A systematic review of viral transmission risk to healthcare staff comparing laparoscopic and open surgery.

BACKGROUND: Throughout the United Kingdom, there have been sweeping changes to the practice of medicine due to the COVID-19 pandemic. For the surgical speciality, there have been changes to both elective and emergency practice. Concern regarding potential aerosolisation during invasive procedures have been raised - including the use of pneumoperitoneum to facilitate laparoscopy. The aim of this study is to systematically review the data available to date regarding the potential risk posed to theatre staff by laparoscopy. METHOD: A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. Only publications in peer-reviewed journals were considered. PubMed, Ovid Embase, SCOPUS, and Cochrane Library were searched. The search period was between 1st January 1980 and 27th April 2020. Bias was assessed using the ROBINS-I tool. RESULTS: 4209 records were identified, resulting in 9 unique studies being selected. The included studies examined viral DNA aerosoliation generated by electrosurgery and CO2 laser ablation, with one study examining viral DNA aerosolisation following laparoscopy. Each of these demonstrated that viral DNA (Hepatitis B Virus and Human Papilloma Virus) was detectable in the surgical smoke plume. CONCLUSION: The data and analysis reported in this study reflect the most up-to-date evidence available for the surgeon to assess risk towards healthcare staff. It was constrained by heterogeneity of reporting for several outcomes and lack of comparable studies. There is currently insufficient data to recommend open or a minimally invasive surgical approach with regard to theatre team safety in the COVID-19 era.

Meta-analysis of patient-reported outcomes after laparoscopic versus open inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is a common low-risk intervention. Patient-reported outcomes (PROs) are being used increasingly as primary outcomes in clinical trials. The aim of this study was to review and meta-analyse the PROs in RCTs comparing laparoscopic versus open inguinal hernia repair techniques in adult patients. METHODS: A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. Only RCTs in peer-reviewed journals were considered. PubMed, Ovid Embase, Scopus and the Cochrane Library were searched. In addition, four trial registries were searched. The search interval was between 1 January 1998 and 1 May 2018. Identified publications were reviewed independently by two authors. The review was registered in the PROSPERO database (CRD42018099552). Bias was assessed using the Cochrane Collaboration risk-of-bias tool. RESULTS: Some 7192 records were identified, from which 58 unique RCTs were selected. Laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from 2 weeks to within 6 months after surgery (risk ratio (RR) 0·74, 95 per cent c.i. 0·62 to 0·88), 6 months to 1 year (RR 0·74, 0·59 to 0·93) and 1 year onwards (RR 0·62, 0·47 to 0·82). Paraesthesia (RR 0·27, 0·18 to 0·40) and patient-reported satisfaction (RR 0·91, 0·85 to 0·98) were also significantly better in the laparoscopic repair group. CONCLUSION: The data and analysis reported in this study reflect the most up-to-date evidence available for the surgeon to counsel patients. It was constrained by heterogeneity of reporting for several outcomes.

A novel approach to improve undergraduate surgical teaching.

BACKGROUND: Undergraduate surgery is at an important crossroads. Many departments report significant difficulties delivering effective teaching. Our student feedback indicated a dated surgical curriculum lacking structure, quality and uniformity. We report on a new "blended" approach employing a combination of professional DVDs, case based discussions, online material and traditional bedside teaching designed to provide structure, standardization, and equality of learning . METHODS: Year 4 students who had undertaken the new course and year 5 students who had participated in the traditional teaching programme were compared. Students completed a 20 item questionnaire about their experiences of the surgical teaching programme. RESULTS: One hundred and seventy-one year 4 (70%) and 148 year 5 students (66%) responded. Domains relating to "Overall Satisfaction with the course", "Approval of innovative teaching methods and interactivity" and "Satisfaction with the clarity of course information" showed improvements when comparing the new and old programmes. However bedside teaching was not rated as highly in the new programme (p<0.05). CONCLUSION: This blended approach has resulted in improved student understanding and engagement. The apparent compromise of bedside teaching may be a reflection of higher expectations. We believe that a similar blended approach has the potential to re-invigorate surgical teaching elsewhere.

Epstein-Barr virus positive inflammatory pseudo-tumour of the spleen: A case report and literature review.

INTRODUCTION: Epstein-Barr virus positive inflammatory pseudo-tumour (IPT) of the spleen is an uncommon, frequently asymptomatic entity, which is typically picked up as an incidental finding on imaging. PRESENTATION OF CASE: We present a case of EBV positive IPT of the spleen which presented as an incidental finding on CT in a patient with a history of malignancy. Splenectomy was performed. DISCUSSION: IPTs are benign spindle cell lesions of varying aetiology, which can arise in a variety of tissues, including the spleen. In situ hybridisation showed strong staining for Epstein-Barr virus RNA in our case, in common with many similar lesions described in the literature. The differential diagnosis of such spindle cell tumours is discussed. CONCLUSION: Radiologically, EBV positive spindle cell tumours are indistinguishable from malignant lesions such as lymphoma and diagnosis is made on histology, usually at splenectomy.

Severe Intraperitoneal Haemorrhage following Suprapubic Catheter Insertion in a Patient Treated with Iloprost.

Suprapubic catheter (SPC) insertion is a common urological procedure, performed both in the elective and emergency settings. The authors present an unusual case of severe intraperitoneal bleeding following the insertion of an SPC under direct vision, where the use of prostacyclin analogue may have been a contributing factor.

Primary plasmacytoma of the kidney.

Primary renal plasmacytomas are an extremely rare clinical condition. Their management is particularly challenging due to the paucity of evidence, with only just over a dozen previously reported cases. We report a case of a primary extramedullary plasmacytoma of the kidney and performed a review of the literature. The case is presented as a learning point that it is imperative to keep plasmacytic tumours in mind and to include them in the differential diagnosis of anaplastic tumours, even in unusual locations, such as the kidney.

Inferior vena cava thrombosis: a review of current practice.

Inferior vena cava (IVC) thrombosis remains under-recognised as it is often not pursued as a primary diagnosis. The aetiology of IVC thrombosis can be divided into congenital versus acquired, with all aetiological factors found among Virchow's triad of stasis, injury and hypercoagulability. Signs and symptoms are related to aetiology and range from no symptoms to cardiovascular collapse. Painful lower limb swelling combined with lower back pain, pyrexia, dilatation of cutaneous abdominal wall veins and a concurrent rise in inflammatory markers are suggestive of IVC thrombosis. Following initial lower limb venous duplex, magnetic resonance imaging (MRI) is the optimal non-invasive imaging tool. Aetiology directs treatment, which ranges from anticoagulation and lower limb compression to open surgery, with endovascular therapies increasingly favoured. The objective of this review is to assess current literature on the aetiology, presentation, investigation, treatment, prognosis and other factors pertaining to IVC thrombosis.

Superficial palmar arch aneurysm after carpal tunnel decompression, a rare complication: a case report.

False aneurysms of the palmar arteries are rare. They are usually associated with traumatic injuries to the hand vasculature. We present a case of superficial palmar arch aneurysm (SPAA), complicating carpal tunnel decompression which presented as a pulsatile mass at the site of previous surgery. Initial diagnosis was made on clinical examination and confirmed on doppler ultrasound (US) and computed tomographic angiography (CTA). The feeding vessel of the aneurysm was subsequently occluded using coil embolization.

Validation of a passive stereophotogrammetry system for imaging of the breast: a geometric analysis.

The overall aim of this study was to assess the accuracy, reproducibility and stability of a high resolution passive stereophotogrammetry system to image a female mannequin torso, to validate measurements made on the textured virtual surface compared with those obtained using manual techniques and to develop an approach to make objective measurements of the female breast. 3D surface imaging was carried out on a textured female torso and measurements made in accordance with the system of mammometrics. Linear errors in measurements were less than 0.5mm, system calibration produced errors of less than 1.0mm over 94% over the surface and intra-rater reliability measured by ICC=0.999. The mean difference between manual and digital curved surface distances was 1.36 mm with maximum and minimum differences of 3.15 mm and 0.02 mm, respectively. The stereophotogrammetry system has been demonstrated to perform accurately and reliably with specific reference to breast assessment.

Breast cancer in women under 40 years of age: a series of 57 cases from Northern Ireland.

BACKGROUND: There are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients. METHODS: We performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome. RESULTS: Fifty-eight women (mean age 34.9 years, range 27-39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n=56) patients presented directly to our symptomatic clinic; 89.5% (n=51) patients had a palpable lump; 71.9% (n=41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13cm (2.58mm) for BCS and 3.95cm (6.38mm) for mastectomy. From a total of 55 primary resections, 85.5% (n=47) of tumours were invasive ductal carcinoma; 57.4% (n=31) and 40.7% (n=22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n=28) while 40.0% (n=22) were lymph node positive for metastatic disease. 76.8% (n=43), 39.3% (n=22) and 30.2% (n=16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2-8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n=5) and 80.0% (n=44) of surgically treated patients respectively while 76.4% (n=42) patients received adjuvant radiotherapy. 76.4% (n=42) of patients were treated with tamoxifen. Four patients received Herceptin therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p=0.038), administration of neo-adjuvant treatment (p=0.019), surgical intervention (p<0.001), progesterone receptor positivity (p=0.018) and tumour recurrence (p<0.001). 86.0% (n=49) patients were alive at mean follow-up of 52 months; 82.5% (n=47) remain disease free. CONCLUSION: Our study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.

Ultrasound is a useful adjunct to mammography in the assessment of breast tumours in all patients.

BACKGROUND: Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years. METHODS: Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses. RESULTS: A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34-89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p < 0.001). Ultrasound upgraded nine of 14 mammographically normal and 16 of 29 mammographically indeterminate X-rays to a cancer. Mammography appeared to be more sensitive in patients over 50 years compared with those patients under 50 years (62.5% vs. 45.7%, p = 0.10). The sensitivity of ultrasound was comparable between patients above and below the age of 50 years (82.8% vs. 77.1%, p = 0.60). Further subgroup analysis demonstrated a higher sensitivity with combined mammography and ultrasound compared with mammography alone in either patient group (below 50: 45.7%-->77.1% and above 50: 62.5%-->82.8%). These results also suggested that the difference in the sensitivities of mammography vs. the combined investigation approach was more marked in patients under 50 years of age (below 50 = 31.4% vs. above 50 = 20.3%). CONCLUSION: Adjunctive ultrasound assessment improves breast cancer detection in women of all ages and should be routinely used in symptomatic breast clinics.

Fine needle aspiration at a Regional Head and Neck Clinic: a clinically beneficial and cost-effective service.

BACKGROUND: Fine needle aspiration (FNA) is an important adjuvant to the diagnosis of a palpable lesion which often permits the complete assessment of patients. The main objective of this study was to determine the clinical benefit of a dedicated FNA service at a tertiary referral Head and Neck Clinic and to assess if such a service is cost effective. METHODS: All patients attending the Head and Neck Clinic during 2004 were prospectively assessed in this study. Patient records were analysed regarding investigative modalities including FNA, the subsequent cytology result and the requirement for further histopathological investigations. A cost analysis for all investigative procedures was performed. RESULTS: A total of 135 patients (36 males) had FNAs performed during the study period. The median age was 51.5 years (range 17-92). Patients presented with lesions of lymph nodes (n = 46), thyroid (n = 41), salivary, parotid or submandibular glands (n = 22) and other cutaneous or cystic lesions (n = 26). Cytological grading results were; C1 = 26, C2 = 93, C3 = 8, C4 = 2 and C5 = 6. Patients with lesions C3 or above normally proceeded to further investigations. The overall cost of the FNA per episode in the out-patient clinic was pound114 per episode compared to day case open biopsy per patient of pound333 and an in-patient stay per patient was pound2371. FNA provided sufficient pathological diagnosis to avoid day case surgery in 57 patients (42.2%), and inpatient surgery in 65 patients (48.1%) resulting in a total saving of pound158 372 in 2004. CONCLUSION: This study demonstrates the clinical benefit and cost-effectiveness of FNA services in a dedicated Head and Neck clinic.

Small bowel obstruction secondary to an appendiceal tourniquet.

BACKGROUND: An 83-year-old lady was admitted with a 3-day history of non-specific abdominal pain that had rapidly increased in severity on the day of admission necessitating an emergency laparotomy. Intra-operative findings demonstrated a mechanical small bowel obstruction secondary to a chronically inflamed appendix acting as a tourniquet around a loop of terminal ileum. LEARNING POINT: This case highlights an extremely rare and life-threatening complication of appendicitis. LITERATURE REVIEW: True mechanical small bowel obstruction secondary to an acutely or chronically inflamed appendix encircling the distal small bowel remains extremely rare with only ten cases reported in the literature. CONCLUSION: Clinical assessment remains paramount in the treatment of these patients to facilitate prompt diagnosis and treatment which is vital to provide an optimal platform for post-operative recovery and survival. Although CT imaging is a highly effective investigative modality in these cases, operative treatment should not be delayed for a radiological investigation in the presence of abdominal peritonism.

Complications of inguinoscrotal bladder hernias: a case series.

Although the urinary bladder is involved in 1-4% of all inguinal hernias, extensive inguinoscrotal herniation of the bladder, termed scrotal cystocele, is very rare. Most small asymptomatic bladder hernias are commonly encountered and reduced successfully via the same incision during elective inguinal hernia repair. However, larger bladder herniations can be associated with bladder infarction or obstruction, which require urgent intervention to preserve renal function and reduce morbidity and mortality. We present two cases of elderly men presenting with significant scrotal cystocele complications which necessitated urgent surgical intervention. We compare and contrast the two cases and discuss the presentation, investigation, diagnosis and treatment of these pathophysiological conditions.

Completion mastectomy after breast conserving surgery.

BACKGROUND: Breast conserving surgery (BCS) is increasingly offered to suitable patients diagnosed with early stage breast cancer. Occasionally the pathological margins on specimens following BCS are positive. The objective of this study is to assess the proportion of patients within our unit who required completion mastectomy after BCS and to determine if predictive factors could be identified to assist the breast surgeon identifying those patients at risk of positive margins following BCS. METHODS: All patients diagnosed with breast cancer between 2001 and 2005 were reviewed. Patients undergoing BCS had their histopathological specimens examined for any evidence of residual tumour at the margins of the resected specimen. These patients then proceeded to completion mastectomy if these margins were positive for residual tumour. Multinominal logistic regression was then performed on clinico-pathological factors for each of these patients to determine if predictive factors existed for determination of residual disease in the mastectomy specimen following BCS. RESULTS: Logistic regression demonstrated that size of the initial tumour was the only significant predictor for the presence of completion mastectomy residual carcinoma (CMRC) (p=0.014) and that tumours with an initial size > 2.5 cm were 15 times more likely to have a CMRC than tumours < 1.5 cm. This prediction model based on the initial tumour size had an 89.5% specificity and 52.2% sensitivity. The odds ratio for CMRC based on histological tumour type for each additional 1cm increase in size of the initial tumour was 2.82 for ductal carcinoma in situ, 2.60 for infiltrating ductal carcinoma and 2.26 for other tumours. CONCLUSION: This study demonstrates that residual disease in total mastectomy specimens following BCS increases significantly with increasing original tumour size. With current data, surgeons can inform patients of the risks of residual cancer associated with BCS with a view to increase the rate of primary mastectomies in those patients with presenting tumours greater than 2.5 cm.

Crohn's disease of the terminal ileum: a cheap diagnosis.

BACKGROUND: A 29-year-old man was admitted with a 7-day history of progressive non-specific abdominal pain that progressed to small bowel obstruction following ingestion of a 20-pence coin 4-months previously. Colonoscopic retrieval was unsuccessful. A subsequent laparotomy revealed a chronically inflamed thickened terminal ileum with mesenteric fat encroachment necessitating a right hemicolectomy. Histopathological analysis confirmed Crohn's disease with impaction of the 20-pence coin in a distal terminal ileum stricture near the ileo-caecal valve. LEARNING POINT: Gastrointestinal foreign body retention should alert the clinician to the presence of an undiagnosed bowel abnormality. Furthermore, failed endoscopic retrieval should be considered as a marker for potential underlying gastrointestinal pathology and a requirement for operative intervention. CONCLUSION: This case describes a rare presentation of Crohn's disease and highlights the need to consider underlying gastrointestinal pathology in patients presenting with a deteriorating clinical condition in the presence of an incidental foreign body.

Penman Lecture. Breast cancer--diet to genes: presented at the Department of Surgery, University of Cape Town, 20 July 2005.

Frank Garfield Penman was a solicitor from England who died while on holiday in Cape Town in March 1963. Under a deed dated 9 November 1965, his widow Robina Douglas Penman established a Trust in his memory--the Penman Memorial Foundation. The object of the Foundation initially included scholarships to assist postgraduate medical students from South Africa, and in particular from Cape Town, to obtain teaching and further experience in the UK. Later, the Frank Penman Travelling Fellowship was established (the Visiting Professorship) to advance medical knowledge and practice in surgery by enabling a surgeon from the UK to give lectures and teach for a period of several weeks in South Africa. This paper is based on a lecture given on 20 July 2005 as part of the Penman Memorial Foundation Visiting Professorship to Cape Town.

Fine needle aspiration cytology (FNAC) in the diagnosis of granulomatous lymphadenitis.

OBJECTIVE: To determine the final histological and clinical diagnosis of patients with granulomatous lymphadenitis on fine needle aspiration cytology (FNAC). METHOD: A retrospective cohort study was carried out over a five year period in a tertiary referral hospital. FNAC of 22 patients with granulomatous lymphadenitis was reviewed and correlated with the final histological diagnosis and clinical outcome. RESULTS: Fourteen cases (64%) underwent surgical biopsy for histological assessment. A definitive diagnosis on FNAC with ancillary investigations was achieved in 82% (18 out of 22) of the cases: four Hodgkin's lymphoma, two non-Hodgkin's lymphoma (NHL), five tuberculosis (TB), two toxoplasmosis, one sarcoidosis and four benign reactive changes. CONCLUSION: A significant number of cases of FNAC diagnosed granulomatous lymphadenitis have an identifiable underlying cause. Patients with reactive cytological changes, who clinically appear benign, can avoid unnecessary surgery.