's lifetime. Screen-detected cancers are treated with standard surgery and adjuvant therapies, with associated morbidities. There is a need to reduce overtreatment of good prognosis tumours and numerous studies have evaluated the omission of radiotherapy in this context. However, there is little evidence to support surgical de-escalation, although percutaneous minimally invasive treatment approaches have been described. Vacuum-assisted excision (VAE) is in widespread use for management of benign lesions and lesions of uncertain malignant potential. SMALL (ISRCTN 12240119) is designed to determine the feasibility of using this approach for treatment of small invasive tumours detected within the UK NHS Breast Screening Programme (BSP). Method(s): SMALL is a phase III multicentre randomised trial comparing standard surgery with VAE for screendetected good prognosis cancers. The main eligibility criteria are age >=47 years, unifocal grade 1 tumours with maximum diameter 15mm, which are strongly ER/PR+ve and HER2-ve, with negative clinical/radiological axillary staging. Patients are randomised 2:1 in favour of VAE or surgery;with no axillary surgery in the VAE arm. Completeness of excision is assessed radiologically, and if excision is incomplete, patients undergo open surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm but may be omitted following surgery. Co-primary end-points are: 1. Noninferiority comparison of the requirement for a second procedure following excision 2. Single arm analysis of local recurrence (LR) at 5 years following VAE Recruitment of 800 patients will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure. This ensures sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. To ensure that the trial as a whole only has 5% alpha, the significance level for each co-primary outcome is set at 2.5% with 90% power. The Data Monitoring Committee will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A novel feature of SMALL is the integration of a QuinteT Recruitment Intervention (QRI), which aims to optimise recruitment to the study. Recruitment challenges are identified by analysing recruiter/patient interviews and audiorecordings of trial discussions, and by review of trial screening logs, eligibility and recruitment data and study documentation. Solutions to address these are developed collaboratively, including individual/group recruiter feedback and recruitment tips documents. Result(s): SMALL opened in December 2019, but recruitment halted in 2020 for 5 months due to COVID-19. At 7st July 2022, 142 patients had been randomised from 26 centres, with a randomisation rate of approximately 45%, and a per site recruitment rate of 0.4-0.5 patients/month, approaching the feasibility recruitment target of 144 patients. Drawing from preliminary QRI findings and insights from patient representatives, a recruitment tips document has been circulated (on providing balanced information about treatments, encouraging recruiters to engage with patient preferences, and explaining randomisation). Individual recruiter feedback has commenced, with wider feedback delivered across sites via recruitment training workshops. Conclusion(s): Despite pandemic-related challenges, SMALL has an excellent recruitment rate to date and is expected to have a global impact on treatment of breast cancer within mammographic screening programmes.
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Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.
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Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.
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Background: NHSwaiting lists for elective surgeries including non-urgent laparoscopic cholecystectomies (LC) have severely escalated during the Covid-19 pandemic, with some patients waiting over 2 years for their operations. LCs are highly variable in terms of operative time, difficulty, and risk making theatre utilisation a challenge to effectively clear waiting lists. Nassar et al.[1] developed and validated a pre-operative risk prediction score for predicting the difficult LC using an objective operative difficulty grading system. We aimed to assess if application of CholeS could be used to predict which LC may have longer operative times, and so aid theatre utilisation planning. Method(s): Consecutive elective LCs performed between May and October 2021 at our institution's day surgery unit were included and analysed. Each patient was scored retrospectively using the CholeS pre-operative risk score from electronic patient records. Operative time was obtained from theatre electronic record systems. Data was collected on conversion to open surgery, post-operative day of discharge, and intra or post-operative complications. Outliers with operating time recorded as <20 minutes were considered data entry errors and excluded from analysis. A ROC analysis was used, which determined a threshold value of 3. This value was used to divide patients into a low-risk (<=3 points) and high-risk (four and above) group. Two-sample independent t-test was used to compare mean operative time between the high-risk and low-risk CholeS score groups. Levene's test was used to determine if variance was equal between groups. SPSS version 27[2] was used for data analysis and statistical tests and p<0.05 was deemed significant. Result(s): 81 LC were included for analysis. 53 patients were low-risk and 26 patients were high-risk. There was a significantly lower operative time in the low-risk group: Low-risk = 57.6 minutes (95% CI 52.4-63.0) vs high-risk = 75.8 minutes (95% CI 58.7-92.9), p=0.046. Nine patients had surgeries lasting >90 minutes;66% of these were in the high-risk LC group. 95% of patients were discharged on day 0, two patients on day 1, and two on day 2 or later. Three patients had conversion to open cholecystectomy and five patients had post-operative complications. Two out of three patients who required conversion to open cholecystectomies were in high-risk patients with high CholeS scores (7 and 10). In one patient, a cholecystoduodenal fistula was found. Cystic duct avulsion occurred in the other. Three out of five patients with post-operative complications were in the high-risk group, with corresponding higher Clavien-Dindo scores (3b, 2 and 2) when compared to the low-risk group (1 for both patients). Conclusion(s): The CholeS pre-operative scoring system could be used to optimise LC theatre allocation. Ascore of <=3 has a shorter operative time than a patient with a score of four or more (mean difference = 18.1 mins, 95% CI 4.4-31.9). Prediction of which LCs will be shorter operations could improve theatre utilisation and allow extra cases booking on the operating list. This, in turn, could help reduce the number of patients on the waiting list. Additionally, CholeS could be used to predict patients with more challenging and prolonged operations as well as those at higher risk of open conversion and complications. This could allow such patients to be managed by allocation to inpatient specialist upper GI specialist lists.
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Background: Specialization influences the way that surgeons deliver care and has a direct impact on doctors, healthcare systems and patients. Hernias impact around 2% of the population and repairs are among the most common procedures performed globally. The European Hernia Society recognizes a growing need for specialist surgeons as abdominal wall surgery becomes more complex with newer techniques and more challenging cases being encountered. At this trust, a new specialized hernia clinic was implemented in response to COVID backlogs and the growing need and proven benefits of specialization. The project's aim was to review the impact on procedure wait times and outcomes for hernia repairs. Method(s): A retrospective review of patients undergoing hernia repairs between June 2019 to June 2021 was compared to similar patients who attended the hernia clinic between February 2021 to March 2022. Included operations were inguinal, femoral, and umbilical hernia repairs. Data collected included diagnoses, percentage of day case and wait times. Result(s): 59 patients underwent surgery pre-intervention with average wait times of 191 days. 72 post-intervention patients had an average wait of 59 days. 59 patients were still awaiting surgery post-clinic. Open surgery incidence increased from 66% to 79%. 86% of patients post-intervention were day cases, compared to 78% of pre-intervention patients. Conclusion(s): The new hernia clinic has reduced wait times for surgery and improved day-case rates despite more cases being performed as open procedures. Following these results, the clinic system shows great promise and hernia surgery has the potential to evolve as a sub-specialty.
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Introduction: Early detection of COVID-19-associated mucormycosis (CAM) is critical for accurate staging and optimal treatment. Three-dimensional computed tomography (3D CT) reconstruction of the face has recently come up as a newer diagnostic tool in CAM. Method(s): This clinical study was done to evaluate the efficacy of 3D CT in diagnosing and managing CAM. We compared 3D CT reconstruction with conventional 2D CT. One hundred twenty-three confirmed cases of mucor were subjected to 3D CT reconstruction in addition to contrastenhanced magnetic resonance imaging after comprehensive clinical workup. The involvement of maxillary walls, alveolus, palate, orbital floor, zygomatic process, and other facial skeleton were noted. The plan of management was decided after assessing the extent in 3D CT. Result(s): Anterior maxillary wall was found to be the commonly involved (9.7%). Involvement of the lateral maxillary wall was noted in 8.1% of subjects. Sixty-seven subjects underwent endoscopic endonasal debridement, 19 underwent total maxillectomy, 3 had infrastructure maxillectomy, 8 had orbital exenteration, and 12 had combined endoscopic and open surgeries. In 21 patients (17%), open surgery was done based on additional 3D CT findings at the first instance and revision surgeries were avoided. Conclusion(s): 3D CT face was found to be superior to conventional CT in diagnosing the extent of disease and plays an important role in preoperative surgical planning of CAM. Minor cortex erosions are not picked up by conventional CT;it also does not show finer details and leaves the surgeon imagining the disease extent. 3D CT decreases delay in diagnosis, facilitates the surgical plan, and reduces the need for multiple surgeries. It is a valuable tool in the assessment of revision cases and follow-up.
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Introduction:Acquired tracheo-esophageal fistula (TEF) is a dreaded complication of lithium button battery (LBB) ingestion in the pediatric population. Traditionally acquired TEFs are managed with surgical interventions. Very few case reports have described successful closure of a TEF secondary to LBB with conservative management. There is no reported literature on the use fibrin glue or laser therapy to enhance closure. Here we describe successful conversative management of TEF secondary to LBB and for the first time, attempted trial of fibrin glue and argon laser therapy. Case presentation: 13-month-old female presented to the emergency department with a 3-day history of croupy cough. Neck X ray demonstrated a radio-opaque foreign body suggestive of a button battery. Patient urgently underwent rigid esophagoscopy and found to have a 20 mm lithium battery in the proximal esophagus. The negative pole was facing anteriorly. Battery was retrieved and inspection revealed a Zagar 2 B grade mucosal injury. Site was washed with 0.25% acetic acid. Direct laryngoscopy and bronchoscopy noted significant posterior tracheal wall edema. Patient was kept NPO overnight and an esophagram obtained next day was reassuring. Therefore, diet was advanced as tolerated and patient discharged next day with plan to repeat esophagram in 2 weeks and endoscopy in 4 weeks. Patient presented 3 days later with drooling, coughing, nasal congestion. She tested positive for SARS Covid 19 PCR on admission. Esophagram at admission noted irregularity and distension of the proximal esophagus with persistent focal outpouching. Patient was kept strict NPO and a repeat esophagram 24 hours later showed large volume aspiration associated with excessive coughing. A nasogastric tube was placed, and tube feedings initiated. Esophogastroduodenoscopy (EGD) was delayed by 1 week due to COVID positive status and upper respiratory symptoms. Initial EGD demonstrated purulent exudates in proximal esophagus and a 6 mm fistulous opening surrounded by ulcerated margins. Bronchoscopy confirmed tracheal end of fistula in addition to posterior tracheal wall ulceration. A fiber-optic scope was used to advance the endotracheal tube so that its distal end was positioned beyond the inflamed mucosa. Patient was kept intubated and sedated, on IV antibiotics and PPI, and on NG tube feeds in the ICU. Repeat scope 7 days post TEF diagnosis showed a 4 mm fistula with healing of the ulcerated mucosa. Fibrin glue was injected into the fistula from the tracheal side in an attempt to close the TEF, but this was unsuccessful and lead to dislodgment of fibrin glue into airway creating a foreign body which necessitated endoscopic retrieval. EGD, 14 days after diagnosis of TEF demonstrated a fistula now ~ 3 mm wide. Argon plasma coagulation (APC) probe (Beamer unit flow of 0.5 L/min,15 W) was directed at the mucosa lining the esophageal end of the fistula with an aim to promote healing by secondary intention. At 21 days post TEF diagnosis complete closure of the fistula was demonstrated on EGD and bronchoscopy and the per-operative esophogram was reported as normal. Patient was discharged 5 days later tolerating an age-appropriate diet. A follow-up esophogram 2 weeks later was reassuring. Patient was asymptomatic on clinical follow up visit 4 weeks from discharge. Discussion(s): Acquired TEF secondary to LBB ingestion is traditionally managened through endoscopic or open surgical repair. However, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula, and mortality. Thus, experts have started to advocate the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. Five pediatric cases to date have reported sustained closure of TEF secondary to LBB with conservative management including strict NPO status and tube feeds/parenteral nutrition. The duration of healing has varied from 4 -11 weeks. We documented successful healing of acquired TEF within 21 days of initial diagnosis making it the shortest recovery period to date. We report the use of argon plasma coagulation at low settings to produce controlled heat coagulation at the fistula site in order to expose the submucosa and enhance healing by secondary intention. Successful closure of congenital TEF have been reported with injection of fibrin glue into the fistulous tract but this technique may not work for acquired TEF because of surrounding inflammation and a patulous tract. We opted to keep our patient sedated and intubated for 2 weeks to minimize movement, and promote healing of the TEF, but risk vs benefit needs to be weighed on a case-to-case basis. In conclusion, conservative management of acquired TEF is a feasible first step and may be considered before opting for surgical repair. Use of APC at low setting may reduce duration of closure of acquired TEF but high-powered, multi-center studies are needed.
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Background: Mammographic screening programmes reduce breast cancer mortality but detect many small tumours with favourable biology which may not progress. These are treated with surgery and adjuvant therapies, but associated morbidities mean there is a need to reduce overtreatment. Minimally invasive treatments such as vacuum-assisted excision (VAE) have been described but there is no prospective randomised evidence to support their routine use. SMALL (ISRCTN 12240119) is designed to establish the feasibility of using VAE to treat small tumours detected within the UK NHS Breast Screening Programme (BSP). Methods: Phase III multicenter randomized trial comparing surgery with VAE for screen-detected good prognosis cancers. Eligibility criteria are age ≥47 years, unifocal grade 1 tumors (maximum diameter 15mm), strongly ER/PR+ve and HER2-ve, with negative axillary staging. Patients are randomized 2:1 to VAE or surgery, with no axillary surgery in the VAE arm. Excision is assessed radiologically, and if incomplete, patients undergo surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm. Coprimary end-points are: (1) Non-inferiority comparison of the requirement for a second procedure. (2) Single-arm analysis of local recurrence (LR) at 5 years after VAE. Recruitment of 800 patients will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure, ensuring sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. The DMC will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A QuinteT Recruitment Intervention (QRI) is integrated throughout SMALL to optimize recruitment and informed consent. Recruitment challenges are identified by analyzing recruiter/ patient interviews, audio-recordings of trial discussions, and by review of screening, eligibility and recruitment data and study documentation. Solutions are developed collaboratively, including recruiter feedback and recruitment tips documents. Results: SMALL opened in December 2019, but recruitment halted for 5 months due to COVID-19. At 11th February 2022, 91 patients had been recruited from 22 centers, with an approached/consented ration of 50%. Drawing from preliminary QRI findings, a recruitment tips document has been circulated (on discussing SMALL, providing balanced information on treatment options and explaining randomization). Individual recruiter feedback has commenced, with wider feedback planned shortly. Conclusion: Despite pandemic-related challenges, SMALL has excellent recruitment to date and is expected to have a global impact on treatment of screen-detected breast cancer.
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Introduction: Hydroceles could cause discomfort, scrotal heaviness, cosmetic problems or adversely impact quality of life. Conventional treatment involves open surgical repair under general anaesthetic. Aspiration and injection sclerotherapy is however an attractive alternative since literature suggests it has comparable outcomes, lower complication rates and can be performed under local anaesthetic (LA) in timely manner. Patients and Methods: Consenting patients were prospectively recruited following necessary approvals. The procedure was carried out under LA and ultrasound guidance at our urology clinic. The hydrocele was drained and sclerosant (3% sodium tetradecyl sulphate) immediately injected into the tunica vaginalis. Post-procedure followup ranged from 3-12months. Results: Thirty-two patients with 35 procedures (2 re-do, 1 bilateral) were studied. Average volume drained was 283ml (18-1000ml). Overall success rate was 77.1% (complete resolution- 21 [60.0%], mild re-accumulation without need for re-intervention- 4 [11.4%], moderate re-accumulation successfully treated with re-do sclerotherapy- 2 [5.7%]). Large/significant recurrence was noted in 8 (22.9%) patients- they all had large (>200ml) hydroceles ab-initio and went on to have straightforward open surgical repair. One procedure was abandoned due to traumatic aspiration and was excluded. Conclusions: Hydrocele aspiration and injection sclerotherapy under LA is safe, easy to set-up and effective, with trend towards better outcomes for smaller hydroceles. This treatment could ease waiting-list pressures occasioned by the COVID-19 pandemic and should be considered as part of informed consent process for all men with hydroceles. Further data is required to define most suitable patients and also to fully assess ease of hydrocele repair after failed sclerotherapy.
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The prevalence of Pheochromocytoma in pat ient with hypertension is 0.1 -0.6%. These types of tumours are known for unpredictable perioperative course and hemodynamic instability. Various different drugs and anaesthesia techniques can be used to tackle these situations. Dexmedetomidine is emerged as newer agent with better hemodynamic stability, reducing requirement of other anaesthesia drugs, blunting of sympathoadrenal response in resection of Pheochromocytoma. We report four cases operated between January 2021 to June 2021.Preoperative preparation was done with α and β blockade. Dexmedetomidine was used during induction as 1 mcg/kg over 10 mins followed by 0.7mcg/kg/hr intraoperatively. Combination of Dexmedetomidine, Fentanyl, NTG, Isoflurane and Epidural analgesia was used. IF needed boluses of Esmolol and Labetalol were used during tumor manipulation. All the patients had an uneventful perioperative course. Dexmedetomidine with pre-operative α and β blockade reduce the need of other drugs intraoperatively and can be used as anaesthetic adjunct to maintain steady hemodynamic.
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Background/Purpose: Candidates for endoscopic treatment for craniosynostosis must be less than 6 months old. Given the narrow window of eligibility for endoscopic therapy, there is significant potential for barriers to health care access to impact the type of surgery a patient receives. We hypothesized that COVID may further worsen these potential disparities. Therefore this study evaluates the impact of COVID on proportion of surgeries for craniosynostosis performed open vs endoscopically based on race and ethnicity as well as socioeconomic status. Methods/Description: Charts were reviewed for children with single suture craniosynostosis from January 2014- March 2020 (pre-COVID cohort) and March 2020- September 2021 (COVID cohort). Children with syndromic craniosynostosis, significant comorbidities, or who presented after age 3 years were excluded. 110 children were in the pre-COVID group;56 were treated open and 54 endoscopically. The mean age of presentation for the endo group was 1.86 months and 10.7 months for the open group;mean age of surgery for the endo group was 2.60 months and 13.4 months for the open group. Of the 47 patients in the COVID cohort, 26 were treated endoscopically and 21 were treated open. The average age of presentation for the endo group in the COVID cohort was 1.91 months and average age of the open group was 10.6 months. Mean age at time of surgery for endoscopy in the COVID cohort was 2.66 months;mean age at time of open surgery in the COVID cohort was 12.66 months. There was no significant difference in age of presentation or age of surgery across cohorts when considering type of surgery performed. Rate of endoscopy in the pre-COVID versus COVID cohorts was not significantly different with 49% of patients in the pre-COVID cohort treated endoscopically and 55% treated endoscopically during the COVID period (P= 0.49). In both the pre-COVID and COVID cohorts there were significant differences between age of presentation, age of surgery, and type of surgery received based on race- black and Hispanic patients presented later, had surgery later and underwent open surgery more frequently than their white/Asian counterparts (P= 0.0095, P=0.0067). With respect to insurance status, in the Pre-COVID cohort 68% of patients without insurance or with Medicaid underwent open surgery and 32.6% underwent endoscopic surgery. In those with private insurance, 40.3% underwent open surgery and 59.7% had endoscopic surgery (P= 0.0071). However, there was no difference in age of presentation or type of surgery based on insurance status during COVID. The pandemic did not alter age of presentation/ age of surgery or rates of patients receiving endoscopic surgery in patients with single suture craniosynostosis. There was no relationship between insurance status and type of surgery received during the pandemic, however Hispanic and black patients continued to present later and underwent surgery at an older age compared to their white/ Asian counterparts as they did pre pandemic.
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Background:. Mammographic screening programmes have been shown to reduce breast cancer mortality. However, they detect many small tumours with favourable biological features which may not progress during a woman's lifetime. These are treated with standard surgery and adjuvant therapies, which have associated morbidities. Thus, there is a need to reduce overtreatment of good prognosis tumours found by screening. Minimally invasive treatment approaches have been described but there is no prospective randomised evidence to support their routine use. Vacuum-assisted excision (VAE) is in widespread use for management of benign lesions and lesions of uncertain malignant potential. SMALL (ISRCTN 12240119) is designed to determine the feasibility of using this approach for treatment of small invasive tumours detected within the UK NHS Breast Screening Programme (BSP). Methods:. SMALL is a phase III multicentre randomised trial comparing standard surgery with VAE for screen-detected good prognosis breast cancers. The main eligibility criteria are age ≥47 years, screen-detected unifocal grade 1 tumours with maximum diameter 15mm, which are strongly ER/PR+ve and HER2-ve, with negative clinical/radiological axillary staging. Patients are randomised 2:1 in favour of VAE or surgery;with no axillary surgery in S the VAE arm. Completeness of excision is assessed radiologically, and if excision is incomplete, patients undergo open surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm but may be omitted following surgery. Co-primary end-points are:1.Non-inferiority comparison of the requirement for a second procedure following excision2.Single arm analysis of local recurrence (LR) at 5 years following VAE. Recruitment of 800 patients over 4 years will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure. This ensures sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. To ensure that the trial as a whole only has 5% alpha, the significance level for each co-primary outcome is set at 2.5% with 90% power. The Data Monitoring Committee will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A QuinteT Recruitment Intervention (QRI) is integrated throughout SMALL to optimise recruitment and informed consent. Recruitment challenges are identified by analysing recruiter/patient interviews and audio-recordings of trial discussions, and by review of screening, eligibility and recruitment data and study documentation. Solutions to address these are developed collaboratively, including individual/group recruiter feedback and recruitment tips documents. Results:. SMALL opened in December 2019, but recruitment halted in 2020 due to suspension of the NHS BSP for 5 months due to COVID-19. As of 1st July 2021, 55 patients had been approached in 10 centres, with 33 patients randomised (randomisation rate 60%). A further 23 centres are in set-up, with 8 suspended due to the pandemic. Drawing from preliminary QRI findings and insights from patient representatives, a recruitment tips document has been circulated (on introducing and discussing SMALL, providing balanced information. on treatment options and explaining randomisation). individual recruiter feedback has commenced, with wider feedback planned shortly. Conclusion:. Despite pandemic-related challenges, SMALL has an excellent recruitment rate to date and is expected to have a global impact on treatment of breast cancer within mammographic screening programmes. SMALL is funded by the UK NIHR HTA programme, award 17/42/32.
ABSTRACT
Aim: Acute appendicitis (AA) is a common indication for abdominal surgery, with more than 30,000 appendicectomies performed in England per year. However, SARS-CoV-2 (COVID-19) changed usual surgical practices following advice to minimise laparoscopic surgery, and instead favouring conservative management, or open surgery for AA. Method: In this study, we compared the management of 50 patients with suspected/confirmed AA during the first wave of the COVID-19 pandemic at a district general hospital (DGH) with our usual practices, against 50 patients admitted with suspected/confirmed AA during a similar time period, one year prior to the pandemic. Results: Demographics of patients in both groups were comparable with median age of 34 in the pandemic vs 32.5 in the pre-pandemic group. 74% of patients in the pandemic group (PG) underwent imaging to confirm appendicitis, compared to 58% of patients in the pre-pandemic group (PPG). 64% of PG patients were treated conservatively, compared to 8% in PPG patients. Outcomes demonstrated re-attendance events of 12% in the PG, as compared to 10% in the PPG, although the follow up period was longer in the PPG. Despite a significantly smaller number of patients managed surgically during the pandemic, 27% of patients undergoing appendicectomies had post-operative complications in the PG, as compared to 7% in the PPG. Conclusions: During the pandemic, more patients at our DGH with AA were treated conservatively, more patients had re-attendance events and post-operative complications when compared to patients in the pre-pandemic group.
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Introduction & Objective: Global Upper Urinary Tract (UUT) stone prevalence is rising. As a consequence, the increased service demand on hospitals may be difficult to manage, increasing the burden on healthcare providers (HCPs) as well as on patients. In this European analysis we explore the evolution of stone diagnoses and surgical procedures in Germany (DE), France (FR), and England (EN) over the past ten years. Methods: We identified the codes related to UUT stones diagnoses using the International Classification of Diseases (ICD-10) and extracted procedure counts for Extracorporeal Shock Wave Lithotripsy (ESWL), Ureteroscopy (URS), Percutaneous Nephrolithotomy (PCNL) and Open Surgery (OS). We used procedure codes from the National databases in DE, FR and EN, and analyzed the hospital diagnosis counts versus surgical procedure counts related to UUT stones from 2010 to 2019. Results: Between 2010-2019, the ICD-10 N20 codes for calculus of kidney and ureter increased by 8%;26% and 15% in DE, FR, EN respectively, whereas stone procedures increased by 3%;38% and 18%. Over time the dominant surgical UUT stone procedure shifted from ESWL (49-60% of all procedures in 2010) to URS (51-75% of all procedures in 2019). PCNL and OS represent <5% of UUT stones procedures in FR and EN. The highest use of PCNL is observed in DE (increase from 7% in 2010 to 11% in 2019). Over the past decade, the overall length of stay (LoS) decreased for all procedures across the three countries. The URS average LoS decreased by 21% in DE;37% in FR and 6% in EN. Daycase stone procedures volume increased in FR by 68% and in EN by 23%. In DE most cases involve at least one overnight stay. Conclusions: This analysis confirms the rise in stone prevalence globally, including an increase in UUT stones diagnoses and surgical procedures in DE, FR, EN over the past decade. The dominant surgical procedure to treat UUT stone has shifted from ESWL to URS, and the average LoS has decreased. These observed trends may be due to clinical advantages, technological advancement as well as, other factors such as HCP preference or costs. The continued rise of UUT stone prevalence has implications for patients, HCPs and hospitals. If we add to that the COVID19 repercussions, solutions to optimize workforce planning, service delivery and length of stay could help to address the situation.
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Background: The coronavirus disease 2019 (COVID-19) had become a health care event endangering humans globally. It takes up a large number of healthcare resources. We studied the impact of COVID-19 on patients with ovarian cancer by comprehensively analyzing their admissions before and after the epidemic, and made reasonable suggestions to improve their current situation. Methods: We randomly divided the enrolled patients into three groups, PreCOVID-19 Group (PCG) (2019.8.20-2020.1.20), COVID-19 Group (CG) (2020.1.21-2020.6.14), and Secondary Outbreak COVID-19 Group (SOCG) (2020.6.15-2020.10.10). One-way ANOVA and chi-square test were used for analysis. Results: The number of patients from other provinces decreased significantly (p < 0.05). The total hospital stay during the epidemic was substantially more extended (p < 0.05). Before the epidemic, our department performed more open surgery while during the epidemic outbreak, we tended to choose laparoscopy (p < 0.01). We took a longer surgery time (P < 0.05). Patients had significantly less post-operative fever during the epidemic (p < 0.001). Conclusion: During the COVID-19 epidemic, no patient was infected with COVID-19, and no patient experienced severe post-operative complications. We recommend maintaining the admissions of patients with ovarian cancer during the epidemic following the rules: 1. The outpatients must complete a nucleic acid test and chest CT in the outpatient clinic; 2. Maintain full daily disinfection of the ward and insist that health care workers disinfect their hands after contact with patients; 3. Increase the use of minimally invasive procedures, including laparoscopy and robotics; 4. Disinfect the ward twice a day with UV light and sodium hypochlorite disinfectant; 5. Patients need to undergo at least three nucleic acid tests before entering the operating room.
ABSTRACT
BACKGROUND: Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers. METHOD: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology. RESULTS: Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion. CONCLUSIONS: The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.