Can laparoscopy be part of a paediatric surgery outreach service?

INTRODUCTION The aim of this study was to assess the outreach laparoscopic service delivered by four paediatric surgeons to a district general hospital (DGH). METHODS A retrospective review was carried out of all laparoscopic procedures performed in a single DGH between January 2004 and November 2014 by the four paediatric surgeons providing the outreach service. All operations were identified from the electronic theatre system and archived correspondence. Demographic and clinical details were obtained from contemporaneous records. RESULTS Over the 11-year study period, 1,339 operations were performed as part of the outreach paediatric surgery service, with 128 patients (9.6%) undergoing laparoscopy. The indications for laparoscopic surgery were impalpable unilateral or bilateral undescended testes (UDT) (n=79, 62%) or request for insertion of a feeding gastrostomy (n=49, 38%). All but six UDT cases (96%) were performed as day surgery and the median length of stay for gastrostomy patients was 3 days (interquartile range: 2–3 days). There were three UDT cases with surgical complications and one had complications related to the anaesthesia. One gastrostomy case required transfer to our tertiary centre for management of postoperative urinary retention and urethral injury. CONCLUSIONS Elective laparoscopic procedures in young children can be provided safely as components of an outreach paediatric surgery service in a DGH setting as part of an increasing volume of operations performed by specialist paediatric surgeons. This enables children to have a high quality service as close to their home as possible.

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Survey of General Paediatric Surgery Provision in England, Wales and Northern Ireland

Annals of The Royal College of Surgeons of England ◽

10.1308/003588408x285766 ◽

2008 ◽

Vol 90 (3) ◽

pp. 193-197 ◽

Cited By ~ 23

Author(s):

JK Pye

Keyword(s):

Northern Ireland ◽

Elective Surgery ◽

High Volume ◽

District General Hospital ◽

Paediatric Surgery ◽

Subtle Change ◽

Tertiary Centre ◽

The Future ◽

Tertiary Hospitals ◽

Current Provision

INTRODUCTION A survey was carried out to ascertain the current provision of general paediatric surgery (GPS) in all hospitals in England, Wales and Northern Ireland with 100% return rate. The provision of GPS is at a crossroads with a drift of these cases to the overstretched, tertiary referral hospitals. METHODS The regional representatives on the council of the Association of Surgeons of Great Britain and Ireland (ASGBI) obtained data from their regions. Any gaps in the data were completed by the author telephoning the remaining hospitals to ascertain their current provision. RESULTS A total of 325 acute hospitals are potentially available to admit elective and/or emergency paediatric patients, of which 25 hospitals provide a tertiary paediatric surgical service. Of the remaining ‘non-tertiary’ hospitals, 138 provide elective GPS and 147 provide emergency GPS. The ages at which GPS is carried out varies considerably, but 76% of non-tertiary hospitals provide elective GPS to those over the age of 2 years. The ages of emergency cases are 24% over the age of 2 years and 51.5% over the age of 5 years. The age at which surgery is carried out is dependent on the anaesthetic provision. Subspecialisation within each hospital has taken place with a limited number of surgeons providing the elective surgery. ‘Huband-spoke’ provision of GPS to a district general hospital (DGH) from a tertiary centre is embryonic with only 11 surgeons currently in post. An estimate of the annual elective case load of GPS based on the average number of cases done on an operation list works out at 23,000 cases done outwith the tertiary centres. DISCUSSION Almost 10 years ago, a change in the training of young surgeons took place. An increase in training posts in Tertiary centres was made available following advice from the British Association of Paediatric Surgeons (BAPS) but these posts were often not taken up. Many DGH surgeons became uncertain whether they should continue GPS training. A subtle change in the wording of the general guidance by the Royal College of Anaesthetists altered the emphasis on the age at which it was appropriate to anaesthetise children. Change in clinical practice, reducing need, and a drift towards tertiary centres has reduced DGH operations by 30% over a decade. Young surgeons are now seldom exposed to this surgery, and are not being trained in it. The large volume of these low-risk operations in well children cannot be absorbed into the current tertiary centres due to pressure on beds. The future provision of this surgery is at risk unless action is taken now. This survey was carried out to inform the debate, and to make recommendations for the future. The principal recommendations are that: (i) GPS should continue to be provided as at present in those DGHs equipped to do so; (ii) GPS training should be carried out in the DGHs where a high volume of cases is carried out; (iii) management of these cases should use a network approach in each region; (iv) hospital trusts should actively advertise for an interest in GPS as a second subspecialty; and (v) the SAC in general surgery develop a strategy to make GPS relevant to trainee surgeons.

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Reversing the Friday peak in metastatic cord compression referrals: Not as simple as previously thought?

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e14050 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e14050-e14050

Author(s):

Olusola Michael Adeleke ◽

Rubyyat A Hakim ◽

Laurence Dean ◽

Huma Zahid ◽

Rongyu Lin ◽

...

Keyword(s):

Goodness Of Fit ◽

Single Point ◽

District General Hospital ◽

Cord Compression ◽

Radiology Reporting ◽

Goodness Of Fit Test ◽

Tertiary Centre ◽

Chi Squared ◽

Early Case ◽

The Uk

e14050 Background: Historically, metastatic spinal cord compression (MSCC) referrals trend towards a Friday peak in incidence (Koiter E, Radioth Onc 2013). However, data from a single, tertiary centre in the UK showed a reversal in the Friday peak (Adeleke S, Annals of Oncology 2020). This was attributed to early case referrals and quicker treatment decisions. In this new study, we explored whether a similar pattern was apparent in multiple district general hospital (DGH) settings and attempt to identify underlying causes. DGHs manage a larger proportion of cancer patients in the UK. Methods: 1,069 patients between 1 Jan 2015 and 31 Dec 2020 were identified across 4 hospitals in Kent, UK with a population of 1.6 million people. 220, 181, 182, 159, 134 and 193 MSCC patients were identified annually (2015-2020). Commonest cancers were prostate (24.1%), lung (19.3%) and breast (12.3%). Thoracic and lumbar regions constituted 80% of MSCC sites. Kruskal Wallis was used to compare differences in referrals across weekdays. Data was then dichotomised to Fridays only vs. other days of the week combined, as previously reported (De Bono B, Acta Neurochir 2019). Chi squared was used to compare frequency of referrals between the two groups. Chi squared goodness of fit test was conducted to detect if Friday reflected the day with highest referrals across the week. Results: Across the region, 2015 saw the highest number of Friday referrals relative to other days, p= 0.002. Friday referrals continued to drop, year on year, until 2018 with a corresponding increase in mid-week referrals. After 2018, there was a return in trend to a further Friday peak across the region, though p= 0.836. On an individual hospital basis, the persistent Friday peak in the region was driven by two hospitals. Having a 7-day acute oncology service (AOS), 7-day radiology reporting and single referral point of contact in the department, were factors identified that kept the referrals across the week uniform. On another note, a substantial shift towards a single 8Gy fraction vs. 20Gy in 5 fractions was observed across the region. This change coincided with SCORAD III data (Hoskin P, ASCO 2017) and demonstrates adherence to evidence-based practice in the region. Conclusions: This large multi-centre retrospective study shows a differential referral pattern in the region, with hospitals with 7-day AOS/Radiology reporting and single point of referral (e.g, similar to MSCC coordinator role) having a quicker treatment turnaround and uniform referrals across the week. The MSCC coordinator has been shown to streamline service, ensure timely decision-making and improved survival outcomes (Richards L, Spine J 2017). The role is recommended by NICE UK. DGHs should consider appointing an MSCC coordinator when designing/auditing their service. The shift towards single 8Gy fraction can provide a ‘one-stop’ service where patients are scanned, planned and treated on the same day.

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178 Suspected Cauda Equina Syndrome in a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab134.378 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

L Ellerton ◽

H Benjamin-Laing ◽

W J Harrison

Keyword(s):

General Hospital ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

District General Hospital ◽

Bladder Function ◽

Mri Scan ◽

Eligibility Criteria ◽

Joint Project ◽

Tertiary Centre ◽

Patient Morbidity

Abstract Introduction Cauda Equina Syndrome (CES) is rare but when the diagnosis is delayed patient morbidity is significant. Recently, NICE Clinical Knowledge Summaries have updated their red flags on CES to be more explicit enabling earlier referral and diagnosis. A joint project between Orthopaedics and Radiology departments aimed to assess the current pathway of Cauda Equina Investigation at a District General Hospital. Method Data was collected from the local Radiology database for requests between July 2017 and August 2018. This included both direct requests to assess for CES and implied. Raw data revealed a potential of 600 patients, of which we have analysed 332 patients met the eligibility criteria. Results Only 58 patients had a documented complete bladder function assessment, of those 33% had incomplete or partial bladder emptying. Time to MRI scan ranged from 50mins – 23 hours & 52 mins. 47% had negative scans with CES or Cord compromise on MRI scan was demonstrated on 9%. 23 patients were transferred urgently to the receiving tertiary centre. Conclusions We found that nearly 90% of patients were being incompletely assessed and time to scan ranged significantly. We are producing a trust wide suspected CES pathway to improve patient assessment.

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General Paediatric Surgical Provision of Percutaneous Endoscopic Gastrostomy in a District General Hospital – A 12-Year Experience

Annals of The Royal College of Surgeons of England ◽

10.1308/003588409x391749 ◽

2009 ◽

Vol 91 (5) ◽

pp. 404-409 ◽

Cited By ~ 8

Author(s):

T Sathesh-Kumar ◽

Hazel Rollins ◽

Sarah Cheslyn-Curtis

Keyword(s):

General Hospital ◽

Percutaneous Endoscopic Gastrostomy ◽

District General Hospital ◽

Late Complications ◽

General Anaesthetic ◽

Paediatric Surgery ◽

Number Of Children ◽

Endoscopic Gastrostomy ◽

Local Access ◽

The Uk

INTRODUCTION A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK. PATIENTS AND METHODS A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic. RESULTS A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5–18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2–7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 ‘buried bumpers’, 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality. CONCLUSIONS We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.

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EP.TH.919Developing A Fast Track Paediatric Herniotomy Service In A District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab309.094 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Tsitsi Chituku ◽

Pradip Gupta ◽

Karen Bartholomew ◽

Michael Moncrieff

Keyword(s):

Critical Care ◽

Inguinal Hernia ◽

Fast Track ◽

Elective Surgery ◽

District General Hospital ◽

Out Of Hours ◽

Clinic Patient ◽

Patient Demographics ◽

Tertiary Centre ◽

Paediatric Critical Care

Abstract Introduction Previously to 2011, babies presented as emergency to our Trust with irreducible inguinal hernia at a rate of 1 baby/year. They were referred to our regional tertiary centre for surgery because there is no out of hours Paediatric Surgeon or Anaesthetist. Usually, patients were either, awaiting an appointment to see surgeon or on an 18-week waiting list. The aims of this SIP were to: expedite elective surgery for paediatric inguinal hernias, and prevent emergency paediatric inguinal hernia referrals to our tertiary centre. Method Referrals to paediatric surgical clinics were triaged by the clinic sister. Hernia referrals were expedited to the next available clinic. A provisional date for surgery was arranged ASAP with an identified surgeon and anaesthetist whilst in clinic. Patient demographics and data collected retrospectively. Results A 73% reduction in waiting time for surgery, 1 baby (1.4%) presented as emergency and was referred to our tertiary centre for surgery, the post-op complication rate fell from 6.5% to 0%. Conclusion The success of the fast-track paediatric herniotomy service at our DGH shows that it is possible to provide timely and safe surgery in a DGH in line with the recommendations of the Paediatric Critical Care and Surgery in Children Review (November 2019).

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Do infants with transposition of the great arteries born outside a specialist centre have different outcomes?

Cardiology in the Young ◽

10.1017/s1047951119001367 ◽

2019 ◽

Vol 29 (8) ◽

pp. 1030-1035 ◽

Cited By ~ 1

Author(s):

Colin Veal ◽

Richard Hunt ◽

Lyvonne N. Tume

Keyword(s):

Arterial Switch Operation ◽

Secondary Data ◽

District General Hospital ◽

Definitive Treatment ◽

General Hospitals ◽

Arterial Switch ◽

Tertiary Centre ◽

South Wales ◽

Switch Operation ◽

Specialist Centre

AbstractBackground:Infants born with undiagnosed transposition of the great arteries continue to be born in district general hospitals despite the improvements made in antenatal scanning. Evidence indicates improved outcomes with early definitive treatment after birth, hence the recommendation of delivery in a tertiary centre. The role of specialist paediatric and neonatal transport teams, to advise, stabilise, and transport the infants to a tertiary centre in a timely manner, is critical for those infants born in a district general hospital. This pilot study aims to compare outcomes between infants born in district general hospitals and those who were born in a tertiary maternity unit in South West England and South Wales.Methods:This was a secondary data analysis of data collected from the local Paediatric Intensive Care Audit Network and the local transport database. Infants born with a confirmed diagnosis of transposition of the great arteries, that required an arterial switch operation as the definitive procedure between April, 2012 and March 2018 were included.Results:Forty-five infants with a confirmed diagnosis of transposition of the great arteries were included. Statistical analysis demonstrated there were no significant differences in the time to balloon atrial septostomy (p = 0.095), time to arterial switch operation (p = 0.461), length of paediatric ICU stay (p = 0.353), and hospital stay (p = 0.095) or mortality between the two groups.Conclusions:We found no significant differences in outcomes between infants delivered outside the specialist centre, who were transferred in by a specialist team.

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Provision of paediatric surgery under threat

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363507x167929 ◽

2007 ◽

Vol 89 (1) ◽

pp. 25-25

Author(s):

Elaine Towell

Keyword(s):

At Risk ◽

General Hospital ◽

Gold Standard ◽

Young Patients ◽

Surgical Care ◽

District General Hospital ◽

British Association ◽

Paediatric Surgery

The British Association of Paediatric Surgeons (BAPS) exists to ensure that young patients receive the best surgical care possible by setting and maintaining a 'gold standard' for paediatric surgery. Currently the association is concerned that the safety of young patients is at risk due to an increasing lack of general paediatric surgery provision in the district general hospital (DGH) setting.

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Undescended testes: a consensus on management

Acta Endocrinologica ◽

10.1530/eje-08-0181 ◽

2008 ◽

Vol 159 (suppl_1) ◽

pp. S87-S90 ◽

Cited By ~ 65

Author(s):

E Martin Ritzén

Keyword(s):

Hormonal Treatment ◽

Nordic Countries ◽

Controlled Study ◽

Optimal Time ◽

Paediatric Surgery ◽

Undescended Testes ◽

Randomized Controlled ◽

Randomized Controlled Studies ◽

Meta Analyses ◽

Local Traditions

The mode of treatment best for undescended testes is controversial, and local traditions often override knowledge gained from randomized controlled studies. In order to reach a consensus within the Nordic countries on the current state-of-the-art of treatment, a group of specialists in testicular physiology, paediatric surgery/urology, endocrinology, andrology, pathology and anaesthesiology from all the Nordic countries met for 2 days. Before the meeting, reviews of the literature had been prepared by the participants. Judging from published meta-analyses, hormonal treatment has low efficacy. Although 15–20% of retained testes descend during hormonal treatment, one-fifth of these re-ascend later on. Also, treatment with human chorionic gonadotropin (hCG) may be harmful to future spermatogenesis through increased apoptosis of germ cells. Orchiopexy, on the contrary, results in about 95% anatomical success, with a low (about 1%) risk of complications. The optimal time for orchiopexy has also been debated. However, a recent randomized controlled study shows that surgery at 9 months of age is followed by a better post-operative growth of the testes than surgery at 3 years, which supports previous arguments for early surgery. The unanimous conclusion of the group was that surgery is generally the preferred mode of treatment, rather than hCG or GnRH treatments. Orchiopexy should be performed between 6 and 12 months of age, or soon after diagnosis, if that occurs later. If a testis is found to be undescended at any age after 6 months, the patient should be referred for surgery. Referral should be to paediatric rather than general surgeons/urologists if the boy is less than 1 year old, if he has bilateral or non-palpable testes, or if he has got relapse of cryptorchidism.

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