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Aims Wire-guided localisation (WGL) has been the standard technique for localisation of non-palpable breast cancers (NPBC) for almost 40 years. However, WGL has disadvantages including peri-operative scheduling challenges and patient discomfort. Savi Scout localisation (SSL) is a novel alternative that utilises an implantable wireless non-radioactive reflector. A systematic review and meta-analysis was performed to compare outcomes of SSL versus WGL in NPBC surgery. Methods Embase, MEDLINE, PubMed and the Cochrane Library (1946 to December 2020) were searched using PRISMA guidelines for studies comparing SSL and WGL in NPBC surgery. Outcome measures analysed were operative duration, positive margins and re-excision. Results were pooled into meta-analyses using a Mantel-Haenszel Random-Effects model as Odds Ratios for dichotomous data and Mean Difference for continuous data. Results Four eligible peer-reviewed cohort studies involving 808 patients were identified comparing SSL (n = 462) and WGL (n = 346). There was no significant difference between SSL and WGL in operative duration (95% CI -0.27, -7.89 to 7.34, p = 0.94), positive margins (OR 0.73, 0.36 to 1.45, p = 0.36) and re-excision (OR 0.62, 0.33 to 1.16, p = 0.13). Inclusion of two non-peer-reviewed cohort studies (additional SSL n = 143, WGL n = 424) altered statistical significance for re-excision in favour of SSL (OR 0.55, 0.36 to 0.83, p = 0.004). Conclusions This study demonstrates that SSL is a safe and effective alternative to WGL. SSL uncouples pre-operative localisation from surgery, reducing scheduling challenges. This is particularly useful in the current COVID-19 climate, with pre-operative patient self-isolation requirements. SSL may decrease re-excision rates. Randomised controlled trials are required to investigate this further.

Aims Electrocautery (EC) remains the dominant dissection tool in modified radical mastectomy (MRM) for breast cancer. However, ultrasonic dissection devices (UDD) have emerged as popular alternatives on the basis that their mechanism of action limits tissue damage resulting in decreased blood loss, seroma formation and post-operative drainage. A systematic review and meta-analysis was performed to compare surgical outcomes for EC versus UDD in MRM surgery. Methods MEDLINE, EMBASE, PubMed and the Cochrane Database were searched and a comprehensive systematic review and meta-analysis performed according to PRISMA guidelines, comparing EC versus UDD in MRM for breast cancer. Outcomes of interest were post-operative drainage, incidence of seroma, intra-operative blood loss and operative time. Meta-analysis was performed using a random effects model to aggregate the data. Odds ratios (OR) were used as the summary statistic for dichotomous data and mean difference (MD) for continuous data. Data heterogeneity was assessed using the I2 statistic. Results Nineteen eligible peer-reviewed studies were analysed involving 1501 patients, UDD:744 EC:757. We demonstrated that in MRM, UDD significantly reduced post-operative drainage (MD = 312.26, 95% confidence interval (CI): 102.59-521.93, p = 0.004); seroma (OR = 0.51, 95% CI: 0.39-0.68, p Conclusion Using UDD in MRM for breast cancer presents significant advantages in decreasing post-operative drainage, seroma and intra-operative blood loss, without lengthening operating time compared to EC. It therefore appears favourable, however further cost-effectiveness analysis would be beneficial to guide selection.

Aims To determine if there is any correlation between the number of positive non-sentinel lymph nodes (NSLN) and the mRNA copy numbers of cytokeratin 19 receptor on one step nucleic acid amplification (OSNA) in the sentinel lymph node (SLN). Methods An 8-year retrospective study of consecutive patients who had primary surgery and sentinel node biopsy for breast cancer from January 2011 to December 2018 was carried out. All these patients had intra-operative analysis of sentinel lymph nodes by OSNA. Patients who had neoadjuvant chemotherapy or neoadjuvant endocrine therapy were excluded. Results There were 1159 patients with an age range of 24 to 90 years and a mean age of 63 years in this study. A total of 1324 SLNs were analyzed by OSNA. Macrometastasis was found in 120 patients and they underwent axillary lymph node dissection (ALND). A total of 2405 NSLNs were analyzed. Of the patients who had ALND, 51 (43%) patients had negative NSLNs and 69 (57%) had positive NSLNs. The mean mRNA copy numbers respectively for the 2 groups were 853,665 and 609,855. The difference between the means is not statistically significant (P = 0.82). Also the Receiver Operating Characteristic (ROC) Curve of the total CK-19 mRNA copy number for both groups-negative and positive NSLN were almost identical (Figure 3) indicating mRNA copy numbers cannot be used to discriminate between positive and negative non-sentinel lymph nodes. Conclusion It is clear from our study that in patients who have ALND due to macromets on OSNA, there is no correlation between the total tumor load as represented by mRNA copy numbers and the likelihood of positive non-sentinel lymph nodes. We therefore cannot rely solely on the mRNA copy numbers to decide on ALND.

Background: The Joint Committee on Intercollegiate Examinations (JCIE- domestic) is responsible for the supervision of standards, policies, regulations and professional conduct of the UK/Ireland Specialty Fellowship Examinations The Joint Surgical Colleges’ Fellowship Examination (JSCFE- International) is organised by the JSCFE Committee in five specialities, and one of them is General Surgery The syllabus for the examination is extensive and needs rigorous preparation The Specialty Trainees (ST) get supervised structured training and regular assessments, and hence their pass rate is not only comparatively higher, but they are better prepared for the challenge However, trainee surgeons who are outside the UK training programmes find the examination difficult The COVID-19 pandemic has impacted surgical training and education by limiting access to conventional teaching methods and available resources We have been running a teaching and formative assessment platform since May 2017 This teaching resource has helped several trainees in passing the examination and has proven to be a valuable learning resource in the pandemic Materials and Methods: We provided examination support, guidance and supervision by running Skype/ Microsoft Teams sessions and weekend courses We emphasised five critical steps in all our sessions and used our course website- WWW PHOENIXFRCSCOURSE COM for material 1- Using Landing Sentences to start at the MRCS level 2- 0- 60 mph concept - a safe but quick pace to move from the MRCS zone onto the FRCS zone 3- The MISTER-model of simulation and learning 4- Maintaining pace and grace under pressure 5- Interleaving- revising, rehearsing and consolidating difficult topics The sessions included model scenarios, table viva, academic reading, virtual clinics and peer to peer learning (Examiners’ Drills) The faculty were recent examination graduates and had attended such sessions before their exam success We followed the JCIE marking descriptors for formative assessment and timely feedback Results: The first such course was organised in May 2017 and since then (over 40 months) a total of 100 attendees: 90 candidates (domestic FRCS and International FRCS) and 10 observers went through our sessions and workshops Some 50 virtual sessions and 8 courses (16 days of simulation workshops) have been held so far 66 (15 CCT and 51 non-CCT) candidates took the examination and 54 passed (82%) Sum 23 candidates have either deferred their examination dates or have been delayed because of the COVID-19 pandemic and are being regularly supported Conclusions: Simulation-based virtual teaching supplemented with weekend inhouse courses has the potential to improve FRCS Section-2 examination preparation and the success rate during COVID-19 pandemic

A previously healthy 10-year-old boy presented to the emergency department with central abdominal pain, loose stool and vomiting. He was diagnosed with gastroenteritis, but was well enough to be discharged. The next day he reattended with ongoing diarrhoea and vomiting, with the pain now localised to the right iliac fossa (RIF). Acute appendicitis was suspected, and he was taken for laparoscopic appendicectomy. At surgery, a gangrenous appendix was found, with pus extending from the pelvis up to the liver. The appendix was excised and thorough peritoneal washout performed. Postoperatively, he received 48 hours of intravenous antibiotics and was discharged home. Unfortunately the boy presented again 11 days later with right lower quadrant pain and fever. Ultrasound revealed a collection in the RIF, and he returned to theatre for washout. His recovery was slow until the peritoneal pus sent for bacterial culture grew Salmonella enteritidis, identification of which facilitated appropriate antibiotic treatment.

INTRODUCTION Skin sparing mastectomies (SSMs) represent a surgical approach that preserves the natural skin envelope of the breast and, when combined with immediate reconstruction, offers a good cosmetic outcome. The aim of this retrospective study was to compare the risk of local recurrence (LR) in this series with the known rate of recurrence following a conventional mastectomy. METHODS A total of 108 patients with breast cancer who underwent an SSM and immediate breast reconstruction over a 6-year period were reviewed. RESULTS A follow-up of more than eight years showed that three patients (2.78%) had developed LR. CONCLUSIONS The rate of LR is low with SSMs and is comparable to that seen with conventional mastectomies.

The incidence of transuterine perforation and migration of intrauterine contraceptive devices (IUCDs) into the abdominal cavity has been estimated at less than 0.1%. It has been suggested that intraperitoneal IUCD have low morbidity and may be left in situ. We report the first case of closed loop small bowel obstruction due to migration of a “Saf-T-Coil” IUCD into the abdominal cavity, where it became embedded in the omentum and ultimately, 31 years after deployment, coiled both arms around a loop of ileum. This late complication underlines the dangers of intra-abdominal foreign bodies, even when chemically and biologically inert.

Pneumoperitoneum in the presence of acute abdominal pain is well recognised as an indication for laparotomy. We present a case of acute abdominal pain in the presence of an incidental pneumoperitoneum secondary to the rupture of pneumatosis intestinalis. We will discuss the importance of clinical context in the diagnosis and management of pneumoperitoneum and pneumatosis intestinalis.

Introduction Gastro-intestinal stromal tumours are the most common mesenchymal tumours of the gastro-intestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to rebleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management. Case presentation A 61-year-old male presented to the accident and emergency department with a one-day history of haemetemesis with coffee ground vomiting. After initial resuscitation, he underwent upper gastrointestinal endoscopy under sedation which demonstrated a large, bleeding, gastric mass with a central crater along the greater curvature of the stomach. A partial gastrectomy was performed taking a wedge of the stomach with clearance from the tumour, with no signs of extraperitoneal disease. Conclusion Early surgical intervention, either open or laparoscopic resection, is the treatment of choice to prevent rebleeds. In general, complete surgical resection is accomplished in 40-60% of all gastro-intestinal stromal tumours patients, and in >70% of those with primary non- metastatic gastro-intestinal stromal tumour. In our case we had completely excised the tumour. Following surgery, all patients must be referred to centres which have more experience in treating gastro-intestinal stromal tumours. Imatinib is proven to be the first effective systemic therapy in cases of unresectable or metastatic disease. All gastro-intestinal stromal tumours have the potential for aggressive behaviour with the risk being estimated from tumour size and mitotic count.

In England, there were 4500 cases of femoral hernia for the year 2005-2006, accounting for 3.5% of all herniae [1]. The femoral hernial sac contents may be varied: preperitoneal fat, omentum, small bowel, or colon. In rare instances, the appendix can be found in the hernial sac, a reported incidence of 0.8%. Whether inflamed or not, the finding of vermiform appendix inside a hernia sac is known as Amyand's Hernia, and it classically refers to an inguinal hernia. Claudius Amyand (1681–1740), a French refugee in England, was one of the leading surgeons of his day; and held the accolade of being surgeon to George II of England. In 1735 he was the first to note the presence of a perforated appendix within the inguinal hernia sac in an eleven-year-old boy, and he subsequently performed a successful appendicectomy (Hutchinson, 1993; Franko and Sulkowki, 2002). Acute appendicitis in a femoral hernia is a rare, potentially serious complication. The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia after Rene Jacques Croissant de Garengeot, an 18th century Parisian surgeon, who is quoted in the literature as the first to describe an appendix in a femoral hernia sac. It presents as an incarcerated or strangulated hernia, and the surgical management is different for the two conditions. Prompt surgery is needed to avoid complications. Awareness of this condition may help to avoid delay in management. We report a case of a patient with an acute appendicitis in a right femoral hernia presenting with a painful groin mass.

The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.

Small cell carcinoma of the anus is a very rare but aggressive tumour. We present a case of a 60-year old lady with small cell carcinoma of the anus. She had no metastatic disease on presentation. She had chemotherapy and radiotherapy but developed distant metastasis after completion of treatment. Immunohistochemistry is required to make a diagnosis. Chemotherapy remains the mainstay of treatment for small cell carcinoma of the anus with or without metastatic disease. Radiotherapy is for local control and relief of symptoms.

Patients who present with a co-existing connective tissue disorder add a degree of complexity to operative intervention. We present an unusual case of a 53-year-old Caucasian female patient with Ehlers Danlos syndrome who presented with an occult perforation of the distal ileum. The patient had known small bowel diverticulae yet the perforation occurred within the normal bowel wall. The pre-operative CT only showed malrotation of the large bowel and did not correlate with the intra-operative findings. Our case has highlighted that although small bowel perforation is a rare occurrence, it may be more common in Ehlers Danlos and may present with atypical features. Perforation may also occur alongside normal bowel as well as diverticulae within the bowel. Where diverticulae exists within a patient with Ehlers Danlos syndrome and there is some diagnostic uncertainty, there should be a lower threshold for operative intervention. We present in the discussion a number of salient features and learning points.

Adrenal myelolipoma is a rare benign neoplasm composed of mature adipose and hematopoietic tissue. Most lesions are small, unilateral and asymptomatic, discovered incidentally at autopsy or on imaging studies performed for other reasons. We would like to present a case report of this rare tumour. Cross-sectional imaging is helpful in making a pre-operative diagnosis. The size of the lesion should be a criterion for surgical intervention.

Introduction Acute compartment syndrome is a surgical emergency requiring immediate fasciotomy. Spontaneous onset of acute compartment syndrome of the lower limbs is rare. We present a very rare case of pneumococcal sepsis leading to spontaneous acute compartment syndrome. Case presentation A 40-year-old Caucasian man presented as an emergency with spontaneous onset of pain in both legs and signs of compartment syndrome. This was confirmed on fasciotomy. Blood culture grew Streptococcus pneumoniae. Conclusion Sepsis should be strongly suspected in bilateral acute compartment syndrome of spontaneous onset.

Highlights • This case has illustrated the difficulty of promptly diagnosing an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease, in the absence of pulmonary involvement in an immunocompetent patient. • A high index of clinical suspicion with a multidisciplinary team approach is required. • The first line of treatment for gastrointestinal tuberculosis is medical treatment, indicating that 6 months of an anti-tuberculosis regime is satisfactory. Surgical treatment should be sought for patients who develop complications such as obstruction, perforation, and stricture formation. • In the absence of positive pathological (polymerase chain reaction or acid-fast bacilli staining) and radiologic tests, the diagnosis is often established by obtaining a surgical histopathology specimen., INTRODUCTION We present a case of primary gastrointestinal tuberculosis that has culminated in ulcer formation, in the absence of pulmonary involvement in an immunocompetent patient. PRESENTATION OF CASE A 28-year-old Asian male presented to casualty with a 1-week history of epigastric cramping abdominal pain and several episodes of non-bilious vomiting. The patient deteriorated clinically, becoming more cachectic and given his unexplained weight loss, an oesophageal-gastro-duodenal endoscopic imaging confirmed a duodenal ulcer. The biopsy of the non-healing ulcer was the hallmark of the disease, revealing evidence of granulomatous inflammation consistent with tuberculosis bacilli. DISCUSSION Gastrointestinal tuberculosis with ulceration is rare with respect to the oesophagus, stomach and duodenum. This case proves to be unique, as our patient had experienced primary isolated gastric tuberculosis in the absence of pulmonary tuberculosis in a healthy individual. Immunohistochemical staining, histopathology and radiological investigations have demonstrated their importance in confirming abdominal tuberculosis and the extent of bowel involvement. CONCLUSION This case has illustrated the difficulties associated with a prompt diagnosis of an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease in an immunocompetent patient.