National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Staged upper and lower lip reanimation following facial palsy: Peer-reviewed, patient-rated and objective outcomes

BACKGROUND

One approach to reanimating both upper and lower lips following facial palsy is through staged surgery: cross-face nerve grafting at stage I, free gracilis muscle transfer to levators at stage II and pedicled anterior belly of digastric muscle transfer (ABDMT) to depressors at stage III. The results of this approach were hitherto unquantified.

METHODS

This study retrospectively assessed peer-reviewed, patient-rated and objective outcomes following staged reanimation in adults between 2010 and 2020. Demographics, palsy characteristics and surgery details were recorded. Pre- and postoperative videos were rated by independent assessors using Terzis' aesthetic and symmetry scale. Photographs were analysed using Emotrics and patients completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.

RESULTS

Ten patients [mean age = 34 (SD = 12.48)] were eligible. All regained lip elevation and depression. All markers of symmetry improved after gracilis transfer. All markers were also improved after ABDMT except for lower lip height when smiling with teeth showing (p > 0.05). Five patients (50%) responded to the GBI (mean score = +39.44). No patients reported detriment from the reanimations. Mean Terzis' scores preoperatively and after stages II and III were 1.5, 2.26 and 2.39, respectively (p < 0.05). Nine patients underwent aesthetic refinements [lipofilling to lower lip notches (n = 5), debulking of gracilis bulk (n = 6), repositioning of muscle insertion (n = 5) and facelifts (n = 2)].

CONCLUSION

The outcomes were positive objectively and as judged by peers and patients themselves. Aesthetic refinements may also be required to enhance these results.

Standardised nurse-led protocol of radiolucent renal and proximal ureteric stones using sodium bicarbonate oral dissolution therapy

Objective:

Oral dissolution therapy is a recognised treatment option for radiolucent kidney stones. A standardised nurse-led protocol was developed. Efficacy and compliance was audited and results reviewed.

Methods:

Twenty-two patients with radiolucent stones were prescribed oral sodium bicarbonate. Patients monitored their urinary pH and the Urology Nurse Practitioner checked compliance. Follow-up with non-contrast computerised tomography of the kidneys, ureters and bladder (CT KUB) was evaluated at 6 weeks.

Results:

Twenty patients with radiolucent stones completed treatment. Mean stone size was 8 mm (2–23 mm). Nine patients (45%) had complete dissolution, three (15%) had partial dissolution and eight (40%) had no visible response on follow-up CT KUB. The Hounsfield unit (HU) average was 464 (116–1285). Those patients with complete dissolution had HU of less than 605. Three patients with encrusted ureteric stents underwent complete dissolution.

Conclusions:

Utilisation of a nurse-led sodium bicarbonate dissolution therapy protocol for the treatment of radiolucent stones is effective and acceptable to patients in carefully selected cases. Orally dissolution therapy (ODT) is a suitable option in patients with multiple co-morbidities and high anaesthetic risk. In our series, ODT was also highly effective in treating radiolucent stent encrustation.

1164 St Andrew’s COVID Surgery Safety (StACS) Study: Skin Cancer

Background

Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19.

Objective

This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-safety guidelines.

Method

A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). ‘Real-time’ 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively.

Results

Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups.

Conclusions

These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic.

Lower lip depressor reanimation using anterior belly of digastric muscle transfer improves psychological wellbeing in facial palsy patients

The authors previously published positive peer-reviewed (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage lower lip reanimations up to 2018. Other series have published surgeon and peer-rated results, but we know of only two (n=12) that have assessed patients' views using patient satisfaction surveys. This paper presents patient-rated outcomes (PROMS) in an 11-year series of both single and two-stage anterior belly of digastric muscle (ABDM) lower lip reanimations. Demographics, paralysis characteristics, operative details, and complications were recorded. Patients were telephoned and requested to complete the Glasgow Benefit Inventory (GBI) to assess patient-rated outcomes. Thirty-two patients were eligible (mean age 36.4 years). Twenty-one (63.6%) completed the GBI (mean score +33.3). More patients reported benefit than detriment (95.2% vs 4.8%). Complications were infrequent and included three cases of superficial infections and one of dermatitis. Four patients (12.5%) underwent minor revisions, mostly lipofilling of lip notches. The median (range) duration of follow up was 2.8 (0.3 - 8.5) years. ABDM transfer for lower lip reanimation is a safe, low morbidity procedure that enhances the psychological wellbeing of patients with facial palsy.

Epidemiology And Outcomes Of Radiator Burns At A High Throughput Burns Centre

Indoor radiator burns can cause significant morbidity and mortality, especially in vulnerable patients. However, the epidemiology and clinical outcomes are poorly characterized. A retrospective study of all radiator burns referred to a tertiary regional burns centre between 2013-2019 was conducted. Four hundred and forty-seven patients (median age 25.6 years, male:female ratio 1.4:1) were referred; 109 (24%) admitted, 201 (45%) managed in outpatients and 137 (31%) managed locally. The incidence of burns leading to referral was 0.65/100,000/year, but increased annually. Contact burns consisted of 99.6%. Age distribution was bimodal: <5 years (43%), >65 years (27%), although all ages were affected. Median TBSA was 0.75% (0.1-11.5%), but 79% had injuries <2%. Childhood burns were predominantly superficial dermal grab injuries, usually manageable as outpatients. Elderly patients had larger burns usually secondary to falls or impaired sensorium, and were more likely to die (p<0.05). Burns due to impaired sensorium were deeper and more likely to require surgery (p<0.05). Sixty-three (14%) patients required surgery. Thirty-day mortality was 1.1%. Age was the only significant predictor of mortality. This study quantifies the epidemiology and outcomes of a growing problem. It identifies at risk populations (extremes of age), and important features of the clinical assessment.

Long-term outcomes of dual innervation in functional muscle transfers for facial palsy

BACKGROUND

This study describes a different approach with a 2-stage facial reanimation in patients with long-standing unilateral facial paralysis using free gracilis muscle transfer, innervated by both cross-facial nerve graft and masseteric nerve. The authors present their rationale, surgical technique, and long-term outcomes.

METHODS

Between August 2012 and March 2016, 11 patients (6 female and 5 male patients) underwent a 2-staged dually innervated gracilis muscle transfer. Patients were evaluated with physical examination and needle electromyography. A standardized assessment of preoperative and postoperative photographs and videos was performed using Terzis' smile functional grading system at 48 months following surgery and the Emotrics software to assess improvement in symmetry over a 36-month postoperative period.

RESULTS

Voluntary contraction of the gracilis muscle was observed in all patients at a mean of 4 months and 4 days following muscle transfer. A spontaneous smile produced without teeth clenching was developed in all patients by 18 months postoperatively. Six patients achieved excellent and 5 good results. The difference between the averaged pre- and postoperative scores was statistically significant. With Emotrics, there were significant improvements in the smile angle, upper lip elevation, commissural excursion, and commissural height, with continuous improvement over 36 months. The postoperative electromyography (EMG) confirmed dual innervation of the gracilis muscle by the facial and masseteric donor motor neural sources. We present our results at minimum 48 months postoperatively.

CONCLUSIONS

Dual innervated two-stage gracilis transfer is an effective method for reanimation in long-standing unilateral facial paralysis, providing both rapid reinnervation of the transferred muscle, together with a powerful, synchronous smile.

Fecal Dipeptidyl Peptidase-4: An Emergent Biomarker in Inflammatory Bowel Disease

INTRODUCTION

Dipeptidyl peptidase-4 (DPP-4) is a membrane-bound glycoprotein that acts as a receptor but also exists in a soluble form. It has been recognized as a mediator of inflammation and considered a biomarker in inflammatory bowel disease (IBD).

METHODS

We evaluated a prospectively recruited cohort, consisting of 101 patients with IBD, using validated clinical indexes; 22 patients with ulcerative colitis (UC) underwent endoscopic evaluation. Fecal DPP-4 (fDPP-4) levels were analyzed and correlated with clinical scores, Mayo endoscopic score (in UC patients), serum DPP-4, C-reactive protein, and fecal calprotectin. Immunohistochemical staining for DPP-4 in intestinal biopsies was also performed.

RESULTS

When compared with remitters, median fDPP-4 levels were higher in patients with ileal Crohn's disease (CD) (7,584 [1,464-7,816] vs 2,104 [630-2,676] ng/mL, P = 0.015) and lower in patients with UC exhibiting clinical activity (1,213 [559-1,682] vs 7,814 [2,555-7,985] ng/mL, P < 0.001). Patients with UC presenting endoscopic activity also had lower levels than remitters (939 [559-1,420] vs 7,544 [4,531-7,940] ng/mL, P = 0.006). Fecal DPP-4 discriminated clinical activity from remission with areas under the curve of 0.76 (95% confidence interval [CI] 0.58-0.94, P = 0.015) and 0.80 (95% CI 0.68-0.93, P < 0.001) in CD and UC, respectively; it allowed to differentiate endoscopic activity in patients with UC, with areas under the curve of 0.84 (95% CI 0.63-1.00, P = 0.009). Immunohistochemical analysis revealed higher DPP-4 apical expression in UC remitters, but no statistically significant differences were revealed between patients with ileal CD.

DISCUSSION

Our results suggest that fDPP-4 can be used as a biomarker of IBD activity, particularly in UC. The expression profiles in intestinal tissue might represent a functional compartmentalization of DPP-4 expression.

St Andrew's COVID-19 Surgery Safety (StACS) study: Skin cancer

BACKGROUND

Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19.

OBJECTIVE

This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines.

METHOD

A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively.

RESULTS

Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups.

CONCLUSION

These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic.

LEVEL OF EVIDENCE

II.

St Andrew's COVID-19 surgery safety study: hand trauma

INTRODUCTION

Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines.

MATERIALS AND METHODS

A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group).

RESULTS

Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups.

CONCLUSION

These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience

Background

The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre.

Methods

A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April–May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described.

Results

Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients.

Conclusions

We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

Serum Dipeptidyl Peptidase 4: A Predictor of Disease Activity and Prognosis in Inflammatory Bowel Disease

BACKGROUND

Serum dipeptidyl peptidase 4 (DPP-4) has drawn particular interest as a biomarker in inflammatory bowel disease (IBD), as this protease inactivates several peptides that participate in the inflammatory cascade.

METHODS

Two prospectively recruited cohorts consisting of 195 patients (101 had Crohn's disease [CD] and 94 had ulcerative colitis [UC]) were evaluated using clinical indexes and followed up to assess for treatment escalation. Sixty-eight patients underwent endoscopic evaluation at baseline. In the second cohort of 46 biologically treated patients, treatment response was assessed. Serum DPP-4, C-reactive protein (CRP), and fecal calprotectin levels were quantified at baseline and during follow-up.

RESULTS

Median DPP-4 levels were significantly lower in active IBD patients when compared with remitters (CD: 1043 [831-1412] vs 1589 [1255-1956] ng/mL; P < 0.001; UC: 1317 [1058-1718] vs 1798 [1329-2305] ng/mL; P = 0.001) and healthy controls (2175 [1875-3371] ng/mL). In fact, DPP-4 was able to distinguish clinical and endoscopic activity from remission, with areas under the curve (AUC) of 0.81/0.93 (CD) and 0.71/0.79 (UC), along with the need for treatment escalation, with comparable AUCs of 0.79 (CD) and 0.77 (UC). Furthermore, DPP-4 levels were higher in responders to treatment and more pronounced among UC (1467 [1301-1641] vs 1211 [1011-1448] ng/mL; P < 0.001) than CD patients (1385 [1185-1592] vs 1134 [975-1469] ng/mL; P = 0.015).

CONCLUSIONS

Our results suggest that serum DPP-4 can be used as a noninvasive biomarker of IBD activity and biological treatment response and a predictor of treatment escalation, particularly when combined with other biomarkers.

A systematic review of outcomes following hand reconstruction using flaps from the superficial palmar branch of the radial artery (SUPBRA) system

BACKGROUND

Flaps based on the superficial branch of the radial artery (SUPBRA) are indicated when homo- or heterodigital flaps are inappropriate, but glabrous or like-for-like reconstruction is required.

AIM

To systematically review the outcomes of hand reconstruction using SUPBRA flaps.

METHODS

PubMed was searched for English-language articles studying SUPBRA flaps in November 2019. Data collected included flap vascular supply, dimensions, complications, donor site closure, and two-point discrimination.

RESULTS

Twenty-six papers were eligible (410 flaps). Flaps were classified as glabrous, nonglabrous or combined. Nonglabrous flaps were either free- (52%) or reverse-flow pedicled (1.7%) wrist flaps. Glabrous flaps were either free palmar (36.3%), reverse-flow pedicled palmar (2%), antegrade-flow pedicled palmar (0.2%) or perforator-based island palmar flaps (3.7%). Combined glabrous/nonglabrous flaps formed 4.1% of flaps. Maximal flap dimensions allowing direct closure were: 3.1 × 6 cm for wrist flaps and <3 × 10 cm for glabrous palmar flaps. Combined flaps can be 10 × 16 cm. Overall, complete and partial flap failure rates were 3.17% and 0.98%, respectively. Most complete failures were due to venous thrombosis. All 220 wrist donor sites were closed directly. Two out of 173 palmar donor sites (≥3.1) could not be primarily closed. Wound complications were rare, but 53.4% of free palmar flaps required debulking. The results of neurorrhaphy were inconsistent.

CONCLUSIONS

Flaps based on the SUPBRA are robust, provide like-for-like reconstruction of glabrous skin defects in one-stage, offer versatility due to diverse skin paddle orientation patterns and are in the same operative field as the defect.

St Andrew's COVID-19 surgery safety (StACS) study: Elective plastic surgery, trauma & burns

Introduction

This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines.

Method

A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group).

Results

Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236).

Conclusion

We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

Management of intraarticular proximal interphalangeal joint fracture-dislocations and pilon fractures with the Ligamentotaxor® device

INTRODUCTION

Fracture-dislocation and pilon injuries of the proximal interphalangeal joints (PIPJ) continue to pose significant management challenges. Stable fracture configurations can be treated with extension block splinting or pinning. Unstable fractures usually require open or closed reduction and fixation either directly/internally onto the fracture using Kirschner wires, cerclage wires, screws or miniplates or indirectly/externally by ligamentotaxis using external fixators which can be dynamic or static. Dynamic external fixators, such as Suzuki's pins and rubber traction system, S-Quattro and Hynes/Giddins frame, appear intuitive as they provide axial distraction, which reduces the fracture whilst obviating the need to open the fracture. They also allow immediate active movement whilst maintaining reduction. The Ligamentotaxor® (Arex, Pallaiseau Cedex, France) is a commercially-available dynamic external fixator which has been used at our institution since 2013.

MATERIALS AND METHODS

This retrospective study assessed the outcomes (interphalangeal joint active range of movement (AROM), QuickDASH score and complications) in 19 patients [mean age of 48.6 (SD 16.2)] whose proximal interphalangeal joint (PIPJ) fracture-dislocations and/or pilon fractures were treated with the Ligamentotaxor®. Injuries were classified according to Seno i.e. (1) volar lip fracture ± dorsal dislocation (2) dorsal lip fracture ± volar dislocation (3) pilon fracture.

RESULTS

There were fifteen (79%) pilon/Seno 3, three (16%) Seno 1 and one (5%) Seno 2 fractures. The mean PIPJ AROM was 70.6° (SD 4.48°) for all Seno classes and 70° (SD 5.6°) for the pilon subgroup. The QuickDASH score averaged to 2.65 (SD 0.88). There were two pin-site infections, three pin-site inflammations, one osteomyelitis and two complex regional pain syndrome diagnoses. One patient required arthroplasty after missing several appointments.

CONCLUSIONS

These results, considering the predominance of pilon fractures, compare favourably the published Ligamentotaxor® and other dynamic external fixator systems.

The mini-temporalis turnover flap for midface reanimation: Photogrammetric and patient-rated outcomes

BACKGROUND

Mini-temporalis transposition (MTT) flaps, modified from Gillies' technique, have become less popular than temporalis tendon transfers for midface reanimation. MTT involves raising the middle third of the temporalis, transposition over the zygomatic arch and lengthening with deep temporalis fascia which is sutured to the orbicularis oris.

AIM

This retrospective study assessed subjective and objective outcomes following MTTs by a single surgeon from 2009 to 2019.

METHODS

Operative and surgical details were recorded. Four blinded consultants rated pre- and postoperative videos according to Terzis' scale. Pre- and postoperative resting, Mona Lisa and canine smile photographs were analysed using Emotrics, the software that automatically computes differences in inter-landmark distances. Patients also completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.

RESULTS

Forty-one patients (mean age 65.8 ± 15.5) underwent MTT, median 3 (0.4-57) years post-paralysis and were followed up for median of 2.2 (0.4-8.8) years. Higher mean postoperative Terzis score demonstrates symmetric and aesthetic improvements (3 ± 1.3 vs. 2 ± 1; p<0.05). Emotrics analysis showed postoperative improvements in resting and dynamic symmetry of all indices, with the majority statistically significant (p<0.003). The mean GBI was 35.19 with 17 (94.4%) patients reporting improvement, whereas one (5.6%) patient reported detriment after surgery. Two (5.4%) patients suffered complications: one haematoma and one infection. Four patients (9.8%) required revisional flap tightening. No patients requested revisional surgery for temporal hollowing or zygomatic fullness.

CONCLUSIONS

MTT effectively improves both subjective and objective resting and dynamic midface symmetry in a single stage. These results suggest this technique is a good alternative to temporalis tendon transfer techniques.

Mortality risk scoring in emergency general surgery: Are we using the best tool?

BACKGROUND

It is imperative that an accurate assessment of risk of death is undertaken preoperatively on all patients undergoing an emergency laparotomy. Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the most widely used scores. National Emergency Laparotomy Audit (NELA) presents a novel, validated score, but no direct comparison with P-POSSUM exists. We aimed to determine which would be the best predictor of mortality.

METHODS

We analysed all the entries on the online NELA database over a four-and-a-half-year period. The Hosmer-Lemeshow goodness of fit test was performed to assess model calibration. For the outcome of death and for each scoring system, a non-parametric receiver operator characteristic analysis was done. The sensitivity, specificity, area under receiver operator characteristic curve and their standard errors were calculated.

RESULTS

Data pertaining to 650 patients were included. There were 59 deaths, giving an overall observed mortality rate of 9.1%. Predicted mortality rate for the P-POSSUM score and NELA score were 15.2% and 7.8%, respectively. The discriminative power for mortality was highest for the NELA score (C-index = 0.818, CI: 0.769-0.867, p < 0.001), when compared to P-POSSUM (C-index = 0.769, CI: 0.712-0.827, p < 0.001).

CONCLUSIONS

The NELA score showed good discrimination in predicting mortality in the entire cohort. The P-POSSUM over-predicted observed mortality and the NELA score under-predicted observed mortality.

An Analysis of the Decision-Making Process After “Decision not to Operate” in Acutely Unwell, High-Risk General Surgery Patients

Objectives:

The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken.

Background:

A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof.

Methods:

We retrospectively evaluated “decisions not to operate” over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth–Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality.

Results:

Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score ( P < .001) and a poorer functional status ( P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively).

Conclusions:

Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.

Single dose versus multiple dose of antibiotic prophylaxis in caesarean section: a systematic review and meta-analysis

BACKGROUND

Prophylactic antibiotics are traditionally given as a single dose for caesarean section. However, inconsistent application of recommendations and recent evidence prompted a literature review.

OBJECTIVES

To assess the optimal regimen for antibiotic prophylaxis in caesarean section by comparing single versus multiple doses of the same intervention.

SEARCH STRATEGY

MEDLINE, Web of Knowledge, SCOPUS, CENTRAL and ongoing trials databases were searched. Reference lists were reviewed and international groups contacted.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing single with multiple dose regimens of the same antibiotic prophylaxis. Quasi-RCT and abstracts were suitable for inclusion.

DATA COLLECTION AND ANALYSIS

Reviewers independently extracted data and assessed quality of evidence. A random-effects model was used and results presented as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Sixteen studies were included, involving 2695 women. Nonsignificant differences were observed between single dose and multiple dose antibiotic prophylaxis in the incidence of postpartum infectious morbidity (RR 0.95, 95% CI 0.75-1.20, I2 = 25%), endometritis (RR 1.03, 95% CI 0.74-1.42, I2 = 0%) and wound infection (RR 1.22, 95% CI 0.72-2.08, I2 = 0%). A trend towards lower risk of urinary tract infection was seen with multiple dose (RR 0.65, 95% CI 0.34-1.24, I2 = 0%).

CONCLUSIONS

There was insufficient evidence to determine whether there is a difference between single and multiple dose regimens in reducing the incidence of infectious morbidity after caesarean section. The quality of evidence was very low and well-designed RCTs are needed.

TWEETABLE ABSTRACT

Insufficient evidence of difference between dosage regimens of antibiotic prophylaxis in caesarean section.