Safety of robotic cholecystectomy as index training procedure: the UK experience.

AIMS: To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. METHODS: A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. RESULTS: A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). CONCLUSION: The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

Pandemic priorities: the impact of the COVID 19 pandemic on ethical leadership in the healthcare profession.

PURPOSE: The COVID 19 pandemic has brought into sharp focus the importance of leadership and the ethics of health-care leadership. The purpose of this study is to investigate the impact of COVID 19 on ethical leadership principles using a validated quantitative survey of NHS leaders to compare pre- and post-pandemic ethical leadership principles. DESIGN/METHODOLOGY/APPROACH: This study involved a quantitative survey of NHS "leaders". Inclusion criteria included consultants and registrars leading clinical teams, or NHS managers, senior nurses and matrons. The survey was designed as a modification of the Ethical Leadership Questionnaire proposed by Langlois et al. (2013). A modification was made to ask questions from the questionnaire pertaining to before the pandemic and presently. This allowed a comparison of responses and measures of ethical leadership qualities before and after the pandemic. Twenty-three questions were on attitudes pre-pandemic, and 23 were post-pandemic. FINDINGS: A total of 79 responses were received. Responses were divided for analysis into those related to an ethics of care dimension, those related to ethics of justice and those related to the ethics of critique. This study has found significant changes in attitudes of health-care leaders with regards to the ethics of critique. Leaders were more likely post-pandemic to speak out against injustice and unfair practices. Leaders were also more concerned with matters of human dignity as well as understanding how some groups may be privileged. Other ethical principles showed no statistical difference. ORIGINALITY/VALUE: This paper highlights the changes the COVID-19 pandemic has had on leaders' attitudes to ethics.

Managing the Open Abdomen in Damage Control Surgery: Should Skin-Only Closure be Abandoned?

During damage control laparotomy, surgery is abbreviated to allow for the correction of physiologic disturbances, with a plan to return to the operating theatre for definitive surgical repair. Re-entry into the abdomen is facilitated by temporary abdominal closure (TAC). Skin-only closure is one of the many techniques described for TAC Numerous sources advise against the use of this technique because of the risk of complications. This case report describes the use of skin-only closure during a damage control laparotomy. We reviewed the literature surrounding the various options for TAC to elucidate the potential role of skin-only closure after damage control laparotomy.

Perioperative Blood Transfusion is Associated with Postoperative Systemic Inflammatory Response and Poorer Outcomes Following Surgery for Colorectal Cancer.

BACKGROUND: The present study investigated relationships between perioperative blood transfusion, postoperative systemic inflammatory response, and outcomes following surgery for colorectal cancer. METHODS: Data were recorded for patients (n = 544) undergoing potentially curative, elective surgery for colorectal cancer at a single center between 2012 and 2017. Transfusion history was obtained retrospectively from electronic records. Associations between blood transfusion, postoperative C-reactive protein (CRP), albumin, hemoglobin, complications, cancer-specific survival and overall survival (OS) were assessed using propensity score matching (n =116). RESULTS: Of 544 patients, the majority were male (n =294, 54%), over 65 years of age (n =350, 64%), and with colonic (n =347, 64%) node-negative disease (n =353, 65%). Eighty-six patients (16%) required perioperative blood transfusion. In the unmatched cohort, blood transfusion was associated with higher median postoperative day (POD) 3 CRP {143 [interquartile range (IQR) 96-221 mg/L] vs. 120 (IQR 72-188 mg/L); p = 0.004}, lower median POD 3 albumin [24 (IQR 20-26 g/L) vs. 27 (IQR 24-30 g/L); p < 0.001], more postoperative complications [odds ratio (OR) 3.28, 95% confidence interval (CI) 2.03-5.29] and poorer OS [hazard ratio (HR) 3.18, 95% CI 2.08-4.84]. In the propensity score matched cohort, blood transfusion was similarly associated with higher median POD 3 CRP [130 (IQR 93-196 mg/L) vs. 113 (IQR 66-173 mg/L); p = 0.046], lower median POD 3 albumin [24 (IQR 20-26 g/L) vs. 26 (IQR 24-30 g/L); p < 0.001], more postoperative complications (OR 2.91, 95% CI 1.36-6.20) and poorer OS (HR 2.38, 95% CI 0.99-5.73). CONCLUSIONS: Perioperative blood transfusion was associated with postoperative inflammation, complications, and poorer survival in patients undergoing colorectal cancer surgery, with and without propensity score techniques.

Adult neuroblastoma: a rare diagnosis of an adrenal mass.

A 22-year-old woman presented to her local district hospital with left-sided abdominal pain. She denied any urinary or gastrointestinal symptoms. She had a CT scan of her abdomen which showed a probable 8×5×8 cm left-sided adrenal mass. Functional tests for hormone excess were negative. She was referred to a tertiary referral centre and given the size of the adrenal mass; she consented for laparoscopic left adrenalectomy. During the operation, the mass was grossly adherent to the celiac axis, left renal pedicle and DJ flexure. A small nodule posterior to the renal vein was also identified. The operation was completed laparoscopically and she made an uneventful recovery. The specimen was reported as a poorly differentiated neuroblastoma. She had a postoperative MIBG scan which was negative for residual or metastatic disease. She was commenced on platinum-based chemotherapy with a plan for further radiological follow-up.

Survival outcomes following adrenalectomy for isolated metastases to the adrenal gland.

BACKGROUND: Adrenal metastases can arise from different primary sites. Surgical resection of the adrenal gland in patients with isolated metastases may offer improved survival in many of these patients. However, the benefit of surgery in this heterogenous group is often disputed. The aim of this study was to identify patients undergoing adrenalectomy for isolated metastases and to describe survival outcomes based on origin of the primary malignancy. METHODS: Patients undergoing surgery for isolated adrenal metastases were retrospectively analysed from a prospectively kept database. Data collected included the age of the patient, gender, size and functional status of the tumour and the site of the primary malignancy. Overall survival and survival based on the primary tumour were calculated using Kaplan-Meier survival analyses. RESULTS: 42 patients were included for analysis. The median tumour size was 40 mm. 91% (n = 38) of operations were performed laparoscopically. Metastases were from the following primary organs: kidney (n = 22), lung (n = 11), breast (n = 2), gastric (n = 1), skin (n = 3), liver (n = 2) and neuroendocrine (n = 1). Overall median survival was 56 (19-93) months with 95% of patients followed up for >6 months. There was a significant difference in median survival between primary organs of origin: 83(42-123), 14(9-18), 15 and 12(3-20) months (p < 0.05) for kidney, lung, breast and skin respectively. CONCLUSION: There is a potential survival benefit for patients undergoing surgery for isolated adrenal metastases; however this survival benefit is greater in patients undergoing resection for metastases arising from kidney primaries. A selective approach should be adopted to identify patients that will clearly benefit from surgery.

Oncocytoma of the adrenal gland in Birt-Hogg-Dube syndrome.

A 32-year-old man was referred to our surgical unit with a left adrenal lesion. He was previously diagnosed with Birt-Hogg-Dube syndrome after presenting with a left pneumothorax and an incidental finding of a right apical lung mass. This syndrome is characterised commonly by benign skin hamartomas, recurrent pneumothoraces and an increased risk of renal tumours. He was unable to tolerate a biopsy of his lung lesion, however, this lung lesion was thought to be benign. Given the size of his adrenal lesion and radiological appearances, we performed a laparoscopic left adrenalectomy. Pathology confirmed that based on morphological appearances and immunohistochemical staining, this may represent an oncocytic tumour of the adrenal gland. This is only the third published case of an oncocytic tumour of the adrenal gland in a patient with Birt-Hogg-Dube syndrome.

Adrenal incidentaloma in a patient with HIV/AIDS.

Human immunodeficiency virus (HIV) is well known to be associated with various neoplasms and opportunistic infections. Kaposi sarcoma (KS), associated with human herpes virus 8 (HHV8) infection, is the most common tumour in HIV positive patients and is also an acquired immune deficiency syndrome (AIDS) defining illness. Cutaneous manifestations are the most common presenting symptom; however, visceral involvement is also recognized. We present the case of a 55-year-old male who was diagnosed with AIDS-related KS, who was referred to our surgical unit with an indeterminate left adrenal lesion. He subsequently started antiretroviral therapy and given the indeterminate nature of his adrenal lesion, we performed a laparoscopic left adrenalectomy, with KS of the adrenal gland confirmed on histology.

Neutropenic enterocolitis affecting the transverse colon: an unusual complication of chemotherapy.

A 66-year-old woman presented with a 1-day history of sudden onset of generalised abdominal pain associated with fever and vomiting. She was previously diagnosed with left breast cancer 2 months ago and completed a course of chemotherapy 1 week prior to presentation. She was clinically unwell with generalised tenderness in her abdomen. Blood investigations showed severe neutropenia. A CT scan was requested which reported a marked oedematous swelling of the transverse colon with features suggestive of a contained perforation. The decision was made to operate. Intraoperatively, the transverse colon was found to be thickened with omentum adherent focally around the distal third. A right hemicolectomy was performed with an end ileostomy and mucus fistula. The patient made a successful recovery and was discharged within 7 days of presenting. Pathology reported typical features of neutropenic enterocolitis affecting the transverse colon with a normal terminal ileum, caecum and ascending colon.

De Garengeot's hernia: diagnosis and surgical management of a rare type of femoral hernia.

De Garengeot's hernia is quite rare and is a femoral hernia that contains a vermiform appendix and can present as a painful, tender swelling or an asymptomatic lump. We present the case of a 70-year-old patient who presented to our surgical unit after being referred for diagnostic imaging of an asymptomatic groin lump which was found to be a De Garengeot's hernia. She had an open repair of her femoral hernia and laparoscopic appendicectomy. Her post-operative stay was uneventful. De Garengeot's hernia is rare; however, imaging is usually required to make a diagnosis preoperatively. Management is usually surgical with simultaneous repair of the femoral hernia and appendicectomy.

Bascule caecal volvulus: a rare cause of intestinal obstruction.

Caecal volvulus is a rare cause of intestinal obstruction, with the bascule subtype accounting for <10% of all cases of caecal volvulus. It is associated with significant morbidity and mortality if left undiagnosed. We present the case of a 58-year-old female who presented to our surgical department with symptoms of intestinal obstruction. She had various radiological investigations, which supported the diagnosis of a caecal volvulus of the bascule subtype. She was subsequently managed surgically and had a right hemicolectomy and ileocolic anastomosis. Her recovery was uneventful and she was discharged within 1 week of having her operation. Fortunately, caecal volvulus of the bascule subtype is rarely encountered; however, clinicians need to be aware of its presentation and subsequent management options so that clinical outcomes are improved.

Surgical emphysema following therapeutic colonoscopy.

Colonoscopy is an invasive procedure used in the detection of colon cancer, inflammatory bowel disease and investigation of bleeding from the rectum. In addition to diagnostic procedures, colonoscopy also has therapeutic indications such as polypectomy and dilation of strictures. We present a case of a patient who presented with cervical emphysema following a therapeutic colonoscopy. The patient had no abdominal or chest pain, shortness of breath and was managed conservatively. Perforation following colonoscopy is a rare complication; however, it is essential that doctors recognize and are aware of the different presentations and management options for this complication.