Local anaesthetics in dermatological surgery: a review of adjuncts and pain reduction techniques.

A variety of adjuncts for local anaesthesia (LA) exists for dermatological surgery, along with many options to reduce the pain of LA. This review aims to summarize the evidence relating to such adjuncts and methods to reduce the pain of LA. Adjuncts to LA can be an important consideration to optimize anaesthetic effect. Current evidence suggests that buffering and warming of LA fluid, along with cooling, pinching and administering vibrations to the skin are effective at reducing pain during administration. In this review, no significant difference in pain reduction was found between cooling and administering vibrations to the skin. Studies demonstrate that, overall, LA injection into distal sites is safe. However, the evidence specific to dermatological surgery is limited with regard to ways to reduce pain during LA injection and in determining the safety of LA for distal sites with confidence. Further high-quality research in the form of multicentre randomized controlled trials is required.

A review of Mohs micrographic surgery for skin cancer. Part 1: Melanoma and rare skin cancers.

Mohs micrographic surgery (MMS) is a precise and effective method commonly used to treat high-risk basal cell carcinoma and squamous cell carcinoma on the head and neck. Although the majority of evidence for MMS relates to keratinocyte cancers, there is published evidence for other types of skin cancer. This review aims to discuss the evidence for using MMS to treat six different types of skin cancer [malignant melanoma, lentigo maligna, dermatofibrosarcoma protuberans, atypical fibroxanthoma (AFX), microcystic adnexal carcinoma and pleomorphic dermal sarcoma (PDS)] particularly in the context of survival rates and cancer recurrence. These cancers were chosen because there was sufficient literature for inclusion and because MMS is most useful when cancers are contiguous, rather than for cancers with marked metastatic potential such as angiosarcoma or Merkel cell carcinoma. We searched MEDLINE, PubMed and Embase using the keywords: 'melanoma', 'mohs micrographic surgery', 'lentigo maligna', 'dermatofibrosarcoma protuberans', 'atypical fibroxanthoma', 'microcystic adnexal carcinoma' and 'pleomorphic dermal sarcoma' along with their appropriate synonyms, to identify the relevant English-language articles from 2000 onwards, given that literature for MMS on nonkeratinocyte cancers is sparse prior to this year. AMSTAR (A MeaSurement Tool to Assess systematic Review) was used to assess the validity of systematic reviews. Further high-quality, multicentre randomized trials are necessary to establish the indications and efficacy of MMS for rarer cancers, particularly for AFX and PDS, for which only limited studies were identified.

'Fast-track' pathway for resectable pancreatic cancer: barriers and facilitators to implementation across a regional network.

INTRODUCTION: The National Institute for Health and Care Excellence guidelines recommend a 'fast-track' approach to avoid preoperative biliary drainage (PBD) when treating resectable pancreatic cancer. For reasons not yet known, there is variable uptake of this approach across the UK. A 'fast-track' pathway which avoids PBD was introduced in University Hospitals Birmingham NHS Foundation Trust (UHB) and referring centres in 2015. METHODOLOGY: Eleven semi-structured interviews were conducted with members of the hepatobiliary multidisciplinary team (MDT) in UHB and referring centres. Barriers and facilitators to pathway implementation were assessed. RESULTS: Facilitators underpinning implementation were collaboration between stakeholders, clinical leadership and careful coordination of referrals. Barriers to implementation included clinician opposition and increased workload. Barriers were mitigated through phased implementation and the appointment of dedicated staff. CONCLUSION: Future work may focus on exploring contextual factors in other tertiary centres and evaluating the emotional impact of 'fast-tracked' versus delayed surgery in patients with resectable pancreatic cancer.

The successful use of a bespoke OssDsign cranial plate to reconstruct an occipital defect following excision of a recurrent epithelioid sarcoma.

A cranioplasty has a number of known associated complications including infection for non-biological implants and bone flap resorption where autologous grafts are used. In recent years, bioactive ceramic cranial implants have been developed as a new reconstructive option. The OssDsign cranial plate (OssDsign AB, Uppsala, Sweden) was first introduced in 2010 and consists of an interconnected mosaic of hydroxyapatite tiles mounted onto a 3D-printed titanium mesh. Each tile is composed of a monetite, beta-calcium pyrophosphate, beta-tricalcium phosphate and brushite compound designed to mimic the process of coupled bone formation once implanted. This case presents a patient's journey from diagnosis of an epithelioid sarcoma over the posterior scalp and its management in the following 7 years. Initial excision of the lesion was reconstructed with a tissue expander and local rotational flap. Recurrence of the disease 3 years later was treated with a course of radical radiotherapy. Persistent osteomyelitis over the next 3 years resulted in chronic ulceration and exposed bone in the treated area. As the first part of a 3-stage treatment plan, two separate tissue expanders became infected. The multidisciplinary team therefore chose to use a bespoke OssDsign cranial plate combined with a deep inferior epigastric perforator (DIEP) free flap to provide a definitive single operative solution. The advantages over other reconstruction options include that the plate can be removed should further excision be required, greater potential for long-term integration with surrounding tissues and the ability to be soaked in antibiotic to reduce the risk of infection.