Breast lumps in service women.

INTRODUCTION: Breast cancer is uncommon in a young population but it does occur. 80% of breast cancer occurs after 50 yrs of age. This article uses current guidelines and evidence to advise military medical staff on how best to investigate and manage serving-age women presenting with breast symptoms. Male breast changes will be dealt with in a future article. DIFFERENTIAL DIAGNOSIS: Young females presenting with breast lumps are unlikely to have cancer. In order of frequency the causes are likely to be benign breast change; fibroadenoma; abscesses in 20-30 year olds; cysts in 30-40 year olds, and lastly cancer. The UK sees 48,000 new cases of breast cancer in women every year; breast cancer can also occur in men but is very rare. DIAGNOSIS AND MANAGEMENT: Management in the deployed, primary and secondary care settings are described. It may be reasonable in young women to wait and see if a lump resolves after the patient's next menstrual cycle before referring the patient. Once referred, current guidelines recommend that all patients are seen by a breast surgeon within two weeks. Within this group, a subgroup of patients with 'red-flag' lumps is identified who need to be referred urgently. The remaining patients have lumps that can be considered non-urgent: however, hospitals will still endeavour to see these patients within two weeks.. CONCLUSIONS: Breast cancer is more difficult to diagnose in the younger patient. In primary care, breast lumps are still simple to manage if the points in this article are followed. Anxious patients can be reassured that cancer is unlikely. However, cancer in this young age group is associated with worse outcomes than breast cancer in older patients.

Methods for siting emergency stomas in the absence of a stoma therapist.

INTRODUCTION: Stomas often have to be sited in emergencies by trainees who may have had little training in this. Emergency stomas and stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient's quality of life. Advice in the literature on how to best site stomas is conflicting. We compared two easy anatomical methods of siting stomas to sites chosen by a stoma therapist and looked at how this site was affected by the patients' body mass index (BMI). METHODS: Patients undergoing elective colorectal surgery were seen either pre or postoperatively. Each patient's BMI was recorded and the positions of three different potential stoma positions (site G: the gold standard, marked by a stoma therapist; site S: marked using a pair of scissors against the umbilicus; site H: halfway between the umbilicus and anterior superior iliac spine) were compared. RESULTS: The two fixed anatomical methods described (method S and method H) both gave poor results. The most common reason for poor siting was the proximity of a skin crease. There was a statistically significant correlation between the patient's BMI and the laterality of the gold standard site. CONCLUSIONS: The two simple anatomical methods described here do not provide a shortcut to effective siting. A more effective method may be calculating the laterality of the site using the patient's BMI, and then moving up/down to avoid a skin crease and improve the patient's view for changing the bag. This deserves further study.

Battlefield scrotal trauma: how should it be managed in a deployed military hospital?

AIM: There is little documented advice on the management of scrotal trauma sustained in combat. This paper reviews this injury, its present surgical management and makes recommendations for the future. METHOD: All UK forces sustaining scrotal injuries between 2003 and 2009, in Iraq and Afghanistan, initially treated at a Role 2 (enhanced) or Role 3 deployed military surgical facility were identified from the Joint Theatre Trauma Registry. The cause and extent of the injury, in addition to the surgical management, are reported. RESULTS: Twenty-seven patients sustained trauma to their scrotum; improvised explosive device (IED) (n=21), mine (n=3), rocket propeller grenade (RPG) (n=2), mortar round (n=1). Of those injured by an IED, eleven had traumatic orchidectomies, of which 4 were bilateral, one received fragmentation wounds to the scrotum with a testicular injury that was salvaged and there were six scrotal fragmentation wounds not associated with a testicular injury. Scrotal exploration was performed with testicular salvage in all cases involving mortar, RPG or mines. For all aetiologies the scrotum was debrided with primary closure over a drain (n=7), debridement and subsequent delayed primary closure (DPC) (n=4) or healing by secondary intension (n=6). Skin grafts were applied in two cases of traumatic bilateral orchidectomy. To date there have been two cases of delayed orchidectomy; chronic pain and delayed presentation of a disrupted testis. All reported patients survived. CONCLUSION: The established principles of debridement should be the mainstay of treatment. Testicular ischaemia, a consequence of cord transaction, necessitates orchidectomy. Salvage of the disrupted testis, with debridement and closure of the tunica rather than orchidectomy, should be performed whenever possible, particularly when there is significant bilateral testicular injury. Scrotal wounds can be treated by closure over a drain, DPC or healing by secondary intention.

An audit of the cost effectiveness of protocol-driven versus surgeon-directed pre-operative assessment of NHS patients referred to a General Surgeon.

AIMS: Pre-operative assessment (POA) is now commonplace and follows established protocols. This audit compares the cost-effectiveness of surgeon-directed (SD) POA compared to the standard practice of protocol-driven (PD) POA. METHODS: One hundred and fifty-six NHS patients who were referred to a single surgeon during 2009 were allocated to one of three groups. Group 1: SDPOA required no investigations, whereas the PDPOA would have mandated only Methycillin-Resistant Staphylococcus aureus (MRSA) screening and urinalysis; Group 2: SDPOA required no pre-operative investigations, whereas the PDPOA would have required investigations to be performed; Group 3: SDPOA recommended selective investigations, PDPOA required additional tests. For each group the investigations requested and performed, their cost and whether the results affected patient care were recorded. There is no individual PDPOA group, but the cost of the extra tests was calculated where the PDPOA protocols were followed and therefore the cost differed between the SDPOA and PDPOA. RESULTS: The total cost for all investigations for the 156 patients was pound 43,985. A potential cost saving of pound 9,694 (group 2) and pound 8,898 (group 3) was demonstrated. The total potential saving identified for all 3 groups was pound 18,592, which was 42% of the total cost of all the investigations. Patient care was not affected by these additional investigations. CONCLUSIONS: There were no observed peri-operative complications during the study, implying that the additional pre-operative investigations were clinically unnecessary and identifying an additional cost saving of pound 18,592.

Making difficult decisions in major military trauma: a crew resource management perspective.

The purpose of this article is to consider three underappreciated but important features of high performance teams: the trade-off relation between social and technical competence, the relevance of team size on productivity, and the inevitability of tensions that, while often experienced as dysfunctional, are in fact quite useful. It does so by reviewing a series of related studies in aviation and the organisation sciences, and by extrapolating insights for crew resource management in major military trauma along two generic themes: team context and team process.

Local anaesthetic wound infiltration following paediatric appendicectomy: a randomised controlled trial: Time to stop using local anaesthetic wound infiltration following paediatric appendicectomy?

OBJECTIVE: This study sought to determine the efficacy of post-operative wound infiltration with local anaesthetic following paediatric appendicectomy. METHOD: In a randomised, controlled, prospective, clinical trial children aged between five and sixteen years were assigned to one of three treatment arms; infiltration of the surgical wound with bupivicaine, saline, or no infiltration. Anaesthetic and analgesic protocols were employed. Patients and observers were blinded to the treatment group. The primary end-points were post-operative pain, scored at intervals during the first twenty post-operative hours, and additional post-operative analgesic requirements beyond that which was provided by a standard protocol. In addition, adverse wound outcomes were recorded. RESULTS: Eighty-eight children were recruited. There were no differences in age, sex or other confounding variables between groups. There was no significant difference in mean pain scores or analgesic requirements between groups through-out the post-operative period. CONCLUSION: Wound infiltration with local anaesthetic following appendicectomy in children provides no additional benefit over regular simple analgesia. Its routine use represents dogmatic practise which ought to be challenged for this patient group.

A comparison of civilian (National Confidential Enquiry into Patient Outcome and Death) trauma standards with current practice in a deployed field hospital in Afghanistan.

BACKGROUND: The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on trauma management, published in 2007, defined standards for United Kingdom (UK) hospitals dealing with trauma. This study compared the NCEPOD standards with the performance of a UK military field hospital in Afghanistan. SETTING: UK military field hospital, Camp Bastion, Helmand Province, Afghanistan. MATERIALS AND METHODS: Data were collected prospectively for all patients fulfilling the trauma team activation criteria during the 3 months of Operation Herrick IXa (from mid October 2008 to mid January 2009) and combined with a retrospective review of prehospital documentation, trauma resuscitation notes, operations notes and transfer notes for these patients. RESULTS: During the study period, there were 226 trauma team activations. Of those patients brought to the medical facility at Camp Bastion by UK assets, 93.7% were accompanied by a doctor with advanced airway skills, although only 6.2% of the patients required such an intervention. Consultants in emergency medicine and anaesthesia were present in 100% of cases and were directly involved (in either leading the team or performing airway management) in 63.5% and 77.6% of cases respectively. Of those patients requiring operative intervention, 98.1% had this performed by a consultant surgeon. Of those patients requiring CT, 93.6% of cases had this performed within 1 h of arrival. CONCLUSIONS: Trauma patients presenting to the medical facility at Camp Bastion during Operation Herrick IXa, irrespective of their nationality or background, received a high standard of medical care when compared with the NCEPOD standards.

Avoiding cavity surgery in penetrating torso trauma: the role of the computed tomography scan.

INTRODUCTION: Surgical decision-making in torso trauma is complex. This paper looks at the role of the computed tomography (CT) scan in this decision-making process. PATIENTS AND METHODS: Patients with significant torso trauma (high velocity gunshot wound [HVGSW], blast, stab) admitted to a military role 2 (enhanced) hospital facility during a 7-week period of Operation HERRICK 9 (Afghanistan, October to November 2008) are reported. The management of those patients undergoing a CT scan as part of the decision-making process at the time of admission is discussed. RESULTS: Twenty eight patients with significant torso trauma were admitted to the facility during the study period; HVGSW (n = 15), blast (n = 9), stab (n = 4). Thirteen patients underwent a CT scan as part of the surgical decision-making process; HVGSW (n = 5), blast (n = 8). Imaging confirmed torso integrity in 12 patients, one of whom subsequently had a laparotomy for vascular control for on-table haemorrhage during lower limb surgery. One patient had a confirmed thoraco-abdominal injury, which was treated conservatively with tube thoracostomy and 'active observation'. CONCLUSIONS: A CT scan formed part of the surgical decision-making process in about half of the patients admitted with significant torso trauma, and helped prevent unnecessary laparotomy in this forward military environment. Those patients with a blast injury were more likely to undergo CT scanning than those where the mechanism of injury was a HVGSW.

Surgery in an Afghan population: is pictorial consent and injury pattern recognition identification of patients appropriate?

OBJECTIVE: The aim of this study was to develop a safe way to obtain informed consent and ensure the correct patient was operated on in a generally poorly educated, non-English speaking Afghan patient population admitted to a military role 2 (enhanced) hospital facility. SUMMARY BACKGROUND DATA: Prior to Herrick 9, surgical consent for Afghan patients was obtained via an interpreter in the traditional manner and documented on a U.K. formatted consent form (MOD form 660) (group 1) with patient identification largely being the responsibility of the interpreter. Patient agreement was documented by placing a thumbprint on the form. During Herrick 9, pictorial consent and injury pattern recognition (IPR) identification of patients was introduced. The consent was written as part of the case note narrative with diagrammatic representation of the injuries and the proposed surgery, which was explained by the interpreter (Group 2). METHODS: We compared the consent and identification process for ten consecutive patients from each group. Each method of consent was examined for documentary evidence of the procedure, patient identification and method of patient agreement. The senior Afghan interpreter was asked for his personal views on the benefit or otherwise of the pictorial consent. RESULTS: For group 1, each of the nine MOD form 660s were completed in English by the operating surgeon and included details of the procedure. Seven had been signed by the interpreter. Each had a thumbprint on the form but there was no name or date alongside it. There was no way of confirming that the thumbprint was that of a particular patient. For group 2, pictorial consent was documented in the narrative with specific documentation of the injury pattern of that patient. Confirmation of consent and patient identification by IPR was by the operating surgeon. CONCLUSIONS: When possible, informed consent is required for all patients undergoing surgery in line with Department of Health guidelines. The use of pictorial consent and IPR identification, as part of patient documentation, would appear to be superior in this particular environment.

Abdominal compartment syndrome: an emergency department perspective.

Compartment syndromes can occur in many body regions. Abdominal compartment syndrome, initially described many years ago, has become increasingly recognised in critical care patients. The key points regarding its definition, pathophysiology, aetiology and treatment are described and discussed. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of organ dysfunction. At risk patients should be identified in the emergency department and early monitoring of intra-abdominal pressure instituted. Interventions in the emergency department potentially contribute to the development of abdominal compartment syndrome during subsequent phases of care. The need to ensure an early multidisciplinary approach in the management of this complex condition is essential for the best possible patient outcome.

Is patient outcome affected by the administration of intravenous fluid during bowel preparation for colonic surgery?

INTRODUCTION: We have previously shown that Picolax bowel preparation causes a significant dehydrating effect, which can be minimised by administering a calculated volume of intravenous fluid. The aim of this prospective study was to assess whether peri-operative outcome is affected by administering a calculated volume of intravenous fluid during bowel preparation. PATIENTS AND METHODS: Patients having bowel preparation (Picolax: Ferring Pharmaceuticals Ltd, Middlesex, UK) prior to colonic surgery were prospectively randomised to receive no intravenous fluid (group 1) or calculated intravenous crystalloid based on their body weight (group 2), during preparation. In both groups, transfusion was protocol-driven. Outcome variables measured included intra-operative and postoperative intravenous fluid requirement, hourly recorded urine output for 24 h, number of patients transfused, number of units of blood transfused, time to the passage of flatus, time to having their bowels open, time until tolerating a full diet, complications and length of stay in hospital. RESULTS: Thirty-three patients were recruited - group 1 (n = 18) and group 2 (n = 15). There were 24 men and 9 women, median age 69 years (range, 29-86 years). There was no significant difference between the groups with respect to age, sex, weight, ASA grade, pre-operative haemoglobin concentration, duration or type of operation. The total number of patients receiving a transfusion (P = 0.026) and the number of units of blood transfused (P = 0.017) was significantly greater in group 1. The number of units of blood transfused intra-operatively was significantly greater in group 1 (P = 0.029). Significantly fewer patients had a urine output < 30 ml/h in the first 24-h after operation (P = 0.046) in group 2. There was no difference between groups in other outcomes measures. CONCLUSIONS: This study indicates that a calculated volume of intravenous fluid administered during bowel preparation improves patient outcomes with respect to blood transfusion and postoperative oliguria. We advocate calculated intravenous fluid administration in all patients undergoing bowel preparation prior to colonic surgery.

Paediatric preputial pathology: are we circumcising enough?

INTRODUCTION: Preputial problems are a common reason for referral to the paediatric surgical out-patient department. Many boys referred do not need surgical intervention. One indication for intervention is balanitis xerotica obliterans (BXO), a potentially serious condition previously considered rare in childhood. PATIENTS AND METHODS: Consecutive boys referred to a paediatric general surgical out-patient department with problems relating to their prepuce during a period of 4 years were included. The out-patient diagnosis and management was recorded. All foreskins excised were sent for histological analysis. RESULTS: A total of 422 boys were referred, median age 6 years 2 months (range, 3 months to 16 years). Over half the boys referred simply required re-assurance that all was normal with their penis. However, 186 boys (44.1%) were listed for surgical procedures - 148 circumcision, 33 preputial adhesiolysis, and 5 frenuloplasty. There were histological abnormalities in 110 specimens (84.8%); chronic inflammation (n = 69; 46.6%), BXO (n = 51; 34.5%), and fibrosis (n = 4; 2.7%). Nineteen (12.8%) specimens were reported as histologically normal. The overall prevalence of BXO in the boys referred was 12.1%. CONCLUSIONS: In this series, the percentage of boys circumcised and the prevalence of BXO were both higher than in other published series. BXO may be more common and present at a younger age than previously thought.

Improving risk disclosure during the consent process.

OBJECTIVES: To provide guidance about the risks which should be disclosed to patients and documented during the consent process. METHODS: The Delphi Consensus Technique was used to decide what constitutes mandatory risk disclosure for three index procedures. Documentation of risk on consent forms was audited and compared to these locally agreed standards. A four stage strategy for change was undertaken following which practice was reviewed. RESULTS: Mean mandatory risk documentation rose from 61.2% (95% CI: 58.1-64.4) pre-intervention, to 78.1% (95% CI: 72.6-83.6) post-intervention (ccc2; P < 0.001). CONCLUSIONS: Although we demonstrated some benefit from this simple approach, the need for pragmatic means of achieving and sustaining complete discussion and documentation of risks across all surgical interventions based on universally accepted standards remains.

Damage control laparotomy.

BACKGROUND: Damage Control Surgery (DCS) is well established in the management of trauma. This study assessed the results of DCS in the management of critically ill patients who had not had trauma. METHODS: This was a prospective series of patients treated by DCS. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth predictor equation (P-POSSUM) were used to predict the risk of death, which was compared with the observed mortality rate. RESULTS: Fourteen patients were studied. Nine had sepsis from gastrointestinal perforation. Eight of these underwent bowel resection without anastomosis or stoma formation at the initial laparotomy. Six patients later underwent bowel anastomosis and two had an end stoma formed at second laparotomy. A further three patients had a ruptured aortic aneurysm, one had a reactionary haemorrhage after elective aortic surgery, and one had a retroperitoneal bleed; all required haemostatic packing that was removed at second laparotomy. Mortality rates predicted by POSSUM and P-POSSUM scoring were 64.5 and 49.6 per cent respectively. One patient (7.1 per cent) died after operation, giving an observed mortality rate significantly lower than predicted (P = 0.002 and P = 0.038 versus values predicted by POSSUM and P-POSSUM, respectively). CONCLUSION: The use of DCS in the treatment of critically ill patients resulted in a lower mortality rate than that predicted by POSSUM or P-POSSUM. DCS should not be restricted to trauma.

A randomised trial of knife versus diathermy in pilonidal disease.

BACKGROUND: Pilonidal disease is a common debilitating condition. This prospective randomised study compared excision of pilonidal disease with a scalpel or diathermy with respect to operation time, postoperative pain, functional recovery and wound healing. PATIENTS AND METHODS: Patients undergoing surgery for pilonidal disease were randomised to excision by scalpel (group 1) or diathermy (group 2). Patients received regular peri-operative oral analgesia and a standardised general anaesthetic technique. Duration of operation was recorded. Following surgery, pain, analgesic requirements, sedation, nausea and vomiting scores and time to mobilise and time to complete healing were compared. RESULTS: Statistical significance between groups was obtained for five outcomes after 32 patients had been recruited; of these, 81% were admitted as emergencies with an abscess. The duration of surgery in group 2 was significantly less, postoperative pain scores and morphine requirements were lower and mobility was regained sooner. CONCLUSIONS: We advocate the use of diathermy needle rather than scalpel blade when undertaking excision of pilonidal disease in both acute and chronic patients.