bluuebunny/crossref_metadata_2025 huggingface dataset:
TU3.7 Increased incidence of gallbladder dysplasia and cancer during COVID19 pandemic
Authors: Muscara Francesca , Jebamani Jennifer , Ivanov Bogdan
Published: November 2022

Aims

Cholecystectomy is one of the most frequently performed operations in the United Kingdom. Following the spread of COVID19 infection, reduced operational capacity has led to lengthen the waiting time for cholecystectomy, which leads to significant readmission rate, growing financial burden and increased complexity of the surgical intervention. Our study aims to identify changes in gallbladder (GB) histopathological findings before and during COVID19 pandemic.

Methods

Data was collected retrospectively on 337 patients who underwent cholecystectomy between 01/2019–12/2019 (pre-COVID19) and 296 patients between 09/2020–10/2021 (during COVID19) at Princess Alexandra Hospital, including preoperative clinical-radiological, surgery waiting time, operation details, postoperative histology and complications. Statistical analysis performed using chi-square tests (p-value<0.001).

Results

A total of 2 (0.6%) female cases (average age 75.6) had gallbladder dysplasia (GD) and 1 of them had GB adenocarcinoma found pre-COVID19 versus 8 (2.7%) (7F:1M, average age 46.6) with GD and 5 (1.7%) (3F:2M, average age 72.6) with adenocarcinoma during pandemic.

Other histopathological findings were 153 (45.4%) GB with chronic inflammation, 2 (0.5%) with necrosis or perforation pre-COVID19 versus 127 (42.9%) and 6 (2%) respectively during pandemic.

The average surgery waiting time for patients with GD or adenocarcinoma was 135 days before COVID19 versus 224.21 (33–676) during pandemic.

Conclusions

GD is associated with increased cancer risk at GB and other biliary tract sites. Our data demonstrated a statistically significant increase of incidence of GD and adenocarcinoma (p-value<0.00089) in patients who underwent cholecystectomy during pandemic versus pre-COVID19. Further ongoing study is recommended to understand the correlation with prolonged surgery waiting time.
TU4.3 Caecal volvulus: A District General Hospital Experience and Review of the Literature
Authors: Chowdhury Ashim , Pangeni Anang , Rai Sujata , Colledge Jann Yee , Shrestha Ashish Kiran
Published: November 2022

Aim

Caecal volvulus (CV) is an uncommon cause of large bowel obstruction with potential for complications such as ischaemia, and perforation. Prompt diagnosis and treatment only will ensure better outcomes. We aim to describe our experience in the largest series of CV reported in the United Kingdom.

Methodology

This was a retrospective study of 16 consecutive patients diagnosed with CV between March 2017 and March 2020.

Results

Out of 16 patients, 11 were female, with a median age of 64 (range 33–80) years. All patients presented with abdominal pain and vomiting. An initial diagnosis of bowel obstruction was made only in 8 patients (50%). Computed tomography (CT) scan of the abdomen and pelvis correctly diagnosed CV in fourteen (87.5%). Fifteen patients (94%) underwent surgical intervention. All but one (n=14,93.4%) underwent laparotomy, and one patient (6.6%) underwent successful laparoscopic intervention. Right hemicolectomy was performed in all operated patients, and fourteen patients (93.4%) had primary anastomosis. Twelve patients (80%) had one or other form of morbidity. Seven patients (47%) and three patients (20%) had grade II and III (Clavien-Dindo Classification) complications respectively with a median hospital stay of 10 (range 1–49) days. One patient (6.7%) managed conservatively was deemed to be futile. There was no postoperative mortality.

Conclusion

CV can present with non-specific symptoms, and a definite preoperative diagnosis is only possible with the aid of CT. Open resectional procedures with primary anastomosis is the most favoured approach in management, though laparoscopic access is also feasible in fit patients.
TU4.7 Audit of pilonidal sinus surgery – our experience in a district general hospital
Authors: Hajiesmaeili Hamed , Clack Aidan , Thomas Pradeep
Published: November 2022

Aim

Pilonidal disease is a common condition affecting the subcutaneous tissue of the natal cleft. There are a number of different types of operations with varied success rate. The purpose of this audit is to analyse our cohort of patients who underwent pilonidal sinus surgery and look at certain risk factors such as smoking and obesity in predicting 30-day post-operative infection rates.

Method

A cohort of 63 patients who underwent all pilonidal sinus surgery between 2017 to 2021 were analysed. Data was gathered using our electronic patient record (Meditech V6).

Result

Total of 63 patients were analysed with a mean age of 27.9. 86% Male Vs 14% Female. Mean BMI of 30.1. More than half of our cohort underwent Karydakis Procedure (52%), 27% modified Bascom technique, 13% Rhomboid flap and the other 8% of patients were not primarily closed. 37% of our cohort developed post-operative wound infection. Furthermore; more than half (52%) of these patients with wound infections were smokers and also 52% were obese with a BMI of more than 30. Interestingly 83% of these patients were either smokers or obese with a BMI>30.

Conclusion

Post-operative wound complications are common following pilonidal sinus surgery specially in patients who are smokers and/or have obesity. Patients who undergo flap surgery should be encouraged to stop smoking and to lose weight when necessary otherwise they may face long and complicated post-operative recovery phase leading to significant financial burden on the NHS.
TU5.1 Challenges Faced by Female IMGs practicing medicine in the U.K
Authors: Elbakri Sabreen , Noaman Islam Mohammed , Dhahri Adeel Abbas , Abohatab Esraa Moustafa
Published: November 2022

Aim

Disparities in medicine may be caused by many variables including sex, ethnic background, specialty choice and practice location. International Medical Graduates (IMGs) in particular face challenges that could impact their learning and career progression. In this study we aim to investigate challenges faced by Female IMGs that could impact their learning and career progression.

Materials and Methods

An electronic survey composed of 36 questions was distributed via different social media platforms to groups including IMGs. Analysis of responses was done via Google forms.

Results

We received a total of 148 responses. The majority of the survey participants (59.5%) perceived their gender and IMG status to be a barrier to their career progression. 94 (63.5%) of the participants reported they did not receive adequate support from their organisations. 65.5% felt they did not receive adequate support from seniors and 43.2% felt they did not receive adequate peer support to facilitate their integration into the U.K. medical system. More than 80% of the participants required more support with access to research/higher degrees and opportunities for leadership roles whilst more than 50% required support with accessing study budgets and less than full time training to progress in their careers.

Conclusion

Disparities caused by gender and ethnic background leave female IMGs vulnerable to additional challenges that could hinder their career progression. Additional support measures addressing these issues should be installed in order to facilitate a smooth career pathway for this subgroup of medical professionals.
TU5.5 Examining the Benefits of One-To-One African Caribbean Mentoring for Prospective Medical Students
Authors: Carey Charles , Jordan Chloe , Wheatle Monique , Edward Shikila
Published: November 2022

Introduction and aims

African Caribbean people are underrepresented in UK medical schools. African Caribbean Medical Mentors (ACMM) is a UK registered charity that provides one-to-one mentoring to prospective African Caribbean medical students. Mentors consist of current African Caribbean medical students and doctors. This study aimed to investigate the specific benefits provided by ACMM and the attributes of successful mentoring relationships.

Methods

Participants were identified using ACMM's database of mentees and mentors enrolled within the last 3 years and an online questionnaire was distributed via Qualtrics. Questions were scored on a scale between 1 and 10 and participants were asked to explain their rankings.

Results

11 mentees and 7 mentors responded to the surveys. 63.6% and 72.7% of mentees gave a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. All mentees reported satisfaction with their mentor, with 45.5% citing individualised interview practice and 63.6% reporting mentor support and availability as positive aspects of their mentoring relationship.

All mentors reported being satisfied with the program, with 57.1% and 71.4% giving a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. 42.9% of mentors reported that improved methods and proactivity with communication could have improved their mentoring relationship.

Conclusions

This study suggests that one-to-one mentoring between African Caribbean mentors and mentees was helpful during medical school applications. Interview practice proved particularly useful, whilst methods and timescales of communication represent areas for improvement.
TU5.11 Do surgical discharge summaries meet national standards? A closed loop clinical audit
Authors: Ferriter Bridgid , Lynch Amie , Tormey Shona
Published: November 2022

Background

High quality health care is information reliant. Access to high quality information in a timely manner is imperative in provision of quality patient care. A national standard for discharge summaries has been developed by the Health Information and Quality Authority (HIQA). A standard for surgical discharge letters is needed to avoid patient readmission, unnecessary presentation to primary care and to ensure continuity of care in the community. The aim is to assess the quality of surgical discharge summaries using the HIQA national Standard. To implement quality improvement strategies recommended by current research. To reassess the quality and close the audit loop.

Methods

For cycle one of audit, one month of discharge summaries in 2020 were generated across four consultant surgeons at the University Hospital Limerick. 33% of those were sampled evenly across consultants. 60 patient discharge summaries were audited. Training was implemented virtually. For cycle two of audit the same methodology was used, 43 discharge summaries were audited.

Results

Overall performance was 49%, improved to 69% following training. The worst performing category was future management, 20%, improved to 45%. The best performing categories were auto-populated, patient details 97% and primary care details, 100%. Patient medications were compliant in 25%, improving to 59%. Admission and discharge details were complete in 36% improving to 59%. Clinical narrative was present in 37% improving to 64%. Consultants had not signed off on any letters.

Conclusions

Surgical discharge summaries audited remain non-compliant with the national standard however, as research shows, NCHD training has improved performance across categories.
TU6.4 Inspiring future surgeons: comparing open vs laparoscopic simulated surgical skills
Authors: Lingam Gita , Shakir Taner , Karim Seiver
Published: November 2022

Background

Applications to surgical training are declining. Whilst early introduction to surgical specialities may develop interest, medical schools do not place enough emphasis on the growing trend towards performing laparoscopic procedures. We hypothesised that exposing medical students to laparoscopy would stimulate an interest in pursuing a surgical career.

Methods

Clinical medical students were randomised into two groups: Laparoscopic skills with box trainer and open surgical skills. Each session lasted one hour and was organised and conducted by the same tutors. Prior to participation in the teaching session, each student completed a pre and post event questionnaires regarding their speciality interest.

Results

A total of 45 students participated. 18 (33%) expressed an interest in a surgical career prior to the event. After the session, 15/23 (65%) of students who participated in the laparoscopic skills session expressed an interest in a career in surgery. The open surgical skills group had a positive response from 9/22 (41%) with respect to a career in surgery.

Conclusions

Participation in our surgical skills course increased interest in pursuing a surgical career amongst clinical medical students. Of note, our laparoscopic skills session increased interest more in comparison to an open surgical skills session. Our study highlights the importance of introducing laparoscopy simulation to the medical school curriculum in order to maintain interest towards the surgical specialities.
TU6.7 How to solve the problem of endoscopy training for General Surgery trainees
Authors: Massie Eleanor , Hughes Rebecca , Vella Mark , Moug Susan , Renwick Andrew
Published: November 2022

Introduction

COVID-19 has negatively impacted on all aspects of surgical training, compounding longstanding issues with surgical trainees achieving required endoscopy training standards. Innovative approaches are required to ensure trainees progress appropriately.

Aims

We aim to present an ideal immersive training pathway for endoscopy training for general surgery trainees.

Results

JAG certification has strict criteria which are achievable during a six month “immersive” training period with six, half day, sessions per week. JAG basic skills courses should be booked in advance and ideally complete in the 2nd to 3rd month of training.

Weeks 1–2: Supervised simulator training to introduce basic scope handling and manipulation. Observation of “upper” and “lower” lists to grasp understanding of patient journey.

Weeks 3–4: Attend at least 3 dedicated training sessions per week with DOPS discussion and completion. Ongoing simulator practice (1–2 sessions per week). Attendance at service lists with recognised trainers (1–2 sessions per week); likely to be opportunities for trainees to participate on ad Hoc basis.

Weeks 4–20: As per weeks 3–4 with an increased attendance of ad Hoc lists and reduction of simulation to one session per week.

Weeks 20–24: Consolidation of learning, endoscopies undertaken with minimal assistance from trainer.

Weeks 24–26: Reduced capacity lists with trainer in the department but out-with scope room in preparation of independent lists after JAG certification.

Conclusions

We have described the ideal immersive endoscopy training pathway. Consideration should be given to incorporating this into the general surgical curriculum around on-call commitments, elective operating and clinics.
TU7.1 “When Can I Go Home?”- Unplanned Admissions following day case elective surgery
Authors: Armstrong Lara , Hughes Paul , McLoughlin Peter
Published: November 2022

Aim

Day case surgery is an effective and economical method to manage patients while maintaining quality of care. During the COVID-19 pandemic and the reinstatement of non-cancerous elective surgery, efficient use of bed space capacity has been crucial. Strategies were implemented to reduce unplanned admission rates, including careful patient selection and preoperative assessment. We aimed to review rates of unplanned admissions (UA) following intended day case procedures and to identify methods of future prevention of UA.

Methods

A retrospective review was carried out of patients undergoing day case hernia repairs or laparoscopic cholecystectomy in a single district general hospital, between May 2021 and September 2021. Data was collated from an institutional data base with follow up data obtained from an electronic care record.

Results

53 patients included, with a median age of 76 years (range 23–79), 56.6% male, 23 inguinal hernia repairs and 30 cholecystectomies. 30.2% were unexpectedly admitted post operatively (9 Cholecystectomies and 7 inguinal hernias). Of those admitted, median length of stay was 3.1 days (range2–10). Reason for admission included pain (43.8%), post-operative complications (18.8%) and urinary retention (18.8%). Patients requiring admission were significantly older (mean age 62 vs 49 years old), were more likely to be male (62.5% vs 37.5%) and had a significantly longer theatre time (1.46 vs 1.08 hours, p=0.0001).

Conclusions

Our short review has identified older and male patient are more likely to require an overnight admission. Improvement in pain management, theatre planning and streamlining along with optimal discharge planning may reduce the volume of patient requiring UA.
TU8.9 Emergency Giant Hiatus hernia repair, Single Centre Experience
Authors: Alasmar Mohamed , Mckechnie Iona , Chaparala Ram
Published: November 2022

Aim

Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair reduces the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery.

Method

A retrospective study looked at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications and mortality.

Results

Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had a symptomatic recurrence of the hiatus hernia that required operative correction during index admission or subsequent admission. The median length of hospital stay was eight days (IQR 5–16). There was a positive correlation between the number of complications and length of stay. Post-operative mortality was 9%.

Conclusion

Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.
WE1.3 Surgical Multi-disciplinary Team's engagement with the Implementation of the New “Safe Anastomosis” Checklist
Authors: Alamin Nadeen , Jeyarajah Maathusha , Vigneswaran Natali , Collins Jen , Shrestha Ashish
Published: November 2022

Aims

Introducing a surgical intervention can only be effective if it is deemed user-friendly by the participants involved in the study. Hence, it is crucial to gather the consensus amongst the users to maximise engagement with the intervention. A questionnaire was created with the aim of gathering data regarding the ease, practicality, and any area for improvement of the ‘safe anastomosis checklist’ at a district general hospital.

Methods

An anonymous questionnaire, with qualitative and quantitative questions, regarding the ‘Safe Anastomosis checklist’ was created. The aim of this study was explained to the surgical department and the questionnaire was given to members of the surgical multi-disciplinary team to complete. The results were gathered and analysed to yield results regarding this intervention.

Results

Of the 22 responses obtained, 77.2% rated the ease of the questionnaire as being 9+ out of 10 while 59% found this intervention very useful especially when it was done during the “team brief”. Although in 68% of cases, it did not lead to any changes with the intra-operative method, it was used an opportunity for the team to re-evaluate the procedure itself and the technique to be used.

Conclusion

The questionnaire was well received amongst the participants, with most of the participants considering the intervention to be a quick, easy, and practical tool to re-enforce the purpose of the procedure and further eliminates any risks that could lead to an anastomotic leak.
WE1.11 Auditing the quality of operation notes in colorectal surgery at University Hospitals of North Midlands
Authors: Poolovadoo Yanish , Malik Aizad , Aziz Haseeb , Nair Nandu , Varghese Gigi , Varghese Philip , Kumar Nakulan Nantha
Published: November 2022

Introduction

Constructing an accurate and comprehensive operation note is an important process in a patients’ journey as it should provide sufficient information to allow continuity of care by other healthcare professionals. We performed an audit of operation notes in colorectal surgery to assess whether they meet the standards as described by the Royal College of Surgeons.

Method

Retrospective data was collected over a period of 10 months to include all major elective colorectal operations. Operation notes were scrutinised for all 17 relevant data points as described in Good Surgical Practice. The electronic patient system at our trust populates the operation note with date/time, surgeons and anaesthetist.

Results

There were a total of 232 major colorectal procedures performed between May 2020 and March 2021. 12 data points were adhered to 100%. Estimated blood loss was only documented in 18.1% (n=42) of operation notes. Pre-operative DVT prophylaxis was documented in 6% (n=14) of operation notes. Details of tissue removed were not documented in 3% (n=7) of operation notes. Antibiotic prophylaxis was not documented in 1.7% (n=4). Theatre anaesthetist was not documented in 1.3% (n=3) of operation notes.

Conclusions

Operation notes in electively colorectal surgery are not meeting the standard as set out in Good Surgical Practice. There is a potential for change by adding drop down sections on the electronic operation note to ensure all operation notes meet the standards and are uniform. These changes will be trialled and the data re-audited in the near future.
WE2.10 Regional vessels wrapping following pancreaticoduodenectomy reduce the risk of post-operative extra-luminal bleeding. A systematic review
Authors: Nour Hussameldin M , Shafique Shehram , Peristeri Dimitra V , Khan Mansoor , Singh Krishna K , Sajid Muhammad S
Published: November 2022

Aim

Post-pancreatectomy bleeding which may be a potentially fatal complication, usually resulting from the erosion of the regional visceral arteries mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether regional vessels wrapping omentum or falciform/teres ligament following pancreaticoduodenectomy reduce the risk of post-operative extra-luminal bleeding.

Method

Standard medical electronic databases were searched with the help of local librarian and relevant published randomized controlled trial (RCT) and any type of comparative trials were shortlisted according to the inclusion criteria. Summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software.

Result

One RCT and 6 retrospective trials on 4100 patients undergoing pancreaticoduodenectomy for any indication were found suitable for this met-analysis. There were 1404 patients in the wrap-group (WG) group and 2696 patients in the no-wrap group (NWG). In the random effects model analysis, the incidence of extra-luminal hemorrhage rate was statistically lower in WG [odd ratio 0.51, 95%, CI (0.31, 0.85), Z=2.59, P=0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant.

Conclusion

The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting higher number of patients are required to validate these findings because current study presented combined data of one RCT and 6 retrospective studies.
WE2.11 Optimal Utilisation of Cross-Sectional Imaging in Patients with Painful Jaundice Undergoing Bile Duct Exploration or Conservative Management for Suspected Bile Duct Stones on a Specialist Unit
Authors: Ibrahim Basil , Tait Sophie , Nassar Ahmad
Published: November 2022

Aim

Laparoscopic management of bile duct stones relies on intraoperative cholangiography, optimising utilisation of preopertative imaging. This study aims to determine whether such a policy is justifiable in jaundiced patients over 50 years of age with no risk factors for malignancy.

Methods

Prospectively collected data of patients presenting with gall stones and painful jaundice undergoing biliary surgery or treated conservatively was analysed. The presentation, preoperative imaging, cholangiography/ choledochoscopy findings and postoperative outcomes were recorded. Patients with risk factors for malignancy were excluded.

Results

1220 jaundiced patients over 50 years were referred over 24 years.

684 underwent surgery having had CT in 15.3%, MRCP 10% and ERCP 2.5%. 536 unfit patients were managed conservatively (CT 15.7%, MRCP 27.8% and ERCP 29.5%). Most had these investigations under the care of other departments prior to referral.

21/684 (3%) presenting with painful jaundice associated with acute cholecystitis or bile duct stones and no risk factors for malignancy were diagnosed with malignancy on IOC and choledochoscopy. 7 patients had preoperative cross sectional imaging, one with ERCP showing no evidence of malignancy. The remaining 14 patients underwent postoperative imaging; 7 had radiologically undetectable disease, 6 had advanced disease and only one was suitable for a “curative resection”. 21/536 (3.9%) cancers were diagnosed in patients who were treated conservatively.

Conclusion

Based on the little diagnostic yield of curable biliary malignancies, a policy of no cross sectional imaging in patients with obstructive jaundice and no risk of malignancy is justifiable in units adopting single session management of bile duct stones.
WE3.2 Analgesia Prescription in Surgical Patients
Authors: Morsy Hesham , Patel Miraj , Zimmerman Matthew , Kukreja Madhav , Salsabil Sharaf , Sivarajah Vernon
Published: November 2022

Aim

We objectively re-assessed prescribing of analgesia for surgical admissions at Watford General Hospital, in accordance with Trust Guidelines

Method

Total of 117 Patients. We collected data prospectively in the 1st Cycle 21/09/2021 – 04/10/2021 and in the 2nd Cycle 04/01/2022 – 17/01/2022.

Intervention was through virtual poster and daily reminders to on-call team

Results & Conclusions

When patients were prescribed analgesia, compliance to Analgesia Trust guidelines vastly improved from 50% to 79%. Most non-compliant prescriptions were prescribed more strong opioids excessively.

Action Plan

We plan to disseminate audit findings to clinical staff in acute services and provide Junior doctors a teaching session on guidelines
WE3.13 Friday Handover Flow
Authors: Jhass Aneka , Kamal Nahid Mohammed Abu , Efiannayi Anthonia , Shrestha Ashish K , Fernandes Roland , Asnani Kusum
Published: November 2022

Aims

Handover between teams is a requirement between colleagues to ensure patient safety. An electronic weekend handover Friday noon with the whole surgical team was implemented in 2017. This is the second cycle to close the loop.

Methods

The implementation of ‘Careflow’ software had all been initiated in 2017 to modernise handover from paper to e-handover. Anonymised questionnaires were sent to all surgical doctors 6 months following the initial intervention. An additional intervention of a Friday afternoon handover prior to the weekend was started following this. For the second cycle a similar questionnaire was distributed to observe whether the changes have been sustained and the impacts beneficial.

Results

From the first cycle 97% felt e-handover was better than paper handover. Comparing first and second cycles; 97% vs 80% reported adequate handover time, 97% vs 57.1reported handover incorporated into the working day, 42% vs 97.2% reported handover usually consultant led, 41% vs 48.6% were aware of RCS handover guidelines 81% vs 85.7% reported ‘Caredlow’ as having a positive impact. Overall 91.1% of staff were more than 60% satisfied with Friday midday weekend handover, and 100% wanted the practice to continue.

Conclusions

A prioritised handover, dedicated room, adequate time and senior presence are all required for an effective handover. To modernise and improve continuity of care, an electronic handover system is a positive, effective tool. In addition a Friday noon handover prior to the weekend enables the modern NHS to provide the best and safest practice for our patients.
WE4.2 Audit of pre-operative blood tests for Elective General Surgery at Northampton General Hospital
Authors: Kumaran Naren , Bin Tariq Muhammad Saad , Bangash Faaraan , Habib Helai
Published: November 2022

Aim

Annually 9.9 million people undergo elective surgery in the NHS. The National Institute of Health and Care Excellence (NICE) published guidelines on ‘Routine pre-operative tests in elective surgery’ in 2016. It aimed to reduce unnecessary testing by taking into account patient comorbidities and the complexity of surgery. Excessive testing can cause significant anxiety in patients, delays in treatment and exposure to COVID caused by unnecessary hospital visits. Additionally, unnecessary blood tests can exacerbate blood bottle shortages.

We are auditing the compliance of NICE guidelines when requesting blood tests for elective general surgical patients in pre-operative assessment clinics at Northampton General Hospital (NGH)

Method

The audit team at NGH provided details of the first 64 patients undergoing elective general surgery (categorised into 22 Minor, 23 Intermediate, 19 Major procedures), from May to July 2021. Electronic records were used to determine patient ASA grades and blood tests requested at pre-operative assessment clinics. These were checked against NICE (2016) guidelines.

Results

Conclusion

There is poor compliance with NICE guidelines. NGH Anaesthetic team have implemented changes in November 2021, as part of MyPreOP online app, to ensure these guidelines are followed. We will re-audit in February 2022 and consider implementing changes across all surgical specialties.
WE4.7 Is Routine Histopathological Examination Required for all Surgically Resected Gallbladders?
Authors: Jones Stacey , Mikhael Youhana , Altabari Mohammad , Bahgat Boules , Parrott Alexandra , Shaaban Hossam
Published: November 2022

Aims

The aim of this study was to identify both pre- and intra-operative factors in individuals diagnosed with incidental gallbladder malignancy on histopathology following a cholecystectomy for symptomatic gallstone disease.

Methods

Retrospective records were analysed from October 2018 to December 2020 of all individuals who underwent a cholecystectomy in a single surgical unit. Demographic data (age, gender), presenting complaint, pre-operative imaging (USS/CT/MRCP/ERCP),pre-operative blood results, type of surgery (laparoscopic/open), intra-operative finding (macroscopic appearance of gallbladder) and histopathological findings were noted.

Results

829 individuals underwent cholecystectomy for symptomatic gallstone disease within the study period. 73.5% were female. Mean age of patients was 51.2 years. Commonest presenting complaint was pain in all cases followed by nausea (33.5%) and vomiting (26.9%). Chronic cholecystitis was found to be the most common histopathological finding (84.4%), followed by cholelithiasis (31.8%) and cholesterolosis (10.3%.) Gallbladder carcinoma was incidentally found in 3 cases (0.4%), of which 2 were female with a mean age of 75.3 years. A thickened gallbladder was found in all cases on pre-operative imaging and macroscopic abnormalities were noted in all cases intra-operatively with each individual having T2 disease on TNM staging. No individual with normal macroscopic appearance had gallbladder malignancy.

Conclusion

Pre- and peri-operative findings play a key role in determining incidental findings of gallbladder malignancy and we advocate a more selective approach in the gallbladders that are sent for histopathological examination based on pre-operative imaging, intra-operative macroscopic appearance and age of individual thereby, reducing both cost and the workload of the pathologist.
WE5.5 Does use of laparoscopy in emergency surgery improve mortality rates? A single centre experience
Authors: Gurowich Louise , Dru Rebecca , Hollyman Marianne
Published: November 2022

Aims

With the progression of minimally invasive surgery across surgical specialties in the elective setting, we aimed to assess the translation of laparoscopic surgery into emergency surgery in our district general hospital. The National Emergency Laparotomy Audit (NELA) provides us with an excellent database to review our single-centre's experience over time.

Methods

Using data collected as part of the NELA, we reviewed available operations between 2013 and 2021 at our centre, and compared outcomes between open, laparoscopic, laparoscopic-assisted (LA), and laparoscopic-converted-to-open (LCTO) operations. The primary outcome was mortality. Our secondary outcomes were variables that guided decision to operate laparoscopically versus laparotomy.

Results

1236 operations were identified; 205 (17%) were either laparoscopic, LA, or LCTO. 60-day mortality in all laparoscopic groups was significantly lower at 4.4% compared with 10.0% in the open group (p-value 0.008). This finding was lost when variables of age, ASA grade, or pre-operative P-possum mortality were adjusted for.

Conclusion

Laparoscopic surgery was performed on a small, selected group. It is a safe and valuable choice for many patients, particularly with upper-GI pathology and may contribute to improved mortality. However, whilst at first glance laparoscopic approaches to the emergency surgical abdomen appear to improve mortality, this likely represents a well-known clinician-led process of selecting patients with greater fitness and lower predicted pre-operative mortality, therefore muddying the significance of this apparent benefit. This is comparable with national data.
WE5.11 Intra-abdominal actinomycosis - an indolent masquerader of malignancy
Authors: Jayasankar Balaji , Abdelsaid Kirolos , Aal Yasser Abdul , Papadopoulos Andreas
Published: November 2022

Introduction

A 54 years old lady who presented with constitutional symptoms of lethargy, weight loss and asthenia. She had been extensively evaluated for a possible gynaecological malignancy but with no definitive outcome. The symptoms were persistent and a decision had to be made towards surgery in the present climate of the covid19 pandemic.

Method

Following oncology multi disciplinary meeting outcome she was taken up for a total abdominal hysterectomy and bilateral salpingo-oophrectomy. She was noted to have an incidental finding of an extensive tumour infiltrating the liver, colon, anterior abdominal wall and the urinary bladder. A surgical resection with ileostomy was performed on suspicion of an underlying malignancy.

Results

The histopathological diagnosis revealed a picture of actinomycosis which had evaded us previously. Following this she was treated with prolonged course of antibiotics and has recovered well, thus altering our entire management plan.

Conclusion

Actinomycosis albeit rare is an interesting mimic of tumours. This case also delves into the on-table decision making when in doubt about cancer.
WE5.13 Improving Pre-operative Risk Score Assessment In Patients Undergoing Emergency Laparotomy
Authors: Patel Maitreyi , Thomas Joel Joy , Sarwary Haschmatullah
Published: November 2022

Aim

This audit was conducted with the aim to assess the compliance of recording of risk (P-POSSUM) scores in patients undergoing emergency laparotomy, with the objectives being to establish how many patients required ITU/HDU admission, documentation of P-POSSUM in patients requiring post-operative critical care admission and, pre operative P-POSSUM documentation in elderly patients aged >70 years.

Methods

Data of all emergency laparotomies at a DGH were obtained from electronic theatre records. The first cycle was from 14/02/2021 to 07/03/2021. The results were presented in the Divisional Audit meeting. Following this, audit cycle was completed with data from 20/06/2021 to 15/08/2021. Patient notes and theatre booking forms were reviewed to assess if P-POSSUM score was recorded and analyzed with Microsoft Excel.

Results

Twenty- three emergency laparotomies were performed between 14th February 2021 and 7th March 2021. Of these, P-POSSUM scores were recorded in 21.7% (5 of 23 patients). During the second cycle, 50 patients underwent emergency laparotomy. Following the presentation of our audit the compliance to recording P-POSSUM increased to 64% (32 of 50 patients). Of those patients requiring critical care admissions, there was a significant increase in the pre-operative recording of risk scores from 13.33% (2 of 15 patients) to 51.61% (16 to 31 patients).

Conclusion

Our compliance with documentation of risk score pre operatively in patients undergoing emergency laparotomy has improved over time. However, there remains a room for improvement. We recommend encouragement to record P Possum Scores compulsorily as standard prior to Laparotomies and to standardize the location of recording scores.
WE7.8 Neck of Femur Fractures with Co-existent History of Malignancy: Do Full-length Femur X-Rays Change Fixation Method?
Authors: MacKinnon Thomas , Ahmed Mosab , Hashim Sophia , Bhattacharya Raj
Published: November 2022

Introduction

In neck of femur (NOF) patients presenting with co-existent history of malignancy, it is regarded as good practice to obtain pre-operative full-length femur X-Rays (FLF-XRs) to identify metastatic disease distal to the fracture site and aid operative planning. Whether the availability of pre-operative FLF-XRs in the trauma meeting influences the surgeon's choice of fixation method between intramedullary nail (IMN) or dynamic hip screw (DHS), is unclear.

Methods

We performed a retrospective analysis of all NOFs that underwent surgical fixation at a major London hospital over a 3-year period (2018–20), and collected data on history of any malignancy, FLF-XR status and fixation method (IMN vs DHS). Our results showed that of the 308 extracapsular NOFs during this time period, 23% had a history of malignancy, and of these, 55% had undergone FLF-XRs. NOFs with co-existent history of Ca who had undergone FLF-XR were more likely to undergo IMN fixation than DHS to a statistically significant degree (p<0.05) than those who did not, despite only 3% of these radiographs demonstrating distal femoral metastases.

Results

The findings of this preliminary audit raise questions around the value of FLF-XRs in NOFs with co-existent malignancy, particularly if IMN fixation is opted for in the majority of cases despite normal radiographs. The next phase of this study is to establish whether IMN/DHS fixation, with or without pre-operative FLF-XRs, amongst this cohort correlate to better or worse complication rates.
WE7.9 Triage in Terror-Related Major Incidents
Authors: Malik Nabeela , Xu Yuanwei , Chernbumroong Saisakul , Bowley Douglas , Hodgetts Timothy , Gkoutos Georgios
Published: November 2022

Introduction

Recent major incidents (MI) in the UK have involved intentional explosions or indiscriminate attacks by perpetrators with bladed weapons. At a MI, on-scene triage vitally identifies those needing time-critical surgery and/or resuscitation (Priority 1, or P1, casualties), facilitating urgent transfer to specialist care. Currently, the National Ambulance Resilience Unit (NARU) Triage Sieve is used. We interrogated the Trauma Audit and Research Network (TARN) registry to compare performance of MI triage tools in predicting P1 status amongst adults.

Methods

TARN patients aged ≥16 years with penetrating and blast injury (January 2008-December 2017) were assigned triage categories (P1, P2, P3, Expectant or Dead) using pre-defined, intervention-based criteria. Ten MI triage tools were applied to patients’ first pre-hospital observations. Tool-predicted and intervention-based P1 assignments were compared.

Results

Of 5,660 patients, 5,635 (92%) suffered penetrating injuries, 25 (0.4%) sustained blast injuries. Mortality was 3.1% (n=171); median Injury Severity Score was 9 (IQR 9–16). 2,639 (46.6%) patients fulfilled P1 criteria: 1,170 (44.3%) required life-saving and 209 (7.9%) required limb-salvage surgery within 4 hours. The NARU Triage Sieve demonstrated sensitivity of 32.2%, over-triage 40.3% and AUC 0.566 (95%CI 0.555–0.578). The tool best-able to identify P1 casualties was the Battlefield Casualty Drills (BCD) Triage Sieve (sensitivity 68.0%, over-triage 47.3%, AUC 0.573 [95%CI 0.561–0.586]).

Conclusions

Terrorist attacks characteristically yield a high proportion of patients requiring urgent surgery. The current UK MI triage tool in use, the NARU Triage Sieve, exhibits unacceptably low detection of P1 casualties; we recommend it is superseded by the BCD Triage Sieve.
WE7.14 Penthrox is effective but is it patient approved?
Authors: Dias Ana , Zeidan Ziad , Copp Matthew , Eslabra Frances , Hassan Rawan , Middleton Rory
Published: November 2022

Background

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

Methods

A focus group of five patients was initially contacted to identify key themes deemed integral to incorporate into the study questionnaire. All uses of Penthrox® in ED from March to August 2021 were retrospectively identified. Qualitative data was gathered using the Trickett short interview method with responses grouped into positive and negative descriptors. In addition, quantitative data using a 5-point-Lickert scale was also gathered.

Results

The focus group felt that side effects and overall satisfaction with Penthrox® should be explored. Thus far, 77 respondents have completed the survey. 91% reported an overall satisfaction ‘≥ Good’, while 95% reported ease-of-use as ‘≥ Good’. The analgesic effectiveness of the device was rated as ‘Excellent’ by 52% of respondents and ‘≥ Good’ by 88%. The most reported side effects were drowsiness (14%) and nausea (18%); however, most patients (71%) reported no side effects. Furthermore, 94% of respondents reported they would use Penthrox again. An NVIVO word cloud was created visually confirming an overall positive experience.

Conclusions

This study highlights that Penthrox® is a well-tolerated and user-friendly method of managing acute trauma pain in ED. Furthermore, it highlights the importance of considering the individual patient journey alongside robust evidence-based data on safety and efficacy for the development of a holistic treatment.
WE8.1 Index admission cholecystectomy with or without single session bile duct exploration for emergency gall stone complications neutralised the adverse effects of COVID
Authors: Tait Sophie M , Katbeh Tarek Z , Ibrahim Basil , Nassar Ahmad H M
Published: November 2022

Aims

The COVID-19 pandemic impacted surgical practice globally. We aim to study the effects this had on the presentations, practice and results of biliary surgery on a unit adopting index admission laparoscopic cholecystectomy (LC) and single session management of bile duct stones for emergency presentations.

Methods

Prospectively collected data of biliary surgery over a period of 12 months pre-COVID (PRE) and 12 months post-COVID (POST) was analysed. The presentation, type of admission, type of operating list and operative and postoperative data were compared.

Results

257 LCs were done PRE and 270 POST. All emergency presentations increased; acute cholecystitis 8.5% to 25.9%, acute pancreatitis 6.2% to 11.8% and jaundice 22.5% to 27.7%. Elective LC decreased from 53% to 20%. With an increase in patients with previous admissions (13.6% PRE vs 20.7% POST), 87% of PRE vs 80% POST had index admission LC, utilising 192 emergency theatre sessions and 29 CEPOD lists. In spite of increased LC difficulty grades (grades 4 and 5 from 20.2% to 30.5%), bile duct explorations (34%), operating time and median total hospital stay the morbidity, mortality and median presentation to resolution intervals were not affected.

Conclusions

Covid-19 caused an increase in all acute biliary presentations requiring emergency admissions, almost certainly the result of a significant decline in elective LC. However, similar numbers of LC PRE and POST were maintained due to a policy of index admission surgery and bile duct exploration, utilising emergency theatre scheduling, optimised clinical outcomes in spite of some logistical parameters being affected.
WE8.2 Has the change in emphasis to conservative management of appendicitis during the first wave of COVID- 19 had a longer lasting affect on assessment and management of patients
Authors: Thakkar Rudrik , Badnenoch Tom , Kosti Angeliki , Rakin Asef , Hollyman Marianne
Published: November 2022

Aims

During the first wave of the COVID-19 pandemic (March-June 2020), surgeons were advised where possible to avoid operating on appendicitis due to the perioperative risk for patients and theatre staff. This resulted in an increase in conservative management and a decreased negative appendicectomy rate (NAR) (COVID:HAREM). We sought to assess if the experience in 2020 had changed practice a year on.

Methods

Data collection was undertaken of patients presenting acutely with appendicitis or clinical appendicitis requiring diagnostic laparoscopy, using the electronic records. Data was collected over the same three-month period in 2019, 2020 and 2021. Patient's electronic records were reviewed.

Results

In total 174 patients were identified over the three-year period (59, 46 and 69). Mean age was 42 and 55% were female. The number of patients undergoing US scans dropped during the pandemic (36%, 26% and 41%) whereas CT use increased (37%, 63% and 46%). In 2021, conservative management of patients had not returned to pre-pandemic levels (5%, 46% and 19%). NAR were 12%, 0% and 5%. Mean length of stay was unchanged (3.3, 3.9 and 3.5days).

Conclusions

This study demonstrates the change of practice during and following the first wave of pandemic. In 2020, more patients were undergoing a diagnostic imaging and fewer patients were undergoing an operation compared to 2019, demonstrated improvement in the NAR in 2020. Although these changes have dampened in 2021, the trend is still present; there is an improved NAR in 2021 compared to 2019, possibly due to more patients undergoing CT.
TH1.6 Management of Phyllodes Tumour - a 10 years experience
Authors: Narayanasamy Sangara , Muntean Brenda , Goyal Amit
Published: November 2022

Introduction

Phyllodes tumors are rare fibroepithelial neoplasm of the breast (phyllodes -leaf like pattern). The three main types of phyllodes tumour are benign, intermediate and malignant.

Current Guidelines: Follow up

Results of Audit

Conclusions

Recommendations