Ultrasound vs. clinical diagnosis-which is better in diagnosing acute appendicitis?: a cohort study.

Acute appendicitis is one of the most common causes of right iliac fossa pain which often warrants surgical management. In many cases, abdominal ultrasonography (USS) is done to confirm the diagnosis however negative appendicectomy is common due to atypical presentations and different visualisation rate. The unnecessary operative intervention can result in complications. The aim of this study was to compare the efficacy between clinical diagnosis and USS in diagnosing acute appendicitis to avoid negative appendicectomy and prevent further complications. Method: A retrospective cohort study was conducted in a district general hospital which 1046 cases of laparoscopic appendicectomy were included and examined for the use of USS or clinical diagnosis. The sensitivity, specificity, negative and positive predictive value in USS and data in clinical evaluation were analysed for their accuracy in the diagnosis of acute appendicitis based on the histology results post appendicectomy. Results: Clinical diagnosis without preoperative imaging was found to have a significantly lower negative appendicectomy rate of 27.20% compared with 42.67% in those who underwent ultrasound. 44.64% of the patients were misdiagnosed with a normal USS result who had a subsequent positive histology of appendicitis. Conclusions: USS has been shown to be less sensitive for diagnosing acute appendicitis which results in high negative appendicectomy and misdiagnosis rate. With an increasing burden of health budget and resources, cautious and appropriate use of USS would avoid the misdiagnosis and prevent further complications. Thorough clinical evaluation remains an important first step and role in the diagnosis of acute appendicitis.

Impact of the COVID-19 pandemic on the management and outcomes of emergency surgical patients: A retrospective cohort study.

INTRODUCTION: The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients. METHODS: Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU. RESULTS: Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 (p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01). CONCLUSION: This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

Virtual surgical education for foundation doctors in the United Kingdom during COVID-19 pandemic: A qualitative study.

Background: Foundation training in the UK has been impacted by the COVID-19 pandemic. Surgical education in particular has been impacted due to the reduced exposure of teaching in theatres and clinics. To combat this waning exposure, an online teaching series for the foundation doctors, in affiliation with the Royal College of Surgeons of Edinburgh, was designed and delivered nationally during the pandemic. The aim of this study is to assess the feasibility and the reception of an online teaching programme to become an integral part of surgical education. Methods: A series of virtual teaching sessions lasting between 30 and 60 mintues were delivered live by senior surgical trainees and consultants to foundation trainees nationwide. Online feedback was completed after each session and the results were analysed using Microsoft Excel™. Results: 95.2% of the foundation trainees felt more confident on the subjects taught and were satisfied with the teaching series. The majority of the trainees preferred sessions which were short, held every two or three weeks, delivered by senior surgeons, covering a wide range of surgical specialties and conditions. Conclusion: An online surgical teaching series has been shown to be well received by foundation trainees. It provides a realistic opportunity to have a blended learning environment for surgical training nationally during the pandemic.

Extensive aortic dissection (Stanford Type A) presenting with confusion in a patient: a case report.

Spontaneous extensive aortic dissection is rarely documented in the literature with a misdiagnosis rate of up to 38% in previous studies. Vital signs and clinical manifestations vary and depend on the extent of the dissection and location. We present a rare case of extensive Stanford Type A dissection in a 60-year-old female patient who presented with confusion. Type A aortic dissection is a surgical emergency that is important for clinicians to have a low threshold of suspicion of the life-threatening condition due to the diverse and potentially atypical clinical presentation of aortic dissection.

The important role of in-situ simulation in preparing surgeons for the COVID-19 pandemic.

BACKGROUND: Effective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19. METHODS: This was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients. RESULTS: 27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy. CONCLUSION: In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.

Acute appendicitis and the role of pre-operative imaging: A cohort study.

INTRODUCTION: Acute right iliac fossa (RIF) pain is amongst the most common presentation to the surgical team. Acute appendicitis is the most common cause of this pain and often warrants surgical intervention. In many cases intervention results in a negative appendicectomy with unnecessary complications as a result. The aim of this study was to compare the efficacy of pre-operative imaging in the diagnosis of acute appendicitis to reduce the rate of negative appendicectomy and unnecessary operative intervention. METHODS: A retrospective single centre cohort study was undertaken in a district general hospital (DGH) of all laparoscopic appendicectomies over a six-year period. 1344 cases were included and were examined for the use of pre-operative imaging (and type) or none. The sensitivity, specificity, negative and positive predictive value for each type of imaging were analysed for their accuracy in diagnosis appendicitis based on the final histological analysis. RESULTS: The negative appendicectomy rate was found to be greatest in those undergoing ultrasonography (48.21%) as their method of pre-operative imaging whilst those who underwent computed tomography (CTAP 20.26%) had a lower rate equivalent to that of clinical diagnosis alone (20.73%). CONCLUSION: USS is less sensitive than CT in diagnosing acute appendicitis. There is no statistically significant difference in negative appendicectomy rate between clinical diagnosis and CT diagnosis. Pre-operative imaging has a role in the diagnosis of appendicitis but needs to be utilised appropriately to reduce the strain on the surgical department and prevent the potential of a negative appendicectomy.

Weekend handover: Improving patient safety during weekend services.

Clinical Handover has been identified as one of the most high-risk processes within medicine. Inadequate handover is a significant cause of avoidable adverse events across many hospitals. A likert-survey of the weekend handover system at a district general hospital demonstrated significant dissatisfaction amongst junior doctors. Intending to improve patient safety and reduce stress for on-call junior doctors, a weekend handover proforma was compiled according to the Royal College of Physicians and Surgeons guidelines. The proforma was trialed on six medical wards for six months with a before and after questionnaire being sent to doctors on the wards involved to determine the proforma's merits on a scale of 1 (least effective) to 10 (most effective). Reports subsequent to implementation demonstrated a 67% increase ease of identifying outstanding weekend jobs. 57% of doctors reported better understanding of their patient's diagnosis and management plan and 53% stated it was easier to identify the patients that required regular medical review over the weekend. Results also highlighted a 55% reported an increase in safety of weekend handovers (p<0.01). A closed loop audit of handover practice through the use of a standardised proforma showed improved quality, detail and consistency of handovers. The reduction in stress for junior doctors managing unknown patients with a clear concise plan, directed by a senior from the parent team during the week, has improved patient safety and doctor satisfaction.

Appendiceal neoplasms and histological involvement of the mesoappendix: A case series.

INTRODUCTION: Acute appendicitis is a common presentation to surgical departments, typically resulting in appendicectomy. Appendiceal tumours may not be visible intraoperatively, and are present in roughly 0.5-1% of specimens. Routine resection of the mesoappendix is not universally practiced, despite the mesoappendix being commonly involved in appendiceal tumours.This is a case series of the histological findings of 21 patients with appendiceal tumours, with consideration to tumour within the resected mesoappendix. METHODS: We reviewed the histology of 1344 patients undergoing laparoscopic appendicectomy over a 6-year period assessing for the presence of appendiceal tumours and resected mesoappendix. RESULTS: Twenty-one patients were found to have appendiceal tumours, with a mean maximum tumour dimension of 7.2 mm. Sixteen of these patients had simultaneous mesoappendix resection, of whom six (38%) were found to have direct or indirect tumour tissue within the mesoappendix. CONCLUSION: Further evidence for routine removal of the mesoappendix, and the need for larger prospective studies to investigate for any survival benefit. We note the worrying trend of conservative management of acute appendicitis.

Management of a trichobezoar caused by consumption of artificial hair extensions.

Trichobezoars are rare, but most commonly found in young women with trichophagia and trichotillomania. Complications can include iron deficiency anaemia and gastric erosion or, rarely, perforation. A 19-year-old woman presented with epigastric pain, vomiting and lethargy. Initial investigations revealed a palpable abdominal fullness on examination and iron deficiency anaemia. Oesophagogastroduodenoscopy found a large trichobezoar associated with gastric erosions, polyps and an ulcer. Subsequently, the patient reported previous consumption of artificial hair extensions, which ceased 5 years previously. Attempts to remove the trichobezoar by endoscopy were ineffective and in line with current literature, laparotomy was successful. This case describes a rare cause of trichobezoar and emphasises the importance of appropriate initial investigations and definitive management.

COVID-19: Adapting to change, general surgery at a district general hospital in the United Kingdom.

The Coronavirus pandemic has caused major change across the world and in the National Health Service. In order to cope and help limit contagion, numerous institutions recognised the need to adjust clinical practice quickly yet safely. In this paper, we aim to describe the changes implemented in a general surgery department at a district general hospital in the United Kingdom. Across the surgical specialties, frameworks, protocols and guidelines have been established locally and nationally. The aerosol generating procedures involved in general surgery required us to alter our daily activities. Modifications to patient management were necessary to try and reduce viral spread. Staff wellbeing was heavily promoted in order to help maintain the frontline workforce. A holistic approach was required.

A Single Centre Experience of Day Case Laparoscopic Cholecystectomy Outcomes by Body Mass Index Group.

AIM: The purpose of this study was to evaluate whether patients with a high BMI can undergo safe day case LC for cholecystitis compared to groups of patients with a lower BMI. SETTING: NHS District General Hospital, UK. METHODS: A retrospective review of 2391 patients who underwent an attempted day case LC between 1 January 2009 and 15 August 2015 was performed. Patients were divided into five groups depending on their BMI. Inclusion criteria were patients undergoing elective day case laparoscopic cholecystectomy with cholecystitis on histology. The endpoints were complication requiring readmission and postoperative length of stay (LOS). RESULTS: There were 2391 LCs performed in the time period of which 1646 were eligible for inclusion. These LCs were classified as 273 (16.9%), 608 (37.8%), 428 (26.6%), 208 (12.9%), and 91 (5.66%) patients in the groups with BMI values of 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and >40, respectively. Average BMI was 30.0 (±5.53, 19-51) with an average postoperative LOS of 0.86, and there was no difference between the BMI groups. Overall complication rate was 4.3%; there was no significance between BMI groups. CONCLUSIONS: Increased BMI was not associated with worse outcomes after day case LC.

Technique to manage persistent leak from a prepyloric ulcer where a distal gastrectomy is not appropriate.

Perforated peptic ulcer disease remains a relatively frequent emergency surgery presentation. Persistent leak is the most common indication for return to theatre. We present a technique to manage patients in whom a more substantial resection is not possible. A 45-year-old woman underwent initial laparoscopic primary closure of a non-malignant perforated gastric ulcer. This subsequently leaked on return to the UK and had a further graham patch formed via a laparotomy. Unfortunately, the patch repair leaked and at reoperation a wedge excision or distal gastrectomy was not possible given the friability of the tissues and instability of the patient, a transgastric drain and perigastric drain were therefore placed. This created a controlled fistula, which was managed eventually as an outpatient. Transgastric drains in the context of the persistent perforated gastric ulcer leak are a safe way to manage the unstable patient with poor tissues where more substantial surgeries such as a distal gastrectomy are not possible.