Royal College of Surgeons of England

Goldring L., Fearnhead N., Bentley-Pattison L.

The Emerging Leaders programme has supported and empowered women and non-binary people in surgical leadership, fostering a more diverse and inclusive professional landscape.

Allum W., Smith K., Joubert T., Kane N.

RCS England's plans to tackle the challenges facing the workforce, increase opportunities for trainees and support future generations of surgeons.

Oladeji E.O., Enemuo T.N., Anthony-Awi T.A., Olaniyi A.A., Olaku J.O., Aransiola P.B., Salawu R.A., Adedoyin G.O., Olatide O.O.

Spinal tuberculosis (STB) is a significant contributor to non-traumatic myelopathy. There is a rising burden in Africa, in parallel with the high prevalence of human immunodeficiency virus. We conducted a scoping review to highlight the disparities in the management and outcomes of STB in Africa.

Glen H., Bahl A., Fleure L., Clarke N., Jain S., Kalsi T., Khoo V., Mobeen J.

ObjectivesThis study aimed to determine the clinical utility of the androgen deprivation therapy (ADT)+docetaxel (DOCE)+androgen receptor-targeted agent (ARTA) triplet therapy in patients with metastatic hormone-sensitive prostate cancer (mHSPC) in the UK.DesignA modified Delphi method. A steering group of eight UK healthcare professionals experienced in prostate cancer care discussed treatment challenges, developing 39 consensus statements across four topics. Agreement with the statements was tested with a broader panel of professionals within this therapeutic area in the UK through an anonymous survey, using a four-point Likert scale. This was distributed by the steering group members and an independent third party. Following the survey, the steering group convened to discuss the results and formulate recommendations.SettingThe steering group convened online for discussions. The survey was distributed via email by the clinicians and the independent third party.ParticipantsHealthcare professionals involved in the provision of prostate cancer care, working in relevant professional roles (oncology, urology or geriatric consultant, oncology nurse specialist, and hospital pharmacist) within the UK. No patients or members of the public were involved within the study.InterventionsNone.Primary and secondary outcome measuresConsensus was defined as high (≥75% agreement) and very high (≥90% agreement).ResultsResponses were received from 120 healthcare professionals, including oncologists (n=73), urologists (n=16), geriatricians (n=15), nurse specialists (n=11) and hospital pharmacists (n=5). Consensus was reached for 37 out of 39 (95%) statements, and 27/39 (69%) statements achieved very high agreement ≥90%. Consensus was not reached for 2/39 (5%) statements.ConclusionsBased on the consensus observed, the steering group developed a set of recommendations for the clinical utility of ADT+DOCE+ARTA in treating patients with mHSPC in the UK. Following these recommendations enables clinicians to identify appropriate patients with mHSPC for triplet treatment, thereby improving patients’ outcomes.

Stott M., Targett I., Kausar A.

Abstract Background Symptomatic gallstones are the most common reason for evaluation by an Emergency General Surgery (EGS) service, with laparoscopic cholecystectomy (LC) being performed by most general surgeons. Previous studies show that most LCs in the United Kingdom (UK) are performed by colorectal surgeons (CR). Emergency cholecystectomy requires advanced skills including intra-operative assessment of the bile ducts, and the ability to perform intra-operative cholangiogram (IOC) is part of the procedure-based assessment (PBA) that evidences competency for certificate of completion of training (CCT). This study aims to assess documented evidence of competency in benign biliary surgery amongst general surgeons in the UK. Method PBAs relating to LC and CBD exploration (CBDE) were retrieved for all UK general surgeons who received CCT between 2016 and 2021 from ISCP (702; 285 (41%) colorectal; 212 (30%) Upper GI (UGI)). All eLogbook entries relating to LC +/- IOC +/- CBDE were also retrieved. Subspecialty interest was determined from Part 2 of the FRCS examination. Competence (Level 4) as well as a granular assessment of IOC and CBDE was compared amongst trainees, taking into account their subspecialty interest. Results 11,733 LC and 553 CBDE assessments from 160,570 LC +/- IOC +/- CBDE procedures recorded on eLogbook were retrieved. Knowledge of IOC indication was assessed in 467 (94%) surgeons, but performance was only assessed in 380 (75%) surgeons. Median satisfactory IOC performance assessments was 3 (2-5). UGI were more likely to do this than colorectal (4 (2-7) vs 2 (1-4) P < 0.001). Satisfactory CBDE was achieved by 86 surgeons (12 CR and 74 UGI). 486 surgeons (97% CR; 94% UGI) received Level 4 (independence) despite never achieving satisfactory ability to perform IOC. Conclusion Competency in acute biliary surgery for general surgeons at certification is extensively assessed using PBAs. Cholecystectomy training and assessment in the UK does not seem to include intraoperative bile duct anatomy assessment or treatment of CBD stones. Assumed competency in cholecystectomy by trainers in the UK does not seem to include the need to do this, as 97% of CR and 94% of UGI trainees achieve documented competence without the ability to perform IOC. This may have an impact on EGS service delivery of acute and emergency gallbladder surgery including the ability to deal with difficult cases.

Han L., Mayne E., Dodkins J., Sullivan R., Cook A., Parry M., Nossiter J., Cowling T.E., Tree A., Clarke N., van der Meulen J., Aggarwal A.

ABSTRACTBackgroundCentralising prostate cancer surgical and radiotherapy services, requires some patients to travel longer to access treatment, but its impact on actual treatment utilisation and outcomes is unknown.MethodsUsing national cancer registry records linked to administrative hospital data, we identified all patients with high risk and locally advanced prostate cancer diagnosed between 1 April 2019 and 31 March 2020 in the English National Health Service (n = 15,971). Estimated travel times from the patient residential areas to the nearest hospital providing surgery or radiotherapy were estimated for journeys by car and by public transport. Multivariable logistic regression was used to model relationships between travel time and receipt of care with adjustment for patient characteristics.Results10,693 (67%) men received radical surgery or radiotherapy (RT) within 12 months of diagnosis. Average travel time to the nearest hospital providing prostatectomy or RT was 23.2 min by private car and 58.2 min by public transport. We found no association between travel time, either by car or public transport and the likelihood of receiving curative treatment. Patients living in the most socially deprived areas, those aged over 70, those with two or more comorbidities, and those of black ethnic origin, were less likely to receive curative treatment (p& =& 0.001 for all associations).ConclusionsThe current configuration of national prostate cancer services is not associated with the likelihood of receiving curative treatment. Further increases in capacity will unlikely improve utilisation rates beyond addressing sociodemographic barriers.

Turani D., Hemmings K., Searson L.

There are a number of protocols that the clinician has to consider when providing implant treatment. Immediate implant placement has its place in implant dentistry and should be considered following a strict case selection. This article discusses the factors that should be taken into account when planning and providing immediate implant placements, with an emphasis on achieving a good outcome. The evidence base is discussed with a description of the surgical stages involved and subsequent restoration. Cases to illustrate this technique and its limitations are presented. CPD/Clinical Relevance: Principles for single tooth implant replacement in the anterior maxilla, where aesthetic expectations are high are relevant to clinicians.

Watkinson-Deane A.

We take a look at how healthcare practitioners developed protections against the damage of x-rays.

Gannon M.R., Dodwell D., Miller K., Medina J., Clements K., Horgan K., Park M.H., Cromwell D.A.

Randomised controlled trials (RCTs) reported adjuvant trastuzumab-based treatment improved overall survival (OS) among patients with HER2-positive early invasive breast cancer (EIBC). Few RCTs included older patients or those with comorbidity/frailty. This study aimed to determine whether the effect of adjuvant trastuzumab-based treatment on survival outcomes varies by patient age and fitness, using national data from routine care.

Hinchliffe R.J.

Wilson E.A., Park C., McMahon J.D., Biddlestone J., McCaul J., Ho M.W., Puglia F.A., Tighe D.

The British Association of Oral and Maxillofacial Surgeons (BAOMS) Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) reconstructive audit aims to provide surgical teams with risk adjusted comparative performance data. The goal is to enable surgeons to optimise surgical pathways. Risk adjustment requires that data on appropriate predictive variables are collected. This study looked at variables predicting major complications and flap failure in a single institution with the aim of determining whether the QOMS dataset adequately captures the appropriate data points. A prospective database of head and neck flap procedures and associated postoperative complications has been maintained in the maxillofacial surgery department since August 2009 up to August 2022 (n=1327). A total of 25 putative risk variables were extracted from the health records for each patient. The outcomes of interest were total flap failure and major complications. Independent predictors of flap failure were recipient site (sinonasal/anterior skull base), previous major surgery, previous major surgery and radiotherapy, and flap selection. For major complications ACE-27 comorbidity score, flap type, use of tracheostomy, elevated preoperative plasma C-reactive protein (CRP) and flap selection were independently predictive. Apart from preoperative activated innate immunity all relevant risk stratification variables identified in this study form part of the QOMS dataset. QOMS is therefore likely to adequately risk stratify patients based upon currently collected variables.

Crumplin M.

Crumplin M.

Wang Z., Shahzad K.A., Li X., Cai B., Xu M., Li J., Tan F.

AbstractMesenchymal stem cell‐derived extracellular vesicles (MSC‐EVs) have shown promising immunomodulatory capabilities for a variety of clinical conditions. However, the potential regulatory mechanisms of MSC‐EVs in allergic rhinitis (AR) remain unexplored. The present study was designed to investigate the immunomodulatory effect of MSC‐EVs in patients with AR. Peripheral blood mononuclear cells (PBMCs) were isolated from AR patients. The number of peripheral CD4+Foxp3+IL‐17+, CD4+Foxp3+IL‐17− and CD4+Foxp3−IL‐17+ T cells in healthy controls and AR patients were evaluated using flow cytometry. Therapeutic effect of MSC‐EVs was determined by detecting IFN‐γ, IL‐4, IL‐17 and IL‐10 cytokines in supernatant by ELISA and flow cytometry. The mean fluorescence intensity (MFI) was calculated in PBMCs for IL‐10, IL‐17 and TGF‐β on T cells after MSC‐EVs treatment. Bioinformatic analysis of microRNA was performed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. CD4+Foxp3+IL‐17+ T cells expression in PBMCs was higher in the AR group and the balance of Treg/Th17 was tilted towards Th17 cells. Supernatant from AR patients revealed that MSC‐EVs treatment upregulated IL‐10 and IFN‐γ, and downregulated IL‐4 and IL‐17. EVs treatment effectively re‐established Th1(CD4+IFN‐γ+cells)/Th2(CD4+IL‐4+cells) balance, reduced CD4+IL‐17+ and increased CD4+IL‐10+ and CD4+TGF‐β+ cells. The MFI of IL‐10 and TGF‐β in CD4+CD25+CD127− T cells were higher, whereas lower levels of IL‐17 were observed. Bioinformatic analysis revealed that the TGF‐β, Wnt signalling pathways and STAT5 transcription factor might mechanistically support the immunomodulatory effect of MSC‐EVs. This study presents the immunomodulatory effect of MSC‐EVs in PBMCs from AR patients. The results provide a new therapeutic strategy for AR.

Harji D., Vallance A., Ibitoye T., Wilkin R., Boyle J., Clifford R., Convie L., Duff M., Elavia K., Evans M., Fleming C., Griffiths B., Jenkins J.T., Mohan H., Morris E.J., et. al.

AbstractAimLocally advanced and recurrent colorectal cancer represents a complex clinical entity, which requires multidisciplinary decision‐making and management. The aim of this work is to understand the provision of clinical services in this cohort of patients across Great Britain and Ireland (GB&I) as a key essential step to help facilitate future service development and improvement.MethodA cross‐sectional, organizational survey was sent to all colorectal cancer multidisciplinary teams (MDTs) across GB&I. It consisted of 12 key questions addressing the provision of specialist services and advanced surgical techniques. Results are reported in line with the CHERRIES guideline.ResultsOne hundred and seventy‐five MDTs across GB&I participated, with 142 English, 13 Welsh, 14 Scottish, 3 Northern Irish and 3 Irish MDTs. The overall response rate was 93.5% (175/187). Ninety (51.4%) hospital sites reported having a specialist dedicated or subsection MDT. Specialist advanced nursing support was available in 46 (26.2%) hospitals, with a dedicated advanced colorectal cancer outpatient clinic available in 31 (17.7%) hospitals. One hundred and thirteen MDTs (64.5%) offered surgery for advanced colonic cancer, 82 (46.8%) for recurrent colonic cancer, 58 (33.1%) for advanced rectal cancer and 39 (22.2%) for recurrent rectal cancer. A variable number of MDTs offered specialist surgical techniques, including distal sacrectomy [33 (18.9%)], high sacrectomy [16 (9.1%)], complex vascular resection ± reconstruction [33 (18.9%)] and extended lymphadenectomy (pelvic sidewall or para‐aortic) [44 (25.1%)].ConclusionThe IMPACT organizational survey highlights the current variation in the delivery and provision of clinical services for patients with advanced and recurrent colorectal cancer across Great Britain and Ireland.