CamSurg conference 2014 Abstracts

Richard Heywood, Editor, Cambridge Medicine Journal.

It is our pleasure to once again be able to publish the abstracts for posters presented at the recent CamSurg conference, which took place on Saturday 22nd February, 2014, at Addenbrooke's Hospital in Cambridge. Following on from the successful 2013 conference, CamSurg organised an interesting mix of keynote speakers, workshops and oral and poster presentations. The full programme can be found on the CamSurg website http://www.camsurg.co.uk/CamSurg/#

The following abstracts were put forward for presentation at the conference:

Obstetric Management of Five Litre Haemorrhage in a Patient with Placenta Praevia: A Case Study

Laura R. Wingfield, BSc, University of East Anglia, Norwich, UK.
Kanwaljeet K. Sandhu, BSc, MSc, University of East Anglia, Norwich, UK
Ms Haroona Khalil MRCOG, MPHC (Australia), Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, Ipswich Hospital, Ipswich, UK.

Placenta Praevia is a serious maternal condition occurring in one out of 250 births, and it carries a three to four times higher mortality rate compared to normal pregnancies. The Royal College of Obstetricians and Gynecologists (RCOG) developed new guidance including ‘Six Elements Care Bundle’ in managing placenta praevia in efforts to lower maternal morbidity and mortality. A 31 year old woman had a secondary repeat elective caesarean delivery for a complete (Grade IV) placenta praevia. Following removal of the placenta, there was no sign of placenta accreta but the patient experienced a massive blood loss of five litres. Conservative, uterus-sparing techniques were utilised to manage the bleeding and resulted in rapid control of the haemorrhage. All six elements of the RCOG care bundle were implemented. RCOG Guidance was developed in 2010, but despite its implementation, relatively limited evidence is available on its effectiveness. In the case presented, implementation of the care bundle resulted in better equipped and prepared operating staff and subsequent rapid control of haemorrhage and avoidance of hysterectomy.

An investigation into student perceptions of the incorporation of surgical skills training into undergraduate medical education

Joseph W.Dixon, University of Leeds Medical School,
May McCrea, University of Leeds Medical School,
Mr Alan White, St James' University Hospital Trust

Background

Since the introduction of the European Union working time directive the time available to postgraduate surgical training has been dramatically reduced. As a result, the specialist training programme needs to become more efficient in order to ensure junior doctors reach the expected and necessary standards of consultancy. Within much of the emerging literature it is proposed that incorporation of surgical skills training at an undergraduate level, as part of a student selected module for example, could go some way towards addressing this deficit it training hours.

Purpose

This study sought to investigate if early surgical skills training, incorporated into the undergraduate course, would be welcomed by students.

Methods

Students from all years of the MBChB curriculum were invited to participate in this study. In total 29 students were recruited and subsequently partook in a surgical teaching session on knot tying and wound closure. Thereafter participants were asked to complete a questionnaire concerning how effective and relevant they found this teaching to be and whether they would encourage its inclusion into their curriculum as a student selected module.

Results

Results from the questionnaire revealed that 97% of participants felt that a similar teaching programme should be incorporated into the MBChB curriculum at Leeds Medical School.

Conclusions

The researchers’ concluded that further research should be undertaken on a larger scale investigating the inclusion of surgical training into the undergraduate curriculum. Implementation of basic surgical training at an undergraduate level would provide one solution to the changing landscape of surgical training.

Hybrid Aortic Operation for a Complicated Leaking Acute Type A Aortic Dissection

June Yi-Ling Low, Peninsula Medical School,
Sanjay Asopa, Suresh Babu, Sergei Dudnikov, James Kuo,
South-West Cardiothoracic Centre, Derriford Hospital

Background

Acute Type A Aortic Dissection (ATAAD) is a life-threatening emergency with a mortality rate approaching 60% if surgical treatment is delayed. We present a patient with a rare complicated ATAAD treated by a 2 stage hybrid aortic operation.

Report

A 78-year-old man presented with a sudden onset severe central chest pain. CT scan demonstrated an acute type A dissection with a haemopericardium and a contained rupture of the proximal descending thoracic aorta (DTA). The 1st stage of the operation involved re-suspension of the aortic valve, resection of the aortic entry tear and replacement of the ascending aorta under deep hypothermic circulatory arrest with retrograde cerebral perfusion. Inspection from within the aorta confirmed a 5cm re-entry tear and the site of the aortic rupture just distal to the left subclavian artery, which was inaccessible to surgery through a median sternotomy. The 2nd stage involved placing a Thoracic Endovascular Aortic Stent under radiological control just distal to the left carotid artery and covering over the ruptured proximal DTA. The origin of left subclavian artery was closed percutaneously with an Amplatz device to prevent an endoleak. The patient made a full recovery from the operation.

Discussion

This rare complicated ATAAD with contained aortic rupture cannot be treated by conventional dissection surgery alone. Modern technological devices such as the endovascular aortic stent and the frozen elephant trunk have made the treatment of this case possible.

Conclusion

An innovative hybrid operation, requiring a multidisciplinary team approach, had been used to treat a complicated ATAAD successfully.

Paraplegia Following Oesophagectomy: Is Transthoracic Oesophagectomy (Ivor-Lewis approach) To Blame?

Mohammed Omer Anwar, Barts and the London,
Omar Musbahi, Barts and the London,
Abdullatif Aydin, Barts and the London.

Transthoracic oesophagectomy is an invasive procedure required for removal of carcinomas indicated in the mid to distal one-third of the oesophagus. It is also known as Ivor-Lewis oesophagectomy which otherwise was proposed in 1946. It involves a midline sternotomy with mobilisation of the stomach followed by a subsequent thoracotomy incision to allow resection of the tumour; which is concluded by an oesophagogastric anastomosis.

Our aim involved investigation of spinal cord paraplegia following hypoperfusion after initiating the Ivor-Lewis oesophagectomy procedure. This rare event is often unforeseen causing devastating consequences for patients.

Initially we demonstrated the arterial anatomy of the spinal cord through a cadaveric dissection of an 84 year old female patient. This was subsequently compared with relation to the oesophageal blood supply sharing a bi-common origin with the thoracic aorta. A further systematic review of current literature from PubMed, MedLine and Elsevier databases, revealed nine cases for paraplegia following elective oesophagectomy.

Spinal injury was confined to a specific region of T6-L1 apart from one case, which commonly represents the variable origin of the great radicular artery of Adamkiewicz. Seven of eight documented cases used the Ivor-Lewis approach, of which the majority were middle-aged male patients with significant general atherosclerosis. A theory suggests embolisation of the atherosclerotic plaque during mobilisation of patients from supine to the right/left thoracotomy position.

Despite the higher incidence of paraplegia after the Ivor-Lewis approach, it has a long-term prognostic value for reducing post-operative anastomotic tension in leakage of gastrointestinal contents.

The Role of Imaging in the Localization of Parathyroid Adenomas

Tharindra Dissanayake, University of Nottingham Medical School,
Mr Syed Adnan Kabir, Mr Irfan Akhtar, Mr Syed Irfan Kabir, Mr Zubair Khanzada and Mr David Andrew, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust.

Background

Minimally invasive parathyroidectomies have been an important recent development. Therefore preoperative localization plays an important role in detecting the precise location of the affected gland and thereby increasing success rates.

If preoperative localization is deemed necessary the investigations of choice are 99Tc-sestamibi scanning and high-resolution ultrasonography. This will also be required if a “focused’ approach and a limited neck dissection is to be performed.

Aims

To evaluate the choice of investigation in localizing parathyroid adenomas.

Method

A retrospective study consisting of images, frozen sections and quick intraoperative parathyroid assay(qPTH) reports of patients[n=38], with diagnosis of primary hyperparathyroidism, who underwent a parathyroidectomy, were reviewed, at King Mills Hospital between May 2010 and December 2011.

Results

37/38 patients underwent combined ultrasound(USS) and sestamibi scans and one patient a CT scan after a negative exploration. 25/37(68%) parathyroid adenomas were localized via USS as opposed to 34/37(92%) which were localized using sestamibi scans and 36/37(97%) had both a USS & sestamibi scan.

Histology reports confirmed 32/38 adenomas(1 bilateral), 2/38 hyperplasia, 1/38 carcinoma and 3/38 with normal histology(negative USS & sestamibi scans). In 35/38 cases qPTH levels were high. From that 3/35 patients continued to have high levels. All 3/35 patients had normal post-op histology. From the above 1/3 was re-operated (adenoma) and 2/3 refused further surgery.

Discussion

Combined USS and sestamibi scans were found to localize parathyroid adenomas with high degrees of accuracy in our hospital(97%). There was also a significant advantage of obtaining qPTH levels as opposed to performing frozen sections.

Intraosseous territory of the facial artery in the maxilla and anterior mandible: Implications for allotransplantation

Andreana Panayi, University of Cambridge Medical School, UK,
Maurice Y. Mommaerts, Division of Maxillo-Facial Surgery, Department of Surgery and Diagnosis, GH St. Jan Bruges Ostend, Belgium,
Gyongyver Molnar, Gabor Baksa, Lajos Patonay, Department of Anatomy Histology and Embryology, Semmelweis University, Budapest, Hungary,
Mark Plachtovics, Kreativ Dental, Budapest, Hungary.

Background

Maxillo-facial reconstruction raises the issue of blood supply to the bone. The vascular delta, which is opened by arterial anastomosis, greatly determines the survival of the (partial) face allotransplant. The issue is whether a single facial artery, retrieved distally to the submental artery, will guarantee blood supply to the ipsilateral mandibular symphysis and to the contralateral maxilla and mandibular symphysis, thus facilitating maxillo-facial allotransplantation. From a physiological point of view, at least on one side, the facial artery should receive the anastamosis, as bilateral, external carotid artery anastomosis would cut off the blood supply to both the lateral face and upper neck.

Purpose

The aim of this anatomical study was to define the intraosseous vascular territory of the facial artery.

Methods

Of 10 human cadaveric heads, the left facial artery was injected with a positive contrast agent. The maxillae and mandibular symphyses were investigated
with cone-beam computed tomography (CBCT).

Results

Each ipsilateral maxilla and mandibular bone segment showed contrast medium in the intraosseous vessels. In 50% of cases, this was also the case on the contralateral side of the maxilla and anterior mandible.

Conclusion

The maxillae and the mandibular symphyses receive ipsilateral blood supply from the facial artery and, in 50% of cases, also from the contralateral facial artery. Internal maxillary artery anastomosis is not required for a vascularized maxillary bone flap. Additionally, involvement of the submental artery is not needed for a mandibular symphyseal bone flap.

Should antibiotics be used as first line therapy for acute uncomplicated appendicitis?

Patrick Holden, University of Cambridge Medical School,
Nicholas Judkins, University of Cambridge Medical School,
Saadiq Moledina, University of Cambridge Medical School.

Should antibiotics be used as first line therapy for acute uncomplicated appendicitis?

Acute appendicitis is one of the most common causes of abdominal pain in the UK, with 7% lifetime risk. Appendicectomy (APP) is the longstanding first-line therapy and is a significant cost burden to the NHS (NHS tariffs £1579 for an adult or £2089 for a minor). In comparison antibiotic therapy (ABT) is not advocated by NICE, but could be more cost-effective and less invasive than APP. To be considered as a first-line treatment, ABT must be shown to be safe and efficacious compared to APP.

We considered RCTs, qRCTs and systematic reviews comparing the safety and efficacy of ABT versus open / laparoscopic APP. Patients of both sexes with acute, uncomplicated appendicitis were included. Four RCTs, one qRCT and seven systematic reviews were identified by searching Medline, Embase and the Cochrane library databases. Four of the systematic reviews included data from non –randomised trials and were discarded. There is a further RCT in progress.

Comparing the three systematic reviews will form the bulk of our discussion; despite having access to the same body of evidence, they come to three separate different conclusions. This reflects differences in the methods used and the biases inherent in comparing the outcomes of two inherently different treatments. The quality of evidence on which these judgements are made is also substandard.

We conclude that, while ABT is promising, APP should remain the first-line treatment for appendicitis until higher quality evidence is available.