Systematic review of therapeutic nipple-sparing versus skin-sparing mastectomy.

Background: The use of nipple-sparing mastectomy (NSM) is increasing, despite unproven oncological safety in the therapeutic setting. The aim of this systematic review was to determine the safety and efficacy of NSM compared with skin-sparing mastectomy (SSM). Methods: A literature search of all original studies including RCTs, cohort studies and case-control studies comparing women undergoing therapeutic NSM or SSM for breast cancer was undertaken. Primary outcomes were oncological outcomes; secondary outcomes were clinical, aesthetic, patient-reported and quality-of-life outcomes. Data analysis was undertaken to explore the relationship between NSM and SSM, and preselected outcomes. Heterogeneity was assessed using the Cochrane tests. Results: A total of 690 articles were identified, of which 14 were included. There was no statistically significant difference in 5-year disease-free survival and mortality for NSM and SSM groups, where data were available. Local recurrence rates were also similar for NSM and SSM (3·9 versus 3·3 per cent respectively; P = 0·45). NSM had a partial or complete nipple necrosis rate of 15·0 per cent, and a higher complication rate than SSM (22·6 versus 14·0 per cent respectively). The higher overall complication rate was due to the rate of nipple necrosis in the NSM group (15·0 per cent). Conclusion: In carefully selected cases, NSM is a viable choice for women with breast cancer who need to have a mastectomy. More research is needed to help further refine which surgical approaches to NSM optimize outcomes.

Intralesional excision with topical intralesional cryotherapy improves the treatment of keloid scarring in a paediatric patient.

Recurrent keloid scarring has a significant impact on quality of life. Management is complex, particularly for scars resistant to conventional treatments and in paediatric cases where radiotherapy is not a suitable adjunct to surgical excision. We present the case of a nine-year-old African Caribbean girl with multiple large and recurrent keloid scars on both ears and bilateral sensorineural deafness. Following repeated intralesional excisions, corticosteroid and botulinum toxin injections, she continued to experience rapid recurrence of her keloids, worsening pain and pruritus. She was no longer able to wear her hearing aids because of the large size of the keloids. We employed a novel technique using topical intralesional cryotherapy, applying liquid nitrogen intraoperatively to the inside of the skin flaps immediately post-intralesional keloid excision and before wound closure. At 26-month follow-up a good aesthetic and symptomatic result was achieved, with minimal hypopigmentation, significantly reduced scar volume and significantly slowed recurrence. We discuss this case and review the current literature on the use of topical intralesional cryotherapy for keloid scarring.

Impact of the SCARE guideline on the reporting of surgical case reports: A before and after study.

INTRODUCTION: The SCARE guideline was developed in 2016 through an expert Delphi consensus exercise. It aimed to improve the quality of reporting of surgical case reports. The aim of this study was to assess the impact of introducing the SCARE guideline for surgical on reporting of case reports submitted to a single journal. METHODS: A total of 20 case reports published in the International Journal of Surgery Case Reports (IJSCR) and Annals of Medicine and Surgery (AMS) in July and August 2016, prior to the introduction of the SCARE guideline (the pre-SCARE period), were randomly identified and scored against the SCARE criteria. Two independent teams performed the scoring giving a total score out of a theoretical maximum of 34 for each case report, the 'SCARE score' (expressed as a percentage). The scores for the two teams were then compared and consensus was reached to achieve a final sore set. This process was repeated for the January and February 2017 issues of the journal, post implementation of the guideline (the post-SCARE period). SCARE scores were compared between the pre- and post-SCARE periods. RESULTS: The mean pre-SCARE score was 75.0% (standard deviation ± 6.29, Range 62-84), and the mean post-SCARE score was 82.6% (standard deviation ± 8.02, range 66-99), a 10% relative increase in compliance which was statistically significant (P < 0.001). The Cohen's Kappa score between teams A and B was 0.871, implying very substantial agreement. CONCLUSION: Implementation of the SCARE guideline resulted in a 10% improvement in the reporting quality of surgical case reports published in a single journal. Adherence to SCARE reporting guidelines by authors, reviewers and editors should be improved to boost reporting quality. Journals should develop their policies, submission processes and guide for authors to incorporate the guideline.

Impact of the PROCESS guideline on the reporting of surgical case series: A before and after study.

INTRODUCTION: The PROCESS guideline was developed in 2016 through expert Delphi consensus. It aimed to improve the quality of reporting of surgical case series. This study assessed the impact of the introduction of the PROCESS guideline on reporting for surgical case series submitted to three journals. METHODS: 20 case series published in the International Journal of Surgery Case Reports (IJSCR), the International Journal of Surgery (IJS) or the Annals of Medicine and Surgery (AMS) in September to December 2016, prior to the introduction of the PROCESS guideline (the pre-PROCESS period), were randomly identified and scored against the PROCESS criteria. Two authors independently scored each article a total score out of 29, the 'PROCESS score' (expressed as a percentage). Scores for the two researchers were compared and consensus was reached to achieve a final score set. The process was repeated for the January 2017 to April 2017 issues of the three journals, post PROCESS implementation (the post-PROCESS period). RESULTS: The mean PROCESS score was 80% (range 66-90%) for the pre-PROCESS period and 84% (range 72-95%) for the post-PROCESS period, a 4% relative increase [STATS]. The Cohen's Kappa score between researchers was 0.907 implying very substantial agreement. CONCLUSION: Implementation of the PROCESS guideline resulted in a 5% improvement in the reporting quality of surgical case series published in three journals. Further research is needed to identify and successfully navigate existing barriers to greater compliance. Authors, reviewers and editors should adhere to the guidelines to boost reporting quality. Journals should develop their policies and guide for authors to incorporate the guideline and mandate compliance.

Systematic review of the methodological and reporting quality of case series in surgery.

BACKGROUND: Case series are an important and common study type. No guideline exists for reporting case series and there is evidence of key data being missed from such reports. The first step in the process of developing a methodologically sound reporting guideline is a systematic review of literature relevant to the reporting deficiencies of case series. METHODS: A systematic review of methodological and reporting quality in surgical case series was performed. The electronic search strategy was developed by an information specialist and included MEDLINE, Embase, Cochrane Methods Register, Science Citation Index and Conference Proceedings Citation index, from the start of indexing to 5 November 2014. Independent screening, eligibility assessments and data extraction were performed. Included articles were then analysed for five areas of deficiency: failure to use standardized definitions, missing or selective data (including the omission of whole cases or important variables), transparency or incomplete reporting, whether alternative study designs were considered, and other issues. RESULTS: Database searching identified 2205 records. Through the process of screening and eligibility assessments, 92 articles met inclusion criteria. Frequencies of methodological and reporting issues identified were: failure to use standardized definitions (57 per cent), missing or selective data (66 per cent), transparency or incomplete reporting (70 per cent), whether alternative study designs were considered (11 per cent) and other issues (52 per cent). CONCLUSION: The methodological and reporting quality of surgical case series needs improvement. The data indicate that evidence-based guidelines for the conduct and reporting of case series may be useful.

An expanding forearm phlegmon and subsequent compartment syndrome.

We present the case of a young, fit woman who developed a forearm phlegmon with subsequent compartment syndrome. Further investigation found her to be suffering from endocarditis and she had had recent dental work. Presentation and management is discussed, with learning points highlighted.

Practical guide to the Idea, Development and Exploration stages of the IDEAL Framework and Recommendations.

BACKGROUND: Evaluation of new surgical procedures is a complex process challenged by evolution of technique, operator learning curves, the possibility of variable procedural quality, and strong treatment preferences among patients and clinicians. Preliminary studies that address these issues are needed to prepare for a successful randomized trial. The IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) Framework and Recommendations provide an integrated step-by-step evaluation pathway that can help investigators achieve this. METHODS: A practical guide was developed for investigators evaluating new surgical interventions in the earlier phases before a randomized trial (corresponding to stages 1, 2a and 2b of the IDEAL Framework). The examples and practical tips included were chosen and agreed upon by consensus among authors with experience either in designing and conducting IDEAL format studies, or in helping others to design such studies. They address the most common challenges encountered by authors attempting to follow the IDEAL Recommendations. RESULTS: A decision aid has been created to help identify the IDEAL stage of an innovation from literature reports, with advice on how to design and report the IDEAL study formats discussed, along with the ethical and scientific rationale for specific recommendations. CONCLUSION: The guide helps readers and researchers to understand and implement the IDEAL Framework and Recommendations to improve the quality of evidence supporting surgical innovation.

Norman Barrett (1903-79): unorthodox pioneer of thoracic and oesophageal surgery.

It is an interesting quirk of medical history that the legacy of Norman Barrett most ostensibly lies in the name of a disease the he was quite emphatically wrong about, at least when he first described it. Indeed, there are those who argue to remove the eponym in favour of the title 'Columnar Lined Epithelium', in part because of what little Barrett actually had to do with the correct initial characterization of this disease. Yet the sum of Norman Barrett's contributions to modern medicine is much more than a mistaken characterization of a pathological process. Barrett was truly a pioneer of chest surgery in the UK - a specialty in its embryonic stages when he first qualified. He was also renowned as a teacher and academic of the highest calibre. In tracing the story of his life we can see how his natural attributes, life experiences and keen appreciation of the arts (especially history) facilitated personal success and such sharp insight into the vagaries of modern academic medicine.

The teaching of surgery in the undergraduate curriculum--reforms and results.

In the past decade, the teaching of surgery in the undergraduate curriculum has undergone considerable changes in quantity, mode and method of delivery. This is a result of the radical reforms of higher education, the health service and the undergraduate medical curriculum. These reforms are often interrelated and are occurring in conjunction with major changes in healthcare delivery. In this article we discuss this reorganisation, the rationale behind it and the impact on surgical teaching.

The teaching of surgery in the undergraduate curriculum. Part II--Importance and recommendations for change.

In the past decade, the teaching of surgery in the undergraduate curriculum has undergone considerable changes in quantity, mode and method of delivery. This is a result of the radical reforms of higher education, the health service and the undergraduate medical curriculum. The changes are complex and require us to ask the questions: how important is the teaching of surgery in the modern medical undergraduate curriculum and is there a need for change? We aim to tackle these questions and propose practical action which medical schools can take to ensure that they deliver effective surgical teaching within the modern medical curriculum and health service.

The teaching of surgery in the undergraduate curriculum--reforms and results.

In the past decade, the teaching of surgery in the undergraduate curriculum has undergone considerable changes in quantity, mode and method of delivery. This is a result of the radical reforms of higher education, the health service and the undergraduate medical curriculum. These reforms are often interrelated and are occurring in conjunction with major changes in healthcare delivery. In this article we discuss this reorganisation, the rationale behind it and the impact on surgical teaching.