Is there a standardised consent process within the surgical specialties?

IntroductionThe consent process is central to surgical practice. Subsequent to landmark cases such as Montgomery and Thefaut there is increasing consensus that consent should be a staged process. The aim of our survey was to identify if there was any homogeneity in the practice of surgeons with regards to the consent process in comparison to national guidelines.MethodsOur survey was distributed to a broad range of surgical specialties via an anonymous Google Forms questionnaire available online. Consultant Surgeons and Specialist registrars across the United Kingdom were then contacted via their relevant surgical societies and professional. Data collection was based on the Montgomery principles: consent location; face to face meetings; information leaflets (including their source); distribution of copies of letters and consent forms; use of percentage risks; use of pre-printed consent forms.ResultsThe total number of replies was 325. The majority of consent was taken on the day of surgery (166/319; 50.8%). Scheduled meeting for the consent process occurred routinely in only 87 cases (87/319; 27.3%). 103 (103/319; 32.9%) responders indicated the use of pre-printed consent forms. Of which 93 (93/103; 90.3%) were produced locally. Risk percentages were routinely used by 103 responders (103/319; 32.9%) Nearly two-thirds never write specific risk percentages routinely (205/319; 64.3%). Copies of consent forms were routinely given out by 210 responders (210/319; 65.8%). Supporting information was routinely given to patients in 248 cases (248/319; 77.7%).ConclusionOur survey documents significant variation in the practice of consent despite clear guidance on best practice. We believe that most surgeons welcome a more thorough and robust consent process, but hey need the time and infrastructure to be able to do it Introduction.     

Is there still a role for experimental surgery in the surgical sciences?

The firm opposition of public opinion and the reduction in public funding have remarkably curtailed the role of experimental surgery which several years ago was a key aspect of the activity of a surgical department. Experimental surgery in large animals has been virtually banned and experimental research in small animals requires the use of complex microsurgical techniques. In our opinion, experimental surgery is still useful in order to test new surgical devices and new drugs, especially in the field of transplant surgery. Another important function of experimental surgery is to facilitate the training of surgical residents in order to speed up the process of acquiring experience and expertise. Public opinion can be reassured because the legislation is very strict and safeguards the well-being of animals.     

Osteofibrous dysplasia of the tibia. Is there a need for a radical surgical approach?

Osteofibrous dysplasia is an unusual developmental condition of childhood, which almost exclusively affects the tibia. It is thought to follow a slowly progressive course and to stabilise after skeletal maturity. The possible link with adamantinoma is controversial and some authors believe that they are part of one histological process. We retrospectively reviewed 16 patients who were diagnosed as having osteofibrous dysplasia initially or on the final histological examination. Their management was diverse, depending on the severity of symptoms and the extent of the lesion. Definitive (extraperiosteal) surgery was localised "shark-bite" excision for small lesions in five patients. Extensive lesions were treated by segmental excision and fibular autograft in six patients, external fixation and bone transport in four and proximal tibial replacement in one. One patient who had a fibular autograft required further excision and bone transport for recurrence. Six initially underwent curettage and all had recurrence. There were no recurrences after localised extraperiosteal excision or bone transport. There were three confirmed cases of adamantinoma. The relevant literature is reviewed. We recommend extraperiosteal excision in all cases of osteofibrous dysplasia, with segmental excision and reconstruction in more extensive lesions.     

Is there a need for resident general surgical cover in small peripheral hospitals?

AIM: To assess the need for resident general surgical cover in a small peripheral hospital. PATIENTS AND METHODS: The total number of admissions to Caerphilly District Miners' Hospital in the year 2001 was noted along with the admission criterion for elective general and vascular surgical patients. RESULTS: Among the 10,608 in-patients only 120 (1.13%) developed general surgical/vascular problems that merited surgical referral and out of these 30 (0.28%) patients were transferred to neighbouring larger hospitals for specialist care. CONCLUSIONS: A resident staff grade surgeon is not required in a small peripheral hospital and this service could be provided by the resident on-call surgical SpR in a neighbouring larger hospital.     

Is acute appendicitis a surgical emergency?

Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis. Immediate surgery results in the confirmation of diagnosis and the control of sepsis without the risk of recurrent appendicitis. However, when notified by the emergency room of the diagnosis, many surgeons are opting to begin antibiotics and intravenous fluids and to schedule the appendectomy at their convenience. We hypothesize that using intravenous antibiotics and hydration to delay appendectomy until "normal business hours" has a negative impact on patient morbidity and mortality. During a 23-month period, the medical records of 81 patients at a single institution who underwent appendectomy were reviewed. All patients had preoperative CT scans and all operations were performed by one of two surgeons. Group A included those patients who underwent appendectomy within 10 hours of CT diagnosis and group B included those appendectomies performed greater than 10 hours after diagnosis. Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were used for comparison. The average time to operation (3.18 vs 15.85 hours), operative time (54.1 vs 55.7 minutes), length of stay (2.65 vs 2.09 days), wound infections (4 vs 0), and antibiotic use at discharge (19 vs 3) for group A and B were not statistically different. This data suggests that delaying operative intervention for acute appendicitis to accommodate a surgeon's preference or to maximize a hospital's efficiency does not pose a significant risk to the patient.     

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

BACKGROUND: Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined. STUDY DESIGN: From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed. All patients received chemotherapy, five patients received radiotherapy, and three patients also underwent surgical resection. A review of the published pancreatic lymphoma experience in the English-language literature was also undertaken. RESULTS: Three patients underwent pancreaticoduodenectomy with successful resection of the lymphoma and are disease free at 64, 62, and 53 months followup. Five patients were treated with nonresectional therapy. Three are disease free at 128, 51, and 24 months. Two patients died of disease at 9 and 37 months. A review of the pancreatic lymphoma experience in the English-language literature identified 122 cases of pancreatic lymphoma. Fifty-eight of these cases represented stage I or II lymphoma, which was treated without surgical resection with a 46% cure rate. Fifteen patients who had surgical resection for localized disease have been reported with a 94% cure rate. CONCLUSIONS: Based on both our single institution experience and the literature, it is suggested that surgical resection may play a beneficial role in the treatment of localized pancreatic lymphoma, although selection factors cannot be absolutely excluded.     

Is there a "learning curve" for muscle perforator flaps?

Although soft tissue free flaps have been in the mainstream for over 40 years, muscle perforator flaps per se are a relatively recent addition to the armamentarium of the reconstructive microvascular surgeon. Even though actually only a fasciocutaneous flap subtype, a distinctively different approach is necessary for their safe and reliable use, which has deterred many from adopting this valuable asset for fear of not being able to master an implied "learning curve." Whether this is a justifiable excuse led to our examination of our original microsurgical experience from 1982-1986, which in retrospect had its own learning curve. All 30 soft tissue flaps during that initiation period were muscle free flaps, which not only had a now unacceptable 37% major complication rate but also a complete failure rate of 26% due specifically to our technical inadequacies with the requisite microanastomoses. When compared with our first 30 muscle perforator flaps, there was a similar incidence of major complications (30%), although the eventual transferred flap success rate was 97%. This confirmed the existence of a learning curve in our preliminary experience with muscle perforator flaps that was consistent with any surgical innovation. However, our microsurgical prowess by this time had facilitated the acquisition of the skills to comfortably harvest a muscle perforator flap with a very acceptable success rate that minimized the steepness of our particular learning curve. Just what will be the configuration of the unavoidable muscle perforator flap learning curve specific for each individual will depend on their own capabilities, the relative technical difficulty of a given flap, and the level of competency expected.     

Sacrocolpopexy: is there a consistent surgical technique?

Introduction

Sacrocolpopexy is the gold standard treatment for vault prolapse. Current reported standards regarding surgical approach and technique vary. Our aim was to evaluate the surgical techniques used and identify any consistency.

Methods

Electronic surveys were sent to 148 candidates enrolled in a sacrocolpopexy workshop at the 2012 American Urogynecologic Society (AUGS) annual meeting and as a link in the International Urogynecology Association (IUGA) e-magazine. The survey assessed demographics, specific surgical steps including dissection techniques, number and type of sutures, graft materials, and the approach to intraoperative complications.

Results

Within the AUGS group, 61 candidates responded (41 %). From the IUGA membership, 128 responded for a total of 189. Overall, 59 % identified their primary practice as urogynaecology, 43 % having completed a fellowship. Only 33 % reported performing sacrocolpopexy as the primary surgery for vault prolapse. Technical aspects: 99.4 % used polypropylene mesh, with 57 % attaching it to the vagina using non-absorbable monofilament sutures. An average of 3–4 sutures were used on the anterior and posterior walls respectively. Suture location: 22.5 % reported not placing apical sutures and 55.7 % place their anterior wall sutures midway down the vagina. Posteriorly, 47 (30 %) placed sutures through the uterosacral ligaments, 19 (12.4 %) through the levator ani and 15 % extend the mesh to the perineal body. The mesh was attached to the sacrum using permanent sutures by 75 %. Dissection of the sacrum was deemed the most technically difficult aspect.

Conclusion

Surgical technique varies widely despite the level of expertise and training. This study highlights the need for an evaluation of the effect of surgical technique on outcomes.

     

Is congenital lobar emphysema a surgical disease?

Background

The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children.

Methods

All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed.

Results

Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement.

Conclusions

The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.     

Are there gender differences in choosing a surgical career?

BACKGROUND: Interest in general surgery has declined among US medical students, with the increasing number of female medical students being cited as a causative factor. This study evaluates factors related to choosing a general surgery career and determines if they differ between men and women. METHODS: A survey assessing factors that contributed to career choice was distributed to a 2002 graduating medical school class to be returned with their match lists. Students were asked, from a given list, which factors influenced their career choice. Those students who did not pursue a career in general surgery were asked what factors contributed to that decision. The results were stratified by gender. RESULTS: Of 120 surveys, 54 women and 48 men responded (response rate=85%). The reason most commonly cited for a particular career choice by both men and women was the intellectual challenge of the field, chosen by 41 men (85%) and 46 women (85%). The two next most common reasons cited by male students were an elective in the field and practice lifestyle (40 of 48 respondents, or 82%, for each). Practice lifestyle was a contributing factor for 37 of the 54 women, or 69% (P=.132). The other reasons most commonly cited by women were an elective and faculty in the chosen field (46 of 54, or 85%, and 38 of 54, or 70%). Thirty-seven of the 48 men, or 77% (P=.588), felt that faculty in the field contributed to their career choice. The most commonly cited reasons for not choosing general surgery--residency lifestyle, practice lifestyle, and length of training--were the same for both groups. CONCLUSIONS: Fewer women than men considered practice lifestyle in choosing their medical career. However, both men and women considered lifestyle, elective in the field of choice, and faculty important in career choice. In 2002, men and women had the same reasons for pursuing a career in general surgery or seeking another specialty.     

Is there a chronic appendicitis in childhood? Analysis of pediatric surgical patients from 1993-1997

The right lower quadrant abdominal pain and the "chronic" appendicitis in childhood and adolescence are frequently connected with a lot of different diagnostical problems for the treating physician. Since the introduction of diagnostical laparoscopy and laparoscopical appendectomy in our hospital the rate of appendectomy has been increased to 35% in case of the histological diagnosis of "chronic" appendicitis. A special problem in childhood and adolescence is the request of the parents for clarification of chronic recurrent pain in their children and therefore the demand of laparoscopy and not seldom appendectomy. After appendectomy with the pathological-histological findings of "chronic" appendicitis children are in 83% without any abdominal pain. Therefore the question arises whether there exists a "chronic" appendicitis in childhood justifying surgery in these cases. Although the rate of complications and conversions (3.8%) in diagnostical laparoscopy and laparoscopical appendectomy is quite low the indication should only be made after careful examination considering differential diagnostical problems. In our hospital 56.5% of the children with the histological diagnosis of "chronic" appendicitis suffered retrospectively on other diseases, that had been caused the symptoms of appendicitis. Before operation the patients should be informed on the complications in detail.     

Is there a way to avoid surgical complications of twist drill craniostomy for evacuation of a chronic subdural hematoma?

Summary Background. Although twist drill craniostomy for evacuation of a chronic subdural hematoma is a rapid and minimally invasive procedure, it carries the risk of complications because it is a ‘blind’ technique. Our aim was to analyse the complications in a series of patients treated by this technique in order to identify methods of avoidance by modifications in the surgical technique. Method. Thirty-nine patients with a chronic subdural hematoma underwent twist drill craniostomy between November 2002 and December 2005 in our clinic. When a surgical complication happened we modified our surgical technique to see if this avoided it in future patients. Findings. Surgical complications happened in 7 patients (17.9%) including inadequate drainage, brain penetration, acute epidural hematoma and catheter folding. After preventive modifications these complications did not recur. Conclusions. Modifications in the technique of twist drill craniostomy are described in this paper which may minimise the occurrence of surgical complications.     

Is radical prostatectomy primarily a surgical debulking procedure?

Radical prostatectomy has been considered the gold standard for the curative treatment of clinically localized prostate cancer. After an extensive review of the literature, we concluded that surgery probably functions primarily as a tumor debulking procedure rather than a curative one. Morphometric studies suggest that the majority of patients undergoing surgery have tumors too large for cure. Histologic studies demonstrate that 55% of radical prostatectomy specimens show evidence of extraprostatic disease and approximately 15% have tumors so small that a clinical impact on longevity is unlikely. Thus, only 30% of patients have surgery that is clearly beneficial on a histopathologic basis. Given the rather long doubling time of prostate cancers, many patients with residual cancer following surgery die of other causes, giving the false impression of cure. However, long-term studies in men with positive surgical margins have demonstrated that the majority die from prostate cancer. Furthermore, using prostate specific antigen as a measure of progression, the biochemical disease-free survival rates are substantially lower than the cause-specific survival rates. Although radical prostatectomy may be the best tumor debulking procedure available, it is associated with substantial morbidity and cost. This information is important for both physician and patient when deciding on management of prostate cancer.