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Despite advances in opioid-sparing analgesia, opioid prescribing in breast surgery remains suboptimal. Besides delayed rehabilitation, excess post-operative opioids may contribute significantly to opioid dependence. This systematic review of guidelines evaluates current opioid-prescribing recommendations after breast surgery to identify trends in prescribing. Additionally, it compares recommendations on different non-opioid and non-pharmacological adjuncts.Electronic databases were searched systematically using terms "breast surgery", "analgesia", "opioid" and "guidelines". The grey literature was used to supplement the search. All articles that provided guidance on opioid prescribing in breast surgery were included. Quality of the guidelines were assessed using the AGREE II tool. Recommendations pertaining to opioid prescribing, analgesic adjuncts and non-pharmacological interventions were summarised and reported with descriptive statistics.Eight guidelines pertaining to mastectomies, breast conserving surgery and breast reconstructions were included in this review. Although an opioid-sparing approach was unanimous, there were conflicting recommendations on opioid doses. Opioid requirements were stratified by procedure in 3 guidelines, and by patient risk factors in 2 guidelines. There was significant variability in the recommended multimodal adjuncts. Notably, non-pharmacological interventions such as patient education were infrequently included in guidelines.There is a lack of high-quality guidance on opioid prescribing after breast surgery. The optimum approach for personalised opioid prescribing remains unknown. Significant variability between guidelines provide little actionable interventions for prescribers. This could be driven by the paucity in evidence supporting a single efficacious analgesic regimen for patients undergoing breast surgery. Future guidelines should also regularly incorporate non-pharmacological adjuncts to reduce opioid prescribing.

Background High quality health care is information reliant. Access to high quality information in a timely manner is imperative in provision of quality patient care. A national standard for discharge summaries has been developed by the Health Information and Quality Authority (HIQA). A standard for surgical discharge letters is needed to avoid patient readmission, unnecessary presentation to primary care and to ensure continuity of care in the community. The aim is to assess the quality of surgical discharge summaries using the HIQA national Standard. To implement quality improvement strategies recommended by current research. To reassess the quality and close the audit loop. Methods For cycle one of audit, one month of discharge summaries in 2020 were generated across four consultant surgeons at the University Hospital Limerick. 33% of those were sampled evenly across consultants. 60 patient discharge summaries were audited. Training was implemented virtually. For cycle two of audit the same methodology was used, 43 discharge summaries were audited. Results Overall performance was 49%, improved to 69% following training. The worst performing category was future management, 20%, improved to 45%. The best performing categories were auto-populated, patient details 97% and primary care details, 100%. Patient medications were compliant in 25%, improving to 59%. Admission and discharge details were complete in 36% improving to 59%. Clinical narrative was present in 37% improving to 64%. Consultants had not signed off on any letters. Conclusions Surgical discharge summaries audited remain non-compliant with the national standard however, as research shows, NCHD training has improved performance across categories.

Aim Acute appendicitis (AA) is among the most common emergency surgical presentations to Irish hospitals. In 2020, the World Society of Emergency Surgery (WSES) updated its Jerusalem guidelines for the investigation, diagnosis, and management of AA. We aimed to evaluate our institutional compliance with these guidelines in the COVID era and outline potential areas for improvement. Methods We performed a retrospective chart review of all patients admitted to our institution with the diagnosis of AA in July 2021 and compared them against the standards outlined in the WSES Jerusalem guidelines. Results 39 patients were identified. Average age was 25.4 years. 2.6% (n=1) had clinical scores documented. 33.3% (n=13) had computerised tomography scans performed, 33.3% (n=13) underwent ultrasound scans and 33.3% (n=13) had no diagnostic imaging. 100% proceeded with surgical management. Average time to theatre was 16.9 hours. 23.1% (n=9) were open appendectomies, 74.4% (n=29) were laparoscopic appendectomies and 2.6% (n=1) was a laparoscopic converted to open appendectomy. 100% had histopathological analyses. 69.2% (n=27) were true AAs, 15.4% (n=6) were negative appendectomies and 15.4% (n=6) were non-inflamed appendices with other pathology including lymphoid hyperplasia, fecolith or enterobius. Average length of stay (AvLOS) was 3.6 days. Conclusions As regards timely surgical intervention and routine histopathology, we are compliant with the guidelines. However increased utilisation of validated clinical scoring systems could potentially reduce negative appendectomy rates and AvLOS. We believe an educational intervention is required to improve our compliance with these standards.

Aims This audit aims to determine if standards of best practice according to NICE guideline pancreatitis (September 2018) are being met. Methods Using the Hospital In-Patient Enquiry (HIPE) system, 129 admissions with AP during 2020 were retrospectively identified. Audit targets included adequate fluid resuscitation and nutritional support, frequency of radiological investigations, emergency cholecystectomy, lifestyle advice and appropriate follow up. Results Aetiologies identified were biliary (33.3%), alcohol (33.3%), idiopathic (7.8%), hypertriglyceridemia (3.8%), autoimmune (1.6%), medication (0.8%), anatomical variant (0.8%) and the remainder (18.6%) were unidentified since not fully investigated (NFI). 47.3% (n=61) had ultrasound while 61.2% (n=79) had computed tomography of abdomen and pelvis (CTAP) during hospital-stay. Out of 33.3% (n=43) with biliary aetiology, 25.6% (n=11) had successful ERCP and 41.9% (n=18) were referred for outpatient clinic or already awaiting outpatient laparoscopic cholecystectomy. No emergency cholecystectomies were performed. Out of 28 readmissions, biliary pathology accounted for 35.7% (n=10), alcohol 25% (n=7) and NFI 17.9% (n=5). 37.2% (16) of alcoholic pancreatitis admissions had documented cessation advice either as in-patient or on discharge. There was no documentation for HbA1C in 6 months or DEXA scan in 2 years’ time, or a yearly fecal elastase for chronic pancreatitis patients. Conclusion Audit of current practice identified areas for improvement, including bettering access to emergency theatre, increased focus on encouraging lifestyle modification and monitoring pancreatic endocrine and exocrine function. We aim to create an institutional standard operating procedure for investigating and managing pancreatitis, and re-audit next year to discern if management has moved closer to the established standard.

Aim Significant heterogeneity exists in the recommendations for the diagnosis and management of acute lower gastrointestinal bleeding (LGIB). This study aims to demonstrate the contemporary management strategies adopted by a busy tertiary hospital. Methods We conducted a single-centre retrospective review of adults presenting to our institution with LGIB between January and March 2021. Demographic data, observations, laboratory results, endoscopy and radiology reports, operation notes and discharge summaries were collected for each patient via a retrospectively maintained registry. Results 23 patients were included. Mean age was 66.6 years with a mean initial haemoglobin of 10.9 g/dL (Range 4.1–15.5g/dL). 17% of patients were in circulatory shock on presentation. 70% of patients presented with haematochezia. 47.8% of patients were on either an anticoagulant or anti-platelet agent at presentation. The transfusion index in this cohort was 30%. 26.1% of patients had a re-bleed during their admission. The diagnostic yield of cross-sectional imaging amongst 11 patients was 27.3% with no correlation with haemodynamic status or active bleeding. 47.8% of patients underwent endoscopy and 27% of patients who underwent an endoscopic procedure required endoscopic haemostasis. Flexible sigmoidoscopy was the commonest endoscopic modality (55%), followed by gastroscopy (27%) and colonoscopy (18%). No patients required surgical or radiological intervention. No cause of bleeding was identified in 26% of patients. Conclusion This study confirms the variation in diagnosis and management of LGIB. Despite access to onsite interventional radiology, endoscopy remained the predominant diagnostic and therapeutic modality. Routine cross-sectional imaging may not be justified given its suboptimal diagnostic yield.

Background Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Methods Interns pursuing a career in surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Results Of the 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. On completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusions Near-peer delivery of surgical training has enhanced the basic surgical skills of interns. Similar programmes in other sites would ensure that interns have the skills required to safely care for surgical patients.

Aims Only 1% of all diagnosed breast cancers are in male patients. Overwhelmingly, current literature addresses breast cancer in female patients. This study aims to analyse the investigation and management of male breast cancers in a busy Symptomatic Breast Unit. Methods We conducted a single-centre review of male breast cancers diagnosed in our institution between January 2016 and December 2020. Initial presenting symptoms, imaging findings, histology and follow-up data were collected via a prospectively maintained database. Results The most common presenting symptom was a palpable breast lump (69%). Other symptoms included nipple bleeding/discharge (15%) and skin ulceration (8%). 62% of cases were located centrally behind, or involved, the nipple. The most common pathology was invasive ductal carcinoma (77%). One patient was diagnosed with invasive papillary carcinoma, while two patients were diagnosed with different cancers (spindle cell sarcoma and metastasis of medullary carcinoma of the thyroid). 77% of patients were managed operatively, with all undergoing a simple mastectomy. A sentinel lymph node biopsy or axillary clearance was performed in 62% and 8% of cases respectively. Several patients underwent adjuvant radiotherapy (62%) and chemotherapy (54%). 77% of patients were ER/PR positive, with 15% HER2+ positive. 100% of these patients received appropriate endocrine therapy. Conclusions Although female breast cancer commonly presents in the upper outer quadrant of the breast this study found that more male breast cancers occur centrally and involved the nipple. As breast cancer in male patients is rare, larger cohorts are required to confirm the findings of this study.

IntroductionInefficient theatre utilisation is costly for patients, staff and healthcare organisations. Active management projects have proven effective at identifying and streamlining delays in the perioperative patient journey.AimThe aim of this study is to assess whether a novel, wearable, autonomous, Wi-Fi-based real-time location services (RTLS) device could be used to accurately record and process theatre utilisation data.MethodsA novel RTLS device was employed in our theatre department between June and September 2017. Data were collected pertaining to time of arrival and departure from the surgical day ward, operating theatre and recovery using this device, and compared with our institution’s existing written record of theatre data.Results101 patients were enrolled, but manually recorded data were unavailable on 18 patients. Among the remaining 83 patients, mean difference in recorded start times was 0.43 min (p=0.64). Mean difference in theatre end times was 1.63 min (p=0.41). Mean difference recorded in overall time in theatre was 1.19 min (p=0.59).ConclusionThe RTLS device provided a reliable record of theatre utilisation, without requiring manual input, with potential as a tool to identify and improve inefficiencies in the theatre department.

Background Tranexamic acid (TXA) is a synthetic anti-fibrinolytic agent used in various surgical procedures to achieve haemostasis and reduce blood loss. Recently TXA has seen an increase in perioperative utility as a result of its ease of administration, high therapeutic index and low cost. Its safety and effectiveness in oncological breast surgery (OBS) remain understudied. Method PubMed, EMBASE, SCOPUS and other relevant sources were searched for studies investigating the effect of TXA in OBS, published up to October 2020. Primary outcomes of interest were local wound effects. Estimates of effect, when quantitative data was available, were pooled with a random effects model to estimate summary hazard ratios and 95% confidence intervals. Qualitative data was reported using descriptive statistics. Evidence quality was assessed using the Cochrane Collaboration tool. Results 7 studies involving 1844 patients were included. Quantitative data was available for: mean total drainage volume, duration of drain in-situ and rates of seroma and haematoma formation. A significant reduction in rate of haematoma formation (OR 0.40, 95% CI 0.18-0.89, P = 0.02, I2=28%) was observed in the TXA group. There were no significant differences in the other outcomes. There was no significant increase in rates of adverse events. Conclusions Trends were observed in the present meta-analysis, although TXA did not appear to significantly alter the OBS outcomes. Current studies are insufficiently powered to isolate the effects of TXA on surgical morbidity. Further large prospective studies are needed to assess complications and determine the ideal dosage regime. At this juncture, prophylactic TXA in OBS cannot be recommended.

Background A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. GPFs have been reported following traumatic diaphragmatic ruptures, perforated hiatal hernias and gastric fundal ulcers, and more recently, after bariatric surgery. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings. Method We describe a case of a 53-year-old gentleman who presented to our institution with acute respiratory distress and clinical findings of a pleural effusion. Uniquely he was discharged a week prior following an admission for a traumatic fall down a flight of stairs that resulted in a Grade-IV splenic injury, requiring an emergency splenectomy. A CT-proven massive haemothorax resulted in haemodynamic instability requiring resuscitation and chest drain insertion in the intensive care unit. On commencement of enteral diet, purulent exudate with evidence of food particulates was seen in his chest drain. Results Further diagnostic evaluation of drainage contents demonstrated gut flora and a subsequent positive dye test suggested an aero-digestive connection. Repeat CT revealed a fistula between the fundus of the stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm. Conclusions This is the first case in literature reporting a ‘gastropleural fistula’ presenting in such a fashion. Thorough assessment and decisive action led to a satisfactory outcome. Although rare, a persistent effusion with a history of blunt abdominal and thoracic trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.

Aim A group and hold (G&H) forms part of the pretransfusion compatibility testing and is commonly requested in anticipation of a possible blood transfusion. Requests made in the context of elective procedures with a low transfusion probability, such as a mastectomy, are associated with added financial burden and increases workload in a healthcare system. This audit aims to analyse the cost-benefit associated with the routine request for a preoperative G&H in patients undergoing mastectomies. Method A total of 100 patients undergoing mastectomies from the period of September 2019 to October 2020 were included in the audit. Data regarding blood order requests, units of blood transfused, perioperative haemoglobin and the type of mastectomy (right, left or bilateral) were collected. Results All patients had a routine G&H as part of their preoperative assessment. The average age in this cohort was 60.3. Right-sided mastectomy was the commonest procedure in this cohort (N = 52). The average preoperative haemoglobin was 13.0g/dL. 2/100 patients received post-operative blood transfusions. The transfusion probability in this cohort was 2%. Only 15% of the cohort had a post-operative haemoglobin level checked. The average drop in haemoglobin in this cohort was 2.3g/dL. Conclusions This audit demonstrates the low prevalence of blood transfusions in patients undergoing mastectomies, consistent with current literature. The projected cost savings associated with selective requests for G&H are significant. However, the implementation of a safe and targeted blood ordering approach in patients with high bleeding risks will require a validated stratification system.

Background Delayed diagnosis, unnecessary hospital admissions and extended length of stay are the problems associated with inappropriate access to radiological investigations. The acute surgical assessment unit (ASAU) in Limerick has two dedicated ultrasound scan (USS) slots daily to overcome this problem. The aim of the current study was to investigate the clinical impact on patient care and the cost-effectiveness of such an ASAU USS access. Methods A retrospective review of all patients who underwent USS investigation in the ASAU between May and September 2017 was conducted. Demographic, referral source, presenting complaint, and clinical outcome data were obtained from the ASAU Log. USS data was obtained from the National Integrated Medical System (NIMIS). The Integrated Patient Management System (IPMS) and Therefore Case Manager, Therefore 2014(12.0.2) was utilized to check for any discharged ASAU patient re-presenting to the emergency department (ED) within 30 days. Results A total of 102 patients underwent USS investigation during the study period. The most common presenting complaint was epigastric or right upper quadrant pain (55.8%). Eighty-six patients underwent USS on the same day and the majority (51%) were discharged home with appropriate outpatient follow-up. Approximately 26,000 Euros were saved over four months. Post-discharge ED visits in the ASAU discharged group was zero in the 30 days. Conclusion The ASAU USS dedicated slots in University Hospital Limerick has had a significant positive impact on patient diagnostics, surgical admissions rates and streamlining resource allocation. Having dedicated slots for radiological investigations in the ASAU should become standard of care across all healthcare jurisdictions.

A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings. We describe a case of a 53-year-old gentleman who presented to our institution with respiratory sepsis and a massive haemopneumothorax on imaging. Uniquely, he was discharged a week prior after a splenectomy for a traumatic fall. Gut flora in the pleural fluid and a subsequent positive dye test suggested an aero-digestive connection. Repeat imaging revealed a fistula between stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm. This is the first GPF in literature presenting in such a fashion. Although rare, a persistent effusion with a history of blunt thoracoabdominal trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.

peer-reviewed When breast cancer progresses to a metastatic stage, survival rates decline rapidly and it is considered incurable. Thus, deciphering the critical mechanisms of metastasis is of vital importance to develop new treatment options. We hypothesize that studying the proteins that are newly synthesized during the metastatic processes of migration and invasion will greatly enhance our understanding of breast cancer progression. We conducted a mass spectrometry screen following bioorthogonal noncanonical amino acid tagging to elucidate changes in the nascent proteome that occur during epidermal growth factor stimulation in migrating and invading cells. Annexin A2 was identified in this screen and subsequent examination of breast cancer cell lines revealed that Annexin A2 is specifically upregulated in estrogen receptor negative (ER-) cell lines. Furthermore, siRNA knockdown showed that Annexin A2 expression promotes the proliferation, wound healing and directional migration of breast cancer cells. In patients, Annexin A2 expression is increased in ER- breast cancer subtypes. Additionally, high Annexin A2 expression confers a higher probability of distant metastasis specifically for ER- patients. This work establishes a pivotal role of Annexin A2 in breast cancer progression and identifies Annexin A2 as a potential therapeutic target for the more aggressive and harder to treat ER- subtype.

Surgical techniques in breast cancer (BCa) have seen a dramatic change recently with breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The ACOSOG-Z0011 trial reported equivalence in outcomes for certain patients with SLN metastases treated with axillary lymph node dissection (ALND) or SLNB alone. Our aim was to investigate changes in lymphedema referral patterns in BCa patients over the last 3 years in a specialist unit and to elucidate effects of SLNB, BCS, and Z0011 trial publication on such patterns. A retrospective study was performed over a 3-year period (May 2012–May 2015). Patients were identified using a prospectively maintained lymphedema database and newly referred BCa patients with data availability were included. Overall lymphedema incidence was 11% (19.2% in ALND and 5.1% in SLNB cohort). There was a statistically significant difference in lymphedema referral patterns after Z0011, new referrals reduced by 20% (chi-sq; p = 0.001). Volume of referrals post ALND was reduced by 40% with concomitant 31% rise in those post SLNB alone, reflecting changing surgical patterns. There was a significant change in extent of lymphnode dissection during ALND (p = 0.003). The Z0011 trial in association with wider implementation of SLNB has led to significant changes in the lymphedema referral patterns and extent of ALND.

The Acute Surgical Assessment Unit (ASAU) in University Hospital Limerick (UHL) has provided a solution to overcrowding and long waiting times since centralization of emergency services to UHL. Recognising the importance of its evolving role, the ASAU in UHL has recently undergone a major revamp to ease the pressure in the overcrowded emergency department (ED). This included a new purpose state-of-the-art-built unit and equipment, improved staffing levels and use of a Kaizen Lean system to identify key area of delays and inefficiency with subsequent implementation of suggestions derived after Kaizen Lean. Patient satisfaction reporting was analysed in the older building and subsequently in the new site post Kaizen Lean to complete a closed-loop audit. The aim of the study was to examine patient satisfaction response rates with the ASAU prior to and following Kaizen Lean implementation and transfer to a new purpose-built unit. The survey comprised of two phases. In phase 1, 100 questionnaires were distributed to patients in ASAU (older building, pre-Kaizen Lean). In phase 2, the survey was repeated (100 patients) after Kaizen Lean implementation and transfer to the new state-of-the-art unit. Questionnaire design was based on WHO strategy on responsiveness measurement guidelines and was tailored to a population of surgical patients. Results were analysed using IBM SPSS, version 21 and Excel 2013. Two hundred questionnaires were analysed. Implementation of suggestions derived post Kaizen Lean translated into improved resource usage with reduced waiting time to be seen by nurses and doctors. Patients had better awareness about their treatment plan and planned next steps in the management. Satisfaction across different domains, perceptions of privacy and overall treatment were also improved. A Kaizen Lean approach improved the transition of an ASAU to a new purpose-built unit and further improved overall patient satisfaction with services of the ASAU.

Background Acute abdominal pain in children remains a common presentation to A&E departments across Ireland. Appendicectomy remains a common procedure done in children. In this study we aimed to analyse the number of paediatric appendicectomies from August 2016-August 2018 at the University Hospital Limerick (UHL), and the use of imaging in the diagnosis of acute appendicitis. Methods Using the Hospital Inpatient Enquiry (HIPE) administrative database, all paediatric patients (≤16 years) who underwent an appendicectomy at UHL from August 2016- August 2018 were identified retrospectively. Data were collected on each patient as follows: imaging and results, surgery (open or laproscopic appendicectomy) and histology of appendix. Negative appendicectomy rates and ultrasound diagnostic yields were calculated. Results From August 2016- August 2018, 474 paediatric patients had an appendicectomy at UHL. Of these, 251 were male (52.8%). 373 patients had histological evidence of appendicitis (78.7%), 55 (11.6%) had evidence of lymphoid hyperplasia, enterobius and/or fecolith with no inflammation and 46 (9.7%) had a normal appendix. There were 303 (63.9%) laparoscopic appendicectomies and 171 (36.1%) open appendicectomies. Only 156 (32.8%) patients had ultrasounds. 104 (66.7%) patient ultrasounds were reported inconclusive for appendicitis. 64 (61.54%) of the patients with an inconclusive ultrasound yield had appendicitis. Conclusions Ultrasound remains a poor imaging modality in diagnosing appendicitis, which may contribute to the high negative appendicectomy rates.

Patients with sentinel lymph node (SLN) metastases may not require axillary lymph node dissection (ALND) but it remains unclear if patients with a positive ultrasound-guided axillary core biopsy (ACB) would satisfy such criteria. The aim of this study was to assess if breast cancer patients with a positive pre-operative ACB have more aggressive tumour characteristics/higher axillary nodal burden compared to those with a positive SLN. Data was extracted from a prospectively maintained breast cancer database between 2012 and 2015. Patients who underwent ALND after either positive ACB or SLN were included and tumour characteristics/nodal burden were compared. One hundred eighty patients underwent ALND, 125/180 after positive ACB and 55/180 after positive SLNB. Patients with positive ACB were more likely to undergo mastectomy (chi-square test; p = 0.03) and have higher tumour grades (Mann-Whitney test; p