Mastitis and Mammary Abscess Management Audit (MAMMA) in the UK and Ireland.

BACKGROUND: The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention. METHODS: This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical). RESULTS: A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays. CONCLUSIONS: Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.

Mastitis and breast abscess is a painful infection of the breast. It is an extremely common breast problem. One in three women can get this condition at some stage in their life. To treat a breast abscess, the pus inside should be drained out of the body. This can be done either by cutting into the breast using surgery or by inserting a fine needle using an ultrasonography scan (which uses ultrasound). Fine-needle drainage has the benefit that it does not require admission to hospital. Surgery can cause the breast to look misshapen. It is unknown which method is used more often in the UK and Ireland. The aim of this study was to describe how mastitis and breast abscesses are treated in the UK and Ireland. This study involved a survey of practice (phase 1) and collection of data, which are routinely recorded for these patients (phase 2). This study involved 69 hospitals and 1312 patient records. One in five women had an operation for a breast abscess. This was higher than expected. Six in 10 women had a pus drainage using a fine needle. The chance of having an operation depended on the hospital. Women that came to hospital at the weekend were almost twice as likely to have an operation. One in five women were admitted to hospital. The chances of that more than doubled if a woman came to hospital at the weekend. There are differences in treatment of mastitis and breast abscesses across the UK and Ireland. Changes need to be put in place to make access to treatment more equal.

Scoping review: The terminology used to describe major abdominal surgical procedures.

BACKGROUND: Major abdominal surgery (MAS) can have a profound impact on the patient but there is currently no consensus as to which surgical procedures constitute MAS. The main objective of this work is to ascertain the terminology used to describe MAS procedures and to apply these findings in order to propose a definition of MAS. METHODS: The following databases were searched: Ovid MEDLINE (R) ALL, Embase Classic and Embase (via OvidSP), Global Health (via OvidSP), Health Management Information Consortium (via OvidSP), APA PsycInfo (via OvidSP), PubMed and Web of Science. Original research articles, published between 1980 and April 26, 2022 that contained a description of MAS procedure were included in this study. Article screening and data extraction was undertaken independently by 3 authors. Content analysis was performed to identify key terminology used to describe MAS. RESULTS: Five thousand six hundred and sixty three articles were identified, of which 767 underwent full-text review and 312 were included in the scoping review. Content analysis resulted in 4 main categories: (1) pre-operative factors, (2) intraoperative factors, (3) operation-related factors, (4) post-operative factors. Operation-related factors was the predominant category (1137 references coded). The gastrointestinal resection made the vast majority of the references coded (591). CONCLUSIONS: Based on these results, the term "major abdominal surgery" should be defined as an intra-peritoneal operation with no primary involvement of the thorax, involving either luminal resection and/or resection of a solid organ associated with the gastrointestinal tract. However, further work is required to verify this definition using real world data.

Disinfection of flexible fibre-optic endoscopes out-of-hours: confidential telephone survey of ENT units in England - 20 years on.

BACKGROUND: Flexible upper aerodigestive endoscopy is often performed in the emergency setting. To prevent nosocomial infection on-call clinicians must have access to decontaminated endoscopes. METHODS: A telephone survey of 104 ENT units in England replicated previous cycles conducted 10 and 20 years ago. The on-call clinician was asked about decontamination practices, training and cross-cover. RESULTS: Seventy-one clinicians participated of which 68 had an endoscope available out-of-hours. Twenty-five (36.8 per cent) used single-use endoscopes. Twenty-three (51.1 per cent) of the 45 clinicians using re-usable endoscopes decontaminated them themselves, an increase from 43.3 per cent in 2013 and from 35.1 per cent in 2002. Overall 91.2 per cent had safe practices, up from 68.7 per cent in 2013 and 48 per cent in 2002. One hundred per cent had been trained in decontamination, compared to 37.3 per cent in 2013 and 12.1 per cent in 2002. On-call clinicians from the ENT department increased to 91.5 per cent, compared to 63 per cent in 2013. CONCLUSION: There has been a dramatic increase in patient safety, underpinned by the introduction of single-use endoscopes, increased training and reduced cross-cover.

Case report: Acute appendicitis in appendix duplication.

INTRODUCTION: Duplication of the appendix is a very rare presentation. According to the Cave-Wallbridge classification, there are three types of duplicate appendix. PRESENTATION OF CASE: A 43 year old female presented with classical symptoms of acute appendicitis, with unremarkable inflammatory markers. The diagnosis was confirmed on pre-operative computer tomography (CT). During laparoscopy two tubular structures were identified: one arising from the tenia libera of the caecum adjacent to the terminal ileum and one retrocaecally at the confluence of the teniae. Both structures were excised using a laparoscopic linear stapler. Histopathological analysis demonstrated the accessory structure to be a microscopically unremarkable blind-ended tubular structure. The other specimen demonstrated acute gangrenous inflammation of the appendix. The patient had an uneventful recovery and was discharged home the following day. DISCUSSION: Appendix duplication is rare; however, failure to recognise it in a patient with acute appendicitis could result in a retained source of sepsis, requiring subsequent re-exploration of the abdomen. The case presented here represents a Type B2 according to the Cave-Wallbridge classification and is the most susceptible to inadvertent error due to having appendixes in both typical and atypical anatomical locations. This case also highlights the probability of this diagnosis being missed on pre-operative CT. CONCLUSION: This case report presents a unique opportunity for surgical trainees to review intra-operative laparoscopic images of a duplicate appendix, both to allow them to recognise this pathology if encountered in the future, and to embed the importance of ruling it out with thorough intra-operative examination.