Surgical assessment clinic – One stop emergency out-patient clinic for rapid assessment, reduced admissions and improved acute surgical service: A quality improvement study (2017)

Type of publication:
Journal article

Author(s):
*Macano C.A.W.; *Lake B.; *Clarke R.; Kirby G.C.; Nyasavajjala S.M.

Citation:
Annals of Medicine and Surgery; Nov 2017; vol. 23 ; p. 28-31

Abstract:
Background There is increasing pressure on emergency services within the NHS requiring efficient, rapid assessment and management of patients. A subsequent reduction in hospital admissions reduces overall costs with an aim to improve quality of care. At the Royal Shrewsbury Hospital we run a one stop emergency surgical clinic. With strict criteria for admission to this clinic we have established a care pathway for those patients requiring urgent surgical review but not necessarily hospital admission. Materials and methods We reviewed our initial referral pathway to the emergency surgical assessment clinic. New guidelines were distributed to the local Care Coordination Centre (CCC) through which GP referrals to the clinic were made. A re-audit carried out 6 weeks later assessed change in clinical practice. Results With the introduction of guidelines for referral we significantly increased the percentage of appropriate referrals to the one stop emergency surgical clinic (42.9%-79.4%, p = 0.000017). The majority (75.8%) of appropriate referrals can be successfully managed on an urgent outpatient basis. Appropriate referrals unsuitable for discharge from clinic had genuine reasons for admission such as abnormal results on assessment, or a need for surgery. 97.8% of referrals not deemed appropriate for the clinic were admitted for inpatient management. Conclusion By providing suitable guidance for referring practitioners we have optimised our clinic use significantly and improved our acute ambulatory surgical care. We have reduced admissions, provided rapid treatment and have established a service that helps address the ever increasing demand on acute services within the NHS.

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A Comparison of Operative Time Outcomes in Endoscopic and Open Tympanomastoid Surgery (2016)

Type of publication:
Conference abstract

Author(s):
*Mohamed Rizny Sakkaff and *Duncan Bowyer

Citation:
The Journal of Laryngology and Otology, Volume 130, Issue S3 (Abstracts for the 10th International Conference on Cholesteatoma). May 2016, pp. S207-S208

Link to more details or full-text: https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/div-classtitlea-comparison-of-operative-time-outcomes-in-endoscopic-and-open-tympanomastoid-surgerydiv/260FA9CCDD529CE5E41661ECB229FE81

Inadvertent returns to theatre within 30 days (IRT30) of surgery: an educational tool to monitor surgical complications and improve our performance as surgeons (2015)

Type of publication:
Journal article

Author(s):
*Sukha A., *Li, E. , *Sykes T., *Fox A., *Schofield A., *Houghton A.

Citation:
Clinical Governance, October 2015, vol./is. 20/4(208-214 )

Abstract:
Purpose – When a patient unexpectedly has to go back to the operating theatre, there is often a perceived problem with the primary operation. An IRT30 is defined as any patient returning to the operating theatre within 30 days of the index procedure. IRT30 has been suggested to be a useful quality indicator of surgical standards and surgeon performance. The purpose of this paper is to evaluate t he usefulness of this validated tool, by assessing all IRT30 over a 12-month period. Learning points for individual surgeons, surgical subspecialty units and the clinical governance leads were reviewed. Design/methodology/app roach – Consecutive series of general and vascular surgical patients undergoing elective and emergency procedures between July 2012 and 2013. Prospective data collection of all IRT30s classified as Types 1-5 by a single-rater and in-depth discussion of Types 3-5 cases at the clinical governance meetings. The individual case learning points were recorded and the collective data monitored monthly. Findings – There were 134 IRT30s. In total 84 cases were discussed: Type 3 (n=80), Type 4 (n=4) and Type 5 (n =0). In total 50 cases were not discussed: Type 1 (n=27), Type 2 (n=2 3). Originality/value – It is crucial that surgeons continue to learn throughout their surgical career by reflecting on their own and their colleague’s results, complications and surgical performance. Analysing Types 3 and 4 IRT30s within the governance meetings has identified learning points related to both surgical technique and surgical decision making. By embracing these learning points, surgical technique and individual as well as group surgeon performance can be modified and opportunities for training and focused supervision created.

Laparoscopic anti-reflux surgery (LARS): Determine the hiatal defect repair using the intra-operatively calculated surface area (SA) cm2 (2014)

Type of publication:
Conference abstract

Author(s):
*Sukha A., *Adjepong S., *Pattar J., *Sigurdsson A.

Citation:
International Journal of Surgery, November 2014, vol./is. 12/(S100)

Abstract:
Introduction: The aim of this study was to evaluate laparoscopic antireflux surgery (LARS) techniques when repairing hiatal defects using the intra operatively calculated surface area (SA) at single-centre Upper Gastrointestinal Laparoscopic Unit. Methods: 100 patients (mean age = 59, average BMI 31) with symptoms of GORD underwent LARS. The SA (cm2) was calculated using an endoscopic ruler and the formula;(1/2 x base x height) x2. The method of closure; Surgisis +/-simple tension free sutures, was recorded for each hiatal closure. Results: The mean calculated SA repaired was 9.0cm2 and there was a 2%(2) recurrence rate. There were 3 modalities of repair; 1) Surgisis, posterior and anterior sutures (mean SA=10.0cm2, average BMI = 28); 2) Surgisis and posterior sutures (mean SA=9.5cm2, average BMI=29); 3) posterior sutures only (mean SA =6.1cm2, average BMI=32, mean number of sutures 3). Conclusions: It was found that the greater the average SA cm2 of the hiatus hernia the greater the number of modalities of repair used. There was no correlation found between BMI and the surface area of the hiatus hernia. Currently there are no set standard for method of repair based on the SA of the defect; however guidelines have been derived from this study.

Link to more details or full-text:
http://www.journal-surgery.net/article/S1743-9191(14)00735-3/pdf

Mortality following acute native artery embolecotmy for arterial embolism unrelated to peripheral arterial disease (PAD): 18 year review (2014)

Type of publication:
Conference abstract

Author(s):
*Lambert J., *Premaratne S., *Jaipersad A., *Houghton A., *Fox A., *Merriman K.

Citation:
International Journal of Surgery, November 2014, vol./is. 12/(S114)

Abstract:
Introduction: Arterial embolism unrelated to peripheral vascular disease (AEUPAD) is known to be associated with risk factors such as malignancy, atrial fibrillation and thrombophilias. This study aimed to determine survival following embolecotmy of native arteries for AEUPAD. Methodology: Retrospective analysis was performed of a prospectively maintained database in a single vascular centre for the past 18 years, for all native artery embolectomies. Patients with PAD and graft embolectomies were excluded. Kaplan-Meier survival analysis was performed to calculate overall survival. Relationship between death and known risk factors were also assessed. Results: From 1994 to 2012, 192 patients had 204 native artery embolectomies for AEUPAD. 11 had multiple embolectomies. 100(49%) were male, mean age 72.5 (range: 9-102) years. Embolectomies performed; femoral 115 (56%), popliteal 47(23%), brachial 40 (17%), iliofemoral 1(0.4 %) and tibial 2(0.8%). 80 (41.60%) of patients were alive at the time of analysis. Kaplan-Meier estimates 69.77% survival 12 months post embolecotmy, decreased to 46.42% and 18.61% within 2 and 5 years respectively. Age (p<0.0001) and male sex (p=0.0451) were associated with death. Smoking had a negative correlation with mortality (p=0.0080). Conclusions: There is high mortality following embolecotmy. Though basic investigations are performed, further assessment may be necessary to prevent high mortality.

Link to full-text:
http://www.journal-surgery.net/article/S1743-9191(14)00812-7/pdf

Is the negativity rate of laparoscopic appendicectomies on the increase? (2015)

Type of publication:
Conference abstract

Author(s):
*Sukha A., *Packer H., *Taylor M., *Goodyear S.

Citation:
Surgical Endoscopy and Other Interventional Techniques, April 2015, vol./is. 29/(S313)

Abstract:
Aims: This study investigates the histological appearance of appendixes from laparoscopic and open appendicectomies. We propose that the negativity rate of laparoscopic appendicectomies is when compared to an open appendicectomy due to the advancements in laparoscopic equipment and surgeon skills. Methods Retrospective data collection of all appendicectomies between January – June 2014. Data was collected from Theatre logbooks and the Pathology and PACS computer systems, and analysed in Microsoft Excel. Results 226 appendectomies were performed on the emergency-operating list. 174 (77%) had a laparoscopic appendicectomy and 52(23%) had an open procedure. The negative appendix rate on histology was significantly higher in the laparoscopic group (28.2%, n = 49) versus the open group (11.5%, n = 6) p = 0.05. There was a 2% (n = 5) associated morbidity and 0% mortality. Conclusion Laparoscopic surgery is considered to be a minimally invasive surgical procedure with low associated risks. The appendix is removed when inflamed and often in right iliac fossa pain when no other pathology is found. Our study shows that laparoscopy may be overused resulting in higher than expected negativity rates. Key statement Laparoscopic surgery is fast becoming the preferred operative procedure for the suspected appendicitis diagnostic tool in the unclear presentation of right iliac fossa pain. The minimally invasive procedure is considered to be a safe procedure perhaps resulting in its overuse. We investigate the negativity rate in laparoscopic verses open appendicectomy.

How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study (2015)

Type of publication:
Journal article

Author(s):
Strong S., Blencowe N., Bhangu A., Panagiotopoulou I.G., Chatzizacharias N., Rana M., Rollins K., Ejtehadi F., Jha B., Tan Y.W., Fanous N., Markides G., Tan A., Marshal C., Akhtar S., Mullassery D., Ismail A., Hitchins C., Sharif S., Osborne L., Sengupta N., Challand C., Pournaras D., Bevan K., King J., Massey J., Sandhu I., Wells J.M., Teichmann D.A., Peckham-Cooper A., Sellers M., Folaranmi S.E., Davies B., Potter S., Egbeare D., Kallaway C., Parsons S., Upchurch E., Lazaridis A., Cocker D., King D., Behar N., Loukogeorgakis S.P., Kalaiselvan R., Marzouk S., Turner E.J.H., Kaptanis S., Kaur V., Shingler G., Bennett A., Shaikh S., Aly M., Coad J., Khong T., Nouman Z., Crawford J., Szatmary P., West H., MacDonald A., Lambert J., Gash K., Hanks K.A., Griggs E., Humphreys L., Torrance A., Hardman J., Taylor L., Rex D., Bennett J., Crowther N., McAree B., Flexer S., Mistry P., Jain P., Hwang M., Oswald N., Wells A., Newsome H., Martinez P., Alvarez C.A.B., Leon J., Carradice D., Gohil R., Mount M., Campbell A., Iype S., Dyson E., Groot-Wassink T., Ross A.R., Charlesworth P., Baylem N., Voll J., Sian T., Creedon L., Hicks G., Goring J., Ng V., Tiboni S., Palser T., Rees B., Ravindra P., Neophytou C., Dent H., Lo T., Broom L., O’Connell M., Foulkes R., Griffith D., Butcher K., Mclaren O., Tai A., Yano H., Torrance H.D.T., Moussa O., Mittapalli D., D.Watt, Basson S., Gilliland J., Pilgrim S., Wilkins A., Yee J., Cain H., Wilson M., Pearson J., Turnbull E., Brigic A., Yassin N.A., Clarke J., Mallappa S., Jackson P., Jones C., Lakshminarayanan B., Sharma A., Velineni R., Fareed K., Yip G., Brown A., Patel N., Ghisel M., Tanner N., Jones H., Witherspoon J., Phillips M., Ho M.F., Ng S., Mak T., Campain N., Mukhey D., Mitchell W.K., Amawi F., Dickson E., Aggarwal S., Satherley L.K., Asprou F., Keys C., Steven M., Johnstone M., Muhlschlegel J., Hamilton E., Yin J., Dilworth M., Wright A., Spreadborough P., Singh M., Mockford K., Morgan J., Ball W., Royle J., Lacy-Colson J., Lai W., Griffiths S., Mitchell S., Parsons C., Joel A.S., Mason P.F., Harrison G.J., Steinke J., Rafique H., Battersby C., Hawkins W., Gurram D., Hateley C.A., Penkethman A., Lambden C., Conway A., Dent P., Yacob D., Oshin O.A., Hargreaves A., Gossedge G., Long J., Walls M., Futaba K., Pinkney T., Puig.S, Boddy A., Jones A., Tennuci C., Battersby N., Wilkin R., Lloyd C., Sein E., McEvoy K., Whisker L., Austin S., Colori A., Sinclair P., Loughran M., Lawrence A., Horsnell J., Bagenal J., Pisesky A., Mastoridis S., Solanki K., Siddiq I., Merker L., Sarmah P., Richardson C., Hanratty D., Evans L., Mortimer M., Bhalla A., Bartlett D., Beral D., Cornish J., Haddow J.B., Hall N.J.

Citation:
International Journal of Surgery, March 2015, vol./is. 15/(107-112)

Abstract:
Background: Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons’ accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy. Materials and methods: The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement. Results: The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n=496), histopathological assessment revealed pathology in a substantial proportion (n=138, 27.8%). Where surgeons assessed the appendix as being inflamed (n=2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed tomography was associated with increased false positives. Conclusions: This multi-centre study suggests that surgeons’ judgements of the intra-operative macroscopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.

Monckeberg’s arteriosclerosis: Vascular calcification complicating microvascular surgery (2015)

Type of publication:
Journal article

Author(s):
*Castling B., *Bhatia S., *Ahsan F.

Citation:
International Journal of Oral and Maxillofacial Surgery, January 2015, vol./is. 44/1(34-36)

Abstract:
Monckeberg’s arteriosclerosis is often an incidental finding, identified either clinically or on plain radiography. It can occasionally be associated with diabetes mellitus or chronic kidney disease. It differs from the more common atherosclerosis in that the tunica intima remains largely unaffected and the diameter of the vessel lumen is preserved. Despite such vessels appearing hard and pulseless throughout their affected length, they deliver relatively normal distal perfusion, indeed there is often a bounding pulse at the end of the calcified zone. They appear unremarkable on magnetic resonance angiography but visibly calcified on plain radiography. Monckeberg’s arteriosclerosis has a prevalence of < 1% of the population, but when it does occur it can cause consternation at the prospect of using these vessels for microvascular anastamosis. We report our experience of deliberately using these vessels in an osseocutaneous radial forearm free flap reconstruction. Although there are some technical considerations to bear in mind, we would suggest that unlike vessels affected by atherosclerosis, anastomosis of arteries affected by Monckeberg’s arteriosclerosis has little or no impact on free flap survival.

 

Calcaneus osteotomy (2014)

Type of publication:
Journal article

Author(s):
Tennant J.N., *Carmont M., Phisitkul P.

Citation:
Current Reviews in Musculoskeletal Medicine, 2014, vol./is. 7/4(271-276), 1935-973X;1935-9748 (2014)

Abstract:
Calcaneal osteotomy is an extra-articular, joint-sparing procedure that is used in the correction of cavovarus and planovalgus foot deformity. Careful indications and contraindications for the procedure, with meticulous surgical technique, should be followed to avoid complications and to achieve optimal outcomes. Multiple options of osteotomies exist, including translational (medializing and lateralizing calcaneal osteotomy, with ability to slide proximally or distally, closing wedge (Dwyer), and rotational type osteotomies (Evans, Z-osteotomy). Future directions for innovation include developments of both implants and surgical techniques.

Link to more details or full-text: