Robert Kirby

10 year experience of splenic injury: an increasing place for conservative management after blunt trauma

It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6/45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases (20/22). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparotomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.

Longitudinal trends in trauma mortality and survival in Stoke-on-Trent 1992—1998

OBJECTIVES To identify factors related to mortality and to test the null hypothesis of no longitudinal trend in mortality in patients admitted to the North Staffordshire Hospital (NSH) with an Injury Severity Score (ISS) greater than 15, between April 1992 and March 1998. DESIGN Longitudinal prospective study of 18 factors, including age, sex, mechanism of injury, anatomical injury scores and year of admission. Outcome, based on mortality at discharge, was analysed in two ways: alive or dead at discharge (mortality) and time to death or discharge (survival). RESULTS A decreasing trend (P < 0.01 ) in mortality with year of admission was detected on the log-odds scale. The trend could not be explained by a case-mix analysis, which allowed for the 17 other factors. Using multiple logistic regression analysis (mortality) and Cox proportional hazards analysis (survival), eight factors were identified as determinants of outcome: age, head AIS score, chest AIS score, abdominal AIS score, calendar year of admission, external injury AIS score, mechanism of the injury and primary receiving hospital. CONCLUSIONS The observed improvement in survival in severely injured patients must result from the interplay of factors not controlled in this analysis or improvements in patient care or both.

Influence of Tumor Histology on Preoperative Staging Accuracy of Breast Metastases to the Axilla

Histologic confirmation of axillary nodal metastases preoperatively avoids a sentinel node biopsy and enables a one step surgical procedure. The aim of this study was to establish the local positive predictive value of axillary ultrasound (AUS) and guided needle core biopsy (NCB) in axillary staging of breast cancer, and to identify factors influencing yield. A prospective audit of 142 consecutive patients (screening and symptomatic) presenting from 1st December 2008–31st May 2009 with breast lesions categorized R4–R5, who underwent a preoperative AUS, and proceeded to surgery was undertaken. Ultrasound‐guided NCB was performed on nodes radiologically classified R3–R5. Lymph node size, number, and morphological features were documented. Yield was correlated with tumor size, grade, and histologic type. AUS/NCB was correlated with post surgical pathologic findings to determine sensitivity, specificity, positive and negative predictive value of AUS and NCB. A total of 142 patients underwent surgery, of whom 52 (37%) had lymph node metastases on histology. All had a preoperative AUS, 51 (36%) had abnormal ultrasound findings. 46 (90%) underwent axillary node NCB of which 24 (52%) were positive. The smallest tumor size associated with positive nodes at surgery was 11.5 mm. The sensitivity of AUS was 65%. Specificity was 81%, with a positive predictive value (PPV) of 67% and negative predictive (NPV) value of 80%. Sensitivity of U/S‐guided NCB was 75%, with a specificity of 100%, PPV 100% and NPV 64%. Sensitivity of AUS for lobular carcinoma was 36% versus 76% for all other histologies. Sensitivity of NCB for lobular cancer was 33% versus 79% for all other histologies. The most significant factor producing discordance between preoperative AUS and definitive histologic evidence of lymph node metastasis was tumor type. Accurate preoperative lymph node staging was prejudiced by lobular histology (p < 0.0019).

Effectiveness of regional trauma systems: Improvements have occurred since study

Editor—Nicholl and Turner’s attempt to perform a definitive before and after study on regionalised trauma care was beset by logistical problems.1 Firstly, ambulance workers were not empowered to bypass the surrounding hospitals, who in turn were reluctant to be bypassed during the vulnerable period of health service reforms. Secondly, similar systems were compared. The central hospitals in Stoke, Hull, and Preston are all large hospitals with neurosurgical units on site. Thirdly, data were not collected prospectively. The researchers trawled the patients’ case records often years after admission. Notes from 1990 were not requested for initial examination until 1993, by which time many had been reduced and put on to microfiche. Fourthly, the local researcher was not trained on the nationally recognised injury scaling course. There were no intra-observer variability checks to confirm consistent application of scoring methods over the four years. Lastly, significant discrepancies in data accuracy were evident. When the number of direct admissions with severe trauma in 1993 were compared with those counted by the Trauma Research Group at Keele University there was a 25% difference. An outside expert scored the same patients independently and concurred with the Keele findings to within 3%. Since 1994 we have adopted a strategy to enhance data accuracy. Details on every major trauma patient are checked weekly by a senior clinician and circulated to medical and nursing staff involved in the patient’s care. Data shared freely in the clinical domain acts as a two way feedback system to promote accuracy and militate against entry bias in the trauma database. The problem of data validation must be addressed nationally, especially if audit information is to be released to purchasers of health care. Nicholl and Turner’s study represents at best a snapshot at the start of the development of the trauma system. Since then much progress has been made. Last year, our crude mortality in patients with severe trauma was 20%, compared with 38% in 1989-90.2,3 The pattern of trauma deaths with many cases of potentially salvageable major haemorrhage, referred to in the Royal College of Surgeons’ report,4,5 is no longer evident: 88% of deaths after major trauma were in patients with a critical head injury or aged over 70 years. Nicholl and Turner raise important issues but further careful studies are required to serve as evidence on which to base national policy.

Primary gut aspergillosis in a patient with acute myeloid leukaemia: the importance of early suspicion and definitive treatment.

Aspergillus infection is a known complication in immunocompromised patients, particularly in those with impaired neutrophil function. The pathophysiology of respiratory tract infection and disseminated disease are well understood, and guidelines exist for early detection and treatment. The gut has been speculated to be the potential portal of entry for Aspergillus, though previous case series outline that this is often discovered late and results in high morbidity and mortality. Early clinical suspicion, with definitive surgical intervention and antifungal treatment with voriconazole, can significantly increase the chances of survival. In this article, the authors discuss a case of primary gut aspergillosis with secondary dissemination in a patient with acute myeloid leukaemia who developed serious sequelae.

Three stage axillary lymphatic massage optimizes sentinel lymph node localisation using blue dye

AimsThis paper describes a simple technique of axillary and breast massage which improves the successful identification of blue sentinel nodes using patent blue dye alone.MethodsPatent blue dye was injected in the subdermal part of the retroaroelar area in 167 patients having surgical treatment for invasive breast cancer. Three stage axillary lymphatic massage was performed prior to making the axillary incision for sentinel lymph node biopsy. All patients had completion axillary sampling or clearance.ResultsA blue lymphatic duct leading to lymph nodes of the first drainage was identified in 163 (97%) of the patients. Results are compared with 168 patients who had sentinel lymph node biopsy using blue dye without axillary massage. Allergic reactions were observed in four patients (1.2%).ConclusionThree stage axillary lymphatic massage improves the successful identification of a blue sentinel lymph node in breast cancer patients.

Association of One-Step Nucleic Acid Amplification Detected Micrometastases with Tumour Biology and Adjuvant Chemotherapy

One-step nucleic acid amplification (OSNA) is an intraoperative technique with a high sensitivity and specificity for sentinel node assessment. The aim of this study was to assess the impact of OSNA on micrometastases detection rates and use of adjuvant chemotherapy. A retrospective review of patients with sentinel node micrometastases over a five-year period was carried out and a comparison of micrometastases detection using OSNA and H&E techniques was made. Out of 1285 patients who underwent sentinel node (SLN) biopsy, 76 patients had micrometastases. Using H&E staining, 36 patients were detected with SLN micrometastases (9/year) in contrast to 40 patients in the OSNA year (40/year) (p < 0.0001), demonstrating a fourfold increase with the use of OSNA. In the OSNA group, there was also a proportional increase in Grade III, triple-negative, ER-negative, and HER-2-positive tumours being diagnosed with micrometastases. Also on interactive PREDICT tool, the number of patients with a predicted 10-year survival benefit of more than 3% with adjuvant chemotherapy increased from 52 to 70 percent. OSNA has resulted in an increased detection rate of micrometastases especially in patients with aggressive tumour biology. This increased the number of patients who had a predicted survival benefit from adjuvant chemotherapy.

A Rare Cystic Breast Lump—Schwannoma of the Breast

lowing consultation on staging laparotomy, as a poorly differentiated adenocarcinoma consistent with serous carcinoma of ovarian origin. She was started on a course of carboplatin and paclitaxel. After four cycles of chemotherapy, the patient was taken for interval debulking, total abdominal hysterectomy, bilateral oophorectomy, and paraaortic lymph node dissection. On the first postoperative visit, 7 months following her most recent normal mammogram, the patient was found to have a new 5 · 2 cm right breast mass. This was firm and mobile on physical examination, located in the upper outer quadrant of the right breast. There were no skin changes, nipple discharge, nor palpable axillary lymphadenopathy. The left breast was normal on examination. The patient underwent a mammogram (Fig. 1a,b), a targeted ultrasound (a targeted ultrasound of the right breast) of the breast, and a CT scan of the chest (Fig. 1d). These images identified a solid, irregular mass in the right breast, suspicious for a primary breast cancer or metastatic lesion from ovarian cancer. An ultrasound-guided core needle biopsy of the lesion was undertaken. Histologically, the biopsy showed diffuse foreign body multinucleated giant cell reaction to birefringent crystals (Fig. 2a,b). This was consistent with a breast mass composed of talc from the patient’s previous pleurodesis. Although uncommon, foreign bodies in the breast have been reported in the literature; the majority of these are iatrogenic. Foreign bodies mimicking solid breast masses, cystic fluid collections, and suspicious microcalcifications have been reported. The increasing use of screening mammography and sensitivity of other breast imaging techniques may increase the detection rate of breast foreign bodies. The majority of these lesions are concerning enough to warrant a biopsy to rule out malignancy. The possibility of malignancy can lead to anxiety and distress for patients. A detailed history including previous surgical procedures to the breast or chest wall is important to ascertain. This may assist the clinician in raising the index of suspicion of a foreign body.

Some troubles with staples

With reference to the meta-analysis of Smith and colleagues,1 skin stapling has many disadvantages: