bluuebunny/crossref_metadata_2025 huggingface dataset:
EP-334 The Impact of Combined DNA Repair and Oncogene Mutations in Colorectal Cancer Survival
Authors: Barnable Keeley , Lloyd Vett , Singh-Ranger Gurpreet
Published: November 2022

Aims

To examine the coexistent effect of either KRAS or BRAF gene status with MMR gene status on patient outcomes in a rural population of colorectal cancer patients.

Methods

Using a colorectal cancer database, results for patient mutation status for mismatch repair genes and other oncogenes, obtained by DNA sequencing and immunohistochemical analysis, were assessed to see if there were significant differences in survival probability in patients with and without single and combined risk factors. Kaplan-Meier survival analyses were performed to examine overall survival probability in the different groups of patients.

Results

Comparison of survival outcomes in patients with and without KRAS and MLH1 mutations showed a significant difference (p=0.018). Pairwise analysis reveals that this difference is mostly between the group with wild-type status for both genes and a patient with mutant KRAS and EGFR status with wildtype MLH1 status (p=0.062 with bonferroni correction). Combined KRAS and PMS2 status results in a borderline insignificant (p=0.056) survival difference as well. The effects of mutations in other combinations of oncogenes, as well as sex or tumour sidedness and mutation statuses, were not significant on survival probability.

Conclusions

These preliminary results should be interpreted with caution owing to the relatively small sample size. This study supports previous findings that mutant oncogenes, combined with altered MMR genes can be predictive of colorectal cancer survival outcome.
EP-336 Compliance of Fluid Balance Charts in Surgical Patients According to NICE Guidelines
Authors: Morsy Hesham , Li Michael , Davidson Chris , Gu Kat , Patel Dharti , Hollingshead James , Ali Maryam
Published: November 2022

Aim

Assess compliance of presence & completion of fluid balance charts for fluid replacement in accordance with NICE Guidelines in the acute surgical admissions population

Method

Total of 158 patients were included. We collected data prospectively for surgical patients admitted between 25/02/21–18/03/21 (first cycle) & 12/09/2021–4/10/2021 (2nd cycle). Maximum of 5 patients daily randomly selected via Google random number generator. Data collected in Wards after clerking Data analysed on Day 1 of admission. Surgical Proforma was used to identify if fluid balance chart was requested. Fluid Balance charts used to assess presence & completion of charts Admissions by audit authors were excluded to prevent selection bias.

Intervention

Posters in Emergency Assessment Unit and Wards, Teaching to junior doctors, Regular reminder messages to on-call teams.

Results

Presence and completion of fluid balance chart in acute surgical admissions in compliance with NICE guidelines for IV Fluid replacement rose from 48% to 64% between cycle 1 and 2, respectively. However, presence and completion of the chart rises significantly from 64% to 100% when it is requested, compared to 58% to 87% in cycle 1.

Conclusions

Most patients had a fluid balance chart made available by the nurses still, regardless of having it requested in their surgical proforma. However, we need to request fluid balance charts for all surgical admissions in order to have all of them present and completed properly as most of them will require replacement. This needs to be clearly documented in the surgical proforma on clerking.
EP-346 Laparoscopic extraction of a migrated gastric balloon from the terminal ileum causing small bowel obstruction
Authors: ELzaafarany Ahmed , Al-Shurafa Haider
Published: November 2022

Aim

Laparoscopic management of small bowel obstruction secondary to a migrated gastric balloon.

Method

A 57 years old female patient with BMI of 45 presented to ED by central colicky abdominal pain and recurrent attacks of vomiting with absolute constipation since 2 days. The patient had history of insertion of a gastric balloon since a year. On examination: abdomen: lax soft, mild abdominal distension, central abdominal tenderness, no signs of peritonitis. observations: Pulse:122bpm, BP 90/60, RR 25. blood tests: WCC 22.0×10 /L and CRP 129 mg/L. Venous lactate of 4.

PMH:DM type 2, Missed appointments for gastric balloon extraction about 6months ago.

Admitted under the surgical team resuscitated with IV fluid, IV antibiotics, sepsis 6 protocol activated. AXR: dilated small bowel loops.

CT abdomen with I.V and oral contrast revealed impaction of the gastric balloon at the terminal ileum causing high grade small bowel obstruction.

Patient had underwent laparoscopic extraction of the migrated gastric balloon from the terminal ileum and primary closure of the ileum by endo-stitch.

Patient has smooth recovery postoperatively and discharged home two days after the surgery.

This case highlights one of the complication of the gastric balloon which is migration of a gastric balloon into a terminal ileum as a result of missed appointments for its extraction after 6 months time.

Conclusion

laparoscopic management of SB obstruction in morbid obese patient should be the first choice provided that the surgeon has the required skills and experience.
EP-368 Intraoperative identification of colorectal cancer lesions using indocyanine green labelled antibodies in preclinical murine models
Authors: Lyons Nicholas , Hooper John , Clark David , Riddell Andrew , Kryza Thomas
Published: November 2022

Aims

The ability to identify cancerous tissue intraoperatively has the potential to allow for real time identification of involved margins, lymph node involvement and extra-colonic deposits. Here we investigate whether antibodies targeting a novel receptor, anonymously referred to as LN1, a frequently over expressed protein in colorectal cancer (CRC), labelled with indocyanine green (ICG) can be used for the intraoperative detection of malignant tissue in preclinical models.

Methods

Representative metastatic CRC models were generated in 20 NSG mice using HCT116 human CRC cells. Mice were treated with either intravenous ICG labelled LN1 antibodies (LN1-ICG) or control treatments (untreated, free ICG or cotreatment unlabelled LN1 blocking antibody + LN1-ICG). Signal intensity of normal and malignant tissue was quantified from near infrared (NIR) endoscopy and IVIS® in-vivo imaging system.

Results

LN1-ICG labelled antibodies was highly effective in identifying cancerous lesions down to 500nm diameter. Quantification of NIR and IVIS images demonstrate significantly greater tumour signal in the LN1-ICG group versus controls (p=0.004 and p=0.001 respectively). Examination of normal organ tissues demonstrated signal in the liver and digestive tract in keeping with hepatobiliary clearance of ICG but nil further off-site accumulation of LN1-ICG. No difference in signal from the liver, small bowel or colon was noted between groups (p>0.05).

Conclusion

LN1-ICG labelled antibodies were highly effective at identifying even small cancerous deposits in murine models. It is highly likely that these effects could be replicated in human procedures which may allow for perioperative identification of extra-colonic deposits, involved tumour margins or lymph node involvement.
EP-373 Appropriate requesting of tumor marker, CEA, at a district hospital in Ireland: An audit cycle to improve practice
Authors: Fatima Iayla , Murphy Gearoid , Mhaonaigh Niamh Ni , Sadoon Adham
Published: November 2022

Aims

Tumor markers play an important role in oncology and the appropriate requesting of tumor marker tests are facilitated by national and international guidelines, inappropriate use increases both the laboratory workload and overall cost of management. Our aim was to assess our practice against the ACBI (Association of Clinical Biochemists in Ireland) guidelines for carcinoembryonic antigen (CEA) and conduct teaching sessions to improve practice.

Methods

1st cycle: All carcinoembryonic antigen (CEA) tests ordered in the hospital between the 1st to 31st of October 2020 were obtained through the HSE Online Lab Web Inquiry System, files were then reviewed for indications. Results from the initial audit were presented to the department and two separate teaching sessions were conducted to educate on the guidelines. 2nd cycle: All CEA test ordered from 1st January to 28th February 2021 were obtained, re-audited and results were compared.

Results

76% of the tests ordered by General Surgery in the second cycle were appropriately ordered and incorrectly ordered tests decreased from 35.7% to 23.8%.

Conclusions

Through the process of this audit an improvement was seen in practice of the department. More tests ordered adhered to indications in guidelines.
EP-379 Day-case laparoscopic Nissen fundoplication. Experience from a tertiary center
Authors: Peristeri Dimitra , Jaunoo Shameen
Published: November 2022

Aim

For day-case laparoscopic surgery to be successful, patient selection is of the utmost importance. This study aimed to assess the acceptability, feasibility, and results of day-case laparoscopic fundoplication for gastro-esophageal reflux disease (GERD) in a university tertiary care center.

Methods

A Day-case surgery for GERD was proposed routinely to all patients with proven asymptomatic, uncomplicated GERD. All of them were fulfilling predetermined inclusion criteria from January 2020 and December 2021. All patients underwent standard anesthetic, surgical, analgesic, and antiemetic protocols. Patient age, social circumstances, and other demographics were also recorded as well as any comorbidities and ASA score. The primary endpoint measured was the rate of readmission and complication rates.

Results

Of 23 patients undergoing laparoscopic fundoplication for GERD during the study period, 16 (69.56%) had day-case procedures. Most of them (81.6%) were discharged 6 to 8h after operation. Five patients were converted to in-patient hospitalization because of nausea (n=1), inadequate pain control (n=3), or anxiety (n=1). There were no complications and no re-admissions recorded.

Conclusion

Day-case laparoscopic Nissen fundoplication is a feasible, effective, and safe option for treating selected patients with gastroesophageal reflux disease (GERD) subject to careful patient selection and surgeon expertise.
EP-384 Surgical site infections: A prospective study of incidence and risk factors at a District General Hospital
Authors: Patel Maitreyi , Anad Adam , Warrag Ibrahim , Abidia Ahmed
Published: November 2022

Aims

To determine the incidence of surgical site infection (SSI)amongst patients undergoing general surgery between 1/10/2020 to 30/11/2020 and identify factors associated with SSI.

Methods

Data of adult patients operated between October 10, 2020, and November, 2020 was prospectively collected. Southampton wound scoring was used for categorizing the wound complication. Patient data was collected using electronic patient records. Data were analyzed using Excel Microsoft 2016. Chi square and t-test were used for analysis as appropriate. P-value < 0.05 was considered statistically significant.

Results

The overall incidence of SSI was 13.84% (22 out of 159 patients). The associated risk factors (p<.05) were found to be an increased age, pre operative haemoglobin <100, type of surgery, longer duration of surgery (> 2 h), post operative critical care admission and prolonged duration of hospital stay. Most patients (36%) had Southampton grade of III. They were all managed conservatively with antibiotics and dressing. Emergency surgery did not significantly increase risk of SSI.

Conclusion

Our data suggests that these risk factors could be considered as indicators of SSI. Relevant strategies for targeting the at-risk patients to optimize the modifiable factors where feasible, would enable to decrease the incidence of surgical site infections.

Emergency surgery did not significantly increase risk of SSI.
EP-393 Antegrade Colonic Enema (ACE) Stoma beyond Childhood: A Literature Review
Authors: Nadeem Tehmina , Umair Muhammad , Mockford Katherine
Published: November 2022

Background

Refractory constipation and faecal incontinence among adults is a common presentation to surgical clinics. ACE stoma has been tried and proven as a successful treatment modality in children. Although it is an acceptable treatment modality in adults, there is little prospective evidence available regarding its use and hence it has not yet come in vogue.

Methods

A literature review was carried out using PubMed, Cochrane Library, Embase, Cinahl and Scopus for studies involving ACE stoma in adults with refractory constipation or faecal incontinence; with a view to determine ACE Stoma as a safe treatment modality among adult population.

Results

A total of 27 studies were identified through database searches. 6 full text articles were included in the literature review describing a total of 209 adult patients; with male to female ratio of 1:3.4, mean age of 35 years and a mean follow up of 42.9 months. Complications discussed include perioperative and long-term stenosis (29%) and leak rates (60%); affecting the quality of life. No statistical difference was noted among the different types of ACE Conduit used. There was significant heterogeneity amongst the studies.

Conclusions

ACE stoma is not without complications; however studies reveal that this can be offered as a safe treatment modality among carefully selected adult patients for the treatment of refractory constipation or fecal incontinence.

Keywords

Adults, Refractory Constipation, Faecal Incontinence, Antegrade Colonic Enema (ACE) Stoma
EP-408 Colonic mucosal dehiscence in a patient with ischemic colitis- A case report
Authors: Rauf Fatima , Sial Fakhar Munir , Hanif Muhammad , Farooq Tashfeen , Sabir Alifa , Khan Huma Sabir
Published: November 2022

Introduction

Ischemic colitis (IC) is the condition that results when blood flow to the colon is reduced to a level insufficient to maintain cellular metabolic function.

Case summary

A 36 year old female; diabetic, hypertensive, with history of CVA and IHD, presented in ER with complaints of sudden onset, severe, colicky abdominal pain. Examination revealed a mildly tense, tender abdomen at left iliac fossa with a palpable ill-defined mass. Her TLC was 31.6/L and hemoglobin 9.3 g/dL. Serum amylase, lipase and lactate levels were normal. CECT abd/ pelvis showed thickened, edematous sigmoid and descending colon, with extensive mesenteric haze and stranding. Colonoscopy showed an illdefined, obstructing growth in rectosigmoid region at 25 cm from anal verge. There were multiple ischemic patches and underlying erythema and ulceration with bleed to touch mucosa at few sites. Scope could not be passed further. Biopsy showed active non-specific colitis with no evidence of malignancy. Patient improved on conservative management and was discharged. Patient presented in ER 2 weeks later with a long tubular structure that was expelled per-rectum. The histopathology of this structure revealed intestinal tissue with marked autolytic and ischemic changes. Patient again presented in ER with abdominal pain and vomiting with increased TLC. A diagnosis of severe ischemic colitis (ACG guidelines 2005)presenting as rectosigmoid mass was made and left hemi-colectomy was planned.

Discussion

This is a rare case of colonic mucosal shedding in ischemic colitis only described once in literature.

Conclusion

This case demonstrates the unusual way in which colonic ischemia can present.
EP-410 Improving data quality for emergency surgery: the effect of a dedicated NELA Fellow in a general surgical unit
Authors: Kronberga Madara , Saha Arin
Published: November 2022

Aims

The National Emergency Laparotomy Audit (NELA) has been running for over 8 years; despite this, there are still difficulties faced by some units and clinicians in having time and space to contemporaneously enter data and keep up to date. This study describes the improvements made to data quality after the introduction of a dedicated NELA Surgical Fellow in a single surgical centre. The role of the Fellow has been to liaise and engage with all members of the surgical team regularly to highlight the importance of accurate and timely data entry and, further, to produce monthly summaries of all emergency laparotomies and name surgeons who have not entered data.

Methods

The post of NELA Surgical Fellow was introduced at our DGH general surgical unit in August 2021. All patients who were entered onto the NELA database from our unit from January 2021 to July 2021 were compared to those entered onto the database after the introduction of the NELA Fellow.

Results

After the introduction of the NELA Surgical Fellow, contemporaneous data collection for patients has increased from 67% to 89% and the proportion of patients with complete data fields within a week after surgery has increased from 62% to 85%. The average time to complete data entry has fallen from 67 days after surgery to 52 days.

Conclusions

The introduction of a dedicated NELA Surgical Fellow, and the increased commitment to timely data collection, has led to improved accuracy of data and a faster completion time within just six months.
EP-415 The use of gastrografin in the management of adhesive small bowel obstruction
Authors: Vijayakumar Y , Kim S , Kumaran N , Habib H , Malik K
Published: November 2022

Background

Adhesive small bowel obstruction (aSBO) is a common surgical emergency causing high morbidity and even some mortality. The adhesions causing such small bowel obstructions (SBO) are typically the footprints of previous abdominal surgeries. The National Audit of Small bowel Obstruction (NASBO) recommended that in patients not needing emergency surgery for aSBO, gastrografin should be embedded in clinical management. An audit was undertaken to see our adherence to best practice in the management of aSBO.

Methods

Data of all patients who were admitted with SBO between April and October 2020 were obtained. This list was filtered carefully to extract patients who had aSBO. Data was collected on signs of intestinal ischaemia, administration of gastrografin and progression, need for surgery and length of stay.

Results

26 patients were admitted with aSBO in the above period. Half of all patients needed an emergency operation. Only 30% (8) received gastrografin. Conservative management was successful in 62% (5/8) of patients who received gastrografin. 38% (3/8) needed surgery as they either had signs of intestinal ischaemia or gastrografin failed to pass through. More than half of all patients (55%) who did not receive gastrografin (10/18) required surgery. The average length of stay was significantly higher in patients who did not receive gastrografin.

Conclusion

From the limited data it is evident that the use of gastrografin in patients with aSBO reduces the duration of stay and need for surgery. We have now developed and implemented a local protocol for managing such patients and we aim to re-audit in 6 months.
EP-420 Delayed primary repair of zone 2 flexor tendon injury after 4 weeks: Does it work?
Authors: Labib Amir , Lingamanaicker Vidhya , Fay Emily , Blakeway Megan , Fleming Andrew
Published: November 2022

Aims

To report the outcomes of delayed primary repair of zone 2 flexor tendon injuries after 4 weeks.

Methods

Retrospective evaluation of all adult patients presented with more than 4 weeks of flexor tendon injuries and underwent primary surgical repair between 2016 and 2019.

Results

271 patients’ notes have been reviewed. Only 12 patients met the criteria. 70% of patients were male with a mean age of 25 years and 40% of them were manual workers. Knife laceration was by far the most common mechanism of injury. The little finger was the most affected finger followed by the ring and middle fingers. The mean time interval between initial injury and repair was 40 days. Only one infection was reported that was treated with oral antibiotics. Two cases were in need of tenolysis due to flexed contracture. The mean total active range of motion was 167. Patients reported a good functional outcome with a mean DASH score of 10. The number of hospital visits was 40% less compared with their counterparts who underwent two-stage reconstruction.

Conclusions

In our experience, immediate reconstruction of delayed flexor tendon injuries is a better option for these cases. It is associated with a reasonable range of motion with fewer hospital visits. This facilitates early return to work, especially in the manual workers’ population.
EP-434 Is Cholecystostomy the correct temporising strategy for complicated cholecystitis and how should it be utilised to meet the NICE criteria for ‘early cholecystectomy’
Authors: Ismail Adam , Patel Pranav H , Parmar Chetan
Published: November 2022

Aims

The incidence of undiagnosed gallstones is reported in up to 22% of females, with acute cholecystitis (AC) being a common emergency presentation. NICE guidance recommends index cholecystectomy for patients with proven gallstones. Emergency Laparoscopic Cholecystectomy (LC) in co-morbid patients carries a risk, with percutaneous cholecystostomy tube (PTC) insertion utilised as a temporising measure to relieve sepsis. Whilst effective at decompression, the long-term outcomes are unclear.

Methods

We retrospectively reviewed all patients undergoing emergency PTC between 2019 and 2021 in our hospital. Data collection included: demographics, ASA classification, Clavien-Dindo grades, cholecystostomy complications.

Results

A total 24 patients (12:12 male:female) underwent emergency PTC. Median age was 73 years (range 31–89) and median ASA grade of 3 (ASA 1 n=3, ASA 2 n=8, ASA 3 n=7, ASA 4 n=6). Median time from PTC insertion to LC was 20 weeks (range 6–73 weeks). Morbidity post PTC according to Clavien-Dindo grades were: 4 with grade 3 (16.7%), 5 with grade 4 (8.3%) and 5 with grade 5 (20.8%). 8 patients (33.3%) re-presented with further cholecystitis. 4 (16.7%) patients had completion LC, without complication.

Conclusions

Our findings highlight significant morbidity and mortality in this high-risk cohort secondary to complicated AC. 20 patients (83.3%) did not undergo a completion cholecystectomy, despite 18 being ASA 1–3. We suggest a judicious use of PTC and a greater focus on index multi-disciplinary surgical fitness assessment in order to optimise a patient for acute LC. This strategy is key to enable full adoption of AUGIS guidance for performing LC within 72 hours.
EP-440 A novel approach to extraction of a bezoar
Authors: Abdelsaid Kirolos , Jayasankar Balaji , Aal Yasser Abdul , Bailey Charles
Published: November 2022

Introduction

A young girl presented with a confounding clinical picture of abdominal pain, not tolerating oral feeds on a background of being hypoalbuminemic and anemic. She had been evaluated at multiple instances in the past for similar complaints.

Methods

On further evaluation this turned out to be secondary to a bezoar lodged in her stomach and small bowel. This had been causing her severe distress over a period of 6 months with significant weight loss. Extraction of the bezoar by gastroscopy was not possible and she was taken up for surgery.

Results

Intra-operatively, we describe a novel method of extraction of the bezoar by using laparoscopic instruments through the incision over the gastric wall and extraction of the bezoar.

Conclusion

A novel method describing extraction of foreign body from the intestine
EP-458 Robotic surgery improves outcomes for patients with benign and malignant colorectal conditions
Authors: Karategos Athanasios , Farquharson Ja'quay , Liu Ben , Yassin Nuha
Published: November 2022

Aims

Robotic surgery represents the newest minimally invasive technology available to reduce the impact of surgery and provides unique benefits in pelvic access of the technically challenging colorectal resections. The purpose of this study was to assess the feasibility and clinical outcomes of robotic resections at our trust.

Methods

A series of 106 consecutive patients who underwent robotic surgery between October 2020 and January 2021 was analyzed retrospectively in terms of demographics, perioperative and 30-day postoperative outcomes. Patients divided in three groups: colorectal cancer (CRC), IBD and diverticular disease.

Results

Seventy-four patients underwent robotic resection due to CRC. Fifty-two per cent (n=39/74) had sigmoid cancer followed by right sided colon cancer in 22%(n=16/74) and rectal cancer in 26%(n=19/74). Pathologically complete resection (R0) was achieved in all patients with a median lymph node ratio of 0.14. Twenty-two patients were included in the IBD group (77% Crohn's disease). Four patients underwent robotic resection due to fistulating diverticular disease. For all the groups there were no conversions to open surgery. Return of gut function was noted within 48 hours in 91% of the patients. All patients were discharged on their baseline Hb with no need for iron replacement therapy or blood transfusion. The median length of hospital stay was 5 days. There was no reported 30-day mortality.

Conclusion

Robotic surgery is feasible, safe and improves clinical and surgical outcomes. This novel approach ensures that surgery remains minimally invasive, leading to a significant reduction in length of hospital stay, and rapid postoperative recovery.
EP-468 Impact of COVID19 on surgical training
Authors: Fox Katherine , Parkin Benjamin
Published: November 2022

Aims

Methods

An online survey consisting of 10 questions was sent to general surgical trainees, at different stages of training.

Results

All respondents felt that training has been adversely affected by COVID19. Aside from reduced operating, 96% of respondents felt that training has been adversely affected in other ways including more ward cover, less exposure to clinic and elective work and less availability of teaching. All trainees reported that teaching had moved online; 56% felt that this was less effective. Half of respondents felt that they are likely to require more time in training as a result of the pandemic. When asked what can be done moving forwards to help catch up, responses included increasing access to wet labs and waiting list initiatives. Pre pandemic, 48% of respondents felt that was a lack of cadaver teaching and 20% reported issues accessing mandatory courses.

Conclusion

Surgical training has been adversely affected by COVID19, not only due to less elective operating but also lack of teaching, courses, simulation and increased stress. With half of respondents feeling that they will need additional time, finding ways to address lost training opportunities is of paramount importance to surgical trainees and should be done not only in theatre, but also through wet labs, simulation and teaching.
EP-473 Laparoscopy versus Laparotomy for Abdominal Trauma: a Case of Iatrogenic Haemoperitoneum in a Haemodynamically Unstable patient
Authors: Stavropoulou - Tatla Stavroula , Imad Dora , Fardanesh Armin , Volteas Spiridon
Published: November 2022

Introduction

Laparoscopy is the gold-standard approach to elective abdominal surgery. Nevertheless, its application to abdominal trauma, including the treatment of haemoperitoneum, has been historically challenged by links to missed injuries. The European Association for Endoscopic Surgery does not clearly recommend therapeutic laparoscopy in trauma, despite the recognised potential benefits, in light of the scarcity and poor standardisation of available evidence.

Case description

A 68-year old male, presented with worsening shortness of breath and ascites. He was in type-2 respiratory and renal failure on a background of decompensated heart failure. He was admitted to the ITU for circulatory and ventilatory support and underwent ascitic drainage, removed on day 2. On day 3, the patient became peritonitic, exhibited a haemoglobin drop and went into class 2 haemorrhagic shock. A CT-abdomen showed moderate haemorrhagic ascites. An emergency laparoscopy was undertaken, which revealed active bleeding from the left lower abdominal wall. Haemostasis was achieved with ligation and electrocautery of the deep inferior epigastric perforators. Post-operatively, the patient showed a sustained clinical improvement. On day 4 he was stepped down to the ward and on day 10 discharged without further complications.

Discussion

Therapeutic laparoscopy is efficacious and safe in selected cases of intra-abdominal trauma, as revealed by emerging literature. The haemodynamic stability of the patient is not always a pre-requisite, and the patient's preoperative comorbidities can be key in deciding in favour of laparoscopy. We underline the following important conditions for success: an experienced surgeon, a systematic approach, suitable equipment and short time to surgery.
EP-474 An audit of cardiovascular risk modification in patients undergoing major limb amputation for the complications of peripheral atherosclerotic arterial disease and diabetes mellitus
Authors: Rodger Chloe , Fatima Kinza , Trinder Thomas , McGivney Feldheim , Hussey Keith
Published: November 2022

Introduction

The 5-year mortality for patients with peripheral atherosclerotic arterial disease is significant. Major adverse cardiovascular events are common – 16% of patients will have an event within 1-year of the diagnosis. Patients who present requiring major limb amputation represent a group where cardiovascular complications are significant – we have audited how risk is modified for this group at the point of discharge from hospital following treatment.

Methods

This was a retrospective review of patients admitted for major limb amputation. Specific variables of interest were the prescription of an antiplatelet agent (or oral anticoagulant) and a statin at the time of discharge from hospital. This was defined from immediate discharge letters.

Results

During the period of interest there were 282 major limb amputations performed and 235 patients were discharged from hospital. Most patients had peripheral atherosclerotic arterial disease (68%). A diagnosis of diabetes was mellitus was also common (52%). In this group of patients many had previous major adverse cardiovascular events – myocardial infarct 21%, angina 16% and previous stroke 18%. At the time of discharge on 80% of patients were prescribed an antiplatelet agent (or anticoagulant) and only 82% of patients had been prescribed a statin.

Discussion

Pharmacological management of cardiovascular risk in this high-risk group should be improved. At the point of admission a comprehensive assessment of cardiovascular risk should be made and modifiable risk factors addressed.
EP-482 What is the evidence from in vivo studies that mesenchymal stem cell derived extracellular vesicles can facilitate tendon and ligament repair?
Authors: Lu Victor , Tennyson Maria , Zhang James , Khan Wasim
Published: November 2022

Aim

Tendon and ligament injury pose an increasingly large burden to society. With surgical repair and grafting susceptible to failure, tissue engineering provides novel avenues for treatment. This systematic review explores evidence whether mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) can facilitate tendon and ligament repair in animal models.

Method

A systematic search was performed on PubMed, Web of Science, Cochrane Library, Embase. Risk of bias was assessed using SYstematic Review Center for Laboratory animal Experimentation (SYRCLE). Studies administering EVs isolated from human or animal-derived MSCs into in vivo models of tendon/ligament injury were included. In vitro, ex vivo, in silico studies were excluded. Data on isolation and characterisation of MSCs and EVs, and in vivo findings in animal models were extracted.

Results

Eleven case-control studies were included for analysis. Six studies utilised bone marrow-derived MSCs. All studies characterised MSCs via flow cytometry, which expressed CD44 and CD90, and isolated EVs via ultracentrifugation (average diameter 125nm). Five studies utilised histological scoring systems, all of which reported a lower score with EV treatment, suggesting improved healing ability. Four studies reported increased anti-inflammatory cytokine expression (IL-10, TGF-β1); three studies reported decreased endogenous M1/M2 macrophage ratio with EV treatment. Eight studies reported increased maximum stiffness, breaking load, tensile strength in EV-treated tendons.

Conclusions

MSC-EVs are effective therapeutic agents for tendon/ligament pathologies, attenuating the initial inflammatory response, accelerating tendon matrix regeneration, however evidence linking biomechanical alterations to functional improvement was weak. Future randomised controlled trials are needed to definitely demonstrate MSC-EVs superiority in tendon/ligament injury management.
EP-483 Adipose Tissue-Derived Mesenchymal Stem Cells as a potential restorative treatment for Cartilage Defects: A PRISMA review and Meta-analysis
Authors: Meng Henry , Lu Victor , Khan Wasim
Published: November 2022

Aim

Joint damage through trauma or degeneration causes cartilage defects, leading to osteoarthritis (OA). Current therapies relieve symptoms or replaces damaged joint, which is costly and fraught with complications. Mesenchymal stem cells (MSCs) have immunomodulatory properties and low immunogenicity, making them a novel avenue for research for OA treatment. This systematic review investigates whether adipose derived MSC (AMSCs) can treat cartilage defects.

Method

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Web of Science. Clinical, imaging, functional outcomes were extracted from nineteen included studies. Inclusion criteria was studies conducted on human populations that compared effects of AMSCs on cartilage regeneration to non-exposed controls. Studies conducted on animals, ex vivo studies, in vitro studies were excluded.

Results

Nine studies reported improved Visual Analogue Scale (VAS) scores (mean difference -3.30; 95% CI:-3.72,-2.89; p<0.001). Eight studies reported improved Knee injury and Osteoarthritis Outcome Score (KOOS) in five subscales. Pooled analysis of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in seven studies revealed an improvement (mean difference -25.52; 95% CI:-30.93,-20.10; p<0.001). Cartilage regeneration was assessed using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All studies reported improved regeneration, with a pooled end-point score of 68.12 (95% CI:62.18–74.05; p<0.001).

Conclusions

AMSCs are effective therapeutic agents for cartilage defects. We recommend researchers to determine roles of biochemical components that facilitate AMSC-mediated cartilage repair. Establishing the most efficient methods for MSC extraction, culture, delivery, and performing studies with long follow-up times enable future research to provide evidence needed to bring AMSC-based therapies into the market.
EP-488 Pre-operative electronic checklists as a systematic method to improve patient care
Authors: Bhat Srushti , Al Yasen Nada , Perikleous Periklis , Lau Kelvin
Published: November 2022

Aims

The COVID-19 pandemic has resulted in major changes in pre-operative assessment, as consultations became conducted over the telephone, and pre-operative tests carried out a few days before surgery to coincide with the COVID testing visit. This increased the chances for preoperative tests to be missed. A recent audit in our unit revealed missed investigations just before surgery. A checklist was introduced to identify issues early and help reduce avoidable delays.

Methods

An audit was performed for completeness of preoperative preparations. A pre-operative checklist was created to include pre-operative investigation reports, routine laboratory results, proof of COVID-19 swabs and vaccination records, correct details on the theatre lists, signed consent forms with clearly visible patient marking. The checklist was launched and the team, including doctors and nurses, were educated on its value in improving patient care.

Results

The implementation of electronic pre-operative checklists resulted in an immediate improvement of care, with preliminary results showing issues with a potential of causing delays being promptly identified and addressed. Late identification of issues could not be entirely avoided; however, this was discussed with team members, further education was provided, and data collection continues, to ensure good practice is sustained.

Conclusion

COVID-19 has reduced the time for hospital visit and face to face interactions, but this created the opportunity for missed tests and processes leading to delays and cancellation of surgery. The checklist in our case has proven useful in identifying issues early and promptly managing potential delays in patient care.
EP-491 Retrograde Hindfoot Nailing for the Treatment of Acute Ankle Fractures in the Elderly - A Systematic Review and Meta-Analysis
Authors: Lu Victor , Tennyson Maria , Zhou Andrew , Fortune Mary , Thahir Azeem , Krkovic Matija
Published: November 2022

Aim

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of hindfoot nailing for fragility ankle fractures.

Methods

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded.

Meta-regression analyses were performed to explore sources of heterogeneity, and publication bias was assessed using Egger's test.

Results

312 ankle fractures were included. The mean age was 77.3 (32–101) years. 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06–0.16; I2=44%), 0.08 (95%CI:0.06–0.11, I2=0%), 0.11 (95%CI:0.07–0.15, I2=0%), 0.11 (95%CI:0.06–0.18; I2=51%), and 0.27 (95%CI:0.20–0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98–59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Egger's test (p=0.56) showed no significant publication bias.

Conclusion

TTC nailing is an adequate alternative option for fragility ankle fracture management. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.
EP-494 Ankle Fusion with Tibiotalocalcaneal Retrograde Nail for Fragility Ankle Fractures: Outcomes at a Major Trauma Centre
Authors: Lu Victor , Tennyson Maria , Zhang James , Zhou Andrew , Thahir Azeem , Krkovic Matija
Published: November 2022

Aim

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails.

Method

171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock. Primary outcome was mortality risk from co-morbidities according to Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union.

Results

Mean age was 77.82 years old. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16;OR=4.00).

Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264,OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. Average follow-up time was 499.3 days.

Conclusions

Tibiotalocalcaneal nailing is an effective and safe option for managing fragility ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.
EP-496 Hip Arthroscopy for the Primary Management of Femoroacetabular Impingement with Concomitant Chondral Lesions - A Systematic Review and Meta-Analysis
Authors: Lu Victor , Andronic Octavian , Zhang James , Khanduja Vikas
Published: November 2022

Introduction

Femoroacetabular impingement (FAI) is an important cause of hip pain in the young, active population. Treated by hip arthroscopy (HA), chondral lesions are frequently seen, and there are concerns that patients with chondral defects leading to hip osteoarthritis (OA) will not benefit from HA. This review analyses the use of HA in FAI patients with chondral lesions according to Outerbridge classification.

Methods

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Web of Science. From twenty-four included studies, patient related outcome measures (PROMs), total hip arthroplasty (THA) conversion rate, radiological outcomes were collected. Clinical studies of HA used for primary FAI management, classifying chondral lesions according to Outerbridge classification were included. Patients treated with open procedure, osteonecrosis, Legg-Calve-Perthes disease, previous ipsilateral hip fractures were excluded. Risk of bias was assessed using ROBINS-I.

Results

Improved post-operative PROMs included mHHS (n=18; mean difference:-2.42; 95%CI:-2.99 to -1.85; p<0.0001), NAHS (n=8; mean difference:-1.73; 95%CI: -2.23 to -1.23; p<0.0001), VAS (n=7; mean difference:2.03; 95%CI:0.93–3.13; p<0.0001). Pooled rate of revision surgery was 10% (95%CI: 7%-14%). Most of this included conversion to THA, with a 7% pooled rate (95%CI: 4%-11%).

Patients had worse PROMs if they underwent HA with labral debridement (p=0.0149), have Outerbridge 3 and 4 lesions (p=0.0116), kissing lesions (p=0.0292). Reconstructive cartilage techniques were superior to microfracture (p=0.0416). Even in “kissing” lesions, employing either microfracture or cartilage repair/reconstruction provided a benefit in PROMs (p=0.0267).

Conclusion

This meta-analysis suggests that acceptable post-operative outcomes following HA in patients with FAI and concomitant moderate-to-severe chondral lesions, can be achieved.
EP-506 Kidney transplant rejection rate comparing Alemtuzumab versus Basiliximab during covid pandemic against pre-covid period
Authors: Rai Jason , Sinha Sanjay
Published: November 2022

Aims

To review kidney transplant rejection rate following change in immunosuppression regime due to covid pandemic. Induction immunosuppression changed from Alemtuzumab pre-covid to Basiliximab during covid pandemic period. Maintenance immunosuppressant included the addition of prednisolone to tacrolimus and mycophenolate in the covid period.

Methods

Retrospective analysis of patients that underwent cadaveric kidney transplant in a single transplant surgical unit. Rejection was confirmed following transplant kidney biopsy.

Results

Total of 192 patient records were reviewed. 96 patients underwent kidney transplant between March to November 2019 (pre-covid group). 96 patients underwent kidney transplant between March to July 2020 (covid pandemic group). Rejection number pre-covid group was 6 (total number of biopsy was 30). Rejection number covid group was 5 (total number of biopsy was 14). Pre-covid group follow up was for 16 months. Covid group follow up period was for 6 months.

Conclusions

Early follow up result suggests possibly higher rejection rate with Basiliximab when compared to Alemtuzumab group. Longer term follow up in post-covid kidney transplant needs to be carried out to draw stronger conclusion. Risk of lymphocyte depleting induction agent during covid crisis versus potential higher risk of rejection with non-depleting agent needs to be balanced.
EP-511 The influence of the national lockdown during the COVID-19 pandemic on surgical presentations and admissions in a university hospital
Authors: Dhunnoo Vedika , Haq Iram , Rutka Olga
Published: November 2022

Background

The COVID-19 pandemic has significantly revolutionised medical practice around the world. Healthcare resources had to be prioritise for the management of patients infected with the virus whilst routine and elective surgeries were postponed in order to free up hospital beds in anticipation for the influx of patients with COVID-19 requiring hospital admission. With the government announcing a national lockdown in March 2020, a striking reduction in the number of patients presenting to hospital was noted.

Aim

Our aim was to establish how the COVID-19 pandemic has impacted on the number and presentations of general surgical patients in a university hospital.

Method: We conducted a retrospective study on general surgical patients who were reviewed by the surgical team at the University teaching hospital. Data was collected over two 7-weeks periods; between the 23rd March and 10th May 2020 (the first lockdown duration in the UK) and the corresponding 7-weeks in 2019 (that is between 25th March and 12th May 2019).

Results

The analysis of our data showed that there was a significant reduction in the number of surgical patients being admitted. 399 patients were admitted between 25th March and 12th May 2019 compared to only 245 patients during the lockdown period. The average admissions per day over the 7-weeks period dropped from 9 admissions per day in 2019 to 5 admission per day during national lockdown. Small bowel obstruction and pancreatitis remained common diagnoses in both 7-weeks periods, however diverticulitis was less common during lockdown.
EP-519 A Bit of a Headache: Management of Head Injuries in a District General Hospital
Authors: Bruce Nikki , Young Jamie
Published: November 2022

Aim

Head Injury is a common presentation in our DGH, which covers a large rural area and is now a regional trauma centre. We audited our management of head injuries against current guidelines and planned a new pathway to ensure patients receive the correct advice and follow up on discharge.

Method

Data was requested from IT for all head injury episodes in 2019, to reflect usual numbers pre-pandemic.

Electronic letters, radiology and notes were used to identify whether imaging criteria was met/carried out, discharge destinations, re-presentations, specialty discussions, and head injury advice on discharge.

Results

307 individual patients identified.

13 re-presentations.

10 required neurosurgical discussions.

Destinations

226 (73.6%) discharged direct from ED. Admissions; Surgical - 37 (12%), Medical - 6 (2%), Paeds – 14 (4.5%), ITU 2 (0.7%), Did not wait – 2 (0.7%), Not Recorded – 7 (2.3%).

Imaging

100 patients met NICE criteria for CT, 100% were documented in notes and had CT. 76% reported normal, 18% had a bleed, contusion or haematoma.

HI advice 90% of ED discharges, 16% of Surgical and 16% of Medical discharges had head injury discharge advice documented.

Conclusions

Guidelines were met for 100% of patients requiring imaging Head injury advice was well documented in ED but fell down in ward paperwork.

We have written a robust pathway where all inpatients have a proforma completed during admission with prompts for discharge advice and rehab referral where appropriate, this is currently undergoing a re-audit to ensure improvement and if successful will become an established part of the trauma pathway in our hospital.