Background: The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. Methods: We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/ or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. Ethics and dissemination: Formal institutional ethical board review was not required owing to the nature of the studythis was confirmed with the Health Research Authority, UK. Conclusions: The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.

Abstract This case describes a 9-year-old male who presented to general surgical clinic with a 3-year history of persistent natal cleft swelling, previously unsuccessfully treated as a pilonidal abscess in the community with multiple courses of antibiotics. In clinic, a 50 × 30-mm soft tissue swelling was found in the natal cleft and a clinical diagnosis of a pilonidal cyst was made. A cream-coloured solid mass measuring 50 × 35 × 30 mm was subsequently excised under general anaesthetic, with specialist histology and immunostaining confirming an unexpected diagnosis of a subcutaneous extraspinal myxopapillary ependymoma, a tumour usually found in the neuraxis. Given the atypical anatomical site of the tumour, the case presented a unique management challenge. Ultimately, the patient underwent a re-operation after specialist multi-disciplinary discussion and is currently disease free at 18 months post-surgery. The authors wish to contribute their experiences of managing this rare extraspinal ependymoma to the few existing reports in the literature.

Background During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. Methods A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. Results A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. Conclusions Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

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Background Endotracheal tube cuff pressures should be maintained between 20 and 30 cm H2O to prevent the aspiration of subglottic secretions past the cuff. Guidance recommends regular monitoring of the cuff pressure, performed using a handheld manometer/inflator. Poor technique can lead to transient deflation of the cuff, leading to the bolus aspiration of upper respiratory tract secretions, tracheal colonization and, ultimately, ventilator‐associated pneumonia. Aims and objectives To determine whether intensive care staff transiently deflate the endotracheal tube cuff to below 20 cm H2O during routine cuff pressure checks when using a handheld manometer/inflator device. Design This was an exploratory simulation study. Methods A sample of medical (n = 10) and nursing staff (n = 10), capable of caring for a tracheally intubated patient, participated in the study on a single day. A mannequin was intubated with a standard oral endotracheal tube with the cuff pressure set at 50 cm H2O. Participants were required to check and correct the cuff pressure to the appropriate level with a manometer. The lowest attained and the final target pressures were recorded. Results Three doctors were unfamiliar with the manometer and did not attempt measurement. During cuff pressure readjustment, 59% (10/17) of participants transiently deflated the cuff below 20 cm H2O and then re‐inflated to attain the final pressure. Of these participants, four deflated the cuff pressure to 0 cm H2O before re‐adjusting it back into range. Most participants, 88% (15/17), corrected the final cuff pressure to between 20 and 30 cm H2O. Conclusions Poor technique when using the manometer led to unintentional cuff deflation during routine checks. In clinical practice, this could increase the risk of pulmonary aspiration and ventilator‐associated pneumonia. Further research into alternatives for handheld manometers, such as automated continuous cuff pressure monitors, is warranted. Relevance to clinical practice Cuff deflations can easily occur during routine cuff pressure checks. Staff should be aware of the implications of cuff deflations and seek to improve training with manometers.

ObjectivesGuidewire retention during central venous catheter (CVC) insertion is considered a “never event.” We analyzed the National Health Service England Never Event database (2004–2015) to explore the process of guidewire retention and identify potential preventative measures.MethodsWe performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers.ResultsThere was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator’s mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%).ConclusionsMost retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

Background: Central venous catheter guidewire retention is classed as a ‘never event’ in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel ‘suck out’ technique for bedside guidewire retrieval and compared this against traditional retrieval methods. Methods: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the ‘suck out’ method were compared for efficacy using Fisher’s exact test. Results: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the ‘suck out’ technique was 90% effective (p < 0.001). Conclusion: The ‘suck out’ technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.