A Three-year Retrospective Study Looking at Preventing Hospital Acquired Thrombosis.

BACKGROUND: Hospital-acquired venous thromboembolism (HA-VTE) is defined as cases of venous thromboembolism (VTE) that occur in a hospital and within ninety days of a hospital admission. Deep vein thromboses (DVTs) most commonly occur within the deep veins of the pelvis and legs. If the thrombus dislodges and travels to the lungs, it can result in a pulmonary embolus (PE). VTE is associated with significant morbidity and mortality, accounting for almost 10% of all hospital deaths. If risk factors are correctly identified and VTE prophylaxis is prescribed, VTE can be a preventable condition. In 2010, NHS England launched The National Venous Thromboembolism Prevention Programme. This included NICE guidance, and a VTE risk assessment tool, which must be completed for at least 95% of patients on admission. The National Thrombosis Survey, published by Thrombosis UK, studied how this program was implemented locally, and audited HA-VTE prevention strategies nationally. OBJECTIVES: Using the Thrombosis Survey and NICE guidance as an aide, this study collects data about hospital-acquired DVT (HA-DVT) at the Queen Elizabeth Hospital in Gateshead (QEH) and aims to: 1. Identify cases of HA-DVT and understand the clinical circumstances surrounding these cases 2. Assess the quality of VTE preventative measures at QEH 3. Outline potential improvement in reducing the incidence of HA-VTE at this hospital Methods: This retrospective cohort study used electronic records to identify all cases of DVT between April 2019 and April 2022 at QEH. Cases of HA-DVT were defined as: a positive ultrasound doppler report and either the case occurring in the 90 days following an inpatient stay, or beyond two days into an admission. For these cases of HA-DVT, we recorded the: reason for admission; admitting specialty; presence of an underlying active cancer and deaths occurring within 90 days of diagnosis. We assessed the quality of VTE preventative measures, by recording the: completion of VTE risk assessments; prescription of weight-adjusted pharmacological VTE prophylaxis and provision of VTE prophylaxis on discharge. For HA-DVT cases occurring within 90 days of an inpatient stay, the preventative measures were assessed on the original admission. Electronic records were used to record the completion rate of the National VTE risk assessment tool for all inpatients during this time frame. RESULTS: The VTE risk assessment tool was completed for 98.5% of all admissions. One hundred and thirty-five cases of HA-DVT were identified between April 2019 and April 2022. Sixteen patients with HA-DVT did not have VTE prophylaxis prescribed on admission. Eleven of these patients had a clearly documented reason why anticoagulation was avoided. In HA-DVT cases where pharmacological VTE prophylaxis was prescribed, 23% were prescribed an inappropriate dose for their weight. If anticoagulation was required on discharge, this was prescribed appropriately in 94% of cases. About 31% of the patients with HA-DVT had an underlying active malignancy. Thirty-nine patients died within 90 days of the DVT being diagnosed; in only 1 case was VTE thought to be a contributing factor to death. CONCLUSION: The hospital exceeded the national standard of VTE risk assessment completion on admission (greater than 95%). For almost a quarter of patients with HA-DVT, the dose of thromboprophylaxis prescribed was not appropriate for weight. In five cases of HA-DVT, thromboprophylaxis was omitted with no clear justification. HA-DVT often affects the most clinically vulnerable patients and is associated with a high mortality.

Round ligament varicosity: a rare but important differential diagnosis of groin lumps during pregnancy.

Round ligament varicosity is rare and mainly reported during pregnancy. A systematic review of the literature identified 48 relevant studies reporting a total of 159 cases of round ligament varicosity, 158 of which were associated with pregnancy. Where reported, the mean age of the patients was 30.65 years, and 60.2% were of Asian ethnicity. The laterality of the condition was almost equally distributed, and nearly 50% presented with a painful groin lump. More than 90% of the patients were diagnosed via Doppler ultrasound scan of the affected groin. Conservative management was successful in more than 90% of the patients. Associated maternal complications are rare, with no mortality reported. No fetal complications or loss were reported. Round ligament varicosity can be misdiagnosed as a groin hernia, which may lead to unnecessary surgery during pregnancy. Therefore, increased awareness of this condition among clinicians is important.

Cystic duct cyst in adults: a systematic review of the sixth entity.

Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani's classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3 years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.

Splenic Abscess Complicating Bariatric Surgery : A Systematic Review.

INTRODUCTION: Bariatric surgery has become one of the most rapidly growing subspecialty performed globally, and it has been well reported to be associated with low morbidity and mortality rates. Splenic abscess is a rare but serious complication of bariatric surgery that has not been previously systematically reviewed in the literature. METHODS: The authors have performed a systematic review of the evidence that has looked into the pathophysiology, clinical presentation, and the management options of splenic abscess complicating bariatric surgery. RESULTS: This systematic review has been unsurprisingly based on level-IV evidence due to the rarity of the explored condition. The final analysis included 27 relevant reported cases. The mean age was 38 years and the mean of the time interval between the initial operation and developing splenic abscess was 72 days, with the male to female ratio being 1:1.6. Laparoscopic sleeve gastrectomy was the initial operation in 85.2% of the patients. Nearly half of the patients did not have an objective evidence of local or systemic sepsis that could explain the abscess formation. Nonsurgical management was attempted in 14 patients, with 34% success rate only. Splenectomy was needed in 41.7% of the patients. No mortality was reported. CONCLUSIONS: Splenic abscess is a rare and rather late but serious complication of bariatric surgery that could result in splenectomy in a relatively young group of patients. It is more commonly reported following laparoscopic sleeve gastrectomy. Early diagnosis with intervention in a timely manner is crucial to avoid life threatening complications.

Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults.

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years.

INTRODUCTION: Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice. METHODS: A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches. RESULTS: Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity. CONCLUSION: In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Intraoperative decision making in bariatric surgery.

BACKGROUND: Surgeons may encounter unexpected anatomical or pathological findings during various bariatric surgical procedures for which they must make prompt and critical decisions that had not been planned prior to the operation. In this practice review, we present our experiences with unexpected challenges and on-table decision making in bariatric surgery to share our knowledge with colleagues who may encounter the same challenges during bariatric surgery. This paper's content is of applied learning and practical value focusing on challenging intraoperative decision making; however, it does not discuss the details of the various techniques used during surgery. METHODS: This work is a single-center retrospective review of operations carried out on patients who had unexpected intraoperative findings during bariatric surgery despite the implementation of detailed preoperative evaluations that would have otherwise suggested standard procedures. These findings resulted in abandoned surgery or laparoscopic sleeve gastrectomy instead of the intended Roux-en-Y gastric bypass. RESULTS: A total of 449 patients had received various bariatric interventions in our unit between 2012 and 2016. Eleven patients, representing approximately 2.4% of the total number of patients surveyed had met the inclusion criteria and were added to the final list for analysis. The mean age of the included patients was 40.82 years (range: 30-51 years), and seven of the patients, representing approximately 63.6% of the included cases, were female. The mean body mass index of the 11 cases was 40.8 (range: 38-48). Only two cases (18.9%) had had their surgery abandoned; the rest (81.1%) had received laparoscopic sleeve gastrectomy instead of Roux-en-Y gastric bypass. None of the 11 patients had perioperative morbidity or mortality. CONCLUSION: Intraoperative decision making for unexpected findings in bariatric surgery is challenging. In these circumstances, surgeons must make prompt and critical decisions, including abandoning the operation. The available literature on this subject is unsurprisingly limited because of the rarity of such findings.

The impact of the COVID-19 pandemic on medical education.

The coronavirus pandemic has caused major disruption of systems worldwide, including education and health services. The duration and scale of the impact is yet to be established. The effect of the pandemic on medical education should be managed on the basis of early response, alternative education options and future changes and actions.

Challenges encountered in the management of gall stones induced pancreatitis in pregnancy.

BACKGROUND: Though uncommon, acute biliary pancreatitis in pregnancy carries a potential of serious and life threatening complications to mother and foetus. The management of acute pancreatitis in pregnancy is challenging due to the complexity of physiological and anatomical changes. This becomes even more challenging when invasive interventions are urgently needed. Therefore, there have been various debates among clinicians on the type and timing of these interventions. We systematically reviewed the evidences that looked into these debates to formulate a list of recommendations for clinical practice. METHODS: An electronic literature search of the databases (Medline/Pubmed, EMBASE, Cochrane database, NICE guidelines and Google Scholar) using the keywords "pancreatitis, pancreatitis in pregnancy, biliary pancreatitis, laparoscopy in pregnancy, and gall stones in pregnancy" was conducted. The relevant studies were screened and full text versions were retrieved. The references to all the retrieved texts were searched for further relevant studies. All studies were systematically reviewed and critically analysed. CONCLUSION: The available published literature on management of gall stones induced acute pancreatitis in pregnancy was solely based on retrospective studies and case series. The management of biliary induced pancreatitis in pregnant patients is challenging and complex, and it should involve the input of highly skilled clinicians from different specialities. Each case should be individually and thoroughly assessed by weighing the risks against the benefits. The authors have formulated a list of recommendations for clinical practice that is based on this comprehensive review of the literature.

Extraosseous Multiple Myeloma: Case Report of Presentation in the Lower Extremity Soft Tissues with Literature Review.

A rare presentation of extramedullary multiple myeloma in the soft tissues of the bilateral thighs prompted a literature review of published cases of extramedullary multiple myeloma (EM-MM) and solitary plasmacytomas to determine the relative anatomic distribution of these lesions. All available published cases in English were included in the analysis, dating back to 1966 and including 2,538 extramedullary myeloma or solitary plasmacytoma lesions. Analysis of the anatomic location of EM-MM lesions demonstrates the majority being in the upper airway (33.8%), soft tissues including retroperitoneum and abdomen (14.1%), gastrointestinal tract (10.3%), central nervous system, head and neck (16.0%), and GU (2.4%). We were able to find only 44 documented cases of extremity soft tissue lesions, comprising 1.7% of all lesions.

Primary breast osteosarcoma: a case report and review of literature.

BACKGROUND: Primary soft tissue sarcomas are uncommon. We report a case of primary breast osteosarcoma which was treated successfully. This case report is combined with a literature review of this rare breast malignancy. METHODS: Electronic literature search of databases: Pubmed/Medline, Ovid and EMBASE, in addition to the search engines Google/Google Scholar and Bing. The keywords used were breast osteosarcoma, soft tissue sarcoma and breast cancer. Searches were screened and those studies thought to be relevant had full text versions retrieved. The references to all retrieved texts were searched for further relevant studies. CONCLUSION: Primary breast osteosarcoma is a rare breast malignancy that affects elderly patients. Diagnosis is often challenging and can be debatable due to its rarity, non-specific radiological findings and the complicated histopathological subtypes. Surgery is the treatment of choice.

Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence.

UNLABELLED: Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians. We have critically reviewed the available published evidence in regards with this debate. CONCLUSION: There is no strong current evidence as to the preferred modality of appendicectomy; open or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher rates of foetal loss.

The WHO surgical safety checklist.

Surgery plays a prominent role in healthcare worldwide. It has been estimated that the rate of fatal events occurring in surgery is about one in ten thousand exposures and up to one million deaths per year. Most errors are caused by failure of non-technical skills. The WHO surgical safety checklist has shown that patient safety could be improved by using a simple and effective method. However, achieving high compliance requires research, training and local adaptation.

Stump appendicitis: a review.

Acute appendicitis is perhaps the commonest cause of acute abdomen and surgical intervention in the form of open or laparoscopic appendicectomy. Stump appendicitis is an uncommon late complication of appendicectomy; where inflammation occurs in the remaining appendicular stump. Delayed diagnosis of this condition may result in serious complications. This literature review has looked into the clinical presentation, diagnosis and treatment of Stump appendicitis.

Breast metastasis from a melanoma.

Benign and primary malignant breast tumors are quite common, but secondary tumors in the breast from metastatic malignancies are rare. Nevertheless, metastasis to the breast must be considered in any patient with a known primary malignant tumor history who presents with a breast lump. We report a case of a premenopausal woman diagnosed with a metastatic melanoma in her breast.

Pyoderma gangrenosum: a rare cause of breast ulceration.

Breast ulceration is an alarming sign for clinicians and places a significant physical and psychological burden on the patient. We report a rare presentation of pyoderma gangrenosum of the breast in a patient known to have ulcerative colitis but no active underlying disease process and no history of breast tissue trauma. This case report with literature review highlights the importance of considering pyoderma gangrenosum as a differential diagnosis in breast ulcers.

Colorectal stents: do we have enough evidence?

BACKGROUND: The use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required. RESULTS: The available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate. CONCLUSION: While we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.

The results of high-frequency duplex surveillance after iliac arterial stenting in a single center.

Frequent duplex surveillance after iliac arterial stenting is time-consuming and costly, so solid benefits of this approach must be available. Frequent duplex surveillance was performed at our center, this was reviewed retrospectively.A total of 117 stents were assessed. Duplex was done for 84 (71.8%) of 117 patients at 1 year and 25 (21.4%) of 117 at 5 years, mean follow-up 27.6 months. Totally, 456 scans were performed; 386 (84.6%) scans were normal, 43 (9.4%) showed an abnormality for which intervention was not necessary, 27 (5.9%) showed abnormalities which needed interventions. The maximum attendance of patients was 62%. In all, 18 patients had interventions unrelated to scheduled follow-up; 15 (83.3%) of 18 had no prior abnormalities on duplex, 3 (16.6%) of 18 had prior abnormalities which were not acted upon after clinical assessment. Our findings demonstrate a high nonattendance rate with frequent emergency presentations due to acute complications. We cannot, therefore, recommend frequent duplex surveillance program both in terms of results or resource allocation.