Sacrococcygeal teratomas: midline reconstruction improves cosmesis without compromising outcomes.

AIM: Several studies have addressed the long-term functional, psychosexual and psychosocial outcomes following sacrococcygeal teratoma (SCT) excision. It is well reported that the classical chevron incision and reconstruction can leave a cosmetically unsatisfactory result; however, there is little in the literature focussed on improving this outcome. In our institution the preference is to perform a midline reconstruction, where possible, this is felt to improve appearance without compromising the oncological or functional outcome. The aim of this study was to evaluate patient-perceived cosmetic outcomes of the midline reconstruction. METHODS: All patients undergoing surgery for SCT between 2007 and 2020 were included in the study. Patient demographics, operation type, functional outcome and recurrence were all recorded. The primary outcome measure was patient/parent satisfaction with the cosmetic appearance. This was assessed using both qualitative and quantitative methodologies. Following ethical approval parents were asked questions from two existing validated patient outcome questionnaires: "Patient and Observer Scar Assessment Scale" (POSAS) v2.0 and the "Patient Scar Assessment Questionnaire". RESULTS: Thirty-two patients underwent surgery at our institution for SCT during the study period. Twenty-four had a posterior approach with midline reconstruction, two laparotomy and excision (excluded from this study) and six had a combined approach. Median follow-up was 35 months (8.5-96 months). There were no recurrences. 4/30 (13%) have persistent urological symptoms, and 1/30 (3%) has constipation requiring bowel management. Questionnaires were sent to 26/30 families with a 77% return rate. Median total score was 11 (7.4-17.5) on a 60-point scale (6, as normal skin, 60, worst imaginable scar). Twenty (95%) reported that the scar never affects the child's activities and 15 (71%) said they are "not at all" conscious of the scar. CONCLUSION: Scars can lead to an array of cosmetic, functional, and psychological consequences and as such consideration needs to be given to scarring following surgery for sacrococcygeal teratomas. This study demonstrates that a midline reconstruction produces a cosmetically favourable outcome. We, therefore, recommend where appropriate a midline reconstruction should be considered for SCT.

Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

INTRODUCTION: Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents. MATERIALS AND METHODS: Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion. RESULTS: A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates. CONCLUSIONS: There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.

Manchester Arena bombing: lessons learnt from a mass casualty incident.

On 22 May 2017 Salman Abedi detonated an improvised explosive device in the Manchester Arena resulting in 23 deaths (including the attacker). This was the deadliest terrorist attack on UK soil since the 2005 London bombings, but was only one of five mass casualty terrorist attacks in the UK in 2017. Preparation for mass casualty incidents (MCI) is obligatory, involving such methods as multiagency tabletop exercises, mock hospital exercises, as well as simulation and training for clinicians in managing the injuries that would be anticipated in such an event. Even in the best prepared units, such an incident will pose significant challenges due to the unpredictable nature of these events with respect to timing and number of casualties. Following an MCI, local and national reviews are undertaken to assess the effectiveness of the response, but also to identify areas where lessons can be learnt and to disseminate these to allow inclusion in future planning. We present the experience following a mass casualty terrorist incident along with a number of lessons learnt from this event.

Simple operative management of ingrown toenail using bipolar diathermy.

Ingrowing toenails (IGTN) cause significant discomfort for children and adults alike. Where conservative treatment fails, a surgical approach is usually adopted. Many surgical procedures have been described with varying complexity and outcome. We report a novel, simple technique which involves wedge excision of the ingrowing nail, and bipolar diathermy of the nail bed. Three-hundred and fifty-three procedures were carried out on 302 patients during the study period. Our re-operation rate for recurrence is 9.9%, which compares favourably with other techniques, and which lends itself to utilisation for minor surgery lists in primary care.