Citation: BJU International. 2022 Jun 10. Online ahead of print.
Author: Keiran D Clement, Alexander Light, Aqua Asif, Vinson Wai-Shun Chan, Sinan Khadhouri, Taimur T Shah, Frederick Banks, Trevor Dorkin, Christopher P Driver, Vinnie During, Nia Fraser, Maximilian J Johnston, Marc Lucky, Vaibhav Modgil, Asif Muneer, Arie Parnham, Ian Pearce, Majed Shabbir, Manoj Shenoy, Duncan J Summerton, Shabnam Undre, Alun Williams, Steven MacLennan, Veeru Kasivisvanathan, FIX-IT collaborators
Abstract: Objectives: To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology.
Materials and methods: A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines.
Results: Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred.
Conclusions: We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.
Keywords: Fixation; Orchidopexy; Scrotal exploration; Surgical Technique; Testicular Torsion
Friday 5 August 2022
WUTH publication: A BURST-BAUS consensus document for best practice in the conduct of scrotal exploration for suspected testicular torsion: the Finding consensus for orchIdopeXy In Torsion (FIX-IT) study
WUTH publication: The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias
Citation: European Journal of Trauma and Emergency Surgery. 2022 Jun 21. Online ahead of print.
Author: Walid Ibrahim, Jeremy Wilson, Conor Magee
Abstract: Purpose: Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia.
Methods: A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay.
Results: Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014).
Conclusions: Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .
Keywords: Abdominal wall; Acute symptomatic; CT; Hernia; Preoperative.
WUTH publication: The diagnostic value and accuracy of ultrasound in diagnosing hydatidiform mole: A systematic review and meta-analysis of the literature
Citation: Radiography. 2022, 28(4), 897-905
Author: I Newhouse, A Spacey, B Scragg, K Szczepura
Abstract: Introduction: Hydatidiform moles are the most common type of gestational trophoblastic disease. Internationally the incidence of hydatidiform moles is 1-2:1000 pregnancies. Early detection of women with hydatidiform moles is preferential, as these women are at a higher risk of developing other gestational trophoblastic disease. Despite Ultrasound being the most common modality used to diagnose hydatidiform moles, its diagnostic value and accuracy throughout all trimesters remains uncertain. Thus, the aim of this review was to explore and evaluate the diagnostic value and accuracy of Ultrasound in diagnosing hydatidiform mole throughout all trimesters of pregnancy.
Methods: The databases MEDLINE and CINAHL were searched between 2004 and 2021. Included studies were quality assessed using the Mixed Methods Appraisal Tool.
Results: A total of 8 studies were included. The narrative synthesis identified four themes: Misdiagnosis, Complete and Partial molar pregnancy, Operator dependency and Gestational age. The meta-analysis highlighted although the sensitivity of ultrasound for diagnosing hydatidiform moles is relatively low at 52.2%, the specificity was high at 92.6%.
Conclusion: While histological examination remains the gold standard for detecting hydatidiform moles, our review made evident that ultrasound is a beneficial diagnostic tool in the detection of Hydatidiform moles, especially alongside other diagnostic investigations. This review has highlighted and collated the main barriers and facilitators to diagnosing hydatidiform moles using ultrasound.
Implication for practice: Findings suggest that although sonographic detection of hydatidiform moles remains a diagnostic challenge, seeking a second opinion or repeating scans before making a final diagnosis should be embedded into clinical practice.
Keywords: Complete molar; Gestational trophoblastic disease; Hydatidiform mole; Partial molar; Ultrasound.
WUTH publication: Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy
Citation: Surgical Endoscopy. 2022 Jun 9. Online ahead of print.
Author: Matta Kuzman, Khalid Munir Bhatti, Islam Omar, Hany Khalil, Wah Yang, Prem Thambi, Nader Helmy, Amir Botros, Thomas Kidd, Siobhan McKay, Altaf Awan, Mark Taylor, Kamal Mahawar
Abstract: Background: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure.
Methods: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media.
Results: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy.
Conclusions: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.
Keywords: Cholecystectomy; Cholecystitis; Gallbladder surgery; Gallstone disease; Gallstone pancreatitis; Obstructive jaundice; Variation in practice.
WUTH publication: Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR)
Citation: BMJ Open. 2022, 12(7), e062698
Author: Jayne Ellis, David Harvey, Sylviane Defres, Arjun Chandna, Eloisa MacLachlan, Tom Solomon, Robert S Heyderman, Fiona McGill, National Audit of Meningitis Management (NAMM) group
Abstract: Objectives: To assess practice in the care of adults with suspected community-acquired bacterial meningitis in the UK and Ireland.
Design: Retrospective cohort study.
Setting: 64 UK and Irish hospitals.
Participants: 1471 adults with community-acquired meningitis of any aetiology in 2017.
Results: None of the audit standards, from the 2016 UK Joint Specialists Societies guideline on diagnosis and management of meningitis, were met in all cases. With respect to 20 of 30 assessed standards, clinical management provided for patients was in line with recommendations in less than 50% of cases. 45% of patients had blood cultures taken within an hour of admission, 0.5% had a lumbar puncture within 1 hour, 26% within 8 hours. 28% had bacterial molecular diagnostic tests on cerebrospinal fluid. Median time to first dose of antibiotics was 3.2 hours (IQR 1.3-9.2). 80% received empirical parenteral cephalosporins. 55% ≥60 years and 31% of immunocompromised patients received anti-Listeria antibiotics. 21% received steroids. Of the 1471 patients, 20% had confirmed bacterial meningitis. Among those with bacterial meningitis, pneumococcal aetiology, admission to intensive care and initial Glasgow Coma Scale Score less than 14 were associated with in-hospital mortality (adjusted OR (aOR) 2.08, 95% CI 0.96 to 4.48; aOR 4.28, 95% CI 1.81 to 10.1; aOR 2.90, 95% CI 1.26 to 6.71, respectively). Dexamethasone therapy was weakly associated with a reduction in mortality in both those with proven bacterial meningitis (aOR 0.57, 95% CI 0.28 to 1.17) and with pneumococcal meningitis (aOR 0.47, 95% CI 0.20 to 1.10).
Conclusion: This study demonstrates that clinical care for patients with meningitis in the UK is not in line with current evidence-based national guidelines. Diagnostics and therapeutics should be targeted for quality improvement strategies. Work should be done to improve the impact of guidelines, understand why they are not followed and, once published, ensure they translate into changed practice.
Keywords: BACTERIOLOGY; Diagnostic microbiology; INTERNAL MEDICINE; Infectious disease/HIV; Molecular diagnostics; Protocols & guidelines.
WUTH publication: Small bowel obstruction caused by a fibrotic bow-string appendix: a consequence of non-operative management of acute appendicitis
Citation: Annals of the Royal College of Surgeons of England. 2022 May 31. Online ahead of print.
Author: J Banks, P Shuttleworth, N Day, R Guy
Abstract: A 73-year-old woman presented with small bowel obstruction that failed to settle with conservative management. Over the previous 2 years she had presented twice with computed tomography scan-proven acute appendicitis with localised perforation of the appendix tip. In view of medical comorbidities, she was treated non-operatively with clinical and radiological resolution on each occasion, but on the third presentation laparoscopy was undertaken for non-resolving small bowel obstruction and the non-inflamed appendix itself was identified as a fibrous band causing compression of the distal ileum and complete small bowel obstruction. Following division and appendicectomy, the patient made an uneventful recovery. This case illustrates the potential consequence of repeated appendiceal inflammation and non-operative management and may be seen increasingly as this approach is widely adopted during the COVID-19 pandemic.
Keywords: Acute appendicitis; Non-operative management; Small bowel obstruction.
WUTH publication: Patient worry and concern associated with referral on the two-week suspected head and neck pathway
Citation: British Dental Journal. 2022 Jul 5;1-5. Online ahead of print.
Author: Catherine E P Rowlands, Peter James, Derek Lowe, Simon N Rogers
Abstract: Introduction Patient worry and concern of cancer adds to the latent distress associated with referral on the two-week suspected pathway (2WW). For oral cancer, as the conversion rate is in the region of 5-10%, the majority of people will have needless cause for concern.Aim This study aims to report how worried/concerned patients were that the reason for referral might mean that they had cancer and to relate to referral characteristics.Materials/methods All patients referred on the 2WW to two oral and maxillofacial departments in the three months from January to March 2021 were sent a one-off anonymised study-specific post-consultation survey.Results In total, 107 of 353 patients responded to the survey (30%). The response rate increased notably in the older group (p <0.001). The cancer conversion rate overall was 5.4% (19/353), stratified as 2.4% (4/167) for general dental practitioner and 8.1% (15/186) for general medical practitioner (p = 0.02). When asked how worried/concerned they were that the reason for referral might have been for cancer, the response was 'very much' (34%, 33/98), and 'somewhat' (24%, 24/98). Concerns tended to be higher in women and those under 40.Conclusions In recognition of the proportion of patients on the 2WW pathway without cancer who have 'very much worry and concern', it is appropriate to explore ways to alleviate this anxiety, and the best means to achieve this needs careful consideration.
WUTH publication: Effect of contrast administration on the renal function of predialysis patients undergoing fistuloplasty
Citation: Journal of Vascular Surgery. 2022 Jun 13, S0741-5214(22), 01648-2. Online ahead of print.
Author: Panagiota Birmpili, Thomas Pearson, Ewa Magdalena Zywicka, James Jackson, Ramasubramanyan Chandrasekar
Abstract: Objective: The aim of this study was to investigate if administration of iodinated contrast during endovascular interventions in arteriovenous fistula (AVF) in patients not requiring dialysis (predialysis patients) (1) negatively affects their renal function and (2) if oral hydration has a protective effect.
Methods: All pre-dialysis patients who underwent endovascular interventions in AVF between August 2010 and April 2019 were included in the study. During the procedures, 35 to 50 mL of Iodixanol were administered. A pre-hydration protocol was introduced in March 2015. Data were grouped before and after this date. The difference between pre- and post-contrast estimated glomerular filtration rate (eGFR) and the difference between the eGFR of hydrated and non-hydrated groups were calculated.
Results: Eighty-four patients who underwent 151 procedures were included in the study. In 60.3% of procedures, a mean decrease of 1.35 mL/min/1.73 m2 in eGFR was noted (95% confidence interval [CI], 1.02-1.69 mL/min/1.73 m2), whereas in 35.1% of procedures, there was a mean increase of 1.06 mL/min/1.73 m2 (95% CI, 0.84-1.28 mL/min/1.73 m2). The mean difference between pre- and post-procedure eGFR was -0.44 mL/min/1.73 m2 (95% CI, -0.72 to -0.16 mL/min/1.73 m2; P = .002). Oral hydration was associated with a smaller mean change in eGFR of -0.32 mL/min/1.73 m2 (95% CI, -0.62 to -0.03 mL/min/1.73 m2) compared with the non-hydrated group, with mean change of -0.47 mL/min/1.73 m2 (95% CI, -0.91 to -0.03 mL/min/1.73 m2), but this was not statistically significant (P = .586).
Conclusions: This study demonstrates that administration of up to 50 mL of iodinated contrast for endovascular interventions in AVF in predialysis patients has minimal adverse effect on the eGFR with questionable clinical significance. In addition, oral hydration before and after the procedure has only a mild protective effect against a decrease in eGFR.
Keywords: Arteriovenous fistula; Chronic renal insufficiency; Contrast-induced acute kidney injury; Endovascular; Hemodialysis; Iodinated contrast.
WUTH publication: Knowledge mobilization in critical care and the evolving communication role of nurses
Author: Sioban Kelly, Jayne Garner, Victoria Treadway, Girendra Sadera
Abstract: Background: The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes.
WUTH publication: The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery
Citation: International Journal of Surgery. 2022 Jul 13, 104, 106766. Online ahead of print
Author: Islam Omar, Karl Miller, Brijesh Madhok, Bassem Amr, Rishi Singhal, Yitka Graham, Sjaak Pouwels, Mohammad Abu Hilal, Sandeep Aggarwal, Irfan Ahmed, Ali Aminian, Basil Jaser Ammori, Tan Arulampalam, Altaf Awan, José María Balibrea, Aneel Bhangu, Richard Raymond Brady, Wendy Brown, Manish Chand, Ara Darzi, Talvinder Singh Gill, Ramen Goel, Bussa R Gopinath, Mark van Berge Henegouwen, Jacques M Himpens, David Daniel Kerrigan, Misha Luyer, Christian Macutkiewicz, Julio Mayol, Sanjay Purkayastha, Raul Jacobo Rosenthal, Scott Alan Shikora, Peter Kenneth Small, Neil James Smart, Mark A Taylor, Tehemton E Udwadia, Tim Underwood, Yirupaiahgari Ks Viswanath, Neil Thomas Welch, Steven D Wexner, Michael Samuel James Wilson, Des C Winter, Kamal K Mahawar
Abstract: Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.
Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.
Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.
Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
Keywords: Ergonomics; Gastrointestinal surgery; Guidelines; Hepatobiliary; Laparoscopic surgery; Minimally invasive; Patient safety; Surgical training.