Abstract Background A major shift in treatment of appendicitis occurred early in the SARS-CoV-2 pandemic with non-operative management used commonly outside research protocols and in units with limited previous experience. This study aims to compare real-world outcomes of surgery versus non-operative management of uncomplicated appendicitis in children with 1-year follow-up. Method A prospective multicentre observational study of children treated for uncomplicated appendicitis at 74 hospitals in the UK and Ireland from 1 April to 31 July 2020 was performed. Propensity-score matched analysis was conducted using age, sex, C-reactive protein at diagnosis and duration of symptoms as covariates. Primary outcomes were success of non-operative management defined as achieving 1-year follow-up without undergoing appendicectomy due to recurrent appendicitis or ongoing symptoms, and occurrence of any predefined complication (intra-abdominal collection, wound infection, bowel obstruction or reintervention). Results Of 1464 children with presumed uncomplicated appendicitis, 1027 (70.2 per cent) underwent surgery and 437 (29.9 per cent) underwent non-operative management. Ninety-four children (21.5 per cent) treated by initial non-operative management required appendicectomy during the index hospital admission while recurrent appendicitis after discharge occurred in 25 (10.4 per cent) children within 1 year. The overall success rate of non-operative management at 1 year was 63.1 per cent (95 per cent c.i. 58.0 to 68.3 per cent). For propensity-score matched analyses, 688 children undergoing surgery and 307 undergoing non-operative management were included. Any predefined complication occurred in 50 (7.3 per cent) children undergoing surgery and in four (1.3 per cent) children undergoing non-operative management (OR 5.9 (95 per cent c.i. 2.1 to 16.6)) in the propensity-score matched cohort. There was no mortality or stoma formation. Conclusion Non-operative management is a safe and valid alternative to appendicectomy in children with uncomplicated appendicitis.
Background: The sentinel lymph node biopsy (SLNB) procedure is long considered as an accurate method of staging the axilla for axillary involvement in early stage breast cancer. The question remains as to whether patients with micrometastases should undergo axillary clearance. We aimed to assess the indicators for positive non-sentinel lymph nodes (SLN) following completion axillary lymph node dissection (CALND). Methods: We retrospectively analysed our experience of SLNB between July 2008 and July 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intra-operative gamma probe detection, and blue dye mapping using 99m Tc-nanocolloid and Patent Blue V injected peri-areola. Statistical analysis was performed using Fisher’s exact and χ2 for categorical data. Results: Out of 1,152 SLNBs performed, 224 (19.4%) were positive for metastatic disease; macrometastases in 150 (67.0%), micrometastases in 72 (32.1%) and isolated tumour cells (ITC) in 2 (0.9%). CALND was not performed in 20 cases (9 macrometastases, 10 micrometastases, and 1 ITC), largely due to concerns regarding fitness for anaesthesia. On univariate analysis, positive non-SLN in CALND for patients with micrometastases on SLNB was not predicted by grade (G0–G2, 6/43; G3; 3/19; P=0.565), size of primary breast tumour (<40 mm, 8/58; ≥40 mm, 1/4; P=0.475), lymph vascular invasion (5/30 vs. 4/31; P=0.503), age (<50 years, 3/24 vs. ≥50 years, 6/38; P=0.496), or number of positive SLNB. Conclusions: In our series, 14.5% (9/62) of patients with micrometastases had positive non-SLN on CALND, which was not predicted by any clinicopathological characteristics. However, it is important to inform our patients that 14.5% of patients with micrometastases on SLNB may have positive non-SLN.
Abstract Aims and Objectives Aim of our study was to evaluate the current practices of prescribing opioids for post-operative pain in opioid-naive patients in our region and the risk of prolonged opioid use among them. Methods A retrospective cohort study was performed where cohort consisted of patients who had surgery in 2018 with at least one year follow up. Endpoints were the proportion of all patients and opioid naïve patients, discharged on opioid prescription and proportion of opioid naïve patients who developed opioid dependence after one year. Results During 2018, 17524 patients underwent a total of 20526 surgical procedures by pan surgical specialties in our hospitals. 8772 patients (50%) were discharged with opioid prescription. 673 (7.70%) of those required further opiate prescriptions after discharge, of those requiring opiates, 331 had no opiate exposure before surgery (342 had previous opiate exposure). In opioid naïve patients, at 1 year follow up 151 (45%) had no further opiate prescriptions, but 180 (55%) required ongoing opiate prescriptions after one year follow up. The risk of opioid dependence after surgery is significant in opioid naïve patients. Conclusion Results are alarming and evidence-based strategies, national and local guidelines are needed to prevent the opioid crisis in the UK. There is a need for a national campaign to minimize the dependence on opioids and to find, better alternatives to opioids.
After advancements in surgical and anaesthetics expertise and increased life spans among patients with complex abdominal surgeries, clinicians are left with the next main challenge, to how to improve the quality of life in patients with incisional hernia resulted from previous complex abdominal surgeries. To date there is no consensus over the choice of instrument and time frame for its administration in the literature. The aim of this review was to search for the current literature on measurement of quality of life in patients with ventral incisional hernia repair and to explore how effective each QOL instrument was for measuring impact on quality of life after ventral incisional hernia repair. In accordance with PRISMA guidelines two independent clinicians searched for Mesh and specific terms related to quality of life in patients with ventral incisional hernia. Search was made on PubMed, Embase and other research databases. Trial registries were searched for any published or unpublished trials. Literature search came up with 461 articles. After scanning and removal of duplication, 200 articles were subjected to inclusion and exclusion criterion and 59 articles were selected for qualitative analysis. Different scales for the measurement of quality of life after ventral incisional hernia repair were found. The incidence of incisional hernia itself was found to be the biggest determinant of poor quality of life, regardless of timescale of follow up and type of surgery performed. No single instrument was found to be complete enough to address the wide-ranging health-related quality of life issues in patients after incisional hernia repair.
Abstract Introduction Over the last 20-years there has been increasing opioid related deaths, in the context of a worldwide epidemic of misuse including addiction and overdose. Startlingly, opioid commencement is usually iatrogenic. Most published data is from the USA with little evidence from UK surgical practice. Methods Retrospective analysis of surgical unit opioid prescriptions. Data included opioids prescribed on discharge, 1, 3- and 6-months post-discharge usage and milligrams-of-morphine equivalence(mgEq) used to compare regimes. Results One hundred cases reviewed. 35% of patients were opioid naïve on admission and of these 20%, 5.71% and 8.57% remained on opioids at 1, 3- and 6-months post discharge respectively. Females more likely to remain on long-term opioids at 6 months at lower doses (42% v 30%). Only 6% of discharge summaries recommended GP follow-up and assessment of opioid requirements. Furthermore, none were prescribed a tapering dosage regime on-discharge. Patients receiving Acute Pain Team reviews, more likely to remain on long-term opioids, at lower doses (30.67mgEq, 29.25mgEq and 32.63mgEq at 1-, 3- and 6-months post-discharge) compared to those without (69.16mgEq, 74.25mgEq and 65.13mgEq). Only 11% of patients with pre-existing opioid prescriptions were reviewed by the acute pain team. Worryingly, no documented assessment of opioid misuse risk in patients. Conclusion Standardised assessments i.e., opioid Risk Assessment Tools and mgEq need to be documented and monitored in primary and tertiary care. Acute pain team services should be offered to more patients. Our study hopes to raise awareness of the need for effective opioid stewardship in surgical patients.
Since year 2000 the diagnostic criterion for fast track (FT) referrals for patients with suspected colorectal cancer (CRC) is used in the UK. Iron deficiency anaemia (IDA) is one of the diagnostic criteria. There is a strong evidence in the literature which suggests that Iron deficiency (ID) alone has a strong relationship with CRC. Non-anaemic Iron deficiency (NAID) and all other types of anaemia are investigated outside the scope of FT clinics. We postulated that patients with ID regardless of degree of anaemia have an increased risk of CRC. By confirming this hypothesis, we can broaden the scope of the diagnostic criterion for referral that can help to increase diagnostic yield of FT CRC services.A retrospective observational cohort study was conducted from a dedicated data for FT clinics from 2016-2018. Association between CRC and different forms of anaemia, Iron deficiency alone and bowel symptoms was determined.Patients with iron deficiency (low MCV, MCH and ferritin) regardless of degree of anaemia were found more likely to have CRC. Factors like age, gender, family history and bowel symptoms (except abdominal mass) showed a very weak association with CRC in patients with ID.ID without anaemia has a strong relationship with CRC and should be investigated with the same priority as IDA is investigated.
Background: The role of completion axillary lymph node dissection (CALND) following positive sentinel lymph node biopsy (SLNB) is being actively debated. The involvement of our unit in the POSNOC trial (which has a no-treatment arm), has prompted a review of our unit’s CALND results, in order to examine predictors of involvement of non-sentinel lymph nodes (n-SLN). Methods: We retrospectively analyzed our experience of SLNB between July 2008 to 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peri-areola. Results: Out of 1,152 SLNB performed, 224 were positive for metastatic disease; 203 patients were anesthetically capable of progressing to CALND. On univariate analysis, involved n-SLN on CALND could not be predicted by age, size of tumor, procedure performed, lymph vascular invasion, number of positive SLN, receptor status; ER, PR, HER2 or triple negative. There was a trend toward higher incidence of positive n-SLN with increasing grade, and extracapsular spread, but these did not reach statistical significance. Positive n-SLN on CALND was however predicted by macrometastases in SLN and ratio of positive nodes on SLNB. Conclusions: In our series of more than 200 SLNB, a ratio of >0.5 positive SLN yield and presence of macrometastases in positive SLN, were associated with positive n-SLN on CALND.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
