bluuebunny/crossref_metadata_2025 huggingface dataset:
P-BN13 How has the COVID pandemic affected outcomes in Elective Laparoscopic Cholecystectomy?An observational study in a UK Upper GI Surgical Unit
Authors: Demetriou George , Wanigasooriya Kasun , Elmaradny Ahmed , Al-Najjar Ammar , Rauf Mohammad , Martin-Jones Alicia , Aboul-Enein Mohamed Saad , Robinson Steven J , Perry Anthony , Wadley Martin S , Mourad Moustafa
Published: December 2021

Background

COVID-19  has a significant impact on elective surgery for benign disease. When routine services resumed in April 2021, surgeons were faced with higher number of complicated cases. The aim of this study is to examine the effect of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal unit in the UK.

Methods

Data were collected retrospectively on consecutive patients undergoing elective LC between 1/3/19 to 1/5/19 (Pre-COVID) and 1/4/21 to 11/6/21 (resumption of elective operating following COVID). The indications for surgery, intraoperative details, postoperative complications, length of stay (LoS) and 30- day readmission were compared between the two cohorts. We divided indications for surgery as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) vs non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). Data were analysed using the Mann-Whitney U-test and Chi-square or Fisher’s exact test. A p value of < 0.05 was used for statistical significance. 

Results

159 patients were analysed, 106 in Pre-COVID vs 53 in Post-COVID. Both cohorts had similar age, gender, ASA-grade, BMI. 68 (64.2%) of the pre-COVID cohort were operated for a non-inflammatory pathology compared to 19(35.8%) of the post-COVID cohort (p < 0.001). Less patients had total cholecystectomy (subtotal and failed surgery) in the post-COVID cohort [49(92.5%) vs 159 (100%) p = 0.01]. There was no difference in the operating time, conversion to open surgery, the need for drains, and no difference in the Clavien-Dindo grade complications. Two patients in pre- COVID cohort (1.8%) required re-operation for bile-leak and bowel injury and two in the post COVID cohort (3.7%) for bleeding and CBD-injury. There was no difference in day case discharge or 30-day readmission rate. 

Conclusions

Surgery in the post-COVID cohort was associated with a higher incidence of inflammatory biliary disease, subtotal cholecystectomy and procedure abandoned. 

Although the numbers in our study are small they highlight the need for enhanced preoperative assessment in elective biliary surgery as the NHS emerges from the acute phase of the pandemic.
P-BN15 Outcomes following surgical repair of giant para-oesophageal hernia of over 200 cases with long-term follow up: a 20-year experience
Authors: Siriwardana Priyantha , Lorenzi Bruno , Qamruddin Mohammad , Charalabopoulos Alexandros , Harvey Michael , Kadirkamanathan Sritharan
Published: December 2021

Background

Symptomatic giant para-oesophageal hernia (PEH) can often be troublesome and may require surgical intervention. It commonly presents with dyspnoea, post-prandial pain, vomiting and dysphagia but rarely strangulation. In a good proportion of patients, iron deficiency anaemia may also be present. Patients are often elderly and may have co-morbidities and hence there may be a reluctance to refer and to offer surgery. This long-term study offers an insight to the outcomes following this complex surgery in a relatively elderly cohort of patients.

Methods

A retrospective analysis of prospectively collected data of patients who underwent surgery for symptomatic PEH from January 2001- June 2021 was performed. Clinical presentation, management, post-operative clinical outcomes, radiographic evaluation, pre and post-operative haemoglobin levels, respiratory function {Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1)} as well as quality-of-life (QoL) with SF-36 questioners (including general health, physical, emotional and social components) were assessed.

Results

202 patients (122-females) with median age 68 years (36-88) underwent PEH-surgery. The  commonest symptomEighty-one presented with dyspnoea(41%). Ninety-five(47%) were ASA III, 119(59%) had microcytic-anaemia. 142(70%) had a fundoplication during PEHR. Hospital-stay was significantly lower in laparoscopic group

Mortality:1.8%(2/112).

Median follow-up:10 years. Symptoms improved in 166(82%) with respiratory function and anaemia. 42(21%) had radiological recurrences but only nine (4.5%) clinical recurrence requiring surgery.

Conclusions

Laparoscopic repair of giant para-oesophageal hernia is safe with good outcomes in all age groups with improvement in symptoms, quality of life, respiratory function and associated anaemia.
P-BN25 Redo-Antireflux surgery long term quality of life retrospective study
Authors: Mohamed Hesham , Kawabata Martin , Culmer Cicely , Veerapatherar Keerthanaa , Basu Sanjoy
Published: December 2021

Background

Gastro-oesophageal reflux disease (GORD) can have a significant effect on patients quality of life, especially in sever cases. Laparoscopic Antireflux surgery is the most common approach which offers promising long-term outcomes. However, Failure of antireflux procedures are reported in 5% to 10% of the patients who might require a redo-antireflux surgery (Redo-ARS). This study aims to assess the long-term outcomes of Redo-Antireflux surgeries regarding symptoms control and patient satisfaction.

Methods

Retrospective study for patients who underwent Redo-ARS with a single consultant in the south of England. Follow up was done using The GORD Health-Related Quality-of-Life (GORD-HRQL) scale and patients reported their scores before and after the redo-surgery.   Exclusion criteria included follow up less than one year and failure of contacting the patient.

Results

All patients who underwent Redo-ARS between 2009-2019 were enlisted and 18 -out of the identified 22- were included in the study. Overall, There was a significant decrease in heartburn severity after the redo operation with a median reported severity of 4.5 preoperatively which decreased to 2 after the operation with a P value of 0.00062. This was observed in assessment of heartburn symptoms severity during sleep, laying flat, standing and after meals which all showed improvement after the operation with P values <0.005. There was no statistically significant improvement of dysphagia, odynophagia or bloating. The median follow up was 5 years.

Conclusions

Redo laparoscopic antireflux operations are technically challenging, however, significant heartburn symptoms control is feasible. Further evaluation of types of surgeries and patient selection can guide decisions regarding further management and guidelines.
P-BN40 Fundoplication following lung transplant: A retrospective cohort analysis
Authors: Bundred James , Siddaiah-Subramanya Manjunath , Griffiths Ewen
Published: December 2021

Background

Gastroesophageal reflux disease (GORD) in patients receiving a lung transplant has been associated with worsened graft function and decreased survival. This analysis aimed to identify whether fundoplication following lung transplant can improve graft function and overall survival.

Methods

patients undergoing lung transplantation between January 1993 and January 2020 were included. Data on oesophageal pH, manometry testing, post-transplant lung function testing and overall survival were collected. Cox-regression testing was used to analyse associations between oesophageal manometry and pH testing, fundoplication and overall survival.

Results

Of 345 patients who underwent a lung transplant, 20 patients also received fundoplication. 84 patients received oesopageal pH and manometry testing. Abnormal manometry was recorded in 41 patients. Average Demeester score was 28.45 for patients not receiving fundoplication and 37.28 for those receiving fundoplication. Average pre-operative reflux time was 8.6% for those not receiving fundoplication and 10.3% for those receiving fundoplication.

Of 20 fundoplications, 4 were carried out within 1 year of transplant and 12 within 2 years. 1 patient had a post-operative complication following fundoplication. 13 of 20 patients had a positive response to fundoplication, defined as a less than 10% decrease in FEV1 lung function at 2 years. Receiving fundoplication was associated with better overall survival (p = 0.024) as was total reflux time <7% (p = 0.21).

Conclusions

Fundoplication is a safe operation after lung transplant with good outcomes. Fundoplication was associated with better overall survival on cox-regression analysis.
P-BN43 Giant Hiatus Hernia Repair Significantly Improves Quality of Life
Authors: Elniel Mohammed , Chaudhury Madhu , Desai Nasreen , Daté Ravindra S
Published: December 2021

Background

Giant hiatus hernias (GHH), defined as more than 30% of the stomach herniating into the chest cavity accounts for 5%-10% of all hiatus hernias.

GHH repair is undertaken electively in symptomatic patients, to prevent complications such as volvulus of the stomach with resultant mortality. Advances in laparoscopy and perioperative care have reduced the risk of operation, and improvement in quality of life (QoL) has become an important outcome measure. “Quality of Life in Reflux and Dyspepsia” (QOLRAD) questionnaire is a disease specific validated tool used to assess QoL.

We present our prospective data assessing change in QoL following GHH repair.

Methods

Symptomatic patients undergoing elective repair of GHH, by a single surgical team, between January 2010 and June 2021 were identified from a prospectively kept database. Demographic data and operative details were recorded from patient notes.

From 2015 onwards the QOLRAD questionnaire was introduced. Patients who underwent GHH repair completed the questionnaire pre-operatively and then at 6 weeks, 6 months, 1 year and 2 years post-operatively. Patients, who were not operated on, completed the questionnaire at 6 month intervals over 2 years.

Mann-Whitney U test was used to compare QOLRAD scores between hernia size, type and symptomatology.

Results

Sixty-eight patients underwent GHH repair from 2010 to 2014. Statistically significant(p < 0.001) improvement in QoL was only seen in patients with ‘heartburn’ symptoms.

Thirty patients were included in the post 2015 group. Statistically significant improvement in all QOLRAD domains was observed as demonstrated the table below.

Conclusions

GHH repair is a safe operation in symptomatic patients that results in an improvement in QoL across all QOLRAD domains and may prevent deterioration in QoL.
P-BN48 Utilising spatial geometry to obtain the ideal needle mount for laparoscopic intracorporeal suturing
Authors: Kanitkar Rahul , Muthukumarasamy Girivasan , Patil Pradeep , Tang Benjie , Zino Samer
Published: December 2021

Background

Intracorporeal suturing is an essential component of any advanced laparoscopic procedure like fundoplication, bypass surgery or common bile duct exploration. Obtaining the appropriate needle mount during suturing can be challenging. Spatial geometry defines points in three-dimensional space. Ergonomics in laparoscopic surgery identifies a manipulation angle of 60o to target as being optimal. This knowledge, in combination with the principles of light reflection can be used to understand needle orientation in laparoscopic suturing.

Methods

An experiment was designed on a laparoscopic trainer with three participants. Using the principles of spatial geometry and light reflection, four different points were identified on an angle chart and labelled for a right-hand dominant participant as; centre, right off-centre (5.5cm), right lateral (10 cm) and left off-centre (5.5cm). Each participant was instructed to mount the needle at the defined points using light reflection on the needle shaft as a reference guide. Three readings were taken for each position. Mounted angle was defined as the angle between the shaft of needle holder and long axis of the needle. This was measured using a special application and an average value determined for each position.

Results

The average values for the mounted angle measurements for each spatial position were: Centre(112o), Right off centre(101o), Right lateral (88.8o) and Left off centre (124.6o).

Conclusions

This study describes a novel and reproducible technique to obtain an ideal needle mount. For a needle mount greater than 100o either the centre position or the left off-centre position should be considered.
P-BN49 The predictive role of white cell and platelet count for infective complications following splenectomy
Authors: Karadakhy Ozhin , Poynton-Smith Emma , Beckingham Ian
Published: December 2021

Background

Temporary elevation of white cell count (WCC) and platelets are commonly observed after splenectomy and can therefore make it difficult for the surgeon to distinguish a normal physiological response from potential infection. Clinicians are often misled by elevated post-operative WCC after splenectomy, resulting in delayed discharges and prolonged unnecessary hospital stays for patients. The aim of this study was to establish what constitutes a normal rise in WCC and platelets after splenectomy.

Methods

All 127 patients who had undergone a splenectomy between July 2016 and January 2021 were identified from a search of our centre's hospital episode statistics data.  WCC and platelet count on post-operative days one to seven as well as at least one long-term follow-up result count were identified from electronic hospital records. Hospital records were searched for data on pre-operative steroid administration and peri-operative infections.

These cohort data were retrospectively analysed in SPSS using stepwise logistic regression, correlation analysis, and T-tests, as well as descriptive statistics.

Results

86 (68%) patients underwent an elective splenectomy and 41 (32%) an emergency splenectomy. 35 (27.6%) patients developed infections post-operatively, while 92 (72.4%) did not. Logistic regression suggested that a raised WCC (above 17.5x109/L) at day 3 post-op was a significant predictor of infection (p < 0.001): average WCC at day 3 for patients with infection was 20.00x109/L (SD = 6.23x109/L) compared to 14.86x109/L (SD = 4.01x109/L) for those without. Infective outcomes were not influenced by whether the surgery was emergency or elective. Overall, average WCCs were 9.63x109/L pre-operatively and 15.07x109/L long-term post-operatively. Even in the absence of infection, splenectomy led to a long-term rise in WCC of 3.8x109/L from baseline, to an average of 13.0x109/L [SD = 5.41x109/L): a T-test on the 56 patients without infection and with both pre-op and long-term WCCs showed a mean rise of 3.76x109/L, p < 0.0001).

Platelet count was not correlated with infection, though platelet counts rose from a mean of 261 × 109/L (SD = 103.4x109/L) pre-operatively to 581 × 109/L (SD = 236.3x109/L) at 7-day and 619 × 109/L (SD = 293.5x109/L) at long-term follow up across all patients – an average increase of 357 × 109/L, which did not significantly differ between patients with and without infective complications.

Conclusions

A rise in WCC and platelet count is normal post-splenectomy.  A rise in WCC>17.5x109/L on day 3 post-splenectomy is strongly correlated with infection (regardless of trauma or platelet count). Long-term follow up suggests that while much of the WCC increase is transient, WCC remains higher than pre-operatively, as does platelet count, in post-splenectomy patients. A raised WCC or platelet count without signs of infection should not preclude timely discharge in otherwise well patients.
P-BN53 The ‘Difficult Gallbladder’: do no harm!
Authors: Shivarajan Amber , Shanti Hiba , Patel Ameet G.
Published: December 2021

Background

Laparoscopic cholecystectomy (LC) for a ‘difficult gallbladder’ can incur increased risk of biliary complications. In these challenging conditions where anatomical delineation (commonly through the critical view of safety) is unachievable, it is important to recognise when to proceed and when to consider a bail-out strategy. Subtotal cholecystectomy (SC), cholecystostomy insertion, conversion to open or abandoning the procedure are accepted solutions. In this study we review the outcomes of patients who underwent LC following previous intervention.

Methods

We retrospectively reviewed patients who underwent LC under a single surgeon between January 2009 to July 2020 following a previous intervention with LC, SC or cholecystostomy tube insertion. Data was collected with regards to demographics, clinical presentation, intraoperative details, imaging, conversion to open, length of hospital stay and complications.

Results

40 patients with previous intervention underwent LC. Previous intervention included abandoned LC in 24(60%), on-table cholecystostomy in 8 (20%) and SC in 8 (20%), with 5(13%) converted to open. Reasons for referral included adhesions, intrahepatic gallbladder, possible malignancy, empyema and abnormal anatomy.  Laparoscopic approach attempted in 39/40 (98%), conversion to open in 25%. Reasons for conversion included cholecystoduodenal fistula, and suspected malignancy. Median hospital stay was 4 days (1 – 22). Morbidity was seen in 2(4%) with no biliary complications. Completion of treatment, from previous intervention to definitive LC was 9 months (1-48).

Conclusions

In patients with previously attempted cholecystectomy, LC is feasible and can be performed with low morbidity. When faced with a difficult gallbladder intra-operatively, aborting the procedure and re-attempting at a later date, locally or referral to a specialist Unit, should be considered.
P-BN60 Predicting post-operative length of stay following laparoscopic cholecystectomy: derivation and validation of a pre-operative risk score
Authors: Lucocq James , Scollay John , Patil Pradeep
Published: December 2021

Background

To predict the post-operative length of stay following laparoscopic cholecystectomy (LC) will help guide the utilisation of resources, particularly the allocation of day surgery beds.  Prolonged post-operative stay (PPS) is associated with morbidity and the acknowledgement of pre-operative factors predisposing to morbidity and PPS will influence surgical decision-making. The aim of the present study was to determine pre-operative factors associated with PPS and both derive and validate a risk score to predict the risk of PPS following LC.

Methods

Patients who underwent emergency and elective LC between January 2015 and December 2019 across three surgical centres were included. Pre-operative, operative and post-operative data were collected retrospectively from multiple databases using a deterministic records-linkage methodology. The cohort was randomly divided into a derivation and validation cohort, by a 3:1 ratio, respectively. The derivation cohort was used to create a risk score for PPS (≥3 days post-operatively) using multivariate logistic regression. The risk score was then applied to the smaller set or ‘validation cohort’ for internal validation purposes and the predictive accuracy was assessed using a ROC curve.

Results

The rate of PPS was 10.6% (294/2768). PPS was associated with intra-operative complication (RR-17.0;p<0.001), bail-out procedures (RR-47.1;p<0.001) post-operative complications (RR-11.9;p<0.001), re-admission (RR-2.4;p<0.001) and post-operative imaging/intervention (RR6.5;p<0.001). Variables associated with PPS included ag ≥ 60 (OR-1.56;p=0.011), male sex (OR-1.47;p=0.022), ASA 2 (OR-1.63;p=0.019, ASA≥3 (OR-3.27;p<0.001), 2 hospital admissions (OR-1.56;p=0.046), ≥3 hospital admissions (OR-2.11;p=0.024), cholecystitis (OR-3.19;p<0.001), pre-operative ERCP (OR-3.49;p<0.001) and cholecystostomy (OR-2.77;p=0.025) and emergency LC (OR-5.20;p<0.001). The AUC (area under curve) for the derivation and validation cohorts were 0.83 and 0.81 respectively. The risks of PPS in low-risk (0-5), medium-risk (5.5-10) and high-risk (>10) groups were 3.3%, 14.9% and 45.1%, respectively. 

Conclusions

The rate of PPS following LC is significant and strongly associated with peri- and post-operative morbidity. Our model concludes that multiple pre-operative patient factors can predict the likelihood of prolonged post-operative stay. A patient’s risk score could be used to assess the risk of morbidity. Pragmatic patient selection in accordance with the above model could help surgical centres improve the allocation of beds between tertiary centres and day-surgery units.
P-EGS03 Curious Case of Life Threatening Gastrointestinal Bleed
Authors: SINGH VIBHA
Published: December 2021

Background

Gastrointestinal stromal tumors are mesenchymal in origin, being derived from the interstitial cells of Cajal. These can be found anywhere in the gastrointestinal tract and are commonly found in the stomach followed by the small bowel. Gastrointestinal stromal tumors are usually asymptomatic and are often found incidentally. Chronic bleeding is one of the most common presentation. Gastrointestinal stromal tumors presenting with massive gastro intestinal haemorrhage and mimicking arteriovenous malformation on radiology are rare with only few cases reported.

Methods

Herein we present such a case of a 45-year-old gentleman with massive gastro intestinal bleeding. At presentation, patient was in congestive heart failure due to severe anaemia with a hemoglobin of 2.9g/dL. CECT Angiography localised the bleed to be from a jejunal mass lesion with radiological features consistent with those of arteriovenous malformation. Patient underwent laparoscopy assisted resection and anastomosis.

Results

Histopathology examination revealed a low risk jejunal gastrointestinal stromal tumor with no evidence of arteriovenous malformation. The mass was removed completely and the patient was discharged on 5th post-operative day. Patient was followed up in the out-patient department and was found to be doing well.

Conclusions

Gastrointestinal stromal tumors though relatively uncommon should be kept as important differentials for acute torrential gastrointestinal bleeding. It is highlighted that a presentation of gastrointestinal stromal tumors similar to that of arteriovenous malformations on cross sectional imaging should be kept in mind. The present case is reported in hope of expanding the knowledge of a rare occurrence, its aetiology, clinical impact and treatment.
P-EGS08 What is the Best Risk Prediction Model for Oesophageal Perforation?
Authors: Alasmar Mohamed , Shehata Zak , Altarawni Mohammad , Casey Patrick , Melhado Rachel , Sultan Javed
Published: December 2021

Background

Oesophageal perforation is a challenging surgical condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on. Treatment options include primary repair, t-tube repair, emergency oesophagectomy, endoscopic therapy, and palliation.

Whilst many risk prediction models exist, the only specific score to predict mortality in oesophageal perforations is the Pittsburgh Severity Score (PSS). However, there is limited evidence on its validity and even less literature to predict short and long-term morbidity in these patients.

Methods

We compared and validated commonly used risk prediction models, including the PSS, the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operatic Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The power to predict mortality and morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated using complications for both operative and non-operative cohorts.

Results

Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p < 0.001).

Conclusions

Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.
P-EGS09 The Introduction of an Ambulatory Surgical Pathway
Authors: Wall Joshua , Boag Katie , Kowal Mikolaj , Plotkin Tobias , Maguire Rachel , Peckham-Cooper Adam
Published: December 2021

Background

Since the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK.

Methods

A retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic.

Results

830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction).

After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%).

146 patients attended the ASC, and 15 patients received telephone advice alone.

The control group saw attendance increase by 25% (178 vs 223).

Conclusions

The results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.
P-EGS10 Clinicopathology of Critically Ill Patient With Coffee Ground Vomitus Undergo Oesophagogastroduodenoscopy
Authors: Salleh Muhammad Hafizuddin , Samad Abdul Rahim , Yunus Mohammad Alif , Sagap Ismail
Published: December 2021

Background

The incidence of acute gastrointestinal bleed in Malaysia is approximately 72 per 100000, as the incidence in patients who had mechanical ventilation is 2.6%. Coffee ground vomitus is one of the presentations of upper gastrointestinal bleed, and the decision for upper gastrointestinal endoscopy in a critically ill patient with such presentation would be a dilemma as endoscopy might lead to several complications such as endotracheal tube dislodgement, transient bacteremia, cardiopulmonary event, and perforation. We studied the clinicopathology of patients who were referred to our unit with coffee ground vomitus in a critically ill condition, as it would help us further in determining the severity and outcome of the patients.

Methods

This was a retrospective cross-sectional study from 59 patients in the critical unit in Hospital Melaka who were referred to the surgical department for coffee ground vomitus and underwent esophagogastroduodenoscopy. The study was conducted from November 2020 till July 2021.

Results

The median age of the patient was 73 years old and the mean body mass index was 25.6.. The primary diagnosis of patients in the critical care was Acute Coronary Syndrome 18%, Sepsis 17%, and cerebrovascular accidents 10%. The mean systolic blood pressure was 126 and the mean pulse rate was 94. The mean hemoglobin level upon admission was 10.7 and 9.07 upon referral. Other laboratory parameters that were analyzed were urea, INR, platelet, and lactate. 51% had history of taking antiplatelet or anticoagulants. 92% of patients underwent urgent OGDS (within 24 hours of referral), and 30% of them had findings of high-risk ulcers (Forrest 1b, 2a, and 2b) which need urgent intervention.    

Conclusions

The data from the study would be beneficial in providing evidence for further clinical research in our center on identifying the factors that will predict the outcome of OGDS towards the patient either for endoscopic intervention or diagnostic endoscopy only.
P-EGS14 From Gallstone Disease to Cholecystectomy: An audit looking at the waiting times for cholecystectomy in a small District General Hospital
Authors: Mewse Jacob , Ledda Virginia , Connor Ellie , Mason Peter Frank
Published: December 2021

Background

Gallstone-related disease accounts for a third of emergency general surgery admissions and referrals. The average waiting time for acute gallstone presentations to laparoscopic cholecystectomy is about 7 days in England. This audit aims to identify emergency admissions and compare local management to the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) guidelines standards with a focus on waiting times for laparoscopic cholecystectomy (LC). Where AUGIS standards were not met, number of re-admissions and complications were identified. A cost analysis was also completed looking at the overall costs of delayed treatment.

Methods

We identified all patients admitted as an emergency between September 2019 and September 2020 with gallstone-related pathology. Patients not referred to the surgical team, with negative Ultrasound Scans (USS) or known HPB malignancy were excluded. The patients were divided into a pre- COVID -19 and during COVID-19 category (respectively before and after March 2020), to identify whether the cancellation to non- urgent elective surgery (due to COVID-19) had caused further delays or complications. Each patient’s management was compared to AUGIS guidelines depending on their diagnosis at presentation (biliary colic, cholecystitis, cholangitis, gallstone-related pancreatitis), focusing on the timing between presentation and LC.

Results

A total of 99 patients were identified. Of the patients presenting with biliary colic (n = 9 pre-COVID, n = 5 during COVID), none underwent LC within 72 hours from presentation as recommended by AUGIS. Of the patients presenting with cholecystitis (n = 20 pre-COVID and n = 16 during COVID), none had LC within the recommended 72 hours. 5 patients in each COVID group had LC, with a significantly longer waiting time compared to the pre-COVID group. Re-admissions and complications were similar for the cholecystitis patients in both COVID groups. In the gallstone-related pancreatitis group, only 1 patient underwent LC within the recommended 2 weeks.

Conclusions

This audit showed that locally we are failing to meet AUGIS guidelines for LC within 72 hrs, 2 weeks or 6 weeks both pre and during COVID. This has caused re-admissions of patients with cholecystitis, pancreatitis and perforated gallbladders. Factors that cause delay are limited access to USS, limited staff and theatre availability. To improve outcomes, it is necessary to implement a hot gallbladder service with dedicated theatre slots. A change in the overall perception of LC is also needed: this is should be considered an emergency operation as its delay has a significant negative impact on patients’ outcomes.
P-EGS17 Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Emergency Giant Hiatus and Diaphragmatic Hernia Repairs
Authors: Alasmar Mohamed , Moore Eleanor , McKechnie Iona , Chaparala Ram
Published: December 2021

Background

Emergency presentation of giant hiatus and diaphragmatic hernias are associated with significant morbidity and mortality, and predicting perioperative risks can be difficult. There are several preoperative risk evaluation models used commonly in emergency general surgery. Not only can they help clinicians stratify risk, but they can also be valuable tools to outline surgical risks to patients and families. This study aimed to evaluate the suitability of different risk prediction models when predicting morbidity and mortality in emergency giant hiatus and diaphragmatic hernia repairs.

Methods

This was a retrospective cohort study of all emergency hiatus and diaphragmatic hernia repairs at a tertiary upper gastrointestinal centre from 2010 to 2021. The outcomes were compared to the predicted mortality and morbidity of different risk prediction models. The mortality models SORT (Surgical Outcome Risk Tool), NELA (National Emergency Laparotomy Audit) and ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Programme) were compared using the area under the curve (AUC).  Morbidity was evaluated by calculating the comprehensive complication index (CCI). CCI was compared to P-POSSUM (Portsmouth – Physiological and Operative Severity Score) and ACS-NSQIP predicted morbidity using Spearman correlation.

Results

108 patients were included in the analysis. 49.1% were female, and 50.9% were male. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93%. ACS-NSQIP had the highest predictive power for mortality (AUC = 0.845), in comparison to NELA (AUC=0.809) and SORT (AUC = 0.740). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p < 0.001 and 0.446, p < 0.001 respectively).

Conclusions

ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, P-POSSUM and SORT. ACS-NSQIP may have a role in pre-assessment and consenting of emergency giant hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.
P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair
Authors: Afzal Zeeshan , Gourgiotis Stavros , Hardwick Richard , Safranek Peter , Sujendran Vijayendran , Bennett John , O'Neill Robert , Noorani Ayesha , Hindmarsh Andrew
Published: December 2021

Background

Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management.

Methods

A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube.

Results

The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation.

Conclusions

Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract.  Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.
P-EGS30 Audit of the management of patients presenting with gallstone pancreatitis during the COVID-19 pandemic
Authors: Thomas Christophe , Hutchinson Katie , Brown James
Published: December 2021

Background

In the UK around 50% of cases of pancreatitis are caused by gallstones. BSG guidelines recommend ERCP is undertaken within 72h of onset of pain and patients should undergo definitive treatment with cholecystectomy if fit enough during the index admission or within two weeks of discharge to avoid the risk of potentially fatal recurrent pancreatitis. A national audit in 2015 showed that 34.2% of patients receive definitive treatment. During the first COVID-19 wave our surgical service was forced to modify practice including more conservative/non operative management potentially increasing the possibility of recurrent pancreatitis and thus complications.

Methods

We performed a retrospective audit of patients presenting to our unit with gallstone pancreatitis during the first wave of the COVID-19 pandemic from March to August 2020 (COVID) and compared this to the same period in 2019 (pre-COVID). Patients were filtered from a larger dataset of all admissions with an ICD-10 coding of any biliary disease. Patient demographics, admission details, investigations, surgical management and post-operative complications were recorded. This was then audited against the standards in the BSG guidelines for the management of pancreatitis.

Results

Conclusions

There were significant differences in the management of the groups. Most significantly in the number of hot procedures and number of patients receiving definitive treatment, a consequence of the conservative approach during COVID. Our pre-COVID results are similar to our previous audit in 2016; 76% received definitive treatment. Those that didn’t have definitive treatment were generally due to frailty/co-morbidities. Majority of ERCP delays were due to weekend effect. Of the 40 patients who didn’t receive definitive treatment 16 have represented with biliary flares/pancreatitis in the year following the study period highlighting the importance of definitive treatment.
P-EUS01 Pancreatic metastases from Renal Cell Cancer; endosonographic features and outcomes of a rare clinical entity
Authors: Ahmed Wafaa , Farman Muhammad , Joshi Deepak , Harrison Phillip , Devlin John , Reffitt David
Published: December 2021

Background

The pancreas is a rare site for metastatic deposits in the absence of disseminated metastatic disease. They can be difficult to differentiate from primary pancreatic malignancy based on the clinical history and radiological features alone. Renal cell cancer (RCC) is the most common source. We describe their endosonographic characteristics and clinical outcomes.

Methods

Patients undergoing EUS- FNB with a positive diagnosis of pancreatic metastatic disease from RCC from 2017 to 2019 were retrospectively identified. Recorded variables included patient demographics, endosonographic features and patient outcomes. 

Results

Five patients were identified. Mean age was 63 (range 53-72 years old). Mean time from diagnosis of the primary RCC to diagnosis of pancreatic metastasis was 12.75 years (range 6-18 years). All had resection of the primary lesion.

Mean diameter on EUS was 37.80mm (range 15mm to 100mm).  The lesions were homogenous, well-circumscribed, hypoechoic and hypervascular. Tissue acquisition was performed using a 22G FNB needle.

Two underwent surgical resection of the metastasis, one of which had recurrence at the surgical bed after 26 months.  One had disseminated malignancy at the time of diagnosis. One passed away prior to surgical resection. 

Conclusions

Pancreatic metastasis from renal cell cancer have characteristic endosonographic features and can present many years after initial diagnosis and resection.  EUS-FNB has a central role in confirming this diagnosis.
P-L01 Newly detected liver nodules with a history of colorectal cancer: are they metastasis?
Authors: Zhu Kai , Wang Xiaoying , Zhou Jian
Published: December 2021

Background

The diagnosis of newly detected liver nodules in patients with colorectal cancer (CRC) is crucial for determining prognosis and treatment. Accurate identification of benign nodules can help avoid unnecessary therapy. The aim of our study was to retrospectively review CRC patients who underwent liver resection for newly detected liver nodules in our institution.

Methods

We went over all patients with a history of CRC, who underwent liver resection from January 2012 to December 2019 in our institution. We specifically focused on nodules pathologically confirmed benign. Clinicopathological characteristics of these patients were collected.

Results

From 2012 to 2019, a total of 2632 CRC patients received liver resection for liver nodules, among which 2584 cases were proved to be malignant, and 48 cases were benign. Among these 48 cases, 24 were pathologically confirmed as focal nodular hyperplasia (FNH), 10 were inflammatory lesions, 9 were peliosis, and 5 were hemangioma. At least one pre-operative imaging examination (MRI, US, or PET-CT) indicated CRLM, while no one underwent gadoxetic acid-enhanced MRI. The median size of nodule was 2.0 cm (range, 0.4-8.0 cm). For therapy, ten patients received laparoscopic surgery, and 38 patients received open surgery; ten patients received chemotherapy after discovery of liver nodules.

Conclusions

Newly detected liver nodules with a history of colorectal cancer could be benign. Gadoxetic acid-enhanced MRI should be considered especially for indeterminate liver nodules that would be mimicker of colorectal cancer liver metastasis.
P-L04 Temporal changes in prevalence and associated risk factors for gallbladder dysplasia and adenocarcinoma in patients undergoing cholecystectomy. A UK hospital-based observational study
Authors: Lam Stephen , Chou Wing , Toogood Giles , Wemyss-Holden Simon , Tsigka Alexia , Kumar Bhaskar
Published: December 2021

Background

A metaplasia-dysplasia–carcinoma sequence is the most plausible carcinogenic pathway for gallbladder cancer. Although the incidence of gallbladder carcinoma is increasing, little is known about its precancerous lesions. The aim of this study was to determine temporal changes in the prevalence of low-grade dysplasia (LGD), high-grade dysplasia (HGD) and gallbladder adenocarcinoma and associated risk factors.

Methods

We retrospectively identified consecutive patients who underwent cholecystectomy between January 2011 and March 2020. Patients were grouped according to histology: no dysplasia; LGD; HGD; and adenocarcinoma. Fitted linear models estimated temporal trends in prevalence and mean age for all histological outcomes. Logistic regression estimated associated risk factors.

Results

A total of 5 835 patients were included in the analysis. The prevalence of LGD was 1.47%, HGD 0.17% and adenocarcinoma 0.19%. Prevalence for all diseases increased over time, and mean age at diagnoses decreased over time. In a multivariate logistic regression model, with no dysplasia as the reference group, female sex increased the odds of LGD (OR 4.57, 95% CI 3.07-10.10, p = <0.0001).  BMI was not associated with disease risk.

Conclusions

Our data suggests the prevalence of precancerous gallbladder lesions are increasing in younger patients. Although a risk factor for cholelithiasis, BMI was not associated with disease progression.  If occurring in a dysplasia-carcinoma sequence, mean age of diagnoses suggests a progression period of 20 years. Further research is required to explain both the significant sex disparity and potential environmental risk factors for gallbladder dysplasia.
P-L05 Enterohepatic migration of ingested fishbone resulting in hepatic abscess- Case report and review of literature
Authors: Grayson Niamh , Shanti Hiba , Patel Ameet G.
Published: December 2021

Background

Ingestion of foreign bodies is common, particularly in children. In adults, most foreign body ingestions are related to food bolus or bone. The majority present with pharyngeal symptoms. Most foreign bodies exit the gastrointestinal tract without complication. However, around 1% result in perforation. Patients may have a delayed presentation with nonspecific symptoms and pose a diagnostic dilemma. We report a rare case of silent migration of a fishbone into the liver and a review of the literature.  

Methods

We present the case of a 56 year old man who presented with a liver abscess second to an ingested fishbone. We conducted a PUBMED search and reviewed the published data over a period of thirty years. We identified 52 similar cases and compared the presentation, site of perforation and location of the fish bone. We observed the different approaches in presentation and management of such patients.

Results

A 56-year-old man presented to his local hospital with dull epigastric pain and raised inflammatory markers. CT scan revealed a 4 cm abscess in the left lobe of the liver, with a linear radio-dense body within. The patient was given antibiotics and the abscess was aspirated. The patient was transferred to our Hepatopancreaticobiliary unit for further management. Laparoscopy was performed. The left lateral segment of the liver was adherent to the gastric antrum. The hepato-gastric fistula was disconnected. The fishbone was retrieved from the liver. The abscess was drained and wash out performed. The patient was discharged the following day.

Conclusions

Left lobe liver abscess should raise suspicion of foreign body. Although antibiotic treatment may be effective in the short term, there is no long-term data regarding recurrence. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and reduces the risk of recurrence.