bluuebunny/crossref_metadata_2025 huggingface dataset:
SP3.10 Improvement of quality of operation notes. An audit was performed to assess operation notes in our hospital, detected multiple points commonly missed in the operation notes as well as illegibility of some. Implementation of electronic operation notes took place to improve service
Authors: El-Hakim Hesham , Gan Sylvia , Brockway Emma , Oliphant Raymond
Published: August 2023

Aim

An audit was performed in November 2021 to assess completion of operation notes according to national guidelines.

Methods

18 points were checked in accordance to Royal college of Surgeons guidelines.

Results

Percentage of completion ranged from 47% to 77% according to sub-specialty. Main points that were missed were time of operation, bloods loss and antibiotic prophylaxis. 29% of notes had illegible hand-writing which could not be read appropriately by two or more people. Electronic operation notes have been identified as the ideal plan to help avoid illegibility and to make sure all points are present. Multidisciplinary approach was done to implement electronic typed operation notes in the hospital involving surgical team, management, theatre staff and information technology (IT) specialist. This took place by providing extra computers in both elective and emergency theatres with appropriate software to allow for typed operation notes. Operation note templates were used to ensure all points are filled. Significant improvement in the operation notes was noticed once electronic notes have been used. The percentage of electronic notes went up from 9% to 34% in January 2023, legibility increased from 71% to 96%, time of operation documentation increased from 0% to 22%. There was 100% compliance each of the following; name of surgeons, mode of surgery, date of operation, operative procedure, operative findings and closure technique. Overall completion rate of operation notes improved from 72% to 82%.

Conclusion

it is inevitable that technology can be used to eliminate human error, provide clear documentation and create traceable information.
SP3.12 Cost effectiveness of robotic versus laparoscopic colorectal resections: a mapped systematic review of published studies
Authors: Singh Anurag , Kaur Mandeep , Sains Parv , Baig Mirza Khurrum , Swaminathan Christi , Sajid Muhammad
Published: August 2023

Objective

Robotic colorectal resections (RCR) have been gaining popularity recently due to several advantages in addition to the oncological safety. The objective of this review to evaluate the cost effectiveness of RCR compared to laparoscopic colorectal resection (LCR).

Materials and methods

All types of comparative studies reporting the cost of RCR versus LCR were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.

Results

The search of medical databases yielded 14 comparative studies (one randomised trial and 13 retrospective studies) on 17961 patients undergoing oncological and non-oncological colorectal resections. Thirteen studies reported total cost whereas 7 studies reported only operative cost. In the random effects model analysis, LCR was associated with the reduced total cost [standardised mean difference -91.35, 95%, CI (-104.91, -77.80), Z = 13.21, P=0.00001] as well as reduced operative cost [standardised mean difference -4.75, 95%, CI (-9.09, -3.40), Z = 6.93, P=0.00001] compared to RCR. However, there was significant heterogeneity (Tau2 = 2.95; Chi2 = 902.27, df = 12; (p < 0.00001; I2 = 99%) among included studies.

Conclusion

The LCR seems to be more cost effective compared to RCR in terms of operative cost as well as total cost (operative plus in-patient stay). However, due to statistically significant heterogeneity among included studies and paucity of the randomised trials, these findings should be taken cautiously.
SP4.3 Improving management of post operative hypocalcaemia in Total Thyroidectomy and Parathyroidectomy surgery
Authors: James Rhodri , Scott-Coombes David , Stechman Michael , Patel Neil
Published: August 2023

Aim

Post-operative hypocalcaemia is a serious complication of thyroid and parathyroid surgery if not recognised and treated immediately. With sub specialisation and day case surgery, on call may be unfamiliar with immediate management. This can lead to non standardised and inefficient management of patients. The aim was to develop a patient information card which outlined the symptoms of hypocalcaemia and initial evidenced based management for the managing health care professional.

Method

For this quality improvement work a questionnaire was produced and provided to service users following Total Thyroidectomy and Parathyroidectomy surgery at a regional endocrine surgery unit. Data was collected post surgery before and after the intervention was introduced.

Results

A positive response to the introduction of a card with a QR code leading to management guidelines which is an evidence-based guide for professionals assessing patients with hypocalcaemia. Furthermore, patient confidence identifying symptoms of hypocalcaemia improved.

Conclusion

The introduction of a post-operative hypocalcaemia business sized card has standardised post operative triage and management of symptoms in a regional endocrine surgery service.
SP5.10 Is there a difference in Survival Outcomes of Dual Kidney Transplants (DKTs) of Allografts Procured from DCD versus DBD Donors in absence of a Dedicated National Pathology Service? A Propensity Score Analysis of UK Transplant Registry. An Epidemiology in Transplant Study Group (ETrSG) Initiative
Authors: Khawaja Abdullah , Khawaja Ibrahim , Saedon Mahmud , Mehra Sanjay , Sharma Abhishek , Sharma Hemant
Published: August 2023

Background

Dual kidney transplants (DKTs) are generally from supra-marginal or small-for-size kidneys that are implanted to provide optimum total nephron-mass. Glomerulosclerosis Pathology Scoring is used globally to guide whether single or DKT are indicated for transplant. Additionally, there are reported concerns regarding donation after cardiac death (DCD) transplant outcomes’ inferiority to donation after brain death (DBD) transplants but there are no reported survival outcomes of DKT procured from DCD v/s DBD donors.

Aim

This study aims to research if there is a difference in survival outcomes of DKTs of allografts procured from DCD versus DBD Donors in the UK.

Methods

In this exploratory analysis, adults who underwent DKT in the UK between Jan 1, 2000, and December 31, 2019, were identified in the NHSBT-Transplant registry data. Post-transplantation graft survival at 1& 3 years was assessed with cox-regression analysis, with propensity scores being used to control for selection bias.

Results

51,961 renal transplants were reported to NHSBT during the study period, of whom 525 were DKT. After confounders were controlled for with propensity scores, no significant differences in survival outcomes were found between DCD and DBD transplants. Region of Transplant (OR 1.6, 1.0-2.5; p=0.02), transplant post-Year-2011 (OR 3.0, 1.7-5.2; p<0.00), and non-diabetic donors (OR 2.1, 1.1-3.9, p=0.009) were associated with better graft survival, while DBD transplants were associated with low delayed graft function rates (OR 0.4, 0.27 - 0.59; p<.001).

Conclusions

Survival outcomes of DKT procured from DCD versus DBD donors are equivalent. These results are admirable as the UK does not have a dedicated National-Pathology-Service to report pre-transplant renal biopsies.
SP11.4 Surgical images and Social Media - patient centred or just a search for “likes”?
Authors: Digne-Malcolm Holly , Reid Rebecca , Butler Rebecca , Wilson Jeremy , Magee Conor ,   Wirral Academic Surgical Group
Published: August 2023

Aims

Social media platforms, such as Twitter, are an expanding space for education/interprofessional discussion. Guidance regarding doctors’ use of social media is available but much is left open to interpretation, unlike the stringent guidelines used for traditional media. Public social media postings are unpoliced and can go viral - with sometimes devastating fallout. We aimed to ascertain whether professional standards are adhered to when patient images are shared through Twitter.

Methods

Prospective review of Twitter posts with patient images. Outcomes: is there a statement of patient consent? Has confidentiality been maintained? Does the Tweet purpose justify the images included? Are professional standards maintained?

Results

61 images were identified for review from 18/12/20 to 04/01/23. Most tweets were posted by consultant surgeons (74%). Only one image had a statement of patient consent despite 46% being deemed identifiable or potentially identifiable. Location was shared for 31% of the cases and the external patient was visible in 48% of Tweets. 15% were felt to contain unprofessional content. 53% images had educational value; 31% promoted the owner of the Tweet or their colleagues; 18% were identified as posted for general interest. Only half of the Tweets were felt to justify the use of patient images.

Conclusions

Patient images are being shared through Twitter without being kept to the same rigorous standards as through traditional media. This risks breaching patient confidentiality and undermining professional standards on which patient trust depends. There is a pressing need for robust guidelines to protect both patients and healthcare professionals.
WTP1.11 The impact of the Covid-19 pandemic on discharge practices following vascular surgery
Authors: Moody Nick , Looi Wan Wen , Rushd Ahsan , Hussey Keith
Published: August 2023

Introduction

Standard operating procedures and patient pathways in healthcare have been greatly influenced by the Covid-19 pandemic. The aim of this study is to understand the impact of changes in discharge practices by comparing hospital length of stay and rates of failed discharge in selected common vascular procedures in the pre-Covid-19 and post-Covid-19 periods.

Methods

A single consultant surgeon’s logbook at a major vascular hub was used to identify all patients who underwent common vascular procedures in the pre-Covid-19 period (January to December 2017), and post-Covid-19 period (January 2021 to August 2022). Basic demographic data was recorded, as well as post-operative length of stay (LOS), failed discharge rates (re-admission within 24-hours) and re-admission within 30-days of the index procedure.

Results

65 cases were identified in the pre-Covid-19 period. 71 cases identified in the Post-covid-19 period. For each of the surgical procedures, patient demographics were comparable. There has been a reduction in the median post- operative LOS for each of the surgical procedures. Common femoral endarterectomy from 3-days to 2-days, femoral-popliteal bypass from 10-days to 5-days, major limb amputation from 29-days to 18-days, endovascular aneurysm repair from 4-days to 2-days and fenestrated endovascular aneurysm repair from 4-days to 2- days. There were no recorded failed discharges. There was no increase in re-admission at 30-days.

Conclusion

We have demonstrated a reduction in the median duration of hospital stay in the post-Covid-19 period, without an increase in any readmissions. Early mobilisation and a prompt discharge policy is thought to be relevant.
WTP1.12 Axillary Artery Aneurysm in a Patient of Achondroplasia
Authors: Jamal Zakir , Rauf Sidra , Sharafat Sana , Sajid Hannan , Rehab Ayesha , Sakhizada Fahim
Published: August 2023

Background

Axillary artery aneurysms are extremely rare mainly occurring as pseudo-aneurysms. They are most commonly caused by trauma however; fungal infections, atherosclerosis, connective tissue diseases, vasculitis and thoracic outlet syndrome are also among the etiological factors.

Case Summary

Seventeen years old, unmarried, achondroplasic (three feet height) girl presented to OPD with pulsatile swelling and pian in right axilla for six months. Pain was accompanied by weakness and numbness of hand. The swelling was initially small in size which increased over time. Patient had history of left axillary artery aneurysm back in 2015 for which left axillary repair was done. There was no history of axillary trauma.

On physical examination an approximately 4×2 cm lump was palpable in right axilla. It was round in shape, mobile, pulsatile and non-expanding with no overlying skin changes. The patient had hypotonia with power of 3/5 in all limbs. Deep tendon reflexes were reduced. Rest of systemic examination was unremarkable.

CT angiography was done which showed brachiocephalic trunck and right proximal subclavian artery normal. There was a lobulated enhancing area along the course of the Right axillary artery measuring 3.5×4.7×3.0 cm. The axillary artery aneurysm was excised and arterial continuity was restored by placement of Reverse Saphenous vein graft.

Discussion

The conventional method of axillary artery aneurysm repair is aneurysmectomy followed by placement of bypass graft. Owing to long term patency, saphenous vein graft serves as an ideal for reconstruction.

Conclusion

axillary artery aneurysms should be considered as a differential for pulsatile axillary swellings and should be promptly treated to avoid life threatening complications.
WTP2.2 Subjective Assessment of Frailty Compared to Validated Frailty Assessment in Adults with Chronic Renal Failure presenting for Dialysis-Access/Transplant workup has Poor Estimation of Agreement
Authors: Sharma Hemant , Devkaran Bhavesh , Kapoor Kunal , Odugoudar Avinash , Koufopoulos Georgios , Mehra Sanjay
Published: August 2023

Purpose

Frailty assessment often rely on subjective frailty assessment, such as ‘the end-of-the-bed’ or ‘eyeball’ test. These assessments have traditionally been accurate in 40% of cases only. Frailty assessment is a part of our institutional clinical workup. We examined the association between subjective frailty and formal validated score aided frailty estimation in the adult renal failure population.

Methods

A cohort of all renal failure patients presenting for dialysis access/transplant assessment at a satellite unit over one year (December 2020-2021) was analyzed. Adult patients aged ≥18 years in the outpatient dialysis access/transplant assessment surgical clinic were rated with eyeball test in routine clinical assessment as either: frail, pre-frail, or non-frail, which was then compared to a formal frailty assessment using a modified version of the Frailty Phenotype. The association between clinician-estimated frailty and formal frailty assessment was examined.

Results

A total of 113 patients were approached, producing 109 paired frailty assessments. The median age of the patients was 62 years. The Composite Proportions of Agreement of clinician-estimated frailty to formal frailty was poor (0.57). The sensitivity of the Eyeball test was 0.30 & specificity was 0.43. The sensitivity of the Frailty Score was 0.70 & specificity was 0.57. The validated tool has more than twice the odds of estimating frailty OR 2.86 (1.49- 5.46). p=0.002 (2-tailed).

Conclusion

Subjective frailty assessment is not a reliable replacement for formal frailty assessment in adults with renal failure. The validated Frailty Tool provides a uniform frailty estimation.
WTP2.11 Ipsilateral allograft placement in simultaneous pancreas and kidney transplantation provides equivalent outcomes to standard techniques
Authors: Petagna Lorenzo , Khambalia Hussein , Forgacs Bence , Giuffrida Giuseppe , Moinuddin Zia , van Dellen David
Published: August 2023

Aims

In simultaneous pancreas kidney transplantation (SPK) grafts are conventionally implanted controlaterally (cSPK), with the pancreas allograft (PG) on right iliac fossa and kidney allograft (KG) on the left. Ipsilateral implant (iSPK) of both grafts on the right side has been previously described but remains underutilised, potentially due to concerns regarding technical complications. We aimed to assess feasibility, safety and outcomes of an iSPK implantation technique.

Methods

A retrospective analysis of a contemporaneous database of SPK transplants was performed. Grafts laterality was noted (iSPK or cSPK) with implantation decision dependent on surgeon preference and recipient factors. Recipients’ characteristics, surgical outcomes and graft and patient survival rates were compared.

Results

162 SPKs were performed (cSPK n=126 and iSPK n=36) between 2015-21. Recipient’s' demographics, indications, diabetic burden and comorbidities were comparable between the groups. Cold and and warm ischaemia times, intraoperative time, rates of complications, reoperation and readmission comparison showed no statistically significative difference between the 2 groups (p=NS). Survival rates for grafts (iSPK=97.2% vs cSPK=91.2%, p=NS) and patient (iSPK=97.2% vs cSPK=98.4%, p=NS) at 1 year follow-up was comparable as well.

Conclusions

In our experience iSPK appears to be a safe and feasible alternative, with comparable outcomes to cSPK. With increasing experience, iSPK could be offered to a larger number of recipients as there are no deterious effects on KG outcome. iSPK may provide benefit in reduction of operative time coupled with preservation of the contralateral side for future transplants, impacting on longer term patient longevity.
WTP2.12 Clinical outcomes in combined lung-liver transplants vs isolated lung-transplants: A systematic review and meta-analysis
Authors: Wong William , Sheehan Remarez , Bentley Thomas
Published: August 2023

The combined lung-liver transplant is an infrequent but established therapy for patients with end-stage lung and liver disease. Recent evidence suggests that the liver may reduce rates of graft rejection and increase overall graft survival for cotransplanted organs. To establish a comprehensive summary of safety and efficacy data and explore whether there may be a tolerogenic effect conferred by the liver in combined lung-liver transplants (CLuLi), we systematically searched 4 databases (Medline, Embase, Cochrane, OVID Transplant library) for all studies comparing clinical outcomes between CLuLi and lung transplants alone (LTA). The primary outcome for this study was overall survival at 1 and 5 years. 3 observational studies were deemed eligible for inclusion including a total of 21, 608 transplant patients- 86 CLuLi and 21,522 LTA. The most common indications for CLuLi included cystic fibrosis (50%) and noncholestatic liver disease (23%). 1- and 5-yr survival rates for CLuLi ranged from 80-91% and 59-84%, respectively, and were not significantly different to LTA in any of the studies. A random effects inverse variance meta-analysis demonstrated an insignificant difference in hospital stay length for CLuLi compared to LTA (95% CI -8.10 to +19.52, p=0.42). 1 study reported on acute rejection and found comparable rates between CLuLi and LTA (40% vs 46%). Overall, our study has shown CLuLi transplants to be at least as safe and effective as lung transplants alone. At present, there is insufficient quality evidence to evaluate the tolerogenic effect of the liver in CLuLi transplants.
WTP3.5 Is there microbiological justification for use of intraoperative antibiotics during cholecystectomy?
Authors: Elsamalouty Islam , Mahran Mostafa , Hollyman Marianne
Published: August 2023

Background

Antibiotics are commonly given during cholecystectomy, especially when bile is spilt with little evidence that antibiotics are required when washout of contamination was achieved.

Therefore, we sought to assess if microbes in bile were associated with post operative complications and what predicted their presence.

Methods

Bile samples were taken during cholecystectomy and were sent to culture and sensitivity. Data were collected on indication for operation, use of antibiotics, description of gallbladder bile and post-operative outcomes.

Results

Bile samples were analyses for 43 cholecystectomies, of which 16 (37%) were acute presentations. Bile was spilt intraoperatively in 18 cases (42%).

Eleven (25%) samples grew microbes; the most common was Clostridium perfringens. There was a statistically significant association between microbiology findings with gender (p0.0612) and age (p0.0295), but there was no correlation between the presence of pathogens and those with acute presentation (2/16), those who had antibiotics preoperatively (3/16) those with a history of cholecystitis (4/18), or active cholecystitis (4/19) or a description of turbid fluid/pus (1/4).

23 (53%) patients received antibiotics pre, intra or post-operatively. No patients developed complications related to infection except for one patient who had a wound infection (antibiotics given pre-operative and no bile spilt).

Conclusion

There was no trend correlation between pre-operative factors in identifying patients with microbes in bile, nor spilling of bile or microbes associated with post operative complications except for age and sex. We hypothesis that antibiotics use in patients where the gallbladder is perforated intraoperatively has no impact on post operative complications. Larger sample sizes are required to confirm these findings.
WTP3.9 Procedure-specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors
Authors: Russell Thomas
Published: August 2023

Aims

Pancreatoduodenectomy (PD) remains the only curative-intent treatment option for patients with a cancer affecting the head of the pancreas. It is high-risk and overall morbidity is around 40%. Due to the necessary resection and subsequent anastomoses required, multiple procedure-specific complications are possible. An in-depth understanding of the recent evidence on these will guide the consenting process and allow surgeons to evaluate their own performance. We aimed to consolidate the recent literature on pre-selected PD complications (postoperative pancreatic fistula (POPF), bile leak (BL), gastro-jejunal leak, post-pancreatectomy haemorrhage (PPH), cholangitis, and chyle leak (CL)).

Methods

A search of the PubMed database was carried out on 1st July 2021. Articles from July 2011 through to July 2021 were included. The initial search returned 297 results. After screening, 226 articles were excluded. The remaining 71 were assessed for eligibility and a further 34 were excluded. 37 were included in the final synthesis (two meta-analyses and 35 single/multicentre studies).

Results

Due to recently updated diagnostic criteria, differing definitions among authors and subclinical cases, true incidence rates are difficult to appreciate. The following were obtained: POPF (excluding biochemical leak): 10.0-25.9%, BL: 3.0-7.9%, gastro-jejunal leak: 0.4-1.2%, PPH: 7.3-13.6%, cholangitis: 0.1-21.1% and CL: 2.6-19.0%. Numerous risk factors, both modifiable and non-modifiable, were identified for each.

Conclusions

Most of the recent evidence on the studied complications comes from single institution studies of retrospective design. Robust case-control studies are required so predictive models can estimate the likelihood of specific complications in individual patients.
WTP3.11 The impact of inpatient Magnetic Resonance Cholangiopancreatography on total length of hospital stay
Authors: Ng Shou Kee , Stevenson Carla , Ansari Fraz , Khan Khurram
Published: August 2023

Aims

Magnetic resonance cholangiopancreatography (MRCP) is a frequently performed inpatient imaging modality to rule out bile duct stones (BDS). The aim of the study was to quantify the time delays from request of MRCP to its execution.

Methods

A retrospective cohort study of all consecutive adult inpatient MRCPs was conducted in a single centre from October 2021 to September 2022. Patient demographics, indications for MRCP, system timestamps for MRCP scans and length of stay (LOS) were analysed. Peak liver function test values were used pre-MRCP.

Results

A total of 302 patients were identified, 181 (59.9%) were female. Median age was 65 (IQR 50-76) and median Scottish Index of Multiple Deprivation score was 5 (IQR 3-8).

59 (19.5 %) MRCPs were performed for jaundice and 55 (18.2 %) were for gallstone pancreatitis. 104 (34.3%) had proven bile duct stones (BDS). Ultrasound and/or CT evidence of dilated bile ducts was strongly correlated with positive MRCP findings (p<0.001). Patient age, gender, bilirubin and alkaline phosphatase levels were not predictive for BDS.

112 (37.1%) were urgent requests. The median wait time for urgent MRCP was 1.0 days (IQR 0.6- 1.8) compared to 1.2 days (IQR 0.9- 2.7) for routine requests. Median LOS was 5.9 days (IQR 3.6-10.9).

Conclusion

Inpatient MRCP does not significantly impact total LOS. We conclude that patients with high risk factors for BDS should undergo MRCP as inpatients to mitigate complications of BDS.
WTP3.13 Management of early complications of liver transplantation from a living related donor
Authors: Lamara Abdelhak , Boudjema Karim , Lakhal Mohamed , Nini Badreddine , Boukhane Mohamed , Debbar Brahim
Published: August 2023

Aim

The aim of this study is to highlight the importance of the development of adequate surgical technique, the proper selection of donors, the preparation of recipients and the introduction of new molecules of Immunosuppressants in improving liver transplant (LT) outcomes. The study also shows that early complications, occurring within the first 3 months, are responsible for two-thirds of deaths.

Methods

All LT candidates were assessed for contraindications to immunosuppressants, social and psychiatric assessment, and operative and infectious risk assessment. Patients who received LT were followed according to a rigorous pre-established protocol that allowed the detection of early postoperative complications and surgical revision in some cases.

Results

Post-operative surgical complications occurred in 04 patients who required immediaterevision surgery for hemoperitoneum, portal thrombosis that required unblockage of the TP, thrombosis of the hepatic artery requiring new arterial anastomosis and liver resection, and one patient developed an infectious complication (MAT). Three patients experienced complications related to immunosuppressants. One patient required renal dialysis. Two patients developed biliary stenosis; treated endoscopically in one patient, and biliary repair after failure of endoscopic treatment in another.

Conclusion

Hemorrhage, primary graft non-function, multiple organ failure and infection, acute rejection and surgical complications dominate post-LT follow-up. Immunosuppressive treatments are responsible for a significant morbidity rate. Early detection of complications and their immediate management reducing morbidity and mortality.

The living related donor LT program remains an option in our country due to the impossibility of LT as part of an ODB.
WTP4.2 Reasons for delays in Emergency General surgery services at Night
Authors: Amankwah Dennis , Chukwurah Uchenna , Odo Ezekiel , Bajamo Ore , Pangeni Anang , Chowdhury Ashim
Published: August 2023

Introduction

There are at least 33000 Emergency General Surgery (EGS) cases in the UK annually, with 80-90% of all deaths in general surgery noted in patients undergoing EGS. Delays in undergoing EGS are associated with increased patient morbidity, mortality and increased length of stay. We conducted a study to investigate reasons behind delays in emergency general surgery patients undergoing surgery during the night shift.

Methodology

Prospective data was collected on all surgical activity in the Emergency theatre after 20:00 hours between 26th February 2022 and 16th April 2022 (50 days). Data was collected from paper medical records.

Results

338 patients were booked to undergo surgery during the night shift over the specified time period. 68% (n=230) of cases scheduled for overnight operating had been booked during the day shift (08:00-20:00) whilst 32% (n=108) were booked during the night shift (20:00- 08:00).

70% of cases (n= 236) were rescheduled for surgery the following day. 47% of rescheduled cases were postponed due to surgical decision-making however 31% were postponed due to unavailability of theatre space (Other surgical specialties utilising theatre). All other postponements (22%) were due to anaesthetic team unavailability.

Conclusion

Our study identifies 3 main reasons for reduced emergency theatre utilisation in the night. Modifiable causes for delay include unavailability of theatre space and anaesthetic team. We recommend dedicated staff and theatre for EGS to improve patient outcomes. We recommend discussion with the on call surgical Consultant prior to postponement for surgical reasons. By improving overnight theatre utilisation, hospital pressures and patient outcomes stand to be improved.
WTP5.3 Setting up a Complex Abdominal Wall Reconstruction Unit: Our first 12 months’ experience in a District General Hospital
Authors: Bhandari Mayank , George Jefferson , Chakravartty Saurav , Parampalli Umesh , McCloud Joe , Cheetham Mark
Published: August 2023

Aims

Incisional hernias are distressing post-operative complications which develop in 25% of surgical incisions. We present our initial experience of setting up a Complex Abdominal Wall Reconstruction (CAWR) unit in line with international guidelines and Get It Right First Time (GIRFT) model of care.

Methods

A bespoke CAWR Multidisciplinary Team was established in our trust in January 2022, comprising 2 colorectal surgeons, 2 bariatric surgeons and anaesthetists (who performed the preoperative Botox injections and optimized high-risk patients). The unit had support from radiologists, the weight management service, and the orthotics department. We had approval from our governance, drugs and therapeutics team.

Pathways for risk stratification, risk modification with pre-optimisation, standardised surgical techniques and post-operative care were created.

Results

Between January and December 2022, 8 MDT meetings held and 52 patients were discussed. The average BMI was 34 (22-50.5) All patients underwent a preoperative CT scan to delineate the anatomy of the hernia. The median size of the defect was 6 cm (range 3 to 22 cm). Open Rives-Stoppa repair was performed in 19 patients, with transversus abdominal muscle release in 6 and 3 patients had laparoscopic repair. One recurrence and 2 superficial surgical site infections were noted. 38.4% patients had BOTOX, 40.3% advised preoperative weight loss and 5.7% for bariatric surgery before hernia repair. A high-risk anaesthetic opinion was obtained in for 7.6% and 17% were deemed unfit.

Conclusions

Our initial experience and data highlight the feasibility of delivery of CAWR service at a non-tertiary unit in line with GIRFT principles. The initial follow-up indicates improved patient outcomes and experience.
WTP5.11 Safety of Surgical Repair of Incisional Hernia in Patients with Morbid Obesity
Authors: Omar Islam , Townsend Abby , Hadfield Oliver , Khogali Moataz , Wilson Jeremy , Magee Conor
Published: August 2023

Aims

Incisional hernia (IH) is a common complication after open and minimal access abdominal surgery. The current practice guidelines recommend weight reduction to achieve a body mass index (BMI) < 35 Kg/M2 before surgical repair of ventral hernias. However, this could be challenging to achieve, especially in emergency presentations. This study aims to assess the safety of surgical repair of IH in patients with BMI ≥35 Kg/M2.

Methods

A retrospective comparative study has been conducted to include all patients who had surgical repair of IH on an elective and emergency basis in a UK District General Hospital. The patients were divided into two groups. Group I BMI < 35 Kg/M2 and Group II with BMI ≥35 Kg/M2. A comparison was made between the two groups according to demographics, comorbidities, hernia characteristics, operative data, and outcomes.

Results

The study included 239 patients, 181 in Group I and 58 in Group II. Severe obesity was associated with male patients, and they were younger than Group I, p= 0.001 and 0.013, respectively. 13.8% of Group I had DM compared to 29.3% in Group II, p= 0.007. There were no significant differences in hernia characteristics or mode of surgery between the two groups. However, Group II had more overall and wound-related complications, p= <0.001 each. There were no significant differences in 30-day and 90-day mortality, recurrence rate, or 90-day readmissions.

Conclusions

Surgical repair of IH in patients with morbid obesity is associated with more overall and wound-related complications.
WTP6.1 Enhancing surgical training in the East Midlands through cadaveric simulation
Authors: Parks Ruth , Smith Katherine
Published: August 2023

Aims

Training during COVID presented new challenges for us all including reduced elective activity, less training opportunities, fewer formal courses and redistributing of funding. Building on a pre-existing laparoscopic cadaveric course for general surgery trainees run within our deanery, we have developed an 11-day cadaveric course to provide extra training opportunities.

Methods

Each day of the cadaveric course targets trainees from a different speciality: core surgical training (general, urology and paediatrics), colorectal, upper gastrointestinal, vascular, ENT, maxillofacial, neurosurgery, cardiothoracic, breast, orthopaedics core (orthopaedics and plastics), orthopaedics higher. Candidates perform simulated surgeries on fresh-frozen cadavers with supervision from Consultant faculty. The courses are run with support from University and industry partners to create an environment as close to the real-world as possible. Furthermore, there is time built into each course to complete simulated WBA on ISCP.

Results

The availability of fresh-frozen cadavers has decreased and the cost increased. By bringing on board multiple surgical specialities, this is a cost-effective way to deliver excellent training to the maximal number of trainees. Feedback obtained directly from the participants shows that this type of training is highly regarded and described as ‘the next best thing’ to real-life operating as well as directly contributing to successful CCT outcomes. The courses have allowed for collaboration between different surgical specialities across the region, University and industry partners.

Conclusions

We have created a reproducible programme now run on an annual basis to impact the maximal number of trainees across the region.
WTP6.5 Facile strategies implemented to improve pharmacological venous thromboembolism prescribing practices in an acute surgical assessment unit
Authors: Basit Raja Haseeb , Anwar Adeel
Published: August 2023

Introduction

Venous thromboembolism (VTE) represents a major cause of preventable morbidity and mortality in acute surgical admissions. Whilst previous national audits/NHS campaigns have greatly increased admission VTE prophylaxis assessment (VTEPA), critical reassessment within 24 hours of admission in high bleeding/thrombosis risk patients as advocated by NICE/SIGN/Trust guidelines remains poor; thus, serving as the study aim.

Methods

Data collection was undertaken retrospectively post-discharge (n=269) at admission (within 14 hours post-admission) and reassessment (within 24 hours post-admission). The first cycle determined baseline practices; intradepartmental poster education/sessions and discussion awareness formed the mainstay intervention with a further 2 cycles (2 months/4 months post-intervention) to assess change. An unpaired T-test determined significance (p<0.05) of averaged VTEPA rates across cycles.

Results

Baseline VTEPA practices 92% (admission) and 16% (reassessment) of patients respectively. VTEPA rates significantly improved to 98% (admission, p<0.05) and 86% (reassessment, p<0.001) 2 months post-intervention. At 6 months VTEPA rates decreased to 96% (admission) and 62% (reassessment); p<0.05, p<0.001 compared to baseline practice respectively.

Discussion

VTEPA significantly improved post intradepartmental poster-education and discussion awareness at admission and reassessment, in accordance with national guidelines. We consider the decline in VTEPA at 6-months, partly attributed to the influx of the new cohort of FY1 junior doctors in August with limited exposure to the departmental VTE education sessions. Overall, however, this audit demonstrates that facile, inexpensive, and quick interventions can yield highly effective results translating into improved patient safety; particularly in preventable inpatient VTE events. Further consideration should be given to incorporate such strategies across trusts to maximise VTEPA compliance.
WTP6.8 A Decade of NHS Never Events – Has formal reporting made a difference?
Authors: Petrosyan Vahe , Tsakalidis Michail , Ameerally Phillip
Published: August 2023

Introduction

NHS England defines “Never Events” (NE) as 'patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers'.

NHS Organisations were required to publish data on NE from April 2012. This project aims to identify changes in NE patterns to help inform future learning.

Methods

All published data between April 2012 and March 2022 was collected from NHS England.

Data processing and manipulation was carried out using Microsoft Excel.

Results

A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p<0.001.

The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p<0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p<0.001.

Discussion & Conclusion

The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE.

The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.
WTP6.12 Registrars Perceptions on Performance and Patient Outcome with regard to Appendicectomies
Authors: Richardson Tom , Ahmad Adil , Datta Uttaran , Kamal Mona , Naqvi Mushal
Published: August 2023

Aims

Trainees are encouraged to reflect on performance on a personal level as well as formally by work based assessments such as the procedure based assessment. The Joint Committee of Surgical Training state “There is no place for a PBA form to be completed days, weeks or months after the event. It must be immediate”.

Although an operation may have appeared to go well - early or late complication may still occur or unexpected result may be obtained on histology. Therefore it may also be beneficial to reflect after a period of time when final outcomes are known.

We assessed registrars perceptions on performance and outcomes compared to actual figures with regard to appendicectomies performed.

Methods

Data on all appendicectomies over 9 months obtained from electronic patient and theatre records. Questionnaire regarding registrar perceptions on performance, complications and outcomes given to registrars to complete. Quantitative and qualitative analysis through Microsoft excel.

Results

8/9 middle grade registrars participated with the study. Of which 7 were male and 4 trained within the UK holding national training numbers. The majority overestimated number procedures performed whilst underestimating time taken to perform. The majority underestimated post op complications, post op interventions required as well as post op re-attendance/readmission. There was no significant difference between trainees and non trainees with regard to over or underestimating.

Conclusions

Insight into performance and outcomes post appendix surgery is poor amongst registrars. Such insights may be better in other procedures especially elective and cancer surgery. Systems to notify registrars of post op problems may aid reflection and learning.
WTP7.1 Outcomes of Surgical Repair of Incisional Hernia in The Old Patients ≥70 Years
Authors: Omar Islam , Townsend Abby , Hadfield Oliver , Khogali Moataz , Wilson Jeremy , Magee Conor
Published: August 2023

Aims

Incisional hernia (IH) is a common complication after abdominal surgery. Increasing age and frailty may be associated with poor outcomes after surgical interventions. This study aims to assess the safety of surgical repair of IH in patients ≥ 70-Year-old.

Methods

A retrospective study of patients who had surgical repair of IH on an elective and emergency basis in a UK District Hospital. The patients were divided into two groups, Group I <70 and Group II ≥70 years. A comparison was made between the two groups according to demographics, comorbidities, hernia characteristics, operative data, and outcomes.

Results

262 patients were included with a mean age of 61.8 SD± 14.2 years, and 152 (58%) were females. Group I included 173, and Group II had 89 patients. Group I had more morbidly obese patients, 46 (28.8%) compared to 12 (15.2%) in Group II; p= 0.021. Group II had more patients with at least one comorbidity and COPD than Group I; p= 0.004 and 0.003, respectively. There were no significant differences in overall or wound-related complications, p= 0.587 and 0.125, respectively. The 30-day mortality rates were 3 (1.7%) and 3 (3.4%), and the 90-day mortality rates were 4 (2.3%) and 3 (3.4%) in Groups I and II, respectively, without significant differences between both groups. There were no significant differences in the recurrence rate (with a mean follow-up of 56 months) or 90-day readmissions between the two groups.

Conclusions

Surgical repair of IH is safe and effective in patients ≥ 70 years, with comparable outcomes in younger patients.
WTP8.4 Head and Neck Surgical Site Infections: A Quality Improvement Project
Authors: Seago Imogen , Dunne Henry , Bidaye Rohan , Masterson Liam
Published: August 2023

Aim

Audit incidence of Surgical Site Infection (SSI) and early post-operative infection in open head and neck surgery in a tertiary centre and identify opportunities for improvement.

Method

We performed two 6-month audit cycles of rates of post-operative infection in elective open head and neck surgery against national rates. Cycle 1 was from August 2021-January 2022, and Cycle 2 from March-September 2022.

Between cycles we introduced a flow-chart antibiotics prophylaxis protocol as an improvement measure and presented findings at a local meeting.

Results

172 open head and neck operations were performed in Cycle 1. 7 patients developed SSIs. 169 open head and neck operations were performed in Cycle 2. 6 patients developed SSIs.

Cycle 1 included 14 diabetic patients, of whom 7 received prophylactic antibiotics. Cycle 2 included 19 diabetic patients, of whom 16 received prophylactic antibiotics. In Cycle 1, 2 diabetic patients developed early post-operative infections, one of which was an SSI, compared with 0 in Cycle 2.

SSI was more likely in patients who had surgical drains placed (8 out of 94 patients with drains, p = 0.008498*) and prophylactic antibiotic practice in this group was inconsistent in both cycles.

Conclusion

Our tertiary centre had comparable rates of SSI to national standards. We identified low rates of prophylactic antibiotic prescription for patients with diabetes and introduced a prophylaxis protocol which, despite not reaching statistical significance, appears to have improved rates of infection in diabetic patients. Additional changes should be introduced to reduce rates of infection in patients with surgical drains.
WTP8.6 Contralateral symmetrising mastectomy: A systematic review of clinical and patient reported outcomes
Authors: Griffin Cora , Stables Imogen , Brunsden Sam , Fairhurst Katherine , Potter Shelley
Published: August 2023

Background

Breast reconstruction is offered in the UK to restore symmetry after unilateral mastectomy (UM) for cancer but not all women want (or are suitable for) reconstruction. Contralateral symmetrising mastectomy (CSM) to provide ‘flat symmetry’ is an excellent alternative, but no NICE guidelines to support the offer of the procedure exist. Furthermore, symmetrising mastectomy is often mislabelled as ‘prophylactic’ mastectomy. As this is not recommended for women at population breast cancer risk surgeons are often reluctant to offer the procedure.

Methods

A systematic search in MEDLINE, PubMed, CINAHL and PsycINFO identified studies published in English 01/01/2000 - 30/08/2022 evaluating clinical and/or patient-reported outcomes of women receiving CSM after/with UM for breast cancer. Analysis included simple summary statistics for quantitative data and content analysis for qualitative data.

Results

After de-duplication, 1872 abstracts remained, 89 full-text articles were reviewed and 15 studies (13 quantitative, 1 qualitative and 1 study with both components) reporting outcomes in 1,954 women undergoing CSM were included in the review. Surgical complication rates were the same or higher in bilateral mastectomy versus UM, but far lower than those following reconstruction. A theme of ‘flat denial’ amongst surgeons emerged but patients universally reported high levels of satisfaction with their decision.

Conclusions

High-quality evidence of the clinical and patient-reported outcomes of CSM is needed to inform evidence-based surgical decision making, but such data are currently lacking. CSM is safer than reconstruction and associated with high patient satisfaction making it an excellent option for women who choose to go flat.
WTP8.8 Granulomatous Mastitis: A Service Evaluation
Authors: Rampal Ritika , Macinnes Emma
Published: August 2023

Introduction

Granulomatous mastitis (GM) is a benign, recurrent, inflammatory disease affecting the breast. There is a lack of strong evidence to support guidelines for management of this distressing condition. We performed an exploratory review of assessment and management of GM over a five-year period in a large teaching hospital breast unit.

Methods

This retrospective, observational cohort study included all cases of GM diagnosed from 2015-present. Data collection included patient demographics, presentation, assessment and management. Patient breast clinic attendance, total time spent in outpatient appointments related to GM, and other speciality input was also noted.

Results

19 patients were identified with GM on tissue biopsy (median age 41 years). 53% belonged to black and other ethnic minorities, 47% were Caucasian. 63% had no co-morbidities. 90% were non-smokers. 10% had bilateral and 38% multifocal disease. Most patients scored R3/ U3 or above on imaging. 58% of the cohort attended outpatients for a period greater than 7 months. There was also considerable heterogeneity in both assessment and management approaches.

Conclusion

The results demonstrate the significant morbidity and burden of care associated with Granulomatous Mastitis. Multidisciplinary care is necessary for both diagnosis and management. Bespoke, individualised patient information including a record of all medical input into assessment and management may help to alleviate patient anxiety and streamline care between multiple medical teams.