Charles Douglas

Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score

Abstract Objectives: To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis. Design: A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group). Setting: Single tertiary referral centre. Participants: 302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team. Main outcome measures: Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation. Results: Sensitivity and specificity of ultrasonography were measured at 94.7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45). Conclusion: Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.

Protocol-based approach to suspected appendicitis, incorporating the Alvarado score and outpatient antibiotics

Background:  There is evidence that antibiotics can be used as primary treatment for appendicitis, however, delayed surgical treatment might still be associated with perforation. Most patients at risk of perforation have high Alvarado scores. We designed a protocol‐based approach to suspected appendicitis, in which the Alvarado score was used to select patients for early treatment with surgery or outpatient antibiotics.

Graded compression ultrasonography in the assessment of the “tough decision” acute abdomen in childhood

Abstract The diagnosis of acute appendicitis in childhood is frequently difficult. In some situations the need to operate is clear, but in others the decisions may be much “tougher” because the clinical findings are equivocal. This is a retrospective study of a consecutive series of 253 children presenting with “acute abdominal pain? appendicitis” who had graded compression ultrasonography (GCUS) because the clinical scenario did not warrant immediate laparotomy. This represents 30% of all cases seen in the study period. The aim of the study was to examine the role of GCUS and a clinical scoring system (the Alvarado score) in patients in whom the diagnosis is uncertain.

The ‘keystone concept’: time for some science

The keystone flap closure is a surgical innovation that has been enthusiastically embraced by many surgeons. However, we think a genuinely critical appraisal has been lacking. The keystone closure appears fundamentally different from other flap closures, but the rationale has been only vaguely described, while claims about biomechanics have been anecdotal. The development of substantially different ‘variations’ suggests that there is no shared understanding about what manoeuvres matter and why. The original ‘keystone concept’ is surely the idea asserted by Felix Behan (almost as a footnote to his first paper) that V-Y advancement at each end of the long axis of the keystone island ‘creates a relative redundancy in the central portion of the flap’ and relaxes the tension in the short axis. The implication is that this relaxation allows a substantial increase in short-axis ‘stretch’. In a recent bench-top study, we tested this ‘orthogonal stretch principle’. We showed that complete relaxation of skin in one axis (from in vivo length) does produce modest tension benefits in the orthogonal axis. However, the amount of increased orthogonal stretch was in the order of 1 mm, a dubious benefit. In light of our bench-top study, we have had our doubts about the keystone flap, and have conferred with colleagues. While many are certain that the keystone flap facilitates wound closure, some are unconvinced. Given what we take to be reasonable ‘equipoise’, and given that some surgeons are performing keystone flaps even where they acknowledge that primary closure is achievable (in the belief that it produces better clinical outcomes), we have commenced a pilot randomized trial of keystone closure versus primary closure. In the context of our pilot study, we have been able to develop an in vivo test of the mechanical benefits of the keystone flap. The procedure is illustrated in Figure 1. After creation of a defect (following wide excision of a melanoma), we establish that the wound edges can be approximated and measure the closing tension across the widest part of the defect (A-A’) using a single 0 polypropolene suture and a tensiometer. For patients randomized to a keystone flap, we develop the flap, perform the V-Y advancements and close the V-Y stems and the greater arc of the flap. We then remeasure the closing tension at A-A’ (Fig. 1b). We believe that if the keystone flap offers any mechanical benefit, there should be a substantial drop in the closing tension at A-A’ as a result of the initial flap mobilization (and after greater arc closure). This should be true whether the benefit arises as a result of the ‘orthogonal stretch principle’ or some other principle that has never been made clear. However, in three patients that we have tested to date (one in whom we divided deep fascia around the entire island, one in whom we did not and one in whom there was no appropriate deep fascial plane to divide) there has been negligible drop in tension after flap ‘advancement’ (leg, 3.5 N before and after; back, 8.5 N before and after, ankle 9.5 N before and 9.6 N after). In each case, we were able to close the wound, but it was not obviously easier than the initial approximation. In short, there was no subjective or objective advantage in performing a keystone flap. Critics of our preliminary results have generally made comments to the effect that (i) ‘Your flap technique is flawed’; or (ii) ‘Your single tension measurement is not the appropriate test of benefit.’ These criticisms might ultimately prove justified but we believe that the onus of proof has unreasonably been reversed. No one has yet provided data to show that the flap does reduce tension (relative to primary closure), nor reported objective criteria by which they can prove that they are closing wounds with a flap that they could not possibly have closed primarily. (Pelissier et al., including Behan, described 14 flaps in two fresh cadavers, and reported that all defects were able to be closed primarily.) ‘We don’t know why it works, but it does’ is a fair enough starting point in applied science, but that initial claim must be based on something more than anecdote. We would be very interested in collaborating with other surgeons, starting with intraoperative tension measurements in the operating theatre of a keystone expert in order to provide objective evidence that the keystone flap does work. We can then move on to questions of why it works and

Decision aids for breast and nodal surgery in patients with early breast cancer: development and a pilot study

Aim:  As survival rates for aggressive and conservative breast and lymph node surgery are similar, surgical treatment decisions for patients with early‐stage breast cancer should take patient preference into account. Decision aids have been demonstrated to increase patient knowledge and satisfaction with decision making, while decreasing decisional conflict. Hundreds of decision aids exist; however, few address lymph node surgery in any detail, and none acknowledge that there is a choice comparable to that between mastectomy and breast‐conserving therapy.

Wound tension and ‘closability’ with keystone flaps, V‐Y flaps and primary closure: a study in fresh‐frozen cadavers

Previous publications have implied that the keystone flap provides mechanical benefits compared to primary closure. This has not been objectively demonstrated.

Nudging and the Complicated Real Life of “Informed Consent”

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The Accuracy of the ‘Triple Test’ in the Diagnosis of Papillary Lesions of the Breast

Background and Objective: The literature on fine-needle aspiration (FNA) cytology for papillary lesions presents a very mixed picture. Many authors advocate mandatory excision of these lesions. This recommendation is largely based on the ‘atypical’ nature of the FNA report. The aim of this work is to see if breast papillomas can be treated conservatively. Study Design: We report a retrospective study of outcomes for patients with a provisional diagnosis of a ‘papillary breast lesion’ based on assessment by palpation (no clinically suspicious features), sonography (benign or probably benign according to the Breast Imaging Reporting and Data System ‘BI-RADS®’), and FNA (benign cytological category with a papillary architecture) findings from one integrated breast service. Results: Thirty-six cases were identified over a period of 6 years. Thirty-four of the patients had surgical excision. All of the 34 surgical cases were confirmed to be benign in nature on histopathology (intraduct papilloma). The remaining 2 cases were stable on follow-up. Conclusion: We believe that a policy of mandatory excision of papillary lesions of the breast is unnecessarily cautious.

Moral concerns with sedation at the end of life

Two studies reported in the Journal of Medical Ethics add to the growing body of qualitative evidence relating to the use of sedatives at the end of life.1 ,2 Respondents in the two studies affirm a number of important concerns, most of which have been elaborated in the philosophy and palliative care literature, relating to the use of sedation. There seems little doubt that the common moral thread to most of these concerns is the possibility that end-of-life sedation can resemble assisted death. Most of the Dutch respondents in the paper by Reitjens et al 1 were reported to believe that sedation does not hasten death. That is an oversimplification. Were it not for the potential to hasten death, I doubt we would be discussing the use of sedatives so frequently in ethics journals. It is true that there is little evidence that sedation significantly hastens death when doses are carefully titrated against symptoms —giving only that amount of a drug necessary to make the patient feel less distressed, and preserving consciousness as far as possible.3 Probably most sedative …

INFORMED CONSENT: A REVIEW OF THE ETHICAL AND LEGAL BASIS FOR MEDICAL DECISION-MAKING FOR THE COMPETENT PATIENT

‘What do you do in this situation?’ is a question that one often hears surgeons (and other clinicians) ask of each other at meetings where a difficult clinical problem is being discussed. Clearly with many clinical scenarios, the treatment a patient receives will depend on whether the patient consults one doctor or another.1 Where there are two or more widely held but differing views about what is appropriate treatment, it seems reasonable and is legally defensible for a doctor to recommend one or another. But is there a problem for our notion of informed consent? Is it possible for a patient’s treatment to be more or less decided by the surgeon, and at the same time, for the patient to voluntarily choose that treatment in an informed manner? In this article, it is argued that paradoxically, this is indeed a possibility, but caveats will be discussed.2