Purpose UK data shows 25,000 preventable deaths from hospital acquired venous thromboembolism (VT... more Purpose UK data shows 25,000 preventable deaths from hospital acquired venous thromboembolism (VTE) annually. National Institute of Clinical Excellence (NICE) guidance mandates thromboprophylaxis in patients undergoing surgery. Local protocols provide guidelines for low and high-risk patients. Pathology and treatment in Head and Neck cancer (HNC) patients result in high-risk categorisation. In addition to mechanical VTE prophylaxis, pharmacological VTE prophylaxis uses low molecular weight heparin (LMWH). Major HNC surgery carries risk of post operative haemorrhage but there are no guidelines specific for these procedures. Our local guidelines changed, requiring an increased dose of LMWH. We report haemorrhagic complications in HNC surgical patients with varying LMWH dose and time of administration. Materials and methods HNC patients undergoing major surgery were identified from our database and documentation, drug charts and notes were scrutinized. Patients were classified by dose of LMWH prophylaxis received. Post-operative haemorrhagic complications and time of LMWH administration for each dose category were determined. Results Data from 67 patients were analysed. In total 31.3% were administered low dose LMWH (enoxaparin 20 mg) prophylaxis and 68.7% high dose (40 mg enoxaparin). The low dose group had 5% haemorrhagic complication rate and 17% in the high dose cohort. Ablative and reconstructive surgery was similar in each group. No patients taking antiplatelet therapy prior to surgery suffered haemorrhagic complications. Patients who suffered bleeding complications received LMWH prophylaxis the evening before or on the evening of surgery. No patients receiving prophylaxis on induction suffered haemorrhagic complications. No excess intra-operative bleeding was recorded. No patients developed clinically detectable deep vein thrombosis (DVT) or VTE. Conclusion Our study shows increased post-operative bleeding in patients receiving 40 mg vs 20 mg enoxaparin. No patients developed DVT and no intra-operative haemostatic difficulty was recorded in any case. No bleeding complications were recorded where LMWH was given on induction.
British Journal of Oral & Maxillofacial Surgery, Dec 1, 2015
Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variab... more Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variable and unpredictable risk of transformation to invasive squamous cell carcinoma (SCC). Modern management relies initially on clinical recognition of suspicious lesions and histopathological assessment and grading after incisional biopsy. However, it then varies from wide excision to observation and review, and depends not only on the severity of dysplasia but also on the clinician's preference as there is no high-level evidence to support best practice. We invited clinicians from oral and maxillofacial surgery, oral medicine, ear, nose, and throat (ENT), and plastic surgery, to complete an online questionnaire on current practice, which included 3 fictitious cases, to ascertain their views on the management of PMD and to find out whether they would be interested in becoming involved in a proposed future randomised controlled trial (RCT). Of the 251 who replied, 178 (71%) were oral and maxillofacial surgeons, and 99 (39%) expressed an interest in participating in a future RCT. Most respondents (n=164 or 99%) would always treat severely dysplastic lesions by excision or laser ablation, whereas only 8% (n=13) would always excise mild dysplasia. The greatest equipoise among those interested in taking part in a RCT was found in the case of moderate dysplasia for which 27% (n=27) favoured observation compared with surgical excision or laser ablation. This study shows that there is support for a multicentre, prospective RCT that compares observation with resection and laser ablation in patients with moderate dysplasia.
British Journal of Oral & Maxillofacial Surgery, Sep 1, 2022
Patients undergoing sentinel node biopsy (SLNB) for early oral squamous cell carcinoma (OSCC) who... more Patients undergoing sentinel node biopsy (SLNB) for early oral squamous cell carcinoma (OSCC) who harbour occult metastases (pN+ve) may be at greater risk of mortality due to prolonged overall treatment times than those identified as pN+ve on elective neck dissection (ELND). A retrospective comparative survival analysis was therefore undertaken to test this hypothesis. Patients were identified from the South Glasgow multidisciplinary team (MDT) database. Group 1 comprised 38 patients identified as pN+ve, or who were false negative, on sentinel lymph node biopsy (SLNB). Group 2 comprised 146 patients staged pN+ve on ELND. The groups were compared with the Kaplan Meier method and Cox proportional hazards model. In addition, a matched-pair analysis was performed. A unique and specifically designed algorithm was deployed to optimise the pairings. No difference in disease-specific or overall survival was found between the groups. Patients undergoing SLNB as the initial neck staging modality in early OSCC and are identified as pN+ve do not appear to be at a survival disadvantage compared with those staged with ELND.
Purpose UK data shows 25,000 preventable deaths from hospital acquired venous thromboembolism (VT... more Purpose UK data shows 25,000 preventable deaths from hospital acquired venous thromboembolism (VTE) annually. National Institute of Clinical Excellence (NICE) guidance mandates thromboprophylaxis in patients undergoing surgery. Local protocols provide guidelines for low and high-risk patients. Pathology and treatment in Head and Neck cancer (HNC) patients result in high-risk categorisation. In addition to mechanical VTE prophylaxis, pharmacological VTE prophylaxis uses low molecular weight heparin (LMWH). Major HNC surgery carries risk of post operative haemorrhage but there are no guidelines specific for these procedures. Our local guidelines changed, requiring an increased dose of LMWH. We report haemorrhagic complications in HNC surgical patients with varying LMWH dose and time of administration. Materials and methods HNC patients undergoing major surgery were identified from our database and documentation, drug charts and notes were scrutinized. Patients were classified by dose of LMWH prophylaxis received. Post-operative haemorrhagic complications and time of LMWH administration for each dose category were determined. Results Data from 67 patients were analysed. In total 31.3% were administered low dose LMWH (enoxaparin 20 mg) prophylaxis and 68.7% high dose (40 mg enoxaparin). The low dose group had 5% haemorrhagic complication rate and 17% in the high dose cohort. Ablative and reconstructive surgery was similar in each group. No patients taking antiplatelet therapy prior to surgery suffered haemorrhagic complications. Patients who suffered bleeding complications received LMWH prophylaxis the evening before or on the evening of surgery. No patients receiving prophylaxis on induction suffered haemorrhagic complications. No excess intra-operative bleeding was recorded. No patients developed clinically detectable deep vein thrombosis (DVT) or VTE. Conclusion Our study shows increased post-operative bleeding in patients receiving 40 mg vs 20 mg enoxaparin. No patients developed DVT and no intra-operative haemostatic difficulty was recorded in any case. No bleeding complications were recorded where LMWH was given on induction.
British Journal of Oral & Maxillofacial Surgery, Dec 1, 2015
Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variab... more Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variable and unpredictable risk of transformation to invasive squamous cell carcinoma (SCC). Modern management relies initially on clinical recognition of suspicious lesions and histopathological assessment and grading after incisional biopsy. However, it then varies from wide excision to observation and review, and depends not only on the severity of dysplasia but also on the clinician's preference as there is no high-level evidence to support best practice. We invited clinicians from oral and maxillofacial surgery, oral medicine, ear, nose, and throat (ENT), and plastic surgery, to complete an online questionnaire on current practice, which included 3 fictitious cases, to ascertain their views on the management of PMD and to find out whether they would be interested in becoming involved in a proposed future randomised controlled trial (RCT). Of the 251 who replied, 178 (71%) were oral and maxillofacial surgeons, and 99 (39%) expressed an interest in participating in a future RCT. Most respondents (n=164 or 99%) would always treat severely dysplastic lesions by excision or laser ablation, whereas only 8% (n=13) would always excise mild dysplasia. The greatest equipoise among those interested in taking part in a RCT was found in the case of moderate dysplasia for which 27% (n=27) favoured observation compared with surgical excision or laser ablation. This study shows that there is support for a multicentre, prospective RCT that compares observation with resection and laser ablation in patients with moderate dysplasia.
British Journal of Oral & Maxillofacial Surgery, Sep 1, 2022
Patients undergoing sentinel node biopsy (SLNB) for early oral squamous cell carcinoma (OSCC) who... more Patients undergoing sentinel node biopsy (SLNB) for early oral squamous cell carcinoma (OSCC) who harbour occult metastases (pN+ve) may be at greater risk of mortality due to prolonged overall treatment times than those identified as pN+ve on elective neck dissection (ELND). A retrospective comparative survival analysis was therefore undertaken to test this hypothesis. Patients were identified from the South Glasgow multidisciplinary team (MDT) database. Group 1 comprised 38 patients identified as pN+ve, or who were false negative, on sentinel lymph node biopsy (SLNB). Group 2 comprised 146 patients staged pN+ve on ELND. The groups were compared with the Kaplan Meier method and Cox proportional hazards model. In addition, a matched-pair analysis was performed. A unique and specifically designed algorithm was deployed to optimise the pairings. No difference in disease-specific or overall survival was found between the groups. Patients undergoing SLNB as the initial neck staging modality in early OSCC and are identified as pN+ve do not appear to be at a survival disadvantage compared with those staged with ELND.
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Papers by Jim McCaul