bluuebunny/crossref_metadata_2025 huggingface dataset:
759 Lost in Translation: Breast Surgery Pathology Reporting Audit
Authors: Szepietowski O , Cope P , Blacker S , Anbhalagan V , Lawn A , Kothari M
Published: August 2024

Aim

Accurate and consistent reporting of surgical specimens is essential to guide appropriate clinical decisions in management of patients with breast cancer. In 2017 NHS England consolidated pathology services with hub and spoke networks which aimed to improve efficiency and reduce variation in service delivery. Following a Serious Incident within our well-performing breast unit, it was clear that strengthening communication by standardised reporting in merged services improves patient safety. An audit was performed to review reporting consistency.

Method

The Royal College of Pathologists (RCPath) guideline 'Pathology reporting of breast disease in surgical excision specimens' describes a dataset that 90% of reports should include. We reviewed breast cancer operations from October to December 2021 at one unit and analysed reports for inclusion of guideline components. Margin and lymph node re-excisions were excluded.

Results

Of 126 reports 65 were included. Procedures were wide local excision (65%) and mastectomy (35%). Specimen type, histological grade, and presence of invasive disease were well reported but other items were inconsistently documented, including date of surgery (0%), core biopsy site identified (1.5%) and presence of microinvasion (4.3%).

Conclusions

There was variation in the pathology reporting of breast cancer. Multi-disciplinary team clinical decisions are based upon these results and error could arise if components are omitted or incomplete when reports are published. Investigating incidents drives change that makes services robust and enhances patient safety. Service improvement considerations need not be onerous or impact tight demand and capacity needs. We propose implementation of a streamlined reporting proforma that includes RCPath core dataset components.
763 Emergency Ventral Hernias Management at a Large Tertiary Hospital Against World Society of Emergency Surgery (WSES) Recommendations: 7 Years' Experience
Authors: Loizou A , Nwosu L , Wang A , Druziagina M , Mehrotra S , Tomasi I , Botha A
Published: August 2024

Aim

Ventral hernia (VH) is a common condition in general surgery. Management is conservative or surgical (either electively or emergently). Approximately 10% require emergency surgery, which is associated with higher rates of post-operative complications and mortality. This retrospective audit aims to compare performances of emergency VH management at a tertiary hospital in London over the last 7 years against the 2017 WSES. The study focuses on timing of surgery after emergency admissions, co-morbidities, size of the hernia defect, and post-operative complications.

Method

268 patients (excluding those aged <16) with non-elective VH were identified from patient coding, radiology reports, and patient notes between 2016 and 2023. Cases were analysed in detail with single/multiple attendances, from admission in ED to definitive treatment, focusing on the most relevant co-morbidities in patients with VH, and correlated post-operative complications (inpatient/at 30 days/6 month/1 year).

Results

Many patients with a non-contaminated surgical field could have benefited from mesh implant. No evidence on the notes of discussions on single non-elective VH, such as MDT meetings, before operating or opting for conservative management. Patients with multiple admissions, especially those with co-morbidities, had higher rates of post-operative complications.

Conclusions

A great proportion of patients with a non-contaminated surgical field could have benefited from mesh implant. A longer observational period may be warranted for patients who have had abdominal surgery and are co-morbid for early detection of incisional hernias. Implementation of laparoscopic surgery has the potential to decrease post-surgical complication rates. Consider earlier intervention in co-morbid patients to prevent emergency admission.
858 Post Operative Opioid Prescribing in Patients Undergoing Primary Elective Total Hip Replacement (THR): A Closed-Loop Clinical Audit
Authors: Moosavi H , Rowe C , Sakariya D , Raja H , Alsawada O , Solanzo A , Beasley L , Walters R
Published: August 2024

Aim

To assess departmental performance versus NICE NG180 recommendations for post operative analgesia in patients undergoing primary THR.

Method

Local databases were reviewed, and patients selected based on the following inclusion criteria:Elective patients undergoing Total Primary Hip ReplacementNo contraindications to oral intake.Aged 60+

The extracted data were as follows:Immediate post operative regular opioid prescribed on Day 0 (D0).Regular post operative opioid prescribed on D0?How many hours from end of surgery to receiving 1st oral opioid dose?Pain reported on D0 post operative.Pain reported on Day 1 (D1) post operatively.

The initial loop involved data from May 2023-July 2023, with the second cycle reauditing based on data from collected from September 2023-November 2023 following implementation of printed posters of NICE NG180 and face to face education on post operative analgesia.

Results

In comparison to the first cycle of the audit, there has been a 30% increase in the number of purely regular oral opioid prescriptions on D0. A 10% increase in the number of patients receiving their oral opioid dose within 2 hours post operatively is seen between cycles in those with a regular opioid prescription. Whilst the 2-8 hour and >8-hour prescriptions remained at similar percentages for comparative patient sizes.

Conclusions

The interventions implemented after the first cycle have shown improvement in departmental performance. To better this further, we propose creating an electronic prescription order set to help clinicians appropriately manage post operative analgesia requirements in this patient group.
911 Time to Analgesia
Authors: Moolamannil M , Pak H L , Acharya N , Bevan K
Published: August 2024

Aim

According to the Royal College of Emergency Medicine guidelines 2021, patients in pain should receive analgesia within 15 minutes of arrival. It is known that acute surgical patients in pain often have to wait a considerable amount of time to receive analgesia when presenting to the Emergency department (ED). Hence, we wanted to see if starting a Surgical Assessment Unit(SAU) would help improve the time to analgesia for such patients.

Method

A two-cycle audit was conducted, and data was collected retrospectively. Cycle 1 focused on the time to analgesia for acute surgical patients presenting to ED while cycle 2 was for those presenting to SAU. Data was compared on two factors which were: the time between prescription and administration and the overall time taken to receive the first dose of analgesia.

Results

In cycle 1, which was time to analgesia for patients presenting to ED, a total of 253 patients were included. It was noted that the average time period to receive analgesia after entering the hospital was 210 minutes and the average time taken between prescription and administration of analgesia was 51 mins. Cycle 2 was conducted after the start of SAU and a total of 100 patients were included. In this case, the average time to receive analgesia after arrival was 113 minutes while the average time taken between prescription and administration was 18 minutes.

Conclusions

While not yet up to the Royal College recommendations, having an SAU definitely benefits acute surgical patients in terms of providing earlier analgesia.
965 What Did You Say? a Completed Cycle SSNHL Management
Authors: Rai A , Oktay L , Pankhania R , Bartram J
Published: August 2024

Aim

To compare the management of patients with SSNHL in a district general hospital to the ENT UK guidelines.

Method

Data encompassing the management of individuals presenting with (SSNHL) at an ENT centre in both 2022 and 2023 was collected. Data included: investigations, MRI and audiograms, and treatment: oral and intratympanic steroid (ITS) administration. Subsequently, the collected data underwent analysis and was presented to the respective local department for updated information on the SSNHL guidance and treatment pathway, a second cycle of an audit was then conducted.

Results

In an AUDIT involving 35 patients, 92% underwent same-day diagnostic audiograms, and 76% had MRI scans. All patients received oral steroids, with 80% concurrently receiving proton pump inhibitors in the second cycle. Additionally, 52% required intratympanic steroid (ITS) injections, all administered within six weeks. Subsequent audiograms showed that 66% experienced complete or partial resolution of sudden sensorineural hearing loss (SSNHL).

Conclusions

This centre's adherence to national guidelines was higher for same-day audiograms than including MRI in patient evaluations. Most patients received oral steroids, and 52% underwent intratympanic steroid (ITS) treatment, potentially contributing to observed improvements. Literature supports the benefits of successive ITS with oral steroids in sudden sensorineural hearing loss (SSNHL). The ongoing national STARFISH trial may further contribute to evidence on SSNHL management.
980 Audit of the Day Case Laparoscopic Cholecystectomy Pathway in Frimley Park Hospital
Authors: Oyekan O A
Published: August 2024

Aim

To confirm the proportion of patients that stayed overnight in the hospital after their cholecystectomy. To determine the major causes of patients staying overnight in the hospital. To ensure Laparoscopic Cholecystectomy is being performed according to Get It Right First time (GIRFT) guideline

GIRFT recommendation

Anticipated day case rate of 90%. Standard positioning of patient, with slight head up, table rotation towards surgeon. Use intermittent pneumatic compression for DVT prophylaxis. Local anaesthetic to all port sites before insertion of ports (10mls 0.5% bupivacaine*). Use of three 5mm ports and one 10mm port. Low pressure CO2 insufflation (10mmHg). Meticulous washout at end of procedure. Instillation of 30mls 0.25% bupivacaine* around liver and gallbladder. No drains

Method

All cases of Elective Cholecystectomy done within July 1st, 2023, to October 31st 2023 at Frimley Park Hospital was included in the study. Electronic case notes and Operative notes was used to get required data. A total of 107 Laparoscopic Cholecystectomy was recruited

Results

Day case Rate was 45% (58 of 107 stayed overnight), Although 85% eventually went home the morning after the Surgery. Interestingly , 34% of those that stayed overnight had no Clinical indication to stay and was mostly Patient personal preference and delay in Recovery time. No surgeon documented the Pneumoperitoneum pressure used

Conclusions

Use of GIRFT recommended surgical technique. Proper documentation of the reason patient stayed overnight. All patients should be counselled Preoperatively to have someone to pick them once medically fit to go home even if recovery gets delayed to 20.00hrs.
995 The Standard of Evening Handover in the Acute Surgical Department of a Single Regional Centre: A Closed-Loop Audit
Authors: Tiwari A , Hayat M Y , Everett K L
Published: August 2024

Aim

Handover is an important period that represents a potential risk to patient safety. The Royal College of Surgeons of England (RCSEng) have published guidelines on safe handover practice. The aim of this closed-loop two-cycle audit was to ensure general surgery patients at a single regional centre were handed over according to RCSEng guidelines.

Method

Evening handovers were prospectively audited between May 2023 to July 2023 using a proforma adapted from the RCSEng guidelines. A questionnaire relating to junior doctors’ views on the evening handover was disseminated prior to the first cycle. The intervention was an educational guide for foundation doctors on how to effectively hand over surgical patients, based on the RCSEng guidelines. P-values were calculated using a Mann-Whitney U test.

Results

15 evening handovers were audited in the first cycle; of 84 patients handed over, 31% (26/84) met the RCSEng handover ‘minimum’ standard. 13 evening handovers were audited in the second cycle; 84 patients were handed over, the ‘minimum’ standard rate increased to 67% (56/84) (p=0.003). There were 25 responses to the questionnaire, 92% (23/25) were by foundation doctors, 48% (12/25) volunteered wanting more teaching on handovers.

Conclusions

Introduction of an educational handover guide is a useful method to improve the quality of surgical handovers, particularly in regional centres that may have a more complex case mix. This guide was later introduced as part of the ‘induction pack’ for foundation doctors rotating into surgery.
1065 Beyond the Incision: Optimising Secondary Prevention Prescriptions for Vascular Surgery Admissions Through a Closed Loop Audit
Authors: Ekkunagul T , Francis J , Ngwira W , Drever S , MacLeod C , Renwick B
Published: August 2024

Aim

Vascular surgery patients carry some of the highest chronic disease and mortality burden, often driven by atherosclerotic, pro-thrombotic pathophysiology. Cardiovascular mortality risk reduction through secondary prevention by anti-platelets and statins is essential, but studies repeatedly demonstrate deficiencies in initiating such therapies. We aim to improve the identification and initiation of secondary prevention agents for vascular surgery inpatients at a tertiary centre through education and structured handover practice.

Method

A retrospective audit was performed on pre-admission and on-discharge anti-platelet and statin prescribing in vascular surgery admissions from August-October 2023. Education on guidance-based secondary prevention therapies was delivered, and modifications to the daily handover pro-forma were implemented to monitor prescribing. A prospective post-intervention re-audit was subsequently performed on admissions from October-November 2023.

Results

On admission, 70% of the 89 pre-intervention and 49% of the 47 post-intervention cohorts presented with concurrent anti-platelet or anti-coagulant and statin therapy. Pre-intervention, anti-platelets were initiated by discharge in 36% of patients admitted without anti-platelets or anti-coagulants, and statins were initiated in 20% of patients admitted without lipid-lowering therapy. This increased to 55% and 41% of such patients respectively post-intervention. However, 15% and 13% of the pre- and post-intervention cohorts respectively remain discharged on no secondary prevention therapies.

Conclusions

Education and modifications to handover documentation improved the identification and prescribing of secondary prevention therapy for vascular surgery patients in relative terms. Patients without secondary prevention therapies accounted for a significant proportion of admissions irrespective of time-period and there remains further scope to improve secondary prevention prescribing in this high-risk patient group.
1099 Audit of Immediate Discharge Letters in General Surgery in Royal Alexandra Hospital
Authors: Cunningham M , Robertson I , Robertson V
Published: August 2024

Aim

To determine what percentage of immediate discharge letters for general surgical patients meet pre-defined standards.

Method

All immediate discharge letters (IDLs) for patients discharged over a week-long period from two general surgical wards in a single hospital were analysed. Results were compared to the 16 criteria outlined in current Scottish Intercollegiate Guidelines Network (SIGN) guidelines, plus 3 further criteria agreed locally. A template for IDLs was then created and distributed amongst junior doctors writing IDLs after presentation at a local research meeting. Data was subsequently recollected recording the same criteria. Categorical data was analysed using a chi squared test.

Results

n=129 patients were included (n=67 in round 1; n=62 in round 2). Those without an IDL were excluded. On re-auditing, 15/16 (94%) of the SIGN criteria were documented more frequently, however only 5 of these were statistically significant (31.3%, p < 0.05). Results had also improved in all three of the locally agreed criteria, however only 1 of these was statistically significant. Overall, 0% of IDLs prior to the implementation of the template had all SIGN criteria present, rising to 6% after implementation of the template, however this was not statistically significant.

Conclusions

Implementation of an IDL template has improved the quality of IDLs for general surgery patients in the RAH, however further work is required to improve this further and create substantive change in the long-term.
1111 Care of Elderly Patients with Fractured Hips in an Outlying Ward When Compared to an Others in a Dedicated Hip Fracture Ward
Authors: Khin C , Okata D , Kyaw O , Thangaraj S M
Published: August 2024

Aim

Hip fractures are a significant burden in the UK with roughly 80,000 cases reported per year. The standard of care in our unit is for patients to be admitted to a dedicated hip fracture unit. During busy periods, sometimes patients are admitted to outlying wards and we were concerned that the standard of care was not equivalent to those admitted to the specialist unit. We wanted to identify if this had an impact on their care.

Method

A retrospective audit was conducted from our prospectively collected database. All hip fracture patients over 60 in the outlier wards were included. We adopted the REDUCE hip fracture outlier audit tool. We compared to a cohort of patients on the main hip fracture ward over a 4-month period.

Results

During the study period, there were 54 outliers out of total 273 admissions. All outliers were due to a lack of beds in the main ward rather than a clinical indication. 41% of them did not receive surgery within 36 hours. On the first postoperative day, 24% were not mobilised. There was a 2% mortality, and 18% did not receive appropriate bone strengthening treatment before discharge. These outcomes were worse in the outlying ward when compared to the main hip fracture ward.

Conclusions

Patients on outlier ward did not achieve many of the REDUCE targets and performance was not as good as with patients admitted onto the specialist ward. Certain elements of the findings were lower than the key performance index of the national hip fracture database.
1191 Assessing Fluid Prescriptions in Surgical Wards Within Wishaw Hospital
Authors: Lau S , Wong Q N
Published: August 2024

Aim

There were discrepancies of intravenous (IV) fluids prescriptions on the surgical wards within Wishaw Hospital. This audit was conducted to ensure that 100% of IV fluids prescribed are based on accurate assessment of patients, as per NICE CKS guidelines.

Method

The audit was based off the classic 6 steps of an audit cycle. There were 2 rounds of data collection. This took place in general surgical wards in Wishaw Hospital in November 2022 and July 2023. Data collection comprised of assessing requirements of IV fluids & category of fluids required i.e., maintenance, resuscitation or replacement fluids. Thereafter assessing whether these fluids were correctly prescribed for each patient. Intervention was centred around an education session for staff, poster reminders and departmental presentation to increase awareness.

Results

A total of 836 fluid charts were reviewed across 2 audit cycles. First round of data collection yielded 43% of IV fluids were correctly prescribed, whereas second round of data collection had shown a 24% improvement. Reasons of incorrectly prescribed fluids mainly comprises of administering fluids at the wrong rate or having wrong type of fluids prescribed, which has, overall, decreased in incidence in the second cycle.

Conclusions

There was a substantial improvement in fluid prescriptions, however, it is imperative to continue these efforts to improve fluid prescription as, inappropriate fluid prescriptions is associated with higher post-operative mortality. Mandatory teaching sessions on IV fluids should be delivered at the start of each rotation block. Further intervention can include addressing IV fluids more thoroughly in medical school.
1247 A Service Review to Assess the Liverpool Vascular and Endovascular Services’ (LIVES) Compliance to Targets Set by the Society for Vascular Surgery (SVS) Guidelines for the Care of Ruptured AAA Patients
Authors: Iqbal Z , Neequaye S
Published: August 2024

Aim

A ruptured AAA is a true surgical emergency associated with an estimated mortality rate between 30-80% and accounts for approximately 8000 deaths per year in the UK. Early identification with prompt treatment is necessary to improve outcomes and the presence of a pathway for treatment has demonstrated a reduction in the 30-day mortality rate. The Society for Vascular Surgery and NICE guidelines for the care of ruptured AAA patients have recommended a target of < 90 minutes for intervention for transferred patients and < 60 minutes for non-transferred patients (30 minutes for diagnosis time, 30 minutes for transfer time and 30 minutes for door/diagnosis-to-intervention (skin) (30-30-30 model)). We aimed to review/audit our practice to assess our compliance.

Method

OPCS-4 and ICD-10 codes were used to identify patients who underwent an emergency repair from March 2021-23 and patient electronic clinical systems were used to gather time-related data on Cognitoforms' online data collection tool. The data was analysed using MS Excel.

Results

40 patients were identified. 88% of patients (n=35) had an open repair and 12% (n=5) underwent an EVAR. The door-to-skin time (minutes) for transferred patients (n=27): (Mean: 66.9, Range: 18-214, SD: 52.1, 19% compliant) with a transfer time (minutes): (Mean: 142.7, SD: 119.4). The diagnosis-to-skin time (minutes) for non-transferred patients (n=13): (Mean: 116, SD: 95.4, Range: 23-179, 7.7% compliant). An overall 30-day mortality rate of 35% was reported.

Conclusions

The targets set are very challenging to meet, however with ongoing simulation training, education, and further implementation of our local pathway, improvements can be made.
1263 Audit on the Response to Raised National Early Warning Score (NEWS) in a Small District General Hospital
Authors: Poon T K C , Holden A
Published: August 2024

Aim

Primary objective: percentage of patients seen by a clinician within the Trust's NEWS guidelines.

Secondary objectives

time interval for response, escalation to registrar/critical care outreach team (CCOT) and appropriate changes to NEWS monitoring.

Method

Retrospective study with a sample of 60 patients who scored 3+ in a single parameter or 5+ in total score. Events were categories to 3+ (in a single parameter), 5-6 and 7+.

Timeline of the patient's raised NEWS were identified and documentation surrounding the relevant events were used to identify various information include: time of raised NEWS, time of escalation from nurse to clinician, time for clinician to review, escalation to senior clinician/CCOT, changes to NEWS monitoring.

Results

A total of 172 events occurred (NEWS 3+; 48, NEWS 5-6; 90, NEWS 7+; 34). Patients reviewed were 43.75%, 62.22% and 91.18% respectively. The median time for review for patients scoring 5-6 and 7+ were 1.03h and 1.00h respectively. Only 38.46% of patients scoring 5-6 and 20% of patients scoring 7+ were escalated to the registrar on call or CCOT. Changes to monitoring NEWS interval were 85.56% and 91.18% for NEWS 5-6 and NEWS 7+ respectively.

Conclusions

The data was presented at the local meeting to raise awareness. Downfalls of the audit included small sample size and the risk of implementing escalation changes during August handover.
1017 Out With the Old, in With the New? Virtual Reality vs. Cadaveric Based Teaching Materials for Anatomy Education
Authors: Freer F , Ail G , Chan T , Jones M , Broad J , Canale G P , Elston P , Leeney J , Vickerton P
Published: August 2024

Introduction

Traditionally, cadaveric materials have been essential for undergraduate anatomy teaching, offering a crucial 3D tactile learning experience. Immersive virtual reality (iVR) platforms could supplement cadaveric teaching by providing a 3D-virtual environment for anatomical exploration. However, the literature lacks a clear definition of iVR's effectiveness compared to traditional cadaveric materials.

Aim

To compare the effectiveness of iVR to cadaveric prosection in facilitating understanding of regional anatomy for a cohort of undergraduate medical students.

Method

Students participating in a dissection module were grouped by the anatomical region (upper limb, lower limb, abdomen, or thorax) dissected. Within each group, participants were randomised to two circuits with paired iVR and prosection stations. At each station, assessments were conducted using OculusRift™ iVR headsets and Human Anatomy™ application or traditional prosection materials. Responses, recorded in very short answer format, were double marked based on predefined criteria. Data was retrospectively analysed.

Results

Assessment scores from 92 participants demonstrated that overall, students achieved significantly better anatomical understanding using prosection than iVR (MPD=4.51%, p<0.0001). Sub-analysis by anatomical region indicated no significant differences in scores between prosection and iVR stations for the abdomen (p=0.6745), upper limb (p=0.8557), or lower limb (p=0.9973). However, iVR was significantly inferior to prosection in facilitating understanding of thoracic anatomy. (MPD=11.69%, p<0.0001).

Conclusions

Our study found iVR to be less effective than cadaveric prosection for facilitating anatomy education overall. Crucially, we have also demonstrated significant variability in the effectiveness of i-VR teaching for different anatomical regions, which may provide insight into the limitations and potential applications of iVR within the undergraduate anatomy curriculum.
601 SAVI SCOUT® vs Wire Guided Localization in Breast Conserving Surgery: A Symptomatic Breast Care Centre’s Experience
Authors: Harrington C I , McCormack E , O’Donoghue G , Murphy S , Manning A
Published: August 2024

Aim

Wire localization (WL) for nonpalpable tumours has been the gold standard localization technique in breast conserving surgery. However, issues such as patient discomfort, schedule inflexibility, and dislodgement can be encountered. SAVI SCOUT® (SSL), uses radar localization and can be inserted up to a month pre-operatively and was introduced in this institution in February 2023. This study aims to assess oncological outcomes as well user reported outcomes using WL vs SSL in a tertiary referral centre.

Method

A retrospective analysis was performed of all patients undergoing SSL wide local excision (WLE) and those undergoing WL WLE, for biopsy confirmed breast cancer, over 18 months. Primary outcomes were positive resection margin rate and re-excision rate.

Results

Eighty-two patients were included. Thirty-eight SSL and thirty-nine WL. Successful lesion excision was achieved in 100% of cases. Positive margin rate and re-excision rate was 15.8% for SSL (n=6) and 7.7% in WL (n=3) (p=0.45). 100% of breast radiologists agreed that SSL easier to place and schedule than WL, and believed it was more comfortable for patients than WL. Surgeon outcomes: 50% agreed tumours were easier to identify with SSL and probes were more accurately placed. 100% agreed that SSL led to less operation delays.

Conclusions

Positive outcomes were reported for SSL amongst users. However, a higher positive margin rate was seen in SSL when compared to WL (15.8% vs 7.7%) but was not statistically significant. A larger cohort of patients and increased operator experience is necessary to assess long term outcomes.
1169 Local Trust Audit Reviewing the Use of NABCOP’s Fitness Assessment Guidance in Patients ≥70 Presenting to New Patient Breast Clinic in Royal Bolton Hospital Foundation Trust
Authors: Mallya A , Thomas M , Lim L , Pikoulas P
Published: August 2024

Aim

The National Audit of Breast Cancer in Older Patients (NABCOP) has developed a fitness assessment form which should be completed for all patients who are ≥70 years when initially attending the breast clinic for suspected cancer. This form aims to standardise frailty assessment within this population and assist with treatment decisions. The form comprises of three sections: Clinical Frailty Scale, Abbreviated Mental Test Score and three further questions regarding co-morbidities. The Royal Bolton NHS Foundation Trust Breast Unit was audited against this national standard.

Method

This was a prospective audit assessing the compliance and completion of the fitness assessment form in patients ≥70 years attending new patient breast clinics over a two-week period. The results were then presented, and teaching provided to staff on the importance of this national standard. The fitness assessment forms were re-printed on yellow paper and the nursing staff were instructed to highlight patients ≥70 years on each clinic list. Data was then re-collected over another two-week period to close the audit cycle loop.

Results

During the first cycle, 14 patients who met the inclusion criteria were identified with a 0% compliance rate. After the interventions, as outlined above, the second cycle identified thirty-four patients with an 88.2% (30) compliance rate.

Conclusions

The compliance rate in using NABCOP’s fitness assessment score at the Royal Bolton NHS Foundation Trust Breast Unit significantly increased following education and the introduction of yellow paper visual prompts in clinics.
598 Chest Drain Monitoring Post-Thoracic Surgery: An Audit
Authors: Ahmed A , Jesuyajolu D , Fontaine E
Published: August 2024

Aim

Most patients have a chest drain inserted during thoracic surgery to remove fluid (such as blood, pus, or chyle) and air from the thoracic cavity. They are also inserted to create negative pressure within the pleural space to aid re-expansion of the lungs. The monitoring of chest drains is therefore vital to enable monitoring and thus management of surgical complications.

Manchester Foundation Trust has a protocol concerning chest drain monitoring through documentation of certain parameters:Tube patencyDrain swingingDrain bubblingDrainage volume and typeDrain clampingDrain site conditionSuction levelBottle change date and time.

Our aim was to investigate protocol compliance to ensure optimal patient management.

Method

For the first cycle, electronic records were scrutinised for patients who had thoracic surgery between 1st August 2023 to 14th August 2023 to ascertain if the aforementioned parameters were recorded. Following this, a poster was created highlighting the protocol and distributed across the department. For the second cycle the same method was adopted over a two-week period starting on 23rd October 2023.

Results

The first cycle demonstrated compliance for documentation of drain bubbling, fluid volume/type and suction as 90%, 84% and 87% respectively, and 0% for remaining parameters. The second cycle demonstrated compliance for documentation of drain bubbling, fluid volume/type, suction and drain site condition as 100%. Compliance for tubing patency was 14%, drain swinging 36%, drain clamping 21% and bottle change 21%.

Conclusions

The poster demonstrated improvement in documentation of all parameters, thereby aiding in the management of these patients.
1226 Audit of Chest Drain Stitch Removal in Thoracic Surgery Inpatients
Authors: Samara M , Langham Z , Naidu B
Published: August 2024

Aim

Most Thoracic Surgery inpatients undergo chest drain insertion during their hospitalisation. Some patients, however, experience extended stays or readmission after drain removal. Our departmental guidelines recommend removing stitches 5-7 days post-drain removal. This audit aims to evaluate and enhance our practice in this regard.

Method

This retrospective study included patients who remained as inpatients or were readmitted on day-7 following the removal of a chest drain that required stitches. The study was conducted in two cycles, the first cycle involved patients discharged from Thoracic Surgery between August 23rd and September 23rd. The second cycle took place six weeks after implementing an intervention that involved documenting the date of drain removal on the electronic medical records (EMR) with a recommended range for stitch removal.

Results

In the first cycle, there were 17 patients with 24 drains/stitches, with stitches remaining in place for a range of 6-44 days (median 10.5 days). In the second cycle, involving 14 patients with 22 drains/stitches, the range decreased to 4-18 days (median 7 days) post-intervention. Compliance improved from 20.8% to 54.5%. Importantly, we observed a reduction in incidents of bleeding, difficulty, or abandonment of stitch removal in the second cycle, as opposed to two cases in the first.

Conclusions

Timely removal of stitches following chest drain removal is essential for postoperative care, reducing the risk of complications associated with delayed removal. Our intervention significantly improved our practice. We recommend the continued implementation of EMR documentation as an effective means of enhancing patient care.
449 Pseudomyxoma Peritonei Peritonitis: An Unexpected Finding
Authors: Yannamani P , Oyewole B , Waheed L , Langford S , Shetty R
Published: August 2024

A 42-year-old male was admitted with a one-day history of sudden-onset abdominal pain, worst in the right iliac fossa. He had felt feverish but had no nausea, vomiting or diarrhoea. He had no significant past medical history. On examination he was peritonitic on the right side of his abdomen and the left side was soft. Blood pressure, heart rate and temperature were within normal parameters. His blood tests showed a CRP of 98, a white cell count of 13.6, and all other bloods were unremarkable. He was initially managed for appendicitis and received IV antibiotics.

CT abdomen pelvis with contrast showed a 6.5x10x18cm abscess with extension from the caecum up to the level of the right colonic flexure.

He was taken to theatre for an appendicectomy and a 5cm appendiceal mucocele was found. This had perforated and there was a large amount of mucin in the right anterior and lateral abdominal wall. All abdominal organs appeared grossly normal, there was no gross peritoneal seeding, and the appendiceal base appeared normal. The mucin was suctioned and sent for cytology. The appendix was sent for histology. The patient was booked for a staging CT thorax and outpatient colonoscopy. He was discharged home with no complications.

The learning points here are that operative diagnosis is essential for surgical planning as well as adequate specimen collection for histology and cytology. Secondly, while appendicitis is a common clinical condition, there could be uncommon clinical and histological findings.
491 Metastatic Micronodular BCC – a Multimodal Approach and Reconstruction in the MDT Setting
Authors: Van J , Plonczak A , Hamnett N
Published: August 2024

Introduction

BCC is the most common cancer. Metastatic BCC is limited to a small percentage <1% of cases. This is usually local nodal invasion rather than true metastasis. BCC is deemed low risk with cure rates of 96% with predetermined margins.

Case report

We present a 55-year-old male with no significant past medical history who developed metastatic basal cell carcinoma (BCC) to the regional inguinal lymph nodes 5 years post complete excision of a micronodular/infiltrative BCC with perineural invasion to the lower leg.

CT chest, abdomen and pelvis showed a left groin mass invading the sartorius muscle and MRI pelvis showed encasement of left femoral artery and no evidence of distant metastases.

The patient underwent ilio-inguinal dissection and resection of common femoral artery with Dacron graft reconstruction covered with sartorius muscle flap. The photos show a large soft tissue defect post-resection which was reconstructed using perforator-based flap containing multiple perforators based on lateral femoral circumflex artery. The patient then completed adjuvant radiotherapy 50Gy/25# over 5 weeks.

Conclusions

Metastatic BCC in a young fit patient requires radical surgery and adjuvant radiotherapy. Complex reconstruction was planned within the MDT setting resulting in limb salvage, restoration of form, function and normal gait. Learning points include looking for metastasis in high-risk subtypes of BCCs. It is important to manage these rare cases with an MDT approach and emphasize patient education regarding recurrence and metastatic risk post-diagnosis and at time of discharge.
630 Conservative Management for Recurrent Small Bowel Obstruction Related to Ileostomy in Pregnancy
Authors: Baxter N , Brewis L , Arkle T , Shaikh I
Published: August 2024

Management of small bowel obstruction in pregnancy poses significant challenges, further complicated in rare cases where this is related to an ileostomy. Existing case reports describe both operative and conservative management strategies. This is the first case report to document conservative management of recurrent episodes.

We report the case of a 27-year-old nulliparous patient, who presented at 24+0 weeks gestation with a short history of abdominal pain, bilious vomiting and reduced stoma output. She had a background of subtotal colectomy and ileostomy formation two years prior for refractory ulcerative colitis. MRI demonstrated small bowel obstruction with a transition point close to the ileostomy site. The obstruction was resolved through insertion of a per-stomal nasogastric tube, as in previous case reports, and she was discharged. At 27+0 weeks she was readmitted with recurrent symptoms, to relieve the obstruction a Foley catheter was placed into the ileostomy to traverse the transition point and positioning confirmed on MRI, allowing discharge. At 34+5 weeks she was readmitted and managed similarly, however it became apparent the gravid uterus was contributing to obstruction and early delivery was the best option. She received dexamethasone and underwent an uncomplicated caesarean section at 35+2 weeks with the stoma functioning normally post-delivery. She was successfully discharged with her baby.

In conclusion, novel use of a Foley catheter permitted oral nutrition and time for steroid administration to aid foetal lung maturation. Joint care with obstetrics was vital to determine optimal timing for delivery, balancing risk to the mother and pre-term delivery.
992 Prostatic Abscess in an Immunocompetent Adolescent: A Rare Case Report
Authors: Cheng Y S , Chuang Y H , Hosny K
Published: August 2024

Background

Prostatic abscess (PA) is uncommon, typically seen in the middle age population. PA in adolescents is extremely rare. Risks factors include diabetes mellitus, immunodeficiency, recurrent urinary tract infection and urological procedure. The diagnosis of PA is challenging due to its vague and non-specific symptoms. It is recommended that a PA larger than 1 cm is treated with surgically drainage and adequate antibiotics

Case Presentation

We present a case of PA in a 19-year-old Afro Caribbean male. He presented with swinging pyrexia, generalised abdominal and rectal pain. He denied urinary symptoms. He had no significant past medical history. Digital rectal examination yielded pain on palpation of prostate. Immunodeficiency history and screening were negative. CT showed a multilocular prostatic abscess measuring 6.0 x 3.4 x 4.9 cm. Blood and urine culture were negative. The patient was treated initially with ciprofloxacin and gentamicin for a week. Then later discharged with six weeks of ciprofloxacin. MRI was performed after 3 months which showed only post-inflammatory changes in the prostate gland but no residual PA

Conclusions

We were able to demonstrate treatment success in a large PA in an adolescent without surgical drainage which is usually the mainstay treatment. The early diagnosis and treatment based on patient selection in this case remain pivotal in development of a treatment algorithm and improving patient outcomes.
1117 Treating an Ongoing Headache with a Gastrectomy
Authors: Zulhilmi Nadesan H , Samy A N W , O’Connor D
Published: August 2024

A 51-year-old male originally from the west coast of Africa and at the time of presentation to hospital resident in the west of Ireland, was brought in by ambulance following an unstable upper gastro-intestinal bleed. The patient was resuscitated with packed red cell transfusion and intra venous crystalloid and proceeded to definitive endoscopic management within 12 hours of presentation. During secondary survey, it transpired that the patient had been taking a supra-therapeutic dose of over the counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of a headache during the preceding 8 weeks. At endoscopy, haemostasis was achieved endoscopically with a combination of subcutaneous injection of adrenaline and application of a haemostatic powder, licenced for such cases. The patient made an excellent initial recovery but on day 6 developed catastrophic secondary haemorrhage. Further endoscopic management was unsuccessful, and a decision was made to proceed to laparotomy. At laparotomy the findings included an ulcer of the distal gastric body, multiple lesions of the liver, peritoneum, and extensive lymphadenopathy. The patient proceeded to undergo an oncologic subtotal gastrectomy and D2 lymphadenectomy with biopsy of a representative liver lesion. Histology revealed the surprising finding of tuberculosis and subsequent imaging identified a large tuberculoma of the left parietal lobe as the source of original headache.

This case demonstrates the importance of a wide differential list for intra-operative findings of lymphadenopathy, particularly in a globalised society and describes the unusual presentation of miliary tuberculosis, albeit indirectly, as an upper gastro-intestinal bleed.
1157 A Giant Pseudoaneurysm of Carotid Artery
Authors: Nawaz S M A , Ahmed H , Harkin D , Babiker M , Ahmed A
Published: August 2024

Introduction

Pseudoaneurysm(PA) post carotid endarterectomy(CEA) is infrequent and potentially lethal complication, with incidence rate of less than 1%. Most of the described case reports are associated with infection. We present a case of 73-year-old man with a giant left carotid pseudoaneurysm post bilateral CEA.

Case Presentation

A 73 year old man presented with pulsatile left neck swelling after 17 years of left CEA, also had right CEA 13 years ago. Swelling was pulsatile and gradually increased in size. Initial ultrasound(USS) showed anteroposterior diameter of 1.5cm carotid pseudoaneurysm associated with patch. Decision of embolisation with stenting was made in vascular multidisciplinary-team(MDT) meeting however, patient declined the treament at that time. Following year, size of the swelling progressed, now tender and causing dysphagia. CT-Angiogram demonstrated giant left carotid bulb pseudoaneurysm. Open surgical repair with revision patch angioplasty was performed after the patient agreed. Post operative day-2 patient developed large neck haematoma which was managed conservatively and showed good recovery in follow-up clinic.

Discussion

The most common cause of pseudoanuerysm is trauma or previous surgery. However, presentation after many years of surgery without any signs of infection makes our case interesting.

Conclusions

Carotid artery pseudoaneurysm can be life-threatening if not diagnosed early. Any neck swelling should be investigated vigorously regardless of any previous trauma or surgery.
773 Quality of Life in Patients with Colostomy: A Comparative Analysis of Surgical Settings and Procedure Types
Authors: Binti Yusri N A
Published: August 2024

Aim

Quality of Life (QoL) is a crucial metric for evaluating the success of clinical interventions. This study aims to assess and compare the QoL of patients with a stoma based on surgical settings, types of procedures undergone, and the amount of support received before discharge.

Method

The methodology involved the identification of patients and the administration of a structured QoL questionnaire (ASCN UK). The sample population included individuals who underwent five different surgeries which were Hartman’s, sigmoid colectomy, anterior resection, low anterior resection, and abdominal perineal excision of the rectum in the past three years, encompassing both elective and emergency settings.

Results

Results revealed the mean QoL score for elective procedures was notably higher at 78.6%, compared to 62.6% for emergency settings. Among elective surgeries, sigmoid colectomy demonstrated the highest mean QoL score (90.4%), while Hartman’s procedure showed the lowest (72.4%). In emergency settings, Hartman’s procedure had the highest mean QoL score (75%), contrasting with anterior resection's lowest score (46%).

The study emphasized the multifactorial nature of QoL, highlighting the positive impact of pre-surgery information and support. Gender and age were significant contributors, with males and older individuals exhibiting higher QoL scores.

Conclusions

In conclusion, QoL in patients undergoing elective settings was significantly higher than in emergency settings. This trend was consistent across different procedures, as elective settings consistently yielded higher mean QoL scores compared to their emergency counterparts where applicable. This study highlights the pivotal role of support in enhancing QoL for colostomy patients, providing valuable insights for healthcare decision-making and management planning.
1192 Role of Gastrograffin Enema in Loop Ileostomy Closure Preparative Assessment: A Retrospective Study
Authors: Nasrudin A A B , Mandal I , Dharamavaram S
Published: August 2024

Aim

This study aims to ascertain the role of gastrograffin enema in assessing anastomotic failures, stricture or leaks, in primary loop ileostomy patients with time-to-closure duration longer than 90 days.

Method

A retrospective analysis of ileostomy closure in a district hospital within 2 years (August 2021 to August 2023) with the time-to-closure duration exceeding 90 days from primary ileostomy. Gastrograffin enema and flexible sigmoidoscopy performance and findings will be identified to assess their role in pre-closure anastomotic failure detection.

Results

39 patients were identified, of which 24 (61.5%) had gastrograffin enema before closure and only one patient (4.2%) was found to have an anastomotic leak in the gastrograffin study but with a subsequent normal study. The remainder had normal findings with no strictures reported from any of the gastrograffin studies. 28 patients (71.7%) in total underwent flexible sigmoidoscopy, of which 21 of them (53.8%) had dual study (gastrograffin enema and flexible sigmoidoscopy). 11 sigmoidoscopy findings (39.2%) in total were reported abnormal of which 3 were strictures (10.7%). 2 of the stricture findings had the dual study but were not initially picked up from the gastrograffin enema, while the remainder had no previous enema (p=0.0014).

Conclusions

The sensitivity of gastrograffin for anastomotic stricture was poor in patients with extended time-to-closure duration but was useful in anastomotic leak detection. This raises the question of the safe role of routine gastrograffin as an independent study to specifically detect strictures as opposed to a dual study in patients with absent clinical suspicion of anastomotic failure, regardless of duration.