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Cricopharyngeal spasm and pharyngeal pouch can result in severe dysphagia symptoms that can have a significant impact on a patient’s quality of life. Several surgical interventions have been demonstrated including balloon dilatation, botox injection, and open and endoscopic cricopharyngeal myotomy. The aim of this case series is to describe our technique for endoscopic cricopharyngeal myotomy and compare pre- and postoperative swallowing outcomes using objective swallowing questionnaires in a small series of patients. Seven patients diagnosed with cricopharyngeal spasm or grade 1 pharyngeal pouch on barium swallow were prospectively observed. MD Anderson Dysphagia inventory (MDADI) and Dysphagia handicap index (DHI) were given to patients before and after their operation. All patients underwent the same surgical technique with the cricopharyngeal bar divided and the defect closed with dissolvable sutures. Mean inpatient stay was 7 days (range 1-8) and mean time to resumption of soft diet was 4 (range 1-7) days. All patients resumed oral diet before discharge. MDADI scores showed improvement across all domains, however only the emotional score achieved statistical significance ( P = .04). Dysphagia handicap index scores showed a statistically significant improvement across functional, emotional, and total domains. Postoperative chest infection treated with oral antibiotics occurred in 3 patients (43%) and no other complications were documented. In conclusion, endoscopic cricopharyngeal myotomy with primary sutured endoscopic closure can result in a significant benefit to patient’s swallowing symptoms, emotional well-being, and quality of life.

The improved survival in patients with HPV-positive (human papilloma virus) oropharyngeal squamous cell carcinoma as compared with HPV-negative disease calls for treatment that preserves quality of life, particularly a functional swallow. There are several trials currently assessing treatment de-escalation in terms of less invasive transoral robotic surgery, reduced-dose radiotherapy, and omission of chemotherapy in this disease cohort. It is important for head and neck oncology surgeons to stay abreast of developments in this area to offer their patients the most up-to-date treatment and consider recruiting patients to trials at their institutions. For this purpose, we provide a summary of current trials and associated challenges in managing a disease with fast-evolving treatment algorithms.

Background There is a wide chasm in access to essential and emergency surgery between high and low/middle income countries (LMICs). Surgeons worldwide are integral to solutions needed to address this imbalance. Involving surgical trainees, who represent the future of surgery, is vital to this endeavour. The Association of Surgeons in Training (ASiT) is an independent charity that support surgical trainees of all ten surgical specialties in the UK and Ireland. ASiT convened a consensus meeting at the ASiT conference in Liverpool 2016 to discuss trainee engagement with global surgery, including potential barriers and solutions. Methods A face-to-face consensus meeting reviewed the engagement of, and roles for, surgical trainees in global surgery at the ASiT Conference (Liverpool, England), March 2016. Participants self-identified based on experience and interest in the field, and included trainees (residents and students) and consultants (attending grade). Following expert review, seven pre-determined core areas were presented for review and debate. Extensive discussion was facilitated by a consultant and a senior surgical trainee, with expertise in global surgery. The draft derived from these initial discussions was circulated to all those who had participated, and an iterative process of revision was undertaken until a final consensus and recommendations were reached. Results There is increasing interest from trainee surgeons to work in LMICs. There are however, ethical considerations, and it is important that trainees working in LMICs undertake work appropriate to their training stage and competencies. Visiting surgeons must consider the requirements of the hosting centres rather than just their own objectives. If appropriately organised, both short and long-term visits, can enable development of transferable clinical, organisational, research and education skills. A central repository of information on global surgery would be useful to trainees, to complement existing resources. Challenges to trainees considering a global surgery placement include approval for placements while on a training program, financial cost and dangers inherent in working in a resource poor setting. Currently global surgery experience is generally as an out of program experience and does not count for certificate of completion of training (CCT). Methods to recognise surgical trainee global surgery experience as an integrated part of training should be explored, similar to that seen in other specialties. Conclusion There is a role for surgical trainees to become involved in Global Surgery, especially in partnership with local surgeons and with appropriate ethical consideration. Trainees develop translational skills in resource poor settings. Development of appropriate pathways for recognition of global surgery experience for CCT should be considered.

Surgical care practitioners (SCPs) are defined as non-medical members of the surgical team who perform surgical intervention, pre-operative and postoperative care after completing a Royal College of Surgeons accredited course. Their role across the modern day National Health Service is becoming more significant due to rising waiting times and the European Working Time Directive placing restrictions on the number of hours worked by surgical trainees. The change in consent law after the judgement of Montgomery versus Lanarkshire Health Board means SCPs can play a vital role in enabling a more individualized and effective consent process, whilst evidence suggests their contribution can reduce waiting times and improve continuity of care. However, concern may arise in the future if surgical trainees see their operating exposure significantly cut due to SCPs being granted-consultant supervised elective lists. Clear guidelines are therefore necessary at local and national level to protect surgical trainees' learning opportunities in theatre and to ensure SCPs achieve their ultimate goal of improved patient care.

Introduction This study aimed to assess training of Senior House Officer-grade equivalent doctors in postgraduate surgical training or service (SHO-DIPST) in surgical specialties across the United Kingdom (UK), against nationally agreed Joint Committee on Surgical Training Quality Indicators (JCST QIs). Specific recommendations are made, with a view to improving quality of training, workforce retention and recruitment to Higher Surgical Training. Method Prospective, observational, multicentre study conducted by the Association of Surgeons in Training, using the UK National Research Collaborative model. Any centres in the UK providing acute surgical services were eligible. SHO-DIPST with a permanent contract, on out-of-hours ‘on-call rota' were included across four, one-week data capture periods (September to October 2016, February to March 2017). Adherence to five quality indicators was reported using descriptive statistics. P-values were calculated using Student's t-test for continuous data, with a 5% level of significance. Results 2569 SHO-DIPST were included from all ten surgical specialties in 141 NHS trusts across all 16 Local Education and Training Boards in the UK. 960 SHO-DIPST were in registered ‘training' posts (37.3%). The median number of SHO-DIPST per rota was 7.0 (IQR 5.0–9.0). Adherence to the five included JCST QIs ranged from 6.0 to 53.1%. Only four SHO-DIPST posts across the study population met all five JCST QIs (0.3%). The total number of training sessions was higher for those in registered training posts (p Conclusions Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training.

Large cell neuroendocrine carcinoma is a rare high-grade neuroendocrine neoplasm of the larynx, that exhibits particularly aggressive behaviour. We present a case of a 42-year-old patient with progressive dyspnoea and biphasic stridor, initially treated as asthma and resulting in delayed definitive management. Flow volume loops demonstrated narrowed inspiratory and expiratory flow volume loops. Subsequent CT neck and thorax indicated a mass arising from the subglottis and the patient proceeded to microlaryngoscopy and trans-oral CO2 laser debulking. The case demonstrates that stridor can be confused with wheeze and specialist referral is appropriate if patient’s symptoms do not resolve with initial management

A recent case of advanced, recurrent juvenile nasopharyngeal angiofibroma (JNA) at our institution has highlighted the limited evidence regarding adjunctive treatment. We present the case of a 10-year-old boy who is the first to undergo multiple-staged surgical resections alongside vincristine treatment. We performed a review of the literature analyzing the roles of radiation therapy, cytotoxic drugs, and novel targeted agents in JNA relapse. Small cohort studies suggest radiotherapy and flutamide are the most rational treatment options for residual and recurrent JNA. Our review highlights the need for further research into the management of primary and recurrent JNA.

Since its introduction in 1956, the Duhamel procedure has been and remains one of the most widely performed for Hirschsprung's disease (HD). The most significant modification to this procedure has been the incorporation of laparoscopy, while the original principles of the method have been retained. This study compared long-term outcomes for open Duhamel (OD) and laparoscopic Duhamel (LD) procedures for HD, to identify any added advantage of the laparoscopic technique.We undertook a systematic review of all studies published over a period of 20 years (1994-2014) that assessed functional outcomes for OD and/or LD procedures. Odds ratios were calculated for dichotomous variables, and mean difference values were calculated for continuous variables.From 11 articles 456 patients were included (253 OD, 203 LD), with no significant difference in age at surgery and length of follow-up (P .05). The open group had a significantly greater incidence of soiling/incontinence (11% versus 4%; P = .02) and further surgery (25% versus 14%; P = .005), longer hospital stay (9.79 versus 7.3 days; P .00001), and time to oral feed (4.05 versus 3.27 days; P .00001). Operative time was significantly longer in the laparoscopic group (3.83 versus 4.09 hours; P = .004). There was no significant difference in incidence of enterocolitis (15% versus 10%; P = .14) and constipation (23% versus 30%; P = .12).Our meta-analysis convincingly demonstrates the superiority of LD over OD pull-through for HD. Prospective, randomized control trials are required to overcome limitations in the current literature.

A 2 day old baby boy born at term was referred to the neonatal surgical unit with progressive abdominal distension and failure to pass meconium within his first 24 hours. On examination the boy weighed 2.9 kg and the anus was placed in the normal position. Cardiovascular, respiratory, and other system examinations, along with a brief developmental assessment, were normal. The abdomen was grossly distended but there were no features of peritonitis. The baby was haemodynamically stable. Blood results, including full blood count, urea and electrolytes, C reactive protein, and clotting were normal. Radiographs of the abdomen showed equal distribution of grossly dilated bowel loops throughout the abdomen, with no gas in the rectum. A water soluble contrast enema showed contrast passing from distal spastic colon to dilated proximal normal colon in the area of the transitional zone. This was followed by suction rectal biopsy performed on the ward for histopathological evaluation. ### 1. What is the diagnosis and what are the differential diagnoses? #### Short answer Hirschsprung's disease (fig 1⇓). Differential diagnoses include: anorectal malformations, meconium plug syndrome, small left colon syndrome, colonic atresia, meconium ileus, and jejunoileal atresia. Fig 1 Colour enhanced radiograph showing Hirschsprung's …

Malawi is one of the world9s poorest countries, but despite this, has a dedicated paediatric oncology service. The service has been hampered by the inability to make a timely cytological diagnosis in the majority of patients. A telemedicine programme was commenced to help overcome this problem, and the results for the first 197 consecutive patients are described. The results are compared with the local reports where available. Most samples were fine needle aspirates (104/197–53%), but others included bone marrow aspirates, peripheral blood films and other fluid collections. A diagnosis was arrived at in 52% of the samples; there were 46 discordant results, 38 were when one or other of the local or distant teams were unable to make a diagnosis, and only 8 where the diagnoses of the 2 teams differed. Diagnoses were made and reports were compiled by the ‘distant’ team within 24 h and sent to the centre in Malawi. This simple telepathology initiative has had a positive impact on clinical management, and could be used in other less resourced centres twinned with better resourced ones.