bluuebunny/crossref_metadata_2025 huggingface dataset:
77 Malignancy Incidence in the Residual Rectum of Ibd Patients After Colectomy: Systematic Review and Meta-Analysis
Authors: Georganta I , McIntosh S , Boldovjakova D , Parnaby C , Ramsay G
Published: August 2023

Aim

The primary objective of this study is to estimate the incidence of rectal carcinoma in patients with an Inflammatory Bowel Disease diagnosis, who have had a total colectomy preserving the rectum. The secondary objectives are to identify the risk factors associated with malignancy occurrence and to explore the current recommendations for screening processes for these patients.

Method

A systematic review in 5 databases was conducted to identify studies adhering to the PICO criteria. The included studies were critically appraised, and the relevant data was extracted. Malignancy incidence was estimated from the reported information and risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines.

Results

A total of 24 studies were included. The pooled incidence of rectal carcinoma across 23 studies was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a rectal stump and ileo-rectal anastomosis respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2), similarly to patients with a history of colorectal dysplasia (RR 5.1). Ten studies reported frequent surveillance using endoscopy and rectal biopsies. No studies recommending screening guidelines for the target population could be identified.

Conclusions

The overall risk for malignancy incidence was estimated to be 1.3% which is lower than previously quoted. Due to the paucity of good quality of literature in this field, it is not possible to suggest further guidance for this cohort of patients at present.
205 Single-Centre Review on Incisional Hernia After Laparoscopic Anterior Resection: What Is the Ideal Incision for Specimen Extraction?
Authors: Win M , Htet W , Ngo V , Jeyam T , Rajaganeshan R
Published: August 2023

Aim

Midline incision was reported as the common site of incisional hernia (IH) after hand-assisted laparoscopic anterior resection (LAR). There is no consensus on the ideal site for specimen extraction. Our aim was to compare the rate of IH at various specimen extraction sites at our institution.

Method

We retrospectively reviewed data of 90 cases of LAR from May 2015 to February 2018. Patients were divided into three groups such as Pfannenstiel, iliac fossa (ILF) and midline. Age, sex, BMI, diabetes, steroid use, smoking, wound infection, hernia, post-operative hospital stays (HS) and length of follow up (LOF) were compared among these groups.

Results

There were 13, 44 & 33 patients in Pfannenstiel, ILF and midline groups. There was no significant difference in age, gender, BMI, smoking, steroid use, and mean LOF among groups. Patients in the ILF group had the highest prevalence of diabetes (27%), mean BMI of 28.91, rate of wound infection (16%), and incidence of incisional hernia (16%). The midline group had the highest mean age of 72.45 years and the longest HS of 11.45 days (p < 0.003). At 49-month follow up, none of the Pfannenstiel group developed wound infection or IH (0%). However, there was no strong association between hernia and type of incision (p 0.248).

Conclusions

Although Pfannenstiel incision was found to have the lowest rate of IH, the analysis was not significant due to the small sample. We suggest future studies to have larger samples with proper randomization to propose that Pfannenstiel is the ideal incision for specimen extraction.
311 A Twist in the Tale - Study of the Management of Sigmoid Volvulus (SV)
Authors: Winder J , Rooney P , Ninkovic-Hall G
Published: August 2023

Aim

As SV has no current NICE guidance, nor large UK reviews, there is a requirement to outline best practice in the management. A review was undertaken of SV cases to determine how variation in management affects outcomes.

Method

Forty five patients (35:10 M:F) (median age 79 years, 29-93) with SV contributing 95 admissions 2017-2019 were studied using electronic notes and imaging. Estimated costs per patient were calculated using national tariff documents.

Results

Two groups were identified: conservative (non-operative management) (n = 39) and operative (n = 6), with a 90-day mortality of 41.02% and 16.67% respectively. Mean total days in hospital for each patient was 28.49 (range 1-215), 18.17 for operative and 30.08 for conservative. Nineteen patients had readmissions for SV 2017-2019, 30 in 2013-2021. No readmissions occurred post-surgery. Estimated cost of SV admissions 2017-2019 was £934,151, with no significant difference in cost for operative versus conservative.

Rigid sigmoidoscopy was performed in 65.26% (n = 62) of admissions, 38.71% (n = 24) were successful. Flexible sigmoidoscopy was performed in 61.05% (n = 58) of admissions, 17 without rigid. Decompression was achieved in 72.41% (n = 42) with flexible more successful than rigid sigmoidoscopy (p = <0.0001).

Conclusions

SV patients are mostly male, older, co-morbid and managed conservatively. Mortality is high but reduced in patients managed surgically. Without surgery, patients had multiple admissions, decompressions, and long hospital stays, leading to increased costs. This project recommends the consideration of surgery in order to improve patient outcomes. A prospective large-scale study is required to improve data.
451 An Assessment of Clinical Outcomes of Combined Seton Placement and Infliximab in Perianal Fistulising Crohn’s Disease
Authors: Rao E , Annavarapu S
Published: August 2023

Aim

Perianal fistulising Crohn’s disease (PFCD) is a severe, disabling complication that causes increased morbidity and occurs in approximately 30% of Crohn’s patients. It has a detrimental impact on patients' lives and their abilities to complete their activities of daily living.

The NICE guidelines and various studies demonstrate that combined therapy accelerates primary closure of the perianal fistulae. We assess the clinical outcomes (response rate and recurrence risk) of combined use of Seton placement with anti-TNF therapy (Infliximab) in the treatment of PFCD via a metanalysis of multiple scientific studies over the last 20 years.

Method

Electronic databases, PubMed and Google Scholar, were used for literature search. Key terms (such as perianal fistula, Crohn’s disease, Seton placement, Infliximab) were applied. Of the 34 articles obtained, analysis of the key findings from four peer-reviewed primary sources are presented.

Results

In all studies, best clinical outcomes were obtained when abscess drainage was done in conjunction with induction therapy with Infliximab (5mg/kg) at 0, 2 and 6 weeks. Reguiero et al (2003) obtained 100% fistula closure rates in patient group receiving combined therapy (9/32) as compared to 89% the patient group receiving Infliximab alone (23/32, 89%); other studies also found improved response rates of the fistula in their patients, ranging from in 66% to 77%.

Conclusions

Overall, from the results of the studies, combined use of Seton placement and infliximab significantly improve clinical outcomes in patients with complex PFCD as measured through the reduction in recurrence risk and improved fistula closure rate.
588 Can the Heald Anal Stent Help to Reduce Anastomotic or Rectal Stump Leak in Elective and Emergency Colorectal Surgery? a Case Series
Authors: Jones M , Bunni J , Moran B , Heald B
Published: August 2023

Aim

Anastomotic and rectal stump leaks are feared complications of colorectal surgery. Diverting stomas are commonly used to protect low rectal anastomoses but can have adverse effects. Studies report favourable outcomes for trans-anal drainage devices instead of a diverting stoma. Our aim was to analyse the outcome of a “Heald anal stent” in reducing anastomotic or rectal stump leak after elective or emergency colorectal surgery.

Method

This was a single centre retrospective analysis of patients in whom a Heald anal stent had been used to “protect” a colorectal anastomosis or a rectal stump, in an elective or emergency context, for both benign and malignant pathology. Intra and post-operative outcomes were checked using clinical and radiological records.

Results

The Heald anal stent was used in 93 patients over 4 years. 46 (49%) cases had a colorectal anastomosis, and 47 (51%) had an end stoma with a rectal stump. There were 56 (60%) elective and 37 (40%) emergency cases. In 54 (60%) patients the pathology was benign, and 39 (42%) had malignancy. High anterior resections and Hartmann’s procedures were the most common operations in which the stent was used, comprising 22 (24%) and 20 (22%) of the total. There were no anastomotic or rectal stump leaks.

Conclusions

The Heald anal stent is a simple and affordable adjunct in decreasing anastomotic and rectal stump leak, by reducing intraluminal pressure through facilitating drainage of fluid and gas. We recommend the stent in operations involving colorectal anastomoses and in patients with a residual rectal stump.
1289 A Superior Approach? the Role of Robotic Surgery in Inflammatory Bowel Disease
Authors: Grewal C , Karri R , Yassin N
Published: August 2023

Background

This study compared the short-term outcomes of robotic and laparoscopic surgery for IBD patients to assess the efficacy of using robotics in minimally invasive surgery. The goal was to explore whether robotics is a superior surgical technique with better outcomes.

Method

A retrospective review of of all patients who underwent robotic and laparoscopic surgery for IBD was conducted from 2018-2022 . Demographics, peri, intra and post-operative data were analysed.

Results

This study included 42 surgeries for IBD patients, of which 24 were robotic and 18 were laparoscopic. Right hemicolectomies accounted for 63% of robotic surgery, with stomas formed in 38% of procedures. Amongst laparoscopic procedures, 44% underwent total colectomies and 39% had right hemicolectomies, with 78% requiring stomas. The median operative time for robotics was 30 minutes shorter than laparoscopic procedures. On average, hospital stays were 3 days less for robotic patients. There were 3 cases (17%) of patients returning to the ward within 30 days after laparoscopic surgery, compared to 1 case (4%) after robotic surgery. However, there were 2 cases (8%) of Grade 3 complications after robotic surgery and 1 case (6%) after laparoscopic surgery. One patient in each group required surgery within 30 days, but no cases necessitated conversion to open surgery and there were no deaths.

Conclusions

This study suggest that robotic surgery can be a safe and effective option for IBD patients, with shorter operating times and hospital stays compared to laparoscopic surgery. Overall, these findings suggest that robotic surgery may be a superior approach to minimally invasive surgery for IBD patients.
103 Outcomes and Complications of Simple Layered Closure of Persistent Tracheocutaneous Fistula After Tracheostomy in Childhood
Authors: Wong T , Macpherson O , Docherty S , Gray J , Clement A , Kubba H
Published: August 2023

Aim

Up to half of all children with a tracheostomy develop persistent trachea-cutaneous fistula (TCF) after decannulation. Surgical closure of it is technically easy but post-operative complications can be immediate and life-threatening. We reviewed our experience in TCF closures to identify potential risk factors for complications.

Method

Retrospective case records review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following the development of a persistent TCF after decannulation of a tracheostomy.

Results

67 children were identified. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%): life-threatening air leak occurred in the immediate post-operative period in 2 children (3%) and respiratory distress in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications.

Conclusions

Further analysis of the potential associations between patient factors, surgical factors, and complications is necessitated in guiding future practice.
204 Transoral Laser Microsurgery Versus Radiation Therapy in the Management of Early Glottic Carcinoma: Which Modality Is More Cost-Effective Within the NHS?
Authors: Mallick S , Addison A
Published: August 2023

Aim

To determine whether trans oral laser microsurgery or radiotherapy is the more cost-effective modality in treating patients with T1b-T2 glottic tumours

Method

Ten-year data was retrospectively collected from all patients who presented with T1-T2 glottic cancer. The individual components of the cost associated with trans oral laser microsurgery and radiotherapy were ascertained. The total cost was calculated and the average cost of each modality per patient was compared.

Results

Theatre operating fees were the most significant cost associated with trans oral laser microsurgery, whereas delivery of radiotherapy per fraction was the most significant cost in radiation treatment. The cost for trans oral laser microsurgery was estimated to be £1120.34 whereas the cost of radiotherapy was £3754.6.

Conclusions

Trans oral laser microsurgery appears to be more cost effective compared to radiotherapy in early glottic cancer management.
797 Short-Term Review of the Presentations and Outcomes of Vocal Fold Palsy Cases Identified at a Large DGH
Authors: Dar T , Hunt J , Panesar J , Sood T , Tornari C
Published: August 2023

Aim

Due to the convoluted course of the recurrent laryngeal nerves, vocal cord palsy can be a manifestation of pathologies that cross multiple surgical and medical specialties. The primary role of the vocal folds is that of airway protection. Therefore, it is important that all relevant clinicians understand this clinical scenario in order to prevent aspiration pneumonia in their patients.

Method

We reviewed eight months of referrals and diagnoses of patients with vocal cord paresis or palsy. This was in the setting of a tertiary Head & Neck service within a large DGH. We assessed the aetiology, management, and outcome of these cases.

Results

Eleven new cases were identified over the course of eight months. One was due to intrathoracic vascular pathology; one breast cancer; two from head & neck cancer; one bilateral palsy due to upper-GI cancer surgery; four from thyroid-related pathology; one lung cancer; and one idiopathic. To date, ten of eleven cases appear permanent in nature. One patient underwent in-clinic injection laryngoplasty. Two patients (18%) died within six months of diagnosis, both predictable deaths based on baseline pathology.

Conclusions

Our experience demonstrated the relevance of ENT (Head & Neck), Vascular, Breast, Upper-GI and Thoracic surgeons as well as medical colleagues in Endocrinology, Respiratory Medicine, and Rheumatology. We present diagnostic and management strategies to help surgical trainees across the specialties identify, manage, and refer patients to prevent complication, improve quality of life and provide access to relatively novel procedures such as awake (local anaesthetic) injection laryngoplasty.
880 Otolaryngology (ENT) Surgeons’ Understanding of Radiation Doses to the Eyes
Authors: Tidswell P , McKenna J
Published: August 2023

Aim

Computed tomography (CT) scanning is an invaluable asset in ENT diagnostics. This snapshot study aimed to assess the knowledge ENT surgeons have regarding dose equivalence and dose accumulation of commonly requested.

Method

A sample of 302 dose length products (DLPs) for CT neck with and without contrast, CT sinuses and CT temporal bones were taken from anonymous data in Swansea University Health Board. ENT surgeons were asked to rank the mean doses, state a numerical dose and maximum scan number for each.

Results

From highest to lowest dose, the CT scans rank as follows: 1. Neck with contrast, 2. Neck, 3. Temporal bones, 4. Sinuses. CT neck with contrast was correctly ranked by 62.5% of surgeons, CT neck by 50%, CT sinuses by 12.5%, and CT temporal bones by 37.5%. Seniority of the surgeon did not affect the accuracy of their rankings.

While there is no maximum dose for patients, the maximum doses for bystanders were used to calculate dose equivalence to assess the impact of the scans. The maximum dose would be reached after having 3 CT temporal bones, 2 CT neck, 1.7 CT neck with contrast, and 7 CT sinuses. 84.3% overestimated the maximum number of scans, 12.5% underestimated the maximum, and 3.1% correctly estimated the maximum.

Conclusions

Radiation doses to the lens are poorly understood by ENT surgeons of all levels and while patients can receive as many scans as necessary to provide diagnostic value, it is important to understand the relative risk patients face by undergoing these scans.
886 Assessment of Urgent Neck Lump Referrals to a North West ENT Clinic
Authors: Brenac S , Srinivasan V
Published: August 2023

Aim

NHS cancer diagnostic services are under immense pressures due to high referral numbers. We assessed the volume of urgent neck lump referrals to ENT clinic at a North West hospital, determining the number of cancers and benign cases and calculating the average time to diagnosis and treatment for those with cancer.

Method

We retrospectively reviewed 616 urgent referrals to ENT via the 2-week wait suspected cancer pathway between October 2021 – March 2022, including only primary care referrals for neck, thyroid, or salivary gland lumps.

Results

Of 616 urgent referrals, 46.8% were for neck, thyroid or salivary gland lumps. Primary care accounted for 85.8% of referrals, the majority being female (71.3%). The cancer pick-up rate (thyroid/head and neck/lymphoma) was 10.1%. Benign neck pathology accounted for 57.1% of cases, and in 22.7% of cases no abnormalities were detected. Only 28% of those found to have cancer had an ultrasound scan (USS) prior to clinic. Average time to diagnosis for those with cancer was 46.5 days (58 days for thyroid cancer), and average time to treatment was 62 days (78 days for thyroid cancer).

Conclusions

This audit highlights the strain that cancer diagnostic services are under. In our case, approximately 31.6% of patients could have been downgraded from the cancer pathway if USS was used as a vetting tool prior to clinic. To help relieve the burden on cancer pathways and improve average time to diagnosis and treatment for those found to have cancer, we suggest patients have USS within 7 days of referral.
943 An Audit of the Management of Necrotizing Otitis Externa Within Royal Devon and Exeter Hospital
Authors: Santana A , Jia W , Ricks R
Published: August 2023

Aim

To improve recognition and management of necrotizing otitis externa (NOE) early to prevent disease progression and reduce hospital admissions/length of stay.

Method

A retrospective audit of patients who were treated for NOE during an inpatient admission to the Royal Devon and Exeter Hospital between 1st December 2020 and 1st June 2022.

Results

A total of 15 cases were identified where symptoms were not attributable to an alternative diagnosis. Lab results, inpatient and clinic attendances were analysed to identify areas of improvement in terms of investigations and management.

The mean number of presentations before admission was 2.3. At admission 66% of patients had a swab taken and 7% of patients had imaging. Systemic antibiotics were prescribed in 20% of patients before admission.

IV antibiotics were started within 24 hours in all patients admitted. Microbiology consults were sent within 6 days in 93% of cases. The mean duration of IV antibiotics was 13 days, and the mean inpatient stay was 19 days.

Conclusions

The incidence of NOE is increasing in the UK, yet there is limited guidance and consensus on diagnosis and management. Some advice is provided by ENT UK, who suggest outpatient recognition might be improved by ensuring swabs and imaging are completed to reduce hospital admissions. In lower risk cases, starting oral ciprofloxacin may then aid with management. On admission investigations and management are being promptly started; however, an area for improvement could be the potential introduction of long lines for outpatient IV antibiotic therapy to reduce the length of hospital stays.
991 A Retrospective Review of Thyroid Surgeries Performed at a Tertiary Referral Hospital Between 2015- 2020 to Determine Incidence of Incidental Parathyroidectomy During Thyroid Resection
Authors: Kruczynska A , Shakeel M
Published: August 2023

Aim

Thyroid resection is commonly used to manage thyroid problems. Incidental parathyroidectomy is a recognised complication associated with thyroidectomy. Findings of parathyroid gland in the pathology specimen varies greatly as reported in literature between 6.4%-31%.

The aim of this project was to determine local incidence of incidental parathyroidectomy during thyroid resection and comparing it to the incidence rates reported in the literature.

Method

Retrospective review of 5-year data set of patients undergoing thyroid resection in tertiary referral hospital between June 2015 -June 2020.

Patient electronic records were searched for pathology report and data collected included: parathyroid tissue detected in the specimen, type of thyroid surgery performed, proportion of parathyroid gland present in specimen, number of parathyroid gland present.

Results

During the period specified 305 thyroid surgeries were identified. Parathyroid tissue was present in the pathology specimen in 50 cases (16%). Out of the 50 pathology reports only 4 reported presence of a whole parathyroid glands (8%) in the specimens, 20 (60%) contained only partial parathyroid gland. Most reports did not specify to what extend the parathyroid tissue was present or whether multiple parathyroid glands were excised.

Conclusions

The local incidence rate if incidental parathyroidectomy in in keeping with the date reported in the literature. More work is needed to determine the risk factors contributing the incidence rate such as whether there was extrathyroidal extension of tumour in those cases. To determine the relationship between proportion of parathyroid gland removed and postoperative hypocalcemia additional data is needed.
68 The Diurnal and Seasonal Relationships of Young Pedestrian Injuries Secondary to Motor Vehicles
Authors: Akhtar A , Brooks A , Kitchen S , O'Connor R
Published: August 2023

Aim

There remains a significant morbidity and mortality in young pedestrians hit by motor vehicles. The of this study was to compare the incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population.

Method

Data was retrieved from the National Trauma Audit and Research Network (TARN) database for patients between 10-25 years old who had been involved as pedestrians in motor vehicle accidents between 2013 -2020. The incidence of injuries, their severity (using the Injury Severity Score [ISS]), and mortality were analysed according to the hours of daylight, darkness, and season.

Results

The study identified a seasonal pattern, highlighting that injuries were most prevalent during autumn (34.9% of injuries). Prevalence decreased throughout the year from winter (25.4%) to summer (18.3%). The greatest incident rate (number of incidents/hour) occurred between 1500-1630hrs, correlating to school pick up times. A significant relationship between ISS and daylight hours was demonstrated (p-value = 0.0124), whereby moderate injuries (ISS score: 9-15) were more likely during the day (72.7%), while severe injuries (ISS Score > 15) were more likely at night (55.8%).

Conclusions

We identified a relationship between the time of day and the frequency and severity of pedestrian trauma in young people. In addition, particular time groupings correspond to the greatest incidents rate, suggesting that reduced visibility coupled with school pick up times play a significant role. We recommend targeted public health measures to improve road safety that focus on these high-risk times of the day.
328 Local Delays in Tubogram Completion for Biliary Patency – Why the Wait?
Authors: Kattam A , Ninkovic-Hall G , Zardab M , Digne-Malcolm H , Magee C
Published: August 2023

Aim

Despite the CHOCOLATE Study (CS Loozen et al 2018) recommending laparoscopic cholecystectomy even in high-risk patients, we are completing more cholecystostomies than ever to manage acute cholecystitis, particularly during the COVID pandemic. Fluoroscopic tubogram can be performed to check biliary patency post intervention, this can potentially definitive treatment or discharge.

We locally assessed the time delay in accessing tubograms.

Method

Audit of all local tubograms completed of the biliary system (September 2020-2022).

All tubogram procedures (not just biliary) within the North West Mersey Region over the same period also quantified.

Results

397 tubograms were conducted in the NW; 51 locally. 26/51 were for post IR drain & 1 for biliary t-tube assessment from 26 patients (av. age 73, range 59-90yrs). 19 were as inpatient, 8 outpatients.

Assessing working days between expected completion and actual completion in both groups:

73.7% of inpatient tubograms were completed within 3 or less days (av. 3.6, range 0-17 days).

37.5% of outpatient tubograms were completed within 5 days of less (av. 7.9, range 0-23 days).

There was 1 true complication (tube slippage & removal), 3 extravasations & 1 abandoned procedure. 4 (15%) patients had died at the time of data assessment.

Conclusions

With the rise of cholecystostomy, there has been an increase in biliary tubograms. These are a specialist procedure; there is a time delay in obtaining them and they do not come without risk. Provision of tubograms needs to be assessed, or a move back to traditional initial surgical management considered.
669 Chronological Distribution and Causes of Mortality Following Emergency Laparotomy – an 8 Year Study
Authors: O'Connell E , Kyriakides R , Rutka O , Misra N
Published: August 2023

Introduction

Emergency laparotomies have variable level of mortality and morbidity worldwide. Studying the causes and times of mortality, could enable better patient care and improve future outcomes. We investigated the mortality data in laparotomy patients, to investigate for trends in mortality and other patient and process characteristics.

Method

Data for all emergency laparotomies undertaken between 2014 to 2022 were collected prospectively and retrospectively analysed. The primary outcome was inpatient mortality. Demographics, clinical management, and outcome data was analysed using SPSS.

Results

1410 laparotomies performed, with an overall crude mortality rate of 11.9%. The P-POSSUM mortality and morbidity scores ranged from 2-99 (mean 42.4) and 40.1-100 (mean 86.6) respectively. The time from operation to death ranged from 24 hours to 123 days (mean = day 11.75), with a uni-modal distribution. In the first 48 hours post-operatively 28.57% (N = 56 patients) died, with a mean age of 70.6 and a mean P-POSSUM of 48.1 (SD 30.6). Bowel perforation (N = 19 patients) and bowel ischaemia (N = 13 patients) where the most common intra-operative finding. The patients that died after 48 hours (N = 116 patients) had a mean age of 73.5 (SD 12.4) and a mean P-POSSUM of 39.6 (SD 29.9, P 0.92), compared to those that survived (N = 1241) with a mean age of 61.4 (SD 16.4) and a mean P-POSSUM of 15.6 (P>0.01).

Conclusions

Emergency laparotomy has a high level of mortality and morbidity, with the first 48 hours carrying the highest risk, particularly in those with bowel perforation or ischaemia.
706 An Audit of Antibiotic Prescribing in Acute Pancreatitis and Introduction of a Patient Safety and Cost Saving Diagnostic Tool
Authors: Allen L , Pearman D , O'Connor O , Bagnall M
Published: August 2023

Background

In managing acute pancreatitis it is challenging to distinguish systemic inflammatory response syndrome (SIRS) from bacterial infection, contributing to inappropriate use of antibiotics, which are only recommended in cases of infected pancreatitis. Over prescribing of broad-spectrum antibiotics is associated with C. difficile, adverse reactions and antibiotic resistance, and has a cost implication. Procalcitonin (PCT) is sensitive (93%) and specific (79%) for diagnosing infected pancreatitis and recommended to guide antibiotic therapy.

Method

We performed a retrospective audit of the care received by 88 acute pancreatitis patients over 12-months.

Results

19/52 (36.5%) with uncomplicated pancreatitis were prescribed antibiotics. 22/36 (61.1%) with infected pancreatitis or a secondary infection source received antibiotics. 36/41 (87.8%) were prescribed broad-spectrum IV antibiotics. Seven days of IV co-amoxiclav costs £15.80, excluding consumables or nursing staff/pharmacy time. A single PCT costs £9.64.

Conclusions

These results suggest inappropriate prescribing of antibiotics in managing acute pancreatitis. Where diagnostic uncertainty lies between acute uncomplicated pancreatitis with SIRS versus infected pancreatitis, PCT is a useful diagnostic tool to help guide antibiotic therapy, therefore improving patient safety and antibiotic stewardship, with cost benefits. Following this audit, our trust has approved PCT for use in acute pancreatitis, and future audits will assess ongoing antibiotic prescribing in this cohort.
1088 Acute Pancreatitis: ‘Treat the Cause’-in Compliance with NCEPOD Recommendations
Authors: Seth S , El Boghdady M , Boven C
Published: August 2023

Aim

The objective of this study was to facilitate in identifying remediable factors in the quality of care provided to patients being treated for acute pancreatitis and assess compliance to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines.

Method

All emergency surgical admissions for patients aged 16 or older, diagnosed with acute pancreatitis at the period between August and October 2021 were included. A retrospective analysis in juxtaposition with 8 cardinal NCEPOD recommendations: management of co-morbidity & involvement of relevant specialists, adherence to antibiotic policies, assessment of risk of malnutrition, exclusion of gallstones in all index presentations, early surgical intervention, alcohol liaison support, further investigation - MRCP / ERCP and retrospective morbidity & mortality discussions. Each of the domains were scored based on adherence to the above standards, and subsequently coded as Red–Needing Urgent Attention, Amber–Scope for Improvement and Green–Satisfactory Compliance.

Results

A total of 79 patients were included in this study. Compliance towards the recommendation of routine nutritional assessment of patients was found to be in the RED category, scoring 23.7%. Management of medical co-morbidity & inclusion of specialists, early surgical intervention and alcohol liaison support were all found to be in the AMBER category, scoring 44.8%, 28.0% and 57.1% respectively. The rest of the recommendations showed satisfactory levels of compliance.

Conclusions

Many patients did not receive adequate nutritional assessment. The RED and AMBER areas will need urgent attention. To minimise the risks of severe morbidity and mortality from acute pancreatitis, we envisage a better compliance to NCEPOD recommendations.
1210 Network Meta-Analysis of Associated Mortality with Transfusion Strategies for Major Haemorrhage in Adults
Authors: Crook D , Padfield O
Published: August 2023

Aim

The aetiology of a large proportion of mortality in trauma patients is attributed to acute major haemorrhage. Damage control resuscitation and surgery have been developed as part of management, which often includes large volume blood product transfusion. The aim of this meta-analysis was to investigate differences in mortality between transfusion strategies used in major haemorrhage in adults (18+ years).

Method

A frequentist random effects network meta-analysis (NMA) using the netmeta package in R 4.0.5 of the eligible papers in the systematic review “Optimal dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a systematic review” compared a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (P) to a ratio of 2:1:1, whole blood, and laboratory-guided replacement. Homogeneity and heterogeneity were assessed with Cochran’s Q.

Results

Mortality at one month by group was 21.8% (12/55) for whole blood, 17.0% (58/342) for 2RBC:1FFP:1P, 14.3% (5/35) for laboratory-guided transfusion and 22.3% (96/43) for standard 1RBC:1FFP:1P ratio. The NMA showed no significant differences between groups, with relative risk of death when compared to 1RBC:1FFP:1P by one month of 1.42 (0.631; 3.19, p = 0.398) for whole blood, 0.7643 (0.562; 1.04, p = 0.0871) for 2RBC:1FFP:1P and 0.4396 (0.1741; 1.1099, p = 0.0820) for laboratory-guided transfusion.

Conclusions

The results demonstrated no significant differences in mortality between transfusion strategies in major haemorrhage - however, some arms of the NMA contain few patients and so may be underpowered to detect differences between groups. On this evidence, current use of component therapy is not inferior to another transfusion strategy.
575 Reducing the Risk of Significant Bleeding After Thyroid and Parathyroid Surgery - the Role of a Protocol Driven Approach
Authors: Abbud N , George H , Kirby G , Balasubramanian S
Published: August 2023

Aim

Post-operative haemorrhage following thyroid and parathyroid surgery is a well-recognised life-threatening complication. Following an audit reporting a reoperation for bleeding rate of 1.3% in 1913 patients (World J Surg 2020), a protocol driven approach involving the implementation of several specific measures at the time of wound closure (captured by the ‘ITSRED Fred’ mneumonic - Irrigation of wound, Time, Systolic blood pressure >100 mm Hg, relieving neck extension, Elevating venous pressure, Drain avoidance and Flap evaluation) was implemented and evaluated.

Method

The operative and clinical records of 1525 thyroid and/or parathyroid surgical procedures in a single tertiary unit between 2017 and 2022 were reviewed following the implementation of the ‘ITSRED Fred’ protocol. The rates of re-bleeding requiring surgery were examined.

Results

The median (interquartile range) age of the cohort was 53 (39-66) years with a male: female ratio of 1:4.946 had thyroid surgery, 541 had parathyroid surgery and 38 had both. 0.8% were re-do operations and 20% of procedures included neck dissection.

Twelve (0.79%) patients had re-operation for bleeding (lower than previously reported rate of 1.3% from the same unit). Of these, 5 (0.3%) required re-operation before leaving theatre; 5 (0.3%) had bleeding within 6 hours and two (0.13%) after 6 hours. Bleeding rates were 1.1% (n = 10) in thyroid surgery compared to 0.4% (n = 2) in parathyroid surgery.

Conclusions

A protocol driven implementation of specific measures (such as the ‘ITSRED Fred’ protocol) may reduce the rate of re-operation for bleeding after thyroid and parathyroid surgery.
32 Enhancing Equity in a Widening Participation Scheme for School Students
Authors: Kirkham E , Rozwadowski S , Wijeyaratne M , Ferris L , Bennett J , Coyle M
Published: August 2023

Aim

The Royal College of Surgeons (RCS) Diversity Review 2021 found pre-medical school students from ethnic minority backgrounds were dissuaded from pursuing a career in surgery. Gloucestershire is in the bottom 20% of deprivation; with no widening participation (WP) scheme in the county. We implemented an inclusive WP scheme in Gloucester, with means of accessing virtual and face-to-face work-experience, to enhance the equity of work-experience.

Method

A three-stage project was conducted; 1; virtual Q&A sessions, asking questions about life as a doctor; 2; conversation between the student and patient held virtually, to gain insight into whether medicine is the right career; 3; face-to-face work-experience. Distribution sent to all 58 schools in the county.

Results

129 people attended the Q&A; 70 feedback responses received. 86% female, 56% of ethnic minority background. 26% did not have an immediate family member that attended university, 10% had caring responsibilities. 81% rated the session >8/10 for usefulness. 27 undertook the virtual conversation, feedback from 11; 91% female, 45% of ethnic minority background, 27% did not have an immediate family member that attended university. All rated the session 10/10 for usefulness.

Conclusions

The RCS Report identified barriers with aspiring students from less-privileged backgrounds pursuing a career in surgery. More needs to be done with WP schemes to promote equity. Targeted distribution of WP schemes to all schools, utilisation of a means of offering work-experience, and accessibility to a younger age-group were aspects of our WP, to improve the equity of work-experience in the county.
309 Racial Discrimination in Surgical Practice: A Global Review
Authors: El Boghdady M , Ewalds-Kvist B
Published: August 2023

Introduction

Racial discrimination indicates the unkind conduct towards other persons based on their race or skin color. We aimed to systematically review racial discrimination in surgery and answer the following questions:1) Does racial/ethnic discrimination in surgery exist in the last 5 years. 2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery?

Method

The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE.

Results

A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. The evidence of racial discrimination was justified on strong scientific evidence constituting the basis for grade I. The second question’s answer was ‘yes’ which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II.

Conclusions

There is sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years in the US. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual and on the surgical team’s performance. The existence of the discussed problems needs to be managed in more countries with diverse healthcare systems.
362 Compliance With GMC Guidelines for the Use of a Chaperone in Urology Outpatient Clinic
Authors: Desouky E , Ibrahim M , Sharma H
Published: August 2023

Aim

To Identify our compliance with GMC guidelines for use of a chaperon in urology outpatient clinic.

Method

1st audit included a total of 12 urologists in our team (6 consultants and 6 SpR) For each urologist, we checked records for 10 patients who attended urology OPD and had a physical examination as evidenced in the notes and/ or clinic letter N = 120 patient records checked Each urologist was given a score ( 0 = if no mention of a chaperone, 1 = if a chaperone was just mentioned or 2 = if the chaperone is identified by name or signature)

Results

We found propre documentation of a chaperone in only 75.25% of clinical notes and 14.6% of clinic letters. At individual level, there were poor scores for most urologists involved. Following the discussion of the 1st audit results in the urology clinical governance meeting, posters were made to raise awareness of the audit outcome as well as direct discussions with the urology team members to encourage them to improve their scores in the re audit cycle. Re audit showed significant improvement was achieved for individual as well as overall documentation in 85% of clinical notes and more than 50% of clinic letters.

Conclusions

As per GMC guidelines: The offer, and use, of a chaperone, including their full name and designation, should be clearly documented in patients’ notes. This can be achieved and emphasized by raising awareness of this good medical practice.
191 Penthrox Is Effective but Is It Patient Approved?
Authors: Dias A , Zeidan Z , Copp M , Eslabra F , Hassan R , Midlleton R
Published: August 2023

Aim

Penthrox is a handheld inhaler that administers methoxyflurane. It’s use is approved for analgesia in moderate-to-severe trauma-related pain in adults in emergency department (ED). The literature currently lacks methodologically robust qualitative data on individual patient experience. Using a structured qualitative study, we set out to address this shortcoming.

Method Focus group

Five patients were selected to identify key themes they felt important to explore and these were included in the questionnaire design.

Study Design

We retrospectively identified all uses of Penthrox in ED from June to August 2021. Qualitative data was gathered using the Trickett short interview method and responses grouped into positive and negative descriptors. In addition, quantitative data concerning their experience using 5-point Lickert scales were also gathered.

Results Questionnaires

101 responded to the questionnaire. Penthrox® was utilised mainly for the manipulation of fractures, most commonly for that of the Ankle and Wrist. 90% reported an overall satisfaction of ‘≥ Good’. 97% reported ease-of-use ‘≥ Good’. Its analgesic effectiveness was rated as ‘Excellent’ by 52%, and ‘≥Good’ by 89%. The most reported side-effects were drowsiness (13%) and nausea (7%). The majority reported no side-effects (74%). 94% would take it again if required. A NVIVO word cloud was created visually confirming an overall positive experience amongst the patients.

Conslusions

This study shows that Penthrox is a well-tolerated and user-friendly means of alleviating trauma-related pain in ED. It highlights the importance of taking into consideration the individual patient journey alongside robust evidence-based data on safety and efficacy for the development of a holistic treatment.
312 First Experience in Laparoscopic Surgery in Low- and Middle-Income Countries: A Systematic Review
Authors: Bawa J , Baker O , Ashcroft J , Troller R , Fearnhead N
Published: August 2023

Aim

This study aims to report the challenges and benefits of introducing laparoscopic surgery in low-and-middle-income countries (LMIC) as well as to identify solutions to these challenges for countries with limited finances and resources.

Method

MEDLINE, EMBASE and COCHRANE databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published after 1996 with full text available in English. Exclusion criteria were studies considering only open surgery, ENT, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery.

Results

Ten studies from eight LMIC were eligible for inclusion in the final analysis, totalling 2640 patients. Most reported challenges were related to costs, including affordability of equipment and training programmes, and equipment problems such as faulty equipment and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff.

The benefits of introducing laparoscopic surgery were economic and clinical, including reduced hospital stay, complications and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors.

Conclusions

Despite initial challenges, many studies described the benefits of introducing laparoscopic surgery. Centres proposed practical solutions to these challenges to ensure the sustainability of laparoscopic surgery in LMIC.
917 Building Virtual Reality Into Global Surgical Training: An Innovative Approach Applied in Uganda
Authors: Narang K , Please H , Rowe A , Dhanda J
Published: August 2023

Aim

Virtual Reality in Medicine and Surgery (VRiMS) is an academic working group devoted to creating technology-based solutions in post-graduate surgical and medical education. Based at Brighton and Sussex Medical School (BSMS) with funding from Health Education England they use ‘Extended Reality’ including fully immersive Virtual Reality (VR), Augmented Reality (AR) which overlays digital information onto real-time visualisation, and 360-degree video which offers a partially immersive experience. Benefits include reduced costs of delivering education, improving trainees’ experiences, and improving accessibility to surgical opportunities.

Method

VRiMS utilizes 360-degree video of cadaveric teaching streamed via low-tech cardboard headsets to deliver a novel teaching modality in Low- and Middle-Income Countries (LMICs). Uganda was the first location of a proof-of-concept course over 4 days delivered in 3 modalities: in-person - 10 delegates from East Africa provided scholarships (funded by Saving Faces) to travel to Brighton; 79 delegates attending virtually at a conference centre in Kampala; and over 1000 delegates globally attending remotely from a diversity of nations. Qualitative data was gathered for thematic analysis.

Results

Feedback was very positive, and barriers identified included requirements of a smart phone and sufficient internet. Ongoing links were developed with other LMIC units, with a recent conference run in Kenya.

Conclusions

VRiMS aims to ensure scientific validity in the projects being run, and analysis of the courses have given actionable insights into the experiences of surgical trainees both in the UK and in LMICs, showing that Extended Reality has enormous potential to benefit trainees worldwide.
940 The Metaverse as a Potential Solution for the Delivery of Global Health Education
Authors: Narang K , Please H , Dhanda J
Published: August 2023

Aim

We describe a novel approach to the delivery of global health education (GHE) via the utilisation of the Metaverse. In 2015, the Lancet Commission on Global Surgery identified that the global burden of disease amenable to surgical intervention is substantial and growing. Virtual Reality in Medicine and Surgery (VRiMS) is an academic working group based at Brighton and Sussex Medical School (BSMS) devoted to creating technology-based solutions in surgical and medical training and education.

Method

10 East African surgeons were selected to attend a 5-day cadaveric dissection course in-person in Brighton, on fully funded scholarships. A parallel conference was also run in Kampala, Uganda and >1000 delegates attended remotely from 61 different countries.

A proof of concept of the metaverse was created using the software Spatial. Delegates from the in-person course in Brighton and Kampala used Oculus and PICO headsets in order to access and interact within the metaverse build.

Both a quantitative and qualitative approach was implemented for data collection utilising a survey as well semi-structured interviews.

Results

Feedback was positive and highlighted the interactivity of the platform, the multiple types of content which could be accessed and the level of immersion it provided. The majority of delegates felt that the metaverse could be beneficial in the delivery of medical and surgical education globally.

Conclusions

The Metaverse could be a novel approach in tackling issues in global health and global surgery and extensive future work related to its validity as an educational resource could be beneficial to trainees worldwide.