Seeing White: Management of TIVA during autologous breast reconstruction.

Total IntraVenous Anaesthesia is frequently the anaesthetic of choice for enhanced recovery after surgery pathways during breast reconstruction free flap surgery. This relies upon the continuous intravenous infusion of propofol. We describe our experience of two patients where augmentation of a venously congested DIEP flap with a cephalic vein transposition procedure, risked interruption of the intravenous delivery of anaesthesia to the patient. We also share our steps taken to mitigate this risk going forward.

Mastectomy Without Drains Reduces Cost with No Detriment to Patient Outcome.

Introduction  Use of drains after mastectomy remains highly variable. This study aimed to establish whether simple mastectomy managed without a drain would cost less than the same procedure managed with a drain and whether there would be any difference in complications. Methods  Prospective data were collected on all patients undergoing simple mastectomy ± sentinel lymph node biopsy over sixteen months. Surgeons decided intra-operatively whether to place a drain. Data included operative details, mastectomy weight, length of stay and postoperative complications. Costing data were identified by combining hospital finance costs for admission and follow-up appointments along with the cost of consumables. Results  One hundred and thirty mastectomies were performed on 119 patients. There was a significant difference in mastectomy weight between drain group patients (n=80, median: 730g) and no drain group patients (n=50, median: 424g) (p=<0.001). The mean cost for drain group patients was £639.77 whilst for the no drain group was £365.46, indicating a potential unit saving of £21944.93 over sixteen months. Length of stay was shorter in the no drain group (range: 1-2 days) than the drain group (range: 1-4 days). The presence or absence of drains did not influence complication rates, with no change in seroma interventions (p=0.803). Conclusions  Managing simple mastectomy patients without a drain resulted in no increase in complications or subsequent interventions for seroma. Significant cost savings to both the hospital and to the patient can be achieved by omitting drain use. Routine use of drains in patients undergoing simple mastectomy ± SNB may be unnecessary and costly.

Managing complex trauma injuries in the elderly: a case report of a free flap and circular frame in a 95-year old patient with an open IIIB tibial fracture.

In an ageing population, increasing numbers of patients over the age of 70 are sustaining severe trauma. These patients require careful multidisciplinary team (MDT) management with careful consideration of existing co-morbidities, as such their treatment should be individually tailored. We present the case of a patient believed to be the oldest documented patient treated in a trauma setting with free flap and circular frame fixation to an open tibial fracture. A 95-year-old male presented to the Level 1 Major Trauma Centre (MTC) with multiple injuries after a pedestrian vs car incident. His injury severity score (ISS) was 22. For treatment of his open tibial fracture, he required soft tissue coverage with a free anterolateral thigh (ALT) flap, and circular frame application. Microsurgery was performed after consultation with the MDT and was uneventful. The circular frame was removed after 10 months and the patient went on to regain pre-injury mobility. Use of free tissue transfer in elderly patients is well documented in the elective setting, but less so in trauma. This case demonstrates that careful patient selection, attention to detail and MDT working can result in an excellent outcome for the patient. The challenges faced in treating this patient will be described in detail. LEVEL OF EVIDENCE: Level V, therapeutic study.

Managing soft tissues in severe lower limb trauma in an ageing population.

PURPOSE: With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. METHOD: Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. RESULTS: Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67-95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4-85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). CONCLUSION: Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.

Merkel cell carcinoma in East Yorkshire: A case series and literature review of current management.

INTRODUCTION: Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumour of the skin. The incidence is rising and it is associated with sun exposure and immunosuppression. Our aim was to perform a 10-year retrospective review of MCC treated in East Yorkshire and to examine disease progression, surgical and adjuvant management, and outcomes. METHODS: A 10-year retrospective review was undertaken of patients identified through the histopathology database. Case notes and digital patient records were examined for patient demographics, disease characteristics, management and outcome. Disease stage was calculated using the 2010 AJCC TNM classification. RESULTS: Thirty-seven patients with complete records were included. Twenty-one patients were male and 16 female, with mean age 76.7 years at presentation. Pre-malignant or malignant skin changes were documented in 15 patients, and immunosuppression in 15 patients. Mean duration of lesion was 17.5 weeks. Following diagnosis 22/37 patients underwent further surgery with 11 patients undergoing sentinel lymph node (LN) biopsy. LN disease was palpable at presentation in 8 patients. Three year survival is 40%. CONCLUSIONS: There is no standardised management of MCC and randomised trials are challenging due to relatively small numbers. There has been little progress made in terms of improving survival. Development of a national database for patients with this condition would allow prospective data collection and more accurate assessment of current treatment protocols and their efficacy. LEVEL OF EVIDENCE: IV.

Military trauma care in Birmingham: observational study of care requirements and resource utilisation.

BACKGROUND: The Royal Centre for Defence Medicine is located at University Hospitals Birmingham (UHB). Since 2001 all UK military casualties injured on active duty have been repatriated here for their initial treatment. This service evaluation was performed to quantify the work undertaken, with the aim of providing a snapshot of a year's military trauma work in order to inform the delivery of trauma care in both the military and civilian setting. METHODS: Military patients admitted with traumatic injuries over a 12-month period were identified and the hospital notes and electronic records reviewed. Data were collected focusing on three areas - the details of the injury, information about the in-patient admission, and surgical interventions performed. RESULTS: A total of 388 patients were used in the analysis. Median total length of stay was 10.5 days (IQR: 4-26, range: 0-137 days), and a median 6.0 days (IQR: 3.0-11.0, range: 1-49 days) was spent on intensive care by 125 patients. Surgical intervention was required for 278 (71.6%) patients, with a median of 2.0 operations (IQR: 1.0-4.0, range: 1-27) or 170 min (IQR: 90.0-570.0, range 20-4735 min) operating time per patient. 77% of these patients had their first procedure within 24h of arrival. Improvised explosives accounted for 50.5% of injuries seen. Spearman rank correlation between New Injury Severity Score with length of stay demonstrated significant correlation (p<0.001), with a coefficient of 0.640. A model predicting length of stay based on New Injury Severity Score was devised for patients with battle injuries. CONCLUSION: This report of 12 months work at UHB demonstrates the service commitment to these casualties, describing the burden of care and resource requirements for military trauma patients.

Revised estimates of mortality from the Birmingham Burn Centre, 2001-2010: a continuing analysis over 65 years.

OBJECTIVE: The Birmingham Burn Centre has continued to publish mortality data over the last 65 years. It is one of the longest running cross-sectional cohort studies in the world. We present the latest data from the study, with a comparison to previous results. BACKGROUND: Results from the previous decade failed to show any improvement in mortality despite perceived advances in burn care. The aim of this update was to establish current mortality statistics and ascertain whether improvement had now been made. METHODS: Data were collected for a 10-year period on all burn-injured patients admitted to the Birmingham Burn Centre (Birmingham Children's Hospital, Selly Oak Hospital, and Queen Elizabeth Hospital Birmingham). Patients' age, percentage of burn, date of injury, and outcome were recorded and analyzed with both probit and logistic regression analyses. RESULTS: A total of 4577 patients were included in the analysis, with a mean total body surface area (TBSA) burn of 7.2% and a mean age of 22 years. Comparison of probit model results with previous results demonstrates improvement in predicted mortality and lethal area (LA50) of burns. Logistic regression produces similar results to the probit analysis. Trend analysis proved a statistically significant improvement in mortality. CONCLUSIONS: The last decade of burn care at Birmingham Burn Centre demonstrates an improvement in predicted mortality and LA50. This reflects our structured, multidisciplinary approach to burn-injured patients, early surgical excision and wound closure, and general advances in the intensive care of patients.