Provision of a local anaesthetic minor procedures service by surgical advanced clinical practitioners: 5-year study.

BACKGROUND: Surgical advanced clinical practitioners (SACPs) form part of the extended surgical workforce drawn from a variety of allied healthcare backgrounds. The primary aim of this study was to determine whether there was a financial benefit in having minor surgical procedures undertaken by dedicated SACPs compared with operating lists assigned to consultant surgeons. METHODS: This was a retrospective cohort study including all patients who had minor 'lumps and bumps' procedures undertaken between April 2014 and August 2019 at East Lancashire Hospitals NHS Trust under local anaesthetic by the general surgery team. Clinical patient information, including lesion type, was collected along with operating room staffing levels and duration of operation. The cost of the procedure was calculated as operating time multiplied by cost of staff per minute according to local banding. RESULTS: A total of 1399 patients had a lesion excised; 907 procedures were carried out by a doctor, and the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time taken between SACPs and doctors (20 (i.q.r. 14-28) min). Minor procedures carried out on consultant surgeon lists cost 62.3 per cent (€25.33) more on average than those on SACP lists (median €65.96 versus 40.63 respectively; P < 0.001). CONCLUSION: A dedicated and independent SACP 'lumps and bumps' list was financially beneficial. Operating times were similar to those of doctors. These lists safely free trainee and consultant surgeons to undertake more complex work.

Splenic artery pseudoaneurysm and resultant haematosuccus pancreaticus.

Splenic artery pseudoaneurysm (SAP) is a rare and dangerous diagnosis with a high risk of rupture and death. It is the most common cause of main pancreatic duct haematoma-haematosuccus pancreaticus (HP). Neither SAP nor HP have specific clinical features that allow diagnosis without cross-sectional imaging. Upper gastrointestinal haemorrhage and a history of pancreatitis should raise clinical suspicion but ultimately endoscopy and CT are required. We report a case of a 51-year-old man without clinical symptoms in whom cross-sectional imaging was undertaken for incidental severe acute anaemia. This demonstrated stigmata of chronic pancreatitis and the main pancreatic duct was distended with dense material in keeping with haematoma. The diagnosis of a SAP bleeding into the main pancreatic duct was made radiologically. A subsequent oesophago-gastro-duodenoscopy confirmed the diagnosis. The imaging appearances, pathophysiology and management are discussed.

Hepatic steatosis in patients undergoing resection of colorectal liver metastases: A target for prehabilitation? A narrative review.

The prevalence of elevated intra-hepatic fat (IHF) is increasing in the Western world, either alone as hepatic steatosis (HS) or in conjunction with inflammation (steatohepatitis). These changes to the hepatic parenchyma are an independent risk factor for post-operative morbidity following liver resection for colorectal liver metastases (CRLM). As elevated IHF and colorectal malignancy share similar risk factors for development it is unsurprisingly frequent in this cohort. In patients undergoing resection IHF may be elevated due to excess adiposity or its elevation may be induced by neoadjuvant chemotherapy, termed chemotherapy associated steatosis (CAS). Additionally, chemotherapy is implicated in the development of inflammation termed chemotherapy associated steatohepatitis (CASH). Following cessation of chemotherapy, patients awaiting resection have a 4-6 week washout period prior to resection that is a window for prehabilitation prior to surgery. In patients with NAFLD dietary and pharmacological interventions can reduce IHF within this timeframe but this approach to modifying IHF is untested in this population. In this review, the aetiology of CAS and CASH is reviewed with recommendations to identify those at risk. We also focus on the post-chemotherapy washout period, reviewing dietary interventions applied to the metabolic population and suggest this window may be used as an opportunity to optimise IHF with such a regime as part of a pre-operative prehabilitation programme to produce improved patient outcomes.

Laparoscopic versus open umbilical or paraumbilical hernia repair: a systematic review and meta-analysis.

OBJECTIVES: To compare outcomes of laparoscopic repair to open repair of umbilical and paraumbilical hernias. METHODS: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (Registration Number: CRD42016052131). We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies comparing outcomes of laparoscopic repair to open repair of umbilical and paraumbilical hernias. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Random effects models were applied to calculate pooled outcome data. RESULTS: We identified three RCTs and seven retrospective cohort studies, enrolling a total of 16,549 patients. Our analyses indicated that open repair was associated with a higher risk of wound infection [Odds ratio (OR) 2.35, 95% CI 1.23-4.48, P = 0.010], wound dehiscence (OR 4.99, 95% CI 1.12-22.28, P = 0.04) and recurrence (OR 4.06, 95% CI 1.54-10.71, P = 0.005), longer length of hospital stay (MD 26.85, 95% CI 8.15-45.55, P = 0.005) and shorter operative time [Mean difference (MD) - 23.07, 95% CI - 36.78 to - 9.35, P = 0.0010] compared to laparoscopic repair. There was no difference in the risk of haematoma (OR 2.03, 95% CI 0.22-18.73, P = 0.53) or seroma (OR 0.67, 95% CI 0.19-2.32, P = 0.53) between the two groups. CONCLUSIONS: The best available evidence (randomised and non-randomised studies) suggests that laparoscopic repair of umbilical or paraumbilical hernias may be associated with a lower risk of wound infection, wound dehiscence and recurrence rate, shorter length of stay but longer operative time. Results from a limited number of RCTs showed no difference in recurrence rates. The quality of the best available evidence is moderate, and selection bias is the major concern due to non-randomised design in most of the available studies. Therefore, considering the level of available evidence, the most reliable approach for repair of umbilical or paraumbilical hernia should be based on surgeon's experience, clinical setting, patient's age and size, hernia defect size and anatomical characteristics. High quality RCTs are required.

A case report of duplex gallbladder and review of the literature.

Gallbladder duplication is a rare congenital abnormality first described by Boyden in 1926. Pre-operative diagnosis is essential in identifying anatomical abnormalities in order to avoid biliary injuries at the time of surgery or performance of an incomplete operation. We present a case of a duplex gallbladder and review of the literature.

The influence of FDG PET-CT on the detection of extrahepatic disease in patients being considered for resection of colorectal liver metastasis.

INTRODUCTION: The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis. METHODS: Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings. RESULTS: PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT. CONCLUSIONS: The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.

Laparoscopic liver surgery: An overview of the literature and experiences of a single centre.

In the past two decades there has been an enormous increase in laparoscopic liver surgery. There is a trend from limited to laparoscopic major resections and more centres are adopting laparoscopic liver surgery as a standard of care. Although no randomized clinical trials are published, different reports on minor and major hepatectomies and meta-analyses suggest (at least) equal outcomes and cost-effectiveness compared to open procedures.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center.

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

Hiatal hernias presenting as a late complication of laparoscopic-assisted cardio-oesophagectomy.

The resection of oesophageal cancer offers the only chance of cure. The introduction of minimally invasive oesophagectomy has gained wide acceptance for the surgical treatment of oesophago-gastric cancers. The most commonly reported late complications of minimally invasive oesophagectomy are anastamotic stricture, chylothorax, chronic diarrhoea and delayed gastric emptying. Symptomatic hiatus hernia presenting as a late complication of laparoscopic cardio-oesophagectomy is not a widely reported complication. We have encountered three such cases, two of which were treated laparoscopically.

Litigation claims in vascular surgery in the United Kingdom's NHS.

OBJECTIVES: To establish the incidence, costs and causes of medical negligence claims in relation to vascular surgery in the UK's NHS. METHODS: All claims related to vascular surgery reported to the NHS Litigation Authority from April 1995 to April 2007 were included in the study. Data was subsequently reviewed, coded and analysed. RESULTS: 395 claims were identified (mean: 49/year over last 5 years) of which 303 had been settled. Damage compensation was given in 160 cases, with overall litigation costs of approximately 17 million pounds (21 million euros). The main complaint reasons in successful claims were intra-operative problems (50%), failure/delay of treatment (14%) and failure/delay of diagnosis (11%). Varicose vein (VV) surgery was involved in 48% of successful claims, with intra-operative nerve and vessel damage being the major causes. Peripheral vascular disease (PVD) and abdominal aortic aneurysm (AAA) disease were the next two types of disease/procedures involved in successful claims with 21% and 6% respectively. CONCLUSIONS: The number of claims related to vascular surgery has remained stable over the past 5 years. Improved consenting and higher surgical skill levels especially in relation to VV surgery and increased diagnostic vigilance in PVD, AAA disease and infections are potential areas for future improvement.

Osteocartilaginous choristoma: a case report.

A choristoma is a benign tumour-like mass consisting of mature tissue derived from one or more germ cell layers that are foreign to the site at which they are located. Choristomas of the pharynx are rare with few cases being reported in the English literature. Management of these lesions is usually complete surgical excision. We report a case of osteocartilaginous choristoma arising from the pharynx.

Timing of operative intervention in the management of acutely fractured ankles and the cost implications.

A study of the length of the time between the diagnosis of an ankle fracture and operative intervention and the length of subsequent hospital stay was undertaken. The delay in operative fixation beyond 24 h from injury was associated with a lengthening of stay. The cost implication of a longer stay was assessed. Eighty-seven patients with 87 fractures fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 34 unimalleolar, 35 bimalleolar and 18 trimalleolar fractures. Only 47 (54%) of the patients were operated on within 24 h of injury, even though 74 had presented by 6 h and a further five by 24 h. The mean inpatient stay was 9.6 days for this early operation group. The patients who had their operation delayed were in hospital for a mean of 14 days, a significant difference (P<0.0001) (using Wilcoxon's Signed Rank test). The cost per patient per day of an acute trauma bed is estimated at pound sterlings 225. This translates into an average cost of pound sterlings 990 more per patient whose operation is delayed. We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles as this would result in significant financial savings.