Winning Abstracts GUSS Conference 2017

Abstract

Introduction: Autologous breast reconstruction following mastectomy can be performed using an extended latissimus dorsi (ELD) flap. Seroma is a common complication of this procedure, which may resolve spontaneously or require drainage. It is believed that seroma occurs as a result of the ‘dead space’ that remains when donor tissue is removed. Tisseel is a fibrin adhesive which reduces seroma volume by mechanically fixing the walls of the donor site together.

Aims: The aim of this audit is to determine whether the use of Tisseel reduces seroma volumes in patients with ELD flap reconstruction.

Materials and methods: Retrospective data collection was carried out on 31 consecutive ELD flap cases between April 2015 and April 2017. Seroma volumes were recorded for each case. Nineteen patients underwent ELD reconstruction using only sutures to repair the back wound. Twelve cases involved 10 ml of Tisseel as a method of wound closure. Whether or not patients had axillary node clearance (ANC) was also recorded to determine if this variable had influenced the results.

Results: The median seroma volume for those treated with Tisseel was 1710 ml and the mean volume was 1749.2 ml, while those without Tisseel had a median of 770 ml and a mean of 1458.6 ml drained. The U value was 73.5 which corresponds to a p-value of 0.053. Although this result is insignificant, it is trending towards significance. This outcome appears to be irrespective of whether or not the patient also underwent axillary node clearance.

Conclusion: There is a trend towards Tisseel causing increased seroma volumes compared to the conventional method, but this was not found to be significant. A larger data set may improve the significance. Clinically, Tisseel should be used with caution until further research is carried out.

Abstract

Background: Lateralising calcaneal osteotomies (LCO) are the most frequent surgical treatment for pes cavus. Lateral shifts are much more difficult to achieve than medialising shifts; however, little is known about the mechanism causing this. Some literature suggests the restraining structure is the tarsal tunnel, which formed the basis of our hypothesis. This study aimed to identify which anatomical structure(s) restrain the lateral shift in an LCO.

Methods: Eight embalmed cadavers were split into two groups of four. Group 1 first received an LCO, the lateral shift was fixed and measured as a control, and then the tarsal tunnel was released medially before the lateral shift was refixed and remeasured. The difference before and after tarsal tunnel release was noted. Group 2 received the same control; however, instead of a tarsal tunnel release, the Abductor Hallucis muscle fascia and plantar fascia was released. The lateral shift was repeated, refixed and remeasured. Results before and after the fascia releases were recorded and compared.

Results: Releasing the tarsal tunnel in group 1 made no significant improvement in shifting the calcaneus laterally in an LCO. The average improvement measurement was 1 mm which was not felt to be significant. Releasing the Abductor Hallucis muscle fascia and plantar fascia in group 2, however, increased the lateral shift by an average of 5 mm, which was found to be significant.

Conclusion: Abductor Hallucis muscle fascia and plantar fascia release allow an increased lateral shift in LCOs by an average of 5 mm. It is recommended that this be taken further in a clinical trial in order to be implemented in surgery to decrease risk of under-correction and to improve patient outcome.

Abstract

Introduction: Premature closure of cranial sutures, or craniosynostosis, requires surgical intervention before 18 months to prevent effects on brain development and ICP. It can be classified dependent on the type of suture, or if the abnormality is related to a genetic syndrome. Blood loss is extensive due to the open and aggressive nature of reparative procedures, therefore these patients are at risk of complications such as infection.

Aim: To determine if there is a relationship between the type of craniosynostosis operated on and the volume of blood transfused and on post-operative morbidity, shown by length of stay.

Method: A literature review was carried out on PubMed using criteria like comparisons between the type of craniosynostosis and volume of blood given, and data on length of stay present. The retrospective study looked at a database of 44 patients. Criteria such as primary craniosynostosis surgeries and data accessibility were used for selection. All procedures used tranexamic acid and cell savers.

Results: Literature review yielded our papers showing metopic and multi-suture craniosynostosis having a higher blood volume transfused than other types and highlighted other factors effecting blood transfusions such as administration of tranexamic acid and lower birth weight. The retrospective study showed 17 patients within the criteria: eight sagittal, five metopic, one bicoronal and three unicoronal. The largest volume of blood transfused was sagittal craniosynostosis corrections with average of 41.13 ml/kg transfused and 9.5 ml/kg given from the cell saver. The longest length of stay was in bicoronal patients with six days.

Conclusion: Sagittal synostosis correction has largest transfused volume. An inverse correlation between volume of blood transfused and length of stay was detected. Small cohort size makes these data potentially unreliable.

Abstract

Introduction: Pierre Robin Sequence (PRS) is a rare congenital condition of facial abnormalities, defined by a triad of micrognathia, retroglossoptosis and airway obstruction. PRS may have varied presentations due to associations with syndromes. Hence, the consensus in management remains elusive, with no definitive treatment protocols. We describe a case from a resource-scarce setting that highlights the use of a less commonly performed surgical procedure which is simpler and cheaper than the gold-standard surgery in PRS.

Case description: An 18-month-old boy with PRS presented to A&E with airway obstruction and hypoxia due to retroglossoptosis. He was resuscitated immediately and intubated. Gold-standard treatment was surgery: Mandibular Distraction Osteogenesis (MDO). However, as the patient was unable to afford the surgery, a cheaper procedure called tongue-lip adhesion (TLA) was performed. The procedure involved pulling the base of the tongue anteriorly and tying to the hyoid bone. This maintained airway patency and patient was extubated. Mother was given feeding and child positioning advice. It is expected that the mandibular growth will eventually catch up with the tongue growth.

Discussion: The surgical procedures used to relieve airway obstruction in PRS include TLA, MDO and tracheostomy. In this case, TLA was chosen due to affordability issues. Three different TLA techniques, previously described in the literature for PRS, were discussed. Given the nutritional status of the patient, we decided to avoid extensive dissection. We required a technique that would not restrict mobile segments of the tongue, to allow for normal speech development and feeding. In addition, sutures on the tongue should not be damaged by biting, in the teething child. Lapidot and Ben-Hur technique (briefly described in the case) satisfied above-mentioned requirements and was hence chosen. Overall, this case is of great value in exploring different surgical techniques for PRS management, not widely explained in the literature.

Abstract

Introduction: Our group has demonstrated that right ventricular (RV) dysfunction occurs following lung resection.¹ Although the precise mechanism remains unclear, it is widely hypothesised to result from increased RV afterload. In other settings, it has been shown excess RV volume and increased RV afterload result in deviation of the interventricular septum, deforming the circular left ventricle. The eccentricity index (EI) quantifies this abnormal septal shift and is used for RV haemodynamic assessment in many clinical settings, it has never been used following lung resection.

Aims: This study seeks to use Cardiac Magnetic Resonance (CMR) and Transthoracic Echocardiography (TTE) to explore changes in EI post-lung resection and determine association with RV Ejection Fraction (RVEF) over the same time.

Materials and Methods: Twenty-seven patients consented for lung resection underwent contemporaneous CMR and TTE imaging at pre-op, post-op day (POD) 2 and two months. Systolic EI (sEI) and diastolic EI (dEI) were determined offline by analysis of anonymised and randomised images. Comparison was made with RVEF. Bland Altman was performed to determine agreement between EI measured by CMR (EI^CMR) and TTE (EI^TTE).

Results: There was good inter and intra-observer variability for dEI^CMR (Intraclass correlation coefficient (ICC): 0.83 and 0.98) and sEI^CMR (ICC: 0.84 and 0.89). POD2 dEI^CMR and sEI^CMR were moderately associated with RVEF (r = −0.59 and r = −0.54, p ≤ 0.01, Pearson’s). At two months, dEI^CMR showed moderate correlation with RVEF (r = −0.43, p = 0.03, Pearson’s). There was good inter and intra-observer variability for dEI^TTE (ICC: 0.96 and 0.97) and sEI^TTE (ICC: 0.82 and 0.88). Bland Altman analysis revealed unacceptable limits of agreement for EI^CMR and EI^TTE.

Conclusion: EI^CMR is a simple, reproducible measure of RV function, correlating with RVEF following lung resection. Unfortunately, EI^TTE is not useful as a less invasive measure in this setting.

Reference

1 McCall P, Corcoran D, Arthur A et al. The right ventricular response to lung resection. J Cardiothorac Vasc Anesth 30: S23–S4.

Third Prize

To investigate the use of electronic referrals for acute orthopaedic problems

Andrew Scott Wilkinson, AS Wilkinson, P Jenkins and AGC Hay-David

Email: 2061288w@student.gla.ac.uk

Abstract

Background: Electronic health records have been shown to improve patient care through safer handover. Our unit utilises Trakcare, an electronic health record system that enables clinicians to make referrals directly to the on-call team.

Aim: To investigate the pattern of electronic referrals made to the Trauma and Orthopaedic on-call team at our unit.

Methods: Retrospective review of electronic Trakcare referrals over one year, from February 2016 to January 2017. Details pertaining to age, gender and region of body were collected. Data regarding the referrals included month, clinician, referring speciality and urgency of the referral.

Results: There were 766 consecutive referrals: 429 (56%) females and 337 (44%) males. The majority (n=532, 69%) were aged over 65. There were 139/766(18%) referred as urgent: 92/139 (66%) were patients aged over 65 and 47/139 (34%) aged under 65. Inpatient assessments were requested most frequently, accounting for 608/766 (79%) referrals and 125/608 (21%) being requested as urgent. Doctors accounted for the majority of referrals (735/766; 96%) and were more likely to request inpatient assessments for urgent problems. The most common site of referral was the hip or pelvis (n=214, 28%). Three hundred and seven (40%) patients were referred with suspected fracture and 122 (16%) with infection.

Conclusion: Females with a hip or pelvic injury and aged over 65 years were the most frequently referred via Trakcare. Fracture remained the most frequent injury in this cohort of patients. Referrals for infection tended to be younger individuals, with risk factors being diabetes or intravenous drug use. Overall, Trakcare is a useful referral tool that reduces the workload for the on-call team. Education and training must be provided to the users of the system to improve the efficiency of this service and ensure adequate referrals are being made in the future.