A UK consensus statement on thromboprophylaxis for autologous breast reconstruction.

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base. METHODS: Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached. RESULTS: The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis. CONCLUSION: To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

Sarcomas in the groin and inguinal canal: A 16-year single-centre experience.

INTRODUCTION: Soft tissue sarcomas arising in the groin and inguinal canal can be difficult to diagnose and manage. This is in part explained by the complex anatomy of the region. Early referral to specialist centres has been advocated, as inadvertent excision of these tumours can jeopardise definitive treatment. We present our 16-year experience at a regional sarcoma service. MATERIALS AND METHODS: A retrospective review of patients treated for a sarcoma in the groin and inguinal canal within the North of England Bone and Soft Tissue Tumour Service was performed. Demographic information, along with therapeutic approach and outcomes, was recorded and analysed. RESULTS: A total of 67 patients were identified, out of which 18 presented with new lesions, 32 presented after having a previous inadvertent sarcoma excision, 10 had a planned resection and 7 presented with recurrent disease. Liposarcomas were the most common histological subtype (55%), and the spermatic cord the most common origin (45%). Fifty-seven patients had surgery for this condition, with seven incomplete excision. Regional flaps were used in 60% of the cases, to allow an adequate oncological resection and soft tissue cover. Patients who had undergone a previous inadvertent sarcoma excision did not have worse rates of local recurrence, metastases and disease-specific mortality. Kaplan-Meier disease-specific survival at 5 years was 82%. DISCUSSION: Inadvertent and inadequate groin sarcoma excision outside of specialist centres remains a problem despite clear guidance. Despite this, an aggressive oncological approach to inadequately managed tumours shows similar outcomes as tumour managed exclusively by our specialist centre.

The rules for online clinical engagement in the COVID era.

Coronavirus disease-2019 (COVID-19) has generated a need to rapidly increase online consulting in secondary care, an area in which it has previously been underutilised. We sought to review the guidance on conducting remote consultations and found that while there is a large amount of information about the implementation of remote consultations at an organisation level, there is a paucity of high-quality papers considering the guidelines for online consultations alongside practical advice for their implementation at the individual level. We reviewed guidelines from reputable medical sources and generated practical advice to assist practitioners to perform safe and effective video consultation. Additionally, we noted reports in the literature of a lack of transparency and resulting confusion regarding the choice of telemedicine platforms. We, therefore, sought to summarise key characteristics of a number of major telemedicine platforms. We recognised a lack of clarity regarding the legal status of performing remote consultations, and reviewed advice from medico-legal sources. Finally, we address the sources of these individual uncertainties, and give recommendations on how these might be addressed systematically, so the practitioners are well trained and competent in the use of online consultations, which will inevitably play an increasingly large role in both primary and secondary care settings in the future.

Strain-induced selective growth in 1.5% temper-rolled Fe;1%Si.

Strain-induced selective growth was investigated in a 1.5% temper-rolled Fe∼1%Si alloy using the electron backscatter diffraction (EBSD) technique. The EBSD technique was used to quantify the presence of orientation spreads within grains and to show that this particular case of selective growth can be directly related to differences in stored energy as reflected in the geometrically necessary dislocation content. The differences in stored energy were sufficient to give rise to selective growth as evidenced by bi-modal grain sizes.

Training in microsurgical skills: Does course-based learning deliver?

Practical skill training courses are an increasingly popular method of teaching surgical skills. Few data are available from instructional courses indicating how successful they are at imparting practical skills to those individuals who attend them. We aimed to identify the skill benefits gained by trainee surgeons attending a 5-day microsurgical skills course. A global scoring system was devised to objectively assess the level of skill employed by trainees to complete an arterial microvascular anastamosis. Vessel patency, anastamotic construct, and care of tissue in the surrounding operative field were taken into account. Postoperative tissue viability and physiological vessel function following anastamosis were also investigated. The majority of surgeons (60%) exhibited an increase in their level of microsurgical skill during the course. The remaining candidates remained static or deteriorated. Attendance at this microsurgical training workshop resulted in an improvement in microsurgical skills in most trainees. In-course assessment by training courses would allow identification of individuals requiring further training or skill refinement.

How do we assess microsurgical skill?

How does one demonstrate competence in microsurgery? This will become an increasingly more important question as further reforms in surgical training and revalidation are implemented. Any assessment of competence should include an assessment of technical skill, but there is presently no validated objective assessment technique to do this. We examine the ideal characteristics of an assessment technique and review the methods currently being validated and which could be applicable to microsurgical skills.