bluuebunny/crossref_metadata_2025 huggingface dataset:
1417 Post-Operative Breast Cancer Surveillance: The Crucial Role of Timing in Effective ‘Track and Trace’
Authors: Rees N , Okocha M
Published: October 2021

Aim

The aim of this quality improvement project is to assess our centre’s compliance to current NICE guidelines regarding annual mammogram follow-up for every breast cancer patient for 5 years and to elucidate any mechanisms that may optimise the efficiency of this surveillance process.

Method

We prospectively reviewed individual radiology requests following all wire-guided wide local excisions (WG-WLE), wide local excisions (WLE) and mastectomies undertaken at Bristol Breast Centre, a large tertiary referral centre, from January 2017-August 2020.

Results

Over the almost 4-year audit period, 1,885 operations were carried out. Specifically, 401 operations were performed from January 2017-June 2017, 677 from July 2017-January 2019 and 807 from February 2019-August 2020. Compliance to NICE guidelines was 95%, 100% and 95% from January 2017-June 2017, July 2017-January 2019 and February 2019-August 2020, respectively. Interestingly, compliance rates from February 2019-August 2020 varied according to the type of operation carried out; compliance was 97%, 94% and 91% for WG-WLE, WLE and mastectomy, respectively. This appears to result from the corresponding number of tardy radiological requests that were made following each of the three procedures. Specifically, the proportion of database requests filed in excess of one month post-operatively for each procedure type were 8%, 10% and 21% for WG-WLE, WLE and mastectomy, respectively.

Conclusions

Efficient annual mammographic surveillance depends on prompt post-operative radiological requests. Such database requests should ideally be enacted less than one month post-operatively. We suggest the adoption of an automatic electronic prompt could facilitate more effective post-operative mammogram surveillance.
1488 Cosmetic Tourism in Aesthetic Breast Surgery
Authors: McCrossan S , Martin S , Hill C
Published: October 2021

Introduction

Medical tourism is expanding on a global basis, with patients seeking cosmetic surgery in countries abroad. Little information is known regarding the risks and outcomes of cosmetic tourism, in particular, for aesthetic breast surgery.

Method

A systematic-review was conducted using the PRISMA (Preferred Reporting Items for Systematic-reviews and Meta-analyses) guidelines. Fifty-seven titles were screened, 42 abstracts were reviewed leaving 30 full texts. Twenty-one of these met the inclusion criteria.

Results

One-hundred and fifty patients partook in cosmetic tourism for aesthetic breast surgery. Forty-two percent of patients had an implant-based procedure. Other procedures included mastopexy (n = 4), bilateral breast reduction (n = 10) and silicone injections (n = 2). One-hundred and sixty complications were recorded, common complications included wound infection 31% (n = 46), breast abscess/ collection 14% (n = 21), wound dehiscence 12% (n = 18) and ruptured implant 9% (n = 13). Clavien-Dindo classification of complications includes 67 (45%) IIIb-complications with 78 returns-to-theatre, 2 class-IV complications (ICU stay) and one class-V-death of a patient. Explanation occurred in 38% (n = 24) of implant-based augmentation patients.

Conclusions

Aesthetic breast surgery tourism is popular within the cosmetic tourism industry. However, with infective complications (31%) and return-to-theatre rates (45%) significantly higher than expected, it is clear that having these procedures abroad significantly increases the risks involved. Professional bodies for cosmetic surgery in each country must highlight and educate patients how to lower this risk if they do choose to have cosmetic surgery abroad. In this current era of an intra-pandemic world where healthcare is already stretched, the burden from cosmetic tourism complications must be minimised.
1543 Response to Neoadjuvant Chemotherapy as An Indication for Breast-Conserving Surgery
Authors: Wilkinson A , Lee L , Alford N , Okocha M , Gill J
Published: October 2021

Aim

Pathological response to neoadjuvant chemotherapy (NAC) seeks to induce tumour regression pre-operatively. The present study aimed to assess tumour response to NAC and to evaluate the appropriateness of subsequent breast-conserving surgery (BCS) to avoid disfiguration of healthy breast tissue.

Method

Analysis of all patients undergoing NAC and wide local excision (WLE) surgery for primary breast cancer between April 2012 and December 2020 at a tertiary breast unit was conducted. Statistical analysis was performed using IBM® SPSS Statistics Software v27.0.

Results

A database of 1490 female patients undergoing WLE was retrieved, of whom 88 received NAC. Average patient age was 56 (SD = 11). Tumours were either invasive ductal (n = 86, 97.7%) or lobular (n = 2, 2.27%) carcinomas and grade 2 (n = 31, 35.2%) or grade 3 (n = 57, 64.8%). Chemotherapy regimens included: 30 FEC-T (34.1%), 22 FEC (25%), 19 TC (21.6%) and 17 other (19.3%). On average, tumour diameter (mm) decreased by 45.9%(34.5) with NAC and a further 2.29%(57.7) from NAC cessation to excision. Tumour diameter varied significantly across time points χ2 (3) = 29.057, p < 0.001. Post-hoc tests revealed a significant reduction in tumour diameter from pre- to post-NAC [Mean(SD):

29.6(10.9) vs 16.1(11.3), p < 0.001] and from pre-NAC to excision [14.1(12.0), p < 0.001] but not from post-NAC to excision (p = 1.000).

Conclusions

Tumour diameter significantly reduced with the addition of NAC. There was no statistical difference between post-NAC and post-operative diameter, suggesting no growth between NAC cessation and surgery. Our findings support the use of NAC, where possible, to avoid the need for large resection margins.
1573 Can the Technique of Local Perforator Flaps Reduce the Volume of Mastectomies?
Authors: Karagiannidis G , Mallidis E
Published: October 2021

Aim

National reported mastectomy rate varies from 25% - 45%. Also, when a reduction therapeutic mammoplasty is needed, symmetrisation of the contralateral side will follow. Can the “relative new” technique of local perforator flaps, reduce the volume of mastectomies and contralateral surgery in a District General Hospital?

Method

Retrospective review of yearly breast cancer treatment operations in Ipswich Hospital.

Results

332 surgical operations performed for breast cancer. 79/332 (23,7%) had mastectomy, 54/332 (16,26%) had therapeutic mammoplasty with symmetrisation contralateral surgery, 32/332 (9,63%) had local perforator Flap Surgery. From the perforator flap operations, 23/32 (23/332: 6,92%) would have mastectomy (+/- reconstruction) and 9/32 (11/332: 2,71%) would have therapeutic reduction mammoplasty with contralateral symmetrisation surgery if this surgical option was not available. 0/32 (0,00%) of the local perforator flaps failed.

Conclusions

Local perforator flaps have resulted in 6,92% reduction in mastectomy rate (also eliminating the possible need for reconstructions). This was in small volume breasts and lower pole carcinomas and 2,71% reduction in symmetrisation surgery. This reduction also reduces the cost of cancer treatment without compromising oncological outcome or patient satisfaction.
1577 Using CTS5 Calculator to Predict The 5-10-Year Risk of Late Distant Recurrence for Women With ER-Positive Breast Cancer Who Are Recurrence-Free 5 Years After Endocrine Therapy and To Reduce the Number of Patients Needing Discussion for The Extended Endocrine Therapy in The Breast MDTs: A Quality Improvement Project
Authors: Ahmed S , Kiruparan P , Debnath D
Published: October 2021

Introduction

The increasing number of patients has created a pressure on the services provided that aim to ensure the maximum level of care, particularly MDT meetings. Using the CTS5 calculator can readily reduce the number of patients needing discussion for EET. This is will prevent delays in decisions made for patients and more importantly, an evidence-based tool will be used for more accurate results.

Method

A retrospective data collection was undertaken from the Breast MDT records, initially dating from January to December 2018. Then when the optional use of CTS5 was established, data were retrieved from August to October 2019. As per guidance for the use of the CTS5 calculator; Women were deemed low risk if their 5–10-year risk is less than 5%, intermediate if between 5–10%, and high risk if their 5–10-year risk is more than 10%. Finally, a prospective data collected from January to March 2020 where an agreement was made for all involved Surgeons to use the CTS5 calculator.

Results

Before Introducing the CTS5 Calculator, in 2018, the number of patients was 1523 from which 66 were for EET 4.3%. When CTS5 Calculator was first introduced, 1st of August - 31st October 2019, the percentage reduced to 4.1% and from January to March 2020, a further reduction 3.9% was noticed.

Conclusions

The CTS5 calculator is an effective evidence-based tool used to predict the risk of 5-10 years recurrence in breast cancer patients. Implementing it will reduce the number of patients needing discussion in Breast MDTs, sparing meetings’ and patients’ time.
1646 Breast Cancer Awareness Among Female Nurses in Pakistan: About Time to Scrub Off Assumptions!
Authors: Farooq R , Ahmad Khan M , Isani Majeed A
Published: October 2021

Aim

The main aim of this research is to assess whether the clinical experience influence the knowledge, attitude and practices of female nursing staff and nursing students regarding breast cancer and to provide a baseline for monitoring trends of breast cancer awareness in them.

Method

A cross-sectional study of 280 female nurses was conducted at a tertiary care hospital in Islamabad, Pakistan. A pre-tested structured questionnaire with additional variables like cultural barriers to seeking medical help was used.1 The scores for outcome variables including knowledge, attitude and practices were pre-defined. Data was analyzed using SPSSv23.

Results

Of the 280 participants, with a p-value of 0.018, nurses aged more than 30 years, faced more practical, financial, emotional, and service barriers as compared to women younger than 30 years of age. By application of Chi-square test, there was a significant correlation between marital status and cultural barriers to seeking medical help, showing that single women (58.7%) shy away from talking about breast cancer considering it a taboo (p-value 0.028) whereas, more married nurses (59.2%) were apprehensive that they might be considered at fault by the society. (p-value 0.038)

Conclusions

Our study recognizes the need for delivering effective information to the female nurses regarding breast cancer in the biggest hospital of the capital city. Educating patients is likely to be effective if the female nurses play their part and have correct attitudes towards breast cancer practices. Therefore, we recommend arrangement of special courses and seminars for all healthcare professionals including the nursing staff.
158 Effect of Preoperative Continuation of Aspirin on Postoperative Bleeding After Off-Pump Coronary Artery Bypass Grafting (OPCABG)
Authors: Al-Manzo M I S , Biswas S , Das Gupta S , Rahman Md.Z , Basak B , Talukder Q I , Chanda P K , Biswas S K , Ahmed F
Published: October 2021

Background

Despite ample evidence of continued preoperative aspirin to improve outcomes in coronary artery bypass surgery, practice for routine continued preoperative aspirin use is still inconsistent due to concern for increased postoperative bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on postoperative bleeding after off-pump coronary artery bypass grafting (OPCABG).

Method

This cohort study involved patients (n = 74) who underwent OPCABG at a single center between August 2017 to January 2018. After considering the inclusion and exclusion criteria, they were divided into two groups: one (n = 37) received tablet Aspirin 75mg till the day of surgery and for the other group (n = 37) aspirin was stopped 5 days before surgery. Postoperative bleeding was recorded in both groups. After considering preoperative, intraoperative, and postoperative variables statistical analysis was done.

Results

There was no significant difference between the two groups concerning preoperative and peroperative variables. No significant difference was also observed between the two groups in chest tube drainage at 1sthour, 2ndhour, 3rdhour, 24thhour, next 24 hours (at 48th hour), and next 24 hours (at 72nd hour) (p = 0.845, 0.126, 0.568, 0.478, 0.342 and 0.717 respectively). No significant difference was seen in the transfusion requirement of blood and fresh frozen plasma (FFP).

Conclusions

Continuation of preoperative aspirin till the day of surgery is not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of blood and FFP.
174 Semi-Skeletonized Versus Pedicled Internal Mammary Artery Harvesting: A Systematic Review
Authors: Shafi A M A , Mellor S , Iddawela S , Brown L , Harky A
Published: October 2021

Objectives

To compare semi-skeletonized with pedicled harvesting technique of the internal mammary artery for coronary artery bypass surgery.

Method

A comprehensive literature search was performed on PubMed, Cochrane database, Embase, Google Scholar and Ovid identifying articles that compared semi-skeletonised to pedicled internal mammary artery in the use of coronary artery bypass surgery. Databases were evaluated and assessed from inception to July 2020.

Results

Only five studies fulfilled the criteria for this review. There was no reported incidence of sternal wound infection, myocardial infarction, or mortality. The length of the IMA graft was longer in the semi-skeletonized group compared to the pedicled group, 16.06cm versus 14.63cm respectively (p < 0.001). The intraoperative diastolic flow was significantly greater in the semi-skeletonized grafts than in the pedicled grafts during (p = 0.003) and after (p = 0.005) cardiopulmonary bypass. The incidence of pleural effusion (pedicled, 52.6%; semi-skeletonized, 23.6%; p = 0.002) and atelectasis (pedicled, 42.1%; semi-skeletonized, 20.0%, p = 0.015) were significantly higher in pedicled group. Post-operative chest tube drainage was significantly higher in the pedicled group (608 ± 58 mL compared to 470 ± 48 mL; p = 0.027). Additionally, FEV1 was significantly decreased in the pedicled group 6 days after surgery (pedicled:76.0% ± 1.6%; semi-skeletonized: 83.2% ± 1.6%; p = 0.020).

Conclusions

These results demonstrate that the semi-skeletonized preparation technique is associated with satisfactory outcomes during harvesting the internal mammary artery. Yet, due to limited numbers of studies, there is need for larger comparative studies to assess post-operative outcomes with a longer period of follow up.
415 Clinical outcomes and Patient satisfaction with Bilateral Radial Artery harvest in coronary surgery
Authors: Moawad Nader , Ghaddar Jamal , Nguyen Bao , Marchbank Adrian
Published: October 2021

Aim

Coronary artery bypass graft surgery remains an effective treatment strategy for complex coronary disease.There paucity of data regarding the use of bilateral radial artery conduits with wound, neurological and functional complications following surgical revascularisation.

Method

We reviewed the outcomes with retrospective analysis of prospectively collected clinical data from our database and identified 30 patients who underwent CABG requiring the use of bilateral radial harvest.Patient satisfaction was assessed using a quality of life questionnaire with the descriptors on a Likert Scale.

Results

The mean duration of follow-up was 29.8 ± 8.5 months.The mean age of patients was 69.0 ± 10.8 years.The commonest indications for bilateral radial harvest were existing bilateral varicose veins or previous bilateral vein surgery (combined 74% of cases) precluding venous conduit use. Three out of 24 (12.5%) patients reported arm pain or discomfort ‘rarely’ or ‘sometimes’ whilst all the others (87.5%) were asymptomatic.Three patients (12.5%) reported long term permanent sensory deficit with a further six (25%) patients having some other less significant sensory loss. Significant motor dysfunction was reported in one patient (4.2%) whilst 5 (20.8%) reported milder forms of motor deficit. 95.8% of patients considered the aesthetic outcome of the radial harvest site appearance to be at least acceptable (54.1% rated the appearance as excellent). One patient (4.2%) reported a ‘moderate’ functional change otherwise, the remaining patients reported ‘minimal’(12.5%) or ‘no change’ (83%).

Conclusions

Open bilateral radial artery is acceptable to patients as a conduit choice when alternatives are not favourable for surgical revascularisation.
485 Unexpected Pathological Findings In 189 LVRS Patients: Clinical Relevance
Authors: Ahmadi N , Preston S , Barbar J , Aresu G , Peryt A , Mahadeva R , Coonar A
Published: October 2021

Objectives

LVRS improves survival and quality of life in selected patients with emphysema. In view of the great improvement in the detailed information available from CT, it is important to evaluate the benefit of routine pathological assessment of the resected specimen. We reviewed the histopathological findings in our contemporary LVRS series to determine the rate of pathological findings in addition to emphysema.

Method

Prospectively collected data from a specialised higher volume LVRS centre. The CT and histopathology reports of 189 consecutive LVRS procedures were reviewed. One underwent thoracotomy, 188 were by VATS, of which one was converted to thoracotomy and of which 22 were by a subxiphoid approach. The target reduction volume was 30-50% of the lung.

Results

All patients were reported to have emphysematous changes in both CT and histology. Ten patients, all with radiographic evidence of a lesion preoperatively, had squamous carcinoma (x2), adenocarcinoma, atypical adenomatous hyperplasia (AAH) (x2), squamous metaplasia (x2), carcinoid tumourlet, chondroid hamartoma, and DIPNECH. There were 39 neoplastic histological findings which were not radiologically reported; these were adenocarcinoma (1), AAH (10), squamous metaplasia (7), carcinoid tumourlet (5), squamous dysplasia (3), neuroendocrine hyperplasia (2), and chemodectoma. In addition, 21 inflammatory/infective cases were also reported.

Conclusions

Our systemic retrospective CT and histopathology review of LVRS operations shows that the rate of additional findings is 32%. Of these 83% were not reported on the pre-operative review of the CT. This supports the value of systematic pathological assessment of resected samples.
570 Solitary Fibrous Tumours of the Pleura: Case Series
Authors: Ishak L , Kostoulas N
Published: October 2021

Introduction

Solitary fibrous tumours of the pleura (SFTP) are rare tumours with poorly recognised presentations and aetiology.

Aim

to evaluate the presentations, risk factors, investigations, management and follow up for 4 cases of SFTP

Method

retrospective review of medical records of 4 patients diagnosed with SFTP at the Golden Jubilee National Hospital between January-October 2020. Data was collated on presenting signs and symptoms, co-morbidities, risk factors, investigations, management and follow. A literature review was conducted, and findings discussed.

Results

All cases were males aged 62-85. All were referred from the same geographical area. Pre-disposing risk factors included exposure to cold-dust (1), asbestos (1) and smoking (1). Presenting symptoms were cough (3), shortness of breath (1), weight loss and fatigue (1). Associated co-morbidities were coagulopathy(2) and hyperglycaemia (1). Patients were investigated pre-operatively with chest x-ray (4), pulmonary function tests (4), PET-CT scan (4) and CT biopsy (3). One patient had genetic studies for chromosome 18 translocation. Three out of 4 patients were managed surgically with wedge resection (3) via video-assisted thoracoscopic surgery (2) or open thoracotomy(1), followed by excision biopsy studies (3). Tumours originated from the visceral (1), mediastinal (1) and parietal (1) pleura. Recurrence risk for all patients was deemed to be 20%. Follow up was with 6 monthly CT scans for 5 years (1).

Conclusions

SFTP is a rare tumour which presents with non-specific symptoms. Better understanding of the aetiology, presentation and investigations is needed to aid definitive diagnosis and tailored management
747 A Case Report: Spontaneous Recovery of Type B Aortic Dissection
Authors: Sherif M , Witharana P
Published: October 2021

Introduction

An aortic dissection occurs when there is a tear in the intimal and medial layer of the aorta, leading to a false lumen within the media. Type B aortic dissections (TBAD), according to the Stanford Classification are where the entry tear is located distally from the left subclavian artery. Resolution of a Type B aortic dissection (TBAD) by medical therapy is a very rare event.

Case Presentation

58-year-old gentleman presented with sudden onset central chest pain. A CTPA was organised following a high d-dimer. This showed a TBAD extending from the origin of the left subclavian artery to the level of the diaphragm. His blood pressure was aggressively controlled with IV labetalol and IV isosorbide dinitrate and was monitored for 2 weeks. He was then discharged home on oral antihypertensive medication. A follow up CT aortogram was done 7 months later which showed that the false lumen of the TBAD has improved from 18mm to 2 mm.

Discussion

The anti-inotropic effect of beta blockers reduces the stress on the aortic wall and therefore prevents further dilatation. Aggressive control of blood pressure and heart rate comes with its own disadvantages. It had been shown, patients managed conservatively were more likely to develop renal failure (43%) compared to those having endovascular repair. About half of those patients required surgical treatment. There are not many cases in literature where a TBAD had resolved with medication.

Conclusions

As evident from this case, rigorous management of blood pressure may help with cases of Type B Dissection.
753 Should Mini-Sternotomy Be Favoured Over Conventional Full-Sternotomy Approach in Aortic Valve Replacement
Authors: Aljanadi F , Moawad N , Beattie G , Nzewi O , Jones M , Ahmed A
Published: October 2021

Aim

In view of the increasing interest in Upper mini-sternotomy (UMS) as an alternative approach for conventional full sternotomy AVR (FS), we aimed to compare early and mid-term results between UMS and Full-sternotomy AVR.

Method

This is a retrospective study of 231 patients who had aortic valve replacement via upper mini sternotomy (UMS) compared with 231 patients had their AVR via full sternotomy (FS). Baseline characteristics, operative and postoperative outcomes were compared. Patients’ data are presented as median (interquartile range) or as percentages.

Results

The two groups were almost comparable in terms of preoperative characteristics. Though patients with age >80 were more in UMS AVR group (11.25% vs 8.6%), this was statistically insignificant (p > 0.05). Females were significantly more in UMS AVR group (104 vs 66, p < 0.05), as well as in high BMI patients (120 vs 89, p < 0.05). There was no significant difference in 30-day mortality( 0.43%vs 2.2%, P > 0.05) between the two groups, as well as in cardiopulmonary bypass time (109 vs 103 min, p > 0.05), aortic cross-clamping time (82 vs 83 min, p > 0.05) and the duration of operation(218 vs 213, p > 0.05).Results showed no significant difference in the incidence of major and minor postoperative complications apart from FS AVR patients had a higher incidence of postoperative pneumonia ( 2.1% vs 10.4 %, p < 0.05).

Conclusions

UMS AVR are more commonly used in females and high BMI patients. Our results show that UMS AVR is a safe alternative approach for aortic valve surgery revealing comparable early and midterm results to conventional FS AVR.
780 Rapid Deployment or Sutureless Valves as An Alternative to Conventional Bioprosthetic Aortic Valve Replacement
Authors: Aljanadi F , Moawad N , Jones M
Published: October 2021

Aim

Rapid deployment valves are being used widely. We wanted to compare outcomes for rapid-deployment valves and conventional bioprosthetic aortic valve replacements in order to assess if their use is justifiable.

Method

Outcomes of the last 120 patients who received a rapid-deployment AVR (RDAVR) between Sept 2014-Sept 2019 were compared to the last 120 patients who had conventional bioprosthetic aortic valve replacement (Conv AVR).

Results

Age of RDAVR 77.5±4.93 was compared to Conv AVR 67.9±11.9 years (p > 0.05). Other baseline characteristics were similar. RDAVR group included more elderly (>80 years; 40 vs 11, p < 0.05) and females (83 vs 36, p < 0.05). RDAVR group had shorter cross clamp time (68 vs 89 min, p < 0.05) and cardiopulmonary bypass time (97 vs 110 min, p < 0.05) for isolated AVR. Mortality was equal in both groups (1.7%). Post-operative pressure gradients were similar (mean gradient 10.4±4.44 vs 11±5.31 mmHg and peak gradient 20.32±8.64 vs 22.95±9.72 mmHg). Additionally, patients were divided into size matched subgroups and post-operative pressure gradients were comparable. Hospital length of stay and early post-operative results were similar between the two groups. Early permanent pacemaker rate was similar in both groups (9 vs 5, p > 0.05). Survival rates in group 1 and 2 were 97.5% vs 99.2% at 1 year, 95.8% vs 96.7% at 2 years. and 95% vs 96.7% at 3 years, respectively.

Conclusions

RDAVR had similar haemodynamic outcomes and survival. Where shorter cross clamp and pump times may be desirable RDAVR may be preferred in older high-risk patients.
838 Pulmonary Embolectomy: Techniques and Outcomes from The Literature
Authors: Kwan L Y A , Lee J , Cheung A , Chan J
Published: October 2021

Aim

Pulmonary embolectomy involves the surgical removal of a thrombus from the pulmonary tree, with the most popular approaches being surgical embolectomy (SE), percutaneous pulmonary embolectomy (PPE) and minimally invasive thoracotomy (MIT). The latter two new techniques are gradually increasing in popularity in the treatment of acute pulmonary embolism (PE) due to reduced recovery times. This study aims to evaluate and compare the clinical outcomes of the three aforementioned techniques in the treatment of acute PE.

Method

A literature review was performed with PUBMED to identify studies reporting these interventions. 79 papers were included, involving a total of 2445 patients. Patients’ baseline characteristics and perioperative status, inpatient mortality rates and complication rates of each intervention group were individually assessed and compared.

Results

Among all three interventions, SE studies demonstrated the highest in-patient mortality rate (20.8%). Patients receiving SE are also more likely to have pulmonary (2.8%) and other postoperative bleeding (7.4%). PPE patients are more likely to develop gastrointestinal bleeding and surgical site complications (4%). Scatter graph of the SE studies showed a declining trend of mortality rate over time (R²=0.50).

Conclusions

All three methods are effective in treating acute PE, while SE showed a trend of decreasing mortality over time. Further research on PPE and MIT is needed to define its place in the treatment of acute PE.
1011 The Implications of The Use of Left Ventricular Assist Devices (Lvads) Or Extra-Corporeal Membrane Oxygenation (ECMO) In Patients with Severe Heart Failure
Authors: Kumar A
Published: October 2021

Introduction

Heart failure (HF) is a chronic, debilitating and progressive disease(1). Consequently, guidelines recommend heart transplants for patients suffering from end-stage HF, termed destination therapy(2). However, with increasing disparity between the number of donor hearts available and people on the waiting list, identifying the most suitable interim intervention (bridge-to-transplant) therapy is paramount(3,4).

Method

A scoping search identified controversy surrounding LVAD versus ECMO in end-stage HF. Discussions with an expert in the field at a tertiary centre in the UK (Queen Elizabeth Hospital Birmingham) enabled refinement of the topic. A literature review was conducted, followed by a title and abstract screen. Subsequently, remaining literature was critically appraised.

Results

First generation LVADs may decrease mortality by 48% in comparison to optimal medical management, although have been associated with disabling stroke. Second and third generation LVADs demonstrate impressive survival at 30 days (>95%), a strong favourable long-term prognostic indicator. Additionally, improvement in HF severity and QoL have been demonstrated. Unlike ECMO, LVAD appears to be feasible as a DT, lasting as long as 8 years. However, the cost of LVADs may be prohibitive, higher than transplantation2. However, ECMO may facilitate multi-organ and right ventricular recovery, enabling transplantation to occur with increased stability. Neither option has conclusive evidence for cost-effectiveness.

Conclusions

Both LVADs and ECMO can be considered as effective BTT options, suitable in different clinical scenarios. The decision for BTT intervention should be undertaken on a case-by-case basis, in accordance with NICE guidelines, aiming for optimal outcomes in terms of survival, functionality and QoL.
1269 Five Year Propensity Matched Outcomes of Minimally Invasive vs Conventional Isolated Aortic Valve Surgery
Authors: Oo S , Khan A , Chan J , Vohra H
Published: October 2021

Aim

To analyse the early and mid-term outcomes of the patients undergoing conventional isolated aortic valve replacement (CAVR) versus minimally invasive isolated aortic valve replacement (MIAVR).

Method

This is a single centre retrospective study involving 653 patients who underwent isolated aortic valve replacement either via CAVR (n = 516) or MIAVR (n = 137) between August 2015 and March 2020. Using pre-operative characteristics, patients were propensity matched (PM) to produce 114 matched pairs. Assessment of peri-operative outcomes, early and mid-term survival and echocardiographic parameters was performed.

Results

PM analysis showed the larger sized aortic valve prosthesis were inserted in the MIAVR group (22.8±2.5mm) compared to CAVR group (22.0±2.2mm)(p = 0.010). CPB time was longer with MIAVR (94.4±19.5mins) compared to CAVR (83.1 + 33.3; p = 0.003). There were no differences in the early post-operative complications and mortality between the two groups. Follow-up echocardiographic data showed significant difference in mean aortic valve gradients between CAVR and MIAVR groups (17.3±8.2mmHg and13.0±5.1mmHg, respectively; p = 0.001). There was no significant difference between CAVR and MIAVR in the mid-term survival at 3 years. (log-rank test p = 0.314).

Conclusions

This study found that larger aortic valve sizes with lower mean gradients are being implanted in the MIAVR group. Despite the longer CPB time in the MIAVR group, there was no significant difference in the early complications, mortality, and mid-term survival between MIAVR and CAVR. Further studies will be required to analyse the long-term survival.
1547 An Alternative Approach to High-Risk Resternotomy
Authors: Kho J , Khalil A , Petrou M
Published: October 2021

Introduction

Resternotomies are associated with substantial perioperative morbidity and mortality. Strategies described in literature mostly involve peripheral cannulation pre-sternotomy. Disadvantages of this technique relate to prolonged systemic heparinisation and cardiopulmonary bypass (CPB) time and the sequelae of hypothermic circulatory arrest. We describe a two-stage approach that potentially reduces the complications associated with high-risk resternotomy.

Method

3 high-risk patients (from pre-operative CT images) were referred for redo complex aortic surgery. A right mini-thoracotomy incision was first made in the 4th or 5th intercostal space. The right lung was isolated and careful blunt dissection was carried out to mobilise the heart and great vessels attached to the sternum. Once these structures were free, thoracotomy incision was closed. A standard median sternotomy was then performed and central cannulation carried out after systemic heparinisation. Rest of the surgery was performed routinely. In one patient, aortic aneurysm was heavily adherent and attempts to mobilise it fully proved impossible. Resultantly, systemic heparinisation was administered and the patient was cannulated in the right superficial femoral artery and right atrium (via mini-thoracotomy). CPB was instituted and the patient cooled to 28 °C. Right superior pulmonary vein vent was introduced to prevent left ventricular distension from hypothermic ventricular fibrillation. Once the heart and aneurysm were decompressed on full CPB, complete mobilisation was performed safely. All 3 patients survived surgery without major complications.

Conclusions

Meticulous preoperative planning is key to management of high-risk resternotomy. We describe a novel technique which we believe minimises risk of morbidity and mortality in these complex cases.
1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection
Authors: Benedetto U , Sinha S , Dimagli A , Cooper G , Mariscalco G , Uppal R , Moorjani N , Krasopoulos G , Trivedi U , Angelini G , Akowuah E , Tsang G
Published: October 2021

Background

Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.

Method

Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK.

Results

Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital.

Conclusions

Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.
1655 Thoracic Aortic Aneurysmal Disease: Timing and Outcome of Surgery
Authors: Elghazouli Y , Badran A , Naseer M , Ohri S
Published: October 2021

Aim

A thoracic aortic aneurysm (TAA) is a pathological dilatation of the thoracic aorta. There is significant morbidity associated with a dilated aorta including mortality. Open thoracic surgery is the mainstay of management for proximal lesions, offering definitive treatment. We aim to evaluate the outcomes of patients operated on for TAA and consider high risk associations for mortality.

Method

Data was retrospectively collected from 234 patients that underwent elective open thoracic surgery at UHS for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures were gathered.

Results

There were 166 males (71%) and 68 females (29%), with a mean age of 66 years. We found that 105 operations involved the aortic root, 171 the ascending aorta, 20 the aortic arch and 12 the descending aorta. 30 day mortality was 5.13%. Female patients that underwent aortic root surgery (P = 0.05), as well as those with prosthetic aortic valves (P = 0.01)and post-operative complications were associated with a significantly higher mortality.

Conclusions

A number of factors are associated with morbidity and mortality in this high-risk Surgery. These should be considered when discussing risks of intervention with patients.
32 Congenital Arteriovenous Malformation of The Breast Associated with Giant Hairy Naevus: A Case Report
Authors: O'Beirn E , Elliott J , Neary C , McLaughlin R
Published: October 2021

Introduction

An arteriovenous malformation (AVM) is defined as an abnormal connection between arteries and veins, bypassing the capillary system. AVM of the breast is a rare clinical entity, with limited evidence to guide management. We present the case of a congenital AVM of the breast in an otherwise healthy woman, with an interesting presenting complaint.

Case Description

A 38-year-old female presented with a ‘buzzing’ sensation and mastalgia in her left breast. Examination revealed a visible pulsatile linear abnormality with a bruit on auscultation. Duplex ultrasonography demonstrated mixing of the arterial and venous flow, consistent with an AVM. Operative management entailed ultrasound guided identification, ligation and excision of all aneurysmal segments. Histopathologic evaluation demonstrated an AVM with no malignant features. At one year postoperatively, the patient reported complete symptom resolution. Literature review identified nine case reports, including two cases of congenital breast AVM, both treated surgically. Seven cases of iatrogenic AVM were identified, with diagnosis based on duplex ultrasonography and management by surgical ligation in all except one, which resolved spontaneously.

Conclusions

ongenital AVM of the breast is a rare clinical entity. Diagnosis can be established using duplex ultrasonography, while CT and MRI may be useful for preoperative planning. Endovascular management alone is associated with high recurrence rates and surgical excision is the favoured approach where technically feasible without major aesthetic or functional compromise.
53 A Rare Malignant Lesion of the Jaws
Authors: Patel V
Published: October 2021

Introduction

Primary intraosseous carcinoma (PIOC) of the jaw is an incredibly rare lesion with approximately 200 cases reported in the literature. PIOC are mostly asymptomatic incidental radiographic findings and present as poorly-defined, non-corticated radiolucencies often with root resorption and cortical perforation. Prognosis is considered poor and best predicted by histological grade.

Case report

A gentleman in his 50s presented to his dentist with a draining sinus from his LR6 tooth. A radiograph revealed a non-corticated radiolucency localised to the distal root of the LR6. 7 months later, he returned with pain and mobility of the LR7. Another radiograph revealed a non-corticated radiolucency from around the distal root of the LR6 extending to the LR8. Urgent biopsy of the mandibular bone was arranged by the oral and maxillofacial surgery team. Histopathology revealed the lesion was likely a benign squamous odontogenic tumour. However, it was not possible to exclude a well-differentiated squamous cell carcinoma. Correlation of clinical findings, imaging and multidisciplinary team discussion was recommended. Following the MDT meeting, excision of the bony lesion was undertaken. Histopathology this time returned as primary intraosseous carcinoma NOS T4N0M0, thought to have arisen from a radicular cyst associated with the LR6/7. The treatment was right segmental mandibulectomy, fibular free flap, selective neck dissection (I-III) and adjuvant radiotherapy.

Conclusions

This case highlights how subtle radiographic features can represent malignancy in lesions appearing cystic at first. Although rare, clinicians should be aware of PIOC as a differential diagnosis when presented with radiographic features which could represent malignancy.
96 A Rare Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?
Authors: Chew P R , Hogg F
Published: October 2021

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare subtype of T-cell lymphoma that develops around breast implants and was first described in 1997. To date, the estimated risk of BIA-ALCL in UK is reported to be 1 in 24000, but as yet appears to have a substantial variation of incidence around the world. The aetiology of this recognised clinical entity remained widely unknown.

A 72-year-old woman in remission for systemic anaplastic lymphoma kinase (ALK)-positive ALCL of right axilla, presented with a discoloured lump at the medial mastectomy scar following a progressive enlargement of right breast, 20 years after silicone breast implant reconstruction. Imaging studies showed fluid collection and herniation of the affected breast implant. Subsequently, the discoloured lump burst and patient then had tissue biopsy and removal of her right breast implant in together with intravenous antibiotic. Histocytopathological examination confirmed the presence of BIA-ALCL without capsular invasion and the growth of Gram-negative bacteria were noted in fluid culture. Total capsulectomy was performed and patient continues to be in remission with no local or systemic therapy.

We reported a rare yet interesting case of the coexistence of BIA-ALCL and systemic ALK-positive ALCL in an elderly patient. This case has further strengthened the causal relationship of composition and/or textured implant, and the presence of a theoretical association of a select group of pathogens maybe a trigger and contributes to the pathogenesis of BIA-ALCL. Due to the rarity of this disease, diagnosis can be challenging and requires a multidisciplinary approach.
97 A Case Report: Necrotising Leukocytoclastic Vasculitis (NLV) Of the Breast Mimicking Necrotising Fasciitis (NF)
Authors: Chew P R , Munro K
Published: October 2021

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients.

A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery.

This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.
106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting
Authors: Ng S , Lam M , Gil N , Shamali A
Published: October 2021

Introduction

Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration.

Case Presentation

A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex.

Discussion

Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent.

Conclusions

This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.
128 Rapidly Proliferative Pilomatrixoma On the Eyebrow of A 7-Year-Old Boy – A Case Report
Authors: Patel M , Sinha M
Published: October 2021

Pilomatrixoma or calcifying epithelioma of Malherbe is a benign tumour originating from pluripotent precursors of hair matrix cells. We present a paediatric patient with a rapidly enlarging eyebrow mass with a differential diagnosis of sebaceous cyst, pyogenic granuloma, or malignancy.

A 7-year-old boy presented in primary care with a 0.5cm non-inflammatory nodule on his medial brow present for 2-3 months. History of previous trauma was not elicited and there were no features of bleeding or ulceration. It was then lanced, following diagnosis of an infected sebaceous cyst. Within weeks, the nodule underwent rapid proliferation, enlarging to 2cm in diameter. He was urgently referred to secondary care pending further investigation for possible trauma-induced pyogenic granuloma or malignancy.

Upon presentation in secondary care, we observed a protruding erythematous and ulcerated mass, indurated in texture and adherent to overlying skin. The patient was submitted to excisional biopsy with a vertical elliptical approach to minimise distortion of the brow. Small, calcified deposits were observed in the tumour substance. Histologically, basaloid basophilic cells were predominant and mixed with ghost cells and foci of giant multinucleate cells, verifying diagnosis of a pilomatrixoma.

Pilomatrixoma exhibits tendency towards mimicry of lesions such as epidermoid, sebaceous, dermoid cyst, pyogenic granuloma or even keratoacanthoma with a pre-operative detection rate as low as 11%. With a bimodal age distribution, arising in the first and sixth decades of life, this case highlights a need for a high degree of suspicion in young patients with careful clinical examination in order to aid diagnosis and prompt appropriate treatment.