Paratesticular liposarcoma: a rare cause of scrotal lump.

Paratesticular tumours are tumours arising from within the scrotum not of testicular origin. They may originate from the epididymis, spermatic cord, tunica vaginalis and other supporting structures. Preoperative diagnosis can be difficult as benign and malignant cases are often indistinguishable and may be confused with other benign or malignant pathology (testicular tumours or hernias).We describe the presentation and management of a patient managed at our centre (a tertiary referral teaching hospital).A high index of suspicion for malignancy should be considered when managing atypical scrotal lumps to ensure optimal management. This is particularly important when managing sarcomas due to the risk of local recurrence and spread.

What shape do UK trainees want their training to be? Results of a cross-sectional study.

OBJECTIVES: The British Government is acting on recommendations to overhaul postgraduate training to meet the needs of the changing population, to produce generalist doctors undergoing shorter broad-based training (Greenaway Review). Only 45 doctors in training were involved in the consultation process. This study aims to obtain a focused perspective on the proposed reforms by doctors in training from across specialities. DESIGN: Prospective, questionnaire-based cross-sectional study. SETTING/PARTICIPANTS: Following validation, a 31-item electronic questionnaire was distributed via trainee organisations and Postgraduate Local Education and Training Board (LETB) mailing lists. Throughout the 10-week study period, the survey was publicised on several social media platforms. RESULTS: Of the 3603 demographically representative respondents, 69% knew about proposed changes. Of the respondents, 73% expressed a desire to specialise, with 54% keen to provide general emergency cover. A small proportion (12%) stated that current training pathway length is too long, although 86% felt that it is impossible to achieve independent practitioner-level proficiency in a shorter period of time than is currently required. Opinions regarding credentialing were mixed, but tended towards disagreement. The vast majority (97%) felt credentialing should not be funded by doctors in training. Respondents preferred longer placement lengths with increasing career progression. Doctors in training value early generalised training (65%), with suggestions for further improvement. CONCLUSIONS: This is the first large-scale cross-specialty study regarding the Shape of Training Review. Although there are recommendations which trainees support, it is clear that one size does not fit all. Most trainees are keen to provide a specialist service on an emergency generalist background. Credentialing is a contentious issue; however, we believe removing aspects from curricula into post-Certificate of Completion of Training (CCT) credentialing programmes with shortened specialty training routes only degrades the current consultant expertise, and does not serve the population. Educational needs, not political winds, should drive changes in postgraduate medical education and all stakeholders should be involved.

Outcomes of open partial nephrectomies performed by Australian trainees.

BACKGROUND: Partial nephrectomy (PN) has become the standard of care for small renal tumours, with open partial nephrectomy (OPN) being superseded by minimally invasive PN. Advances in minimal access surgery have resulted in fewer relative contraindications, with subsequently fewer OPN being performed. Consequentially, trainees have less opportunity to gain skills and experience in open renal surgery. The aims of this study were to assess the standard of OPN performed by Australian urological trainees and to define whether OPN is a safe and suitable training opportunity. METHOD: A retrospective review was undertaken on patients who underwent OPN performed by urology trainees from 2010 to 2014 at two training hospitals in Western Australia. Data collected included patient demographics, surgical and oncological outcomes and morbidity. RESULTS: Sixty patients underwent OPN, with a mean age of 56 years. Most tumours were single, with mean size 31 mm. Mean operative time was 157 min, with a mean cold ischaemic time of 27 min. Mean pre- and post-operative creatinine levels were equivalent (77 µmol/L). The overall complication rate was 18%, with no documented urinary leaks, and 1.7% blood transfusion rate. Median length of stay was 4 days. There were no oncological positive margins or recurrence after a median follow-up of 2 years. CONCLUSION: Our data support the notion that Australian urological trainees can perform the majority of OPN cases, with equivalent oncological outcomes. We would advocate that when an OPN is being performed, the supervising consultant should use the case as an adjuvant for open renal surgery training.

Early postoperative bioprosthetic valve calcification.

Bioprosthetic valves are implanted in elderly patients with good follow up results. The degeneration of these valves is slow and there are multiple aetiologies for that. It is unclear whether renal failure accelerates the degeneration of bioprosthetic valves in patients with normal calcium levels. We present a case with tissue valve degeneration 16 months postoperatively in a patient with renal failure.

Ruptured thymoma managed via thoracotomy.

Thymomas rarely present with chest pain due to hemorrhage. This could cause shortness of breath if it ruptures into the pleural space, and is best managed surgically. We describe the case of an 83-year-old woman who presented with such symptoms. Computed tomography showed a ruptured mediastinal mass with pleural effusion. She was managed successfully by thoracotomy with excision of the mass and drainage of the effusion. Histopathology revealed a ruptured thymoma with infarction and necrosis.

Descending mediastinitis managed by sternotomy, taurolidine and delayed closure.

Descending necrotizing mediastinitis is a rare complication of upper respiratory infections. A quick diagnosis and prompt and complete surgical drainage is important for a successful outcome. A 74-year-old man with descending necrotizing mediastinitis needed a sternotomy, multiple washouts, and delayed sternal closure.

Prognostic factors for survival following emergency Hartmann's procedure.

INTRODUCTION: Patients presenting with peritonitis require rapid treatment initiation including laparotomy. In the older population, this often leads to Hartmann's procedure being performed. The decision to perform surgery may be a difficult, multidisciplinary decision balancing premorbid comorbidity and quality of life with knowledge of the postoperative outcome. However, the evidence for survival outcome of emergency surgery based on age is lacking. The aim of this study was therefore to assess the survival implication of age and other prognostic factors on the outcome after Hartmann's procedure. METHODS: A retrospective review of prospectively collected data of all patients undergoing emergency (National Confidential Enquiry into Patient Outcome and Death category 1-3) Hartmann's procedure in one NHS Health Board over a 5-year period. RESULTS: 129 patients underwent Hartmann's procedure between November 2004 and November 2009. The largest group, 61 patients (47.3%) had the procedure performed for perforated sigmoid diverticular disease. When examined at 5-year stratifications around the median, the most significant survival difference was seen at the age of 75 years (log rank χ(2) 11.246, p=0.001). Patients over 75 years had median survival significantly lower than those aged <75 years (p<0.001). However, Cox regression analysis showed that preoperative American Society of Anesthesiologists (ASA) status and haemoglobin were more significant independent predictors of mortality than this age strata (p=0.001 and 0.045 vs 0.660, respectively), adjusting for diagnosis. DISCUSSION: ASA grade and common blood abnormalities were more predictive of mortality after Hartmann's procedure than the most significant age stratification. Furthermore, age was not independently associated with survival. It would therefore be unreasonable to refuse Hartmann's procedure based on an age alone.