bluuebunny/crossref_metadata_2025 huggingface dataset:
SP4.2.5 Did COVID-19 change the way we treat appendicitis?
Authors: Hurt Libor , Mowbray Nicholas , Powell-Chandler Anna , Reeves Nicola , Chandler Susan , Walters Emyr
Published: October 2021

Intro/aims

In repsonse to the COVID-19 pandemic, the United Kingdom (UK) commenced a national lockdown in March 2020. Initial guidance advocated the avoidance of aerosol generating procedures and hence we hypothesised there would be a decrease in the use of surgery to treat acute appendicitis.

Methods

A prospective audit was undertaken across 4 hospitals in South Wales, UK, during April 2020. Patients over 18 years of age with suspected or confirmed appendicitis were identified and data was collected including their history, radiological findings, management, and re-admission. Comparison was made with theatre and radiological data from April 2018 and 2019.

Results

A total of 254 patients were treated over the 3-year period; 95 patients in 2018, 95 in 2019 and 64 in 2020. During the lockdown, the use of Computed Tomography (CT) increased from 36.3% to 85.9% (p < 0.001). An antibiotic only approach to treat appendicits rose from 6.2% to 40.6% (p < 0.001). Four patients in the lockdown cohort failed the conservative approach and required an appendicectomy. The overall rate of laparoscopic appendicectomy was reduced from 85.3% to 17.2% (p < 0.001). A malignancy was identified in 3% of cases.

Conclusions

Whilst less patients presented with acute appendicitis compared to previous years, there was still a significant reduction in the operation rate. The data aligns with the literature confirming the antibiotic-only approach to be safe with a low failure rate. It is essential however that patients are fully consented for this approach including the risk of a missed malignancy.
SP4.2.8 Does Care quality commission need to change its inspection strategy after COVID-19?
Authors: Bodapati Shruti , Gambhir Raghvinder
Published: October 2021

Aim

To see if the Care quality commission’s (CQC) overall inspection ratings and specific domain ratings had any association with COVID-19 related deaths.

Methods

We looked at CQC ratings of the Shelford group of trusts and 10 trusts with maximum number of deaths in the time period from the first wave till 23rd January 2021. We then looked at each of the 5 domains: safe, effective, caring, responsive, and well led, to see if they were in any way indicative of the number of deaths in that trust.

Results

Among the 19 trusts studied (one trust featured in both groups) only 1 had an overall outstanding rating; 10 were rated good, 8 required improvement. None were rated inadequate in any of the domains, 16 /19 were rated good in effective domain which means “there care, treatment and support achieves good outcomes”. In safe domain 13/ the 19 were rated as requires improvement which means that “a patient may not be protected from avoidable harm”.

Conclusion

COVID-19 is no respecter of the CQC ratings, even if the trust was rated as well led and had good ratings in all other domains it could still have the highest mortality figures from COVID in the UK. CQC probably needs to add a 6th domain to its future inspections to assess the readiness the trusts for future Pandemics.
SP5.1.4 A meta-analysis on the impact of bariatric surgery on lower urinary tract symptoms in men
Authors: Stefanova Irena , Currie Andrew , Newton Richard , Albon Lorraine , Hawkins William , Pring Christopher
Published: October 2021

Background

Obesity is a chronic disease with multisystem morbidity. There are multiple studies reporting the effect of bariatric surgery on cardiovascular and metabolic disease but only few examine its impact on lower urinary tract symptoms. This article aims to perform a systematic review with meta-analysis in order to determine the effects of bariatric surgery on lower urinary tract symptoms in male patients.

Methods

Medline, Embase, conference proceeding and reference lists were searched for studies reporting the quantative measurement of lower urinary tract symptoms score pre- and post-weight loss surgery. The primary outcome was International Prostate Symptom Score (IPSS) before and after bariatric surgery. Secondary outcomes were change in Body Mass Index (BMI) and Total Body Weight (TBW). Weighted mean differences (MD) were calculated for continuous outcomes.

Results

Seven studies were included in the analysis of 334 patients undergoing bariatric surgery. Mean study follow-up was between 3 and 36 months. There was a statistically significant improvement in the IPSS score following bariatric surgery (MD 2.82, 95% CI 0.96 to 4.69, p = 0.003). Bariatric surgery also resulted in statistically significant reduction of BMI and TBW.

Conclusion

Bariatric surgery produces a significant improvement on lower urinary tract symptoms in men with obesity. This may be due to improvement of insulin sensitivity, testosterone levels or lipid profile associated with weight loss. Further studies are necessary to investigate in detail the pathophysiological mechanisms through which lower urinary tract symptoms develop in obese patients, and their improvement following weight loss surgery.
SP5.1.7 What did we miss? A 5 - year retrospective cohort study calculating the endoscopy miss rate for UGI cancers in a Scottish district general hospital
Authors: Rashid M , Clyde D , Driscoll P J , Jafferbhoy H
Published: October 2021

Aims

Despite the widespread use of endoscopy, upper gastrointestinal (UGI) cancers still present at an advanced stage. As survival is closely linked to stage and time of diagnosis, failure to detect subtle precancerous changes at endoscopy may compound poor prognoses. This study calculates the miss rate of UGI cancer over a 5-year period at a district general hospital.

Methods

All patients diagnosed with UGI cancer between January 2015 - December 2019 were identified from a prospectively collected cancer registry. Electronic health records and Unisoft GI reporting tool were used to identify patient demographics and previous UGI endoscopies. ‘Missed cancers’ were defined as patients who had a normal endoscopy within 3 years of their cancer diagnosis.

Results

The median age at diagnosis was 72.2 years (age range 24 - 98, n = 408) with a male predominance of 2:1 (66.6% male vs 33.4% female) in keeping with UK statistics.

Within this 5 year study period, there were 22 missed cancers (5.4%, n = 408).

A year by year break down shows miss rate in 2015 of 3% ( 3,n=100), 2016 of 4.2% (5,n=120), 2017 5.5% (5,n=91), 2018 6.4% (6,n=94) and most recently in 2019 3.2% (3,n=94).

Conclusions

In 2014, a meta-analysis by S.Menon et al recorded a miss rate of 11.3%. More recently published UK studies report miss rates between 6% - 7.3%, more in keeping with our local rate of 5.4%. Further assessment is required to assess whether the 2017 BSG and AUGIS UGI endoscopy quality standard statement will improve this rate.
SP5.1.10 Quality of endoscopy reporting in newly diagnosed oesophageal cancers
Authors: Cunningham Danielle , Khan Khurram , Gall Lewis , Craig Carol
Published: October 2021

Aims

The gold standard for diagnosing oesophageal cancer is gastroscopy (OGD). It is essential that the index OGD report is of a high quality to enable effective communication and facilitate appropriate management decisions by the multidisciplinary team (MDT). This study aimed to analyse the quality of index OGD reports in patients with newly diagnosed oesophageal cancer.

Methods

A retrospective cohort study of all newly diagnosed oesophageal cancers registered in a UK Regional Upper GI MDT between October 2019 and September 2020. The index OGD reports were assessed for documentation of 11 previously published quality indicators (QIs) (including proximal and distal margins, level and involvement of oesophago-gastric junction and presence of Barrett’s) and compared by endoscopist grade and parent speciality.

Results

A total of 243 new oesophageal cancers were diagnosed by 86 individual endoscopists. Mean patient age was 69.9 ± 11.2 years and 168 (69.1%) were male. 60 (24.7%) had impassable cancers. Overall, the median total QIs recorded for passable cancers were 7 (IQR 6-8). No report included all QIs. 30 (17.1%) reports were of “good quality” (≥9 QIs). Non consultant grade were more likely to record perfoming retroflexion (82.7 vs 69.0%, p = 0.039). Non surgeons were more likely to take photos (80.8 vs 64.5%, p = 0.015), document Barrett’s (29.3 vs 11.8%, p = 0.006) and to record an overall greater number of QIs (median 8 vs 7, p = 0.011).

Conclusions

Current endoscopy reporting standards of new oesophageal cancers are suboptimal. Further endoscopist education is required to highlight essential QIs and ensure good quality OGD reporting.
SP6.1.8Fundus-first laparoscopic cholecystectomy for complex gallbladders: A systematic review
Authors: Boghdady Michael El , Arang Hossein
Published: October 2021

Aims

Retrograde ‘fundus-first’ cholecystectomy is when the dissection starts from the fundus of the gallbladder to the infundibulum, in case structures of Calot's triangle cannot be identified. Although feasible in laparoscopic cholecystectomy, it remains an underutilized approach. We aimed to systematically review the fundus-first laparoscopic cholecystectomy and study its safety and feasibility.

Methods

A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect and Cochrane-Library for articles published from 2010 to 2020. Search keywords included ‘retrograde cholecystectomy’, ‘fundus-first cholecystectomy’ and ‘fundus-down cholecystectomy’. Quality assessments were applied using the Medical Education Research Quality Instrument (MERSQI) score. The protocol was registered with PROSPERO register.

Results

A total of 3503 studies formed the base for evidence evaluations. 12 studies with 1978 fundus-first cholecystectomies were assessed. Three citations were scored high and 5 moderate quality. Endpoints included blood loss, rate of conversion to open, bile duct injury, gallbladders perforations, postoperative pain and hospital stay. Nine studies provided both strong and moderate scientific evidence for a positive outcome of the fundus-first approach.

Conclusion

The fundus-first cholecystectomy was associated with a reduced need for intraoperative cholangiography, shorter operating time, lower incidence of intra-operative complications, bile duct injury and reduced incidence of conversion to open cholecystectomy.
SP7.2.7 Consenting practice in open inguinal hernia mesh repair and compliance with the British Hernia Society Standards
Authors: Adedeji Janine , Binnie Charlotte , Noureldin Khaled , Shamsiddinova Amira , Praveen Bandipalyam
Published: October 2021

Aims

Inguinal hernia repairs (IHRs) are one of the most frequently performed procedures worldwide with approximately 100,000 taking place in the UK each year. This study analyses open IHR consent practice against British Hernia Society standards, in particular, whether the term ‘mesh’ and significant postoperative complications were stated on consent forms. We also identified whether adequate post operative advice was given upon discharge in order to prevent recurrence.

Methods

This was a retrospective audit of all patients above 18 years old, who underwent open IHR 1 January - 31st December 2019. A total of 94 patients were included.

Results

Although in all cases a prolene mesh was inserted, 8.5% of patients received no mention of mesh in either the clinic letter or consent form.

Postoperative readmission was 5.3% at one week, and 8.5% at one month. Reasons for readmission included pain (1%), haematoma (2%), and wound dehiscence (1%).

In over 90% of consent forms, non-specific complications (bleeding, infection) were documented. However, common IHR postoperative complications, such as chronic pain (not mentioned in 15%), were not mentioned in consent forms.

Only 38% of patients received written postoperative advice.

Conclusion

Adherence to consenting standards benefits both patients and doctors. Our study highlights that further intervention is required to ensure surgeons are consenting patients adequately, as well as providing sufficient postoperative advice. We advise use of pre-filled forms and patient information leaflets, both in line with GMC guidance, to improve the quality of service offered.
SP10.1.4 COVID as a driver of innovation: getting the right patient to the right place at the right time. A novel Registrar-led approach to minimising unnecessary footfall in the Surgical Assessment Unit of a District General Hospital
Authors: Court Emma L. , Lennon Nicola A. , Zarka Anas , Pryor Megan , Lawrence Susan , Alexander Roderick J.
Published: October 2021

Aim

To give shielding Registrars opportunities to innovate and lead service development through telephone triage of Surgical Assessment Unit (SAU) referrals from General Practitioners and Nurse Practitioners.

Prior to the COVID pandemic, referrals were taken by Nurse Coordinators. Increasing call volumes put pressure on the department and disrupted clinical duties. Furthermore, referrers often expressed difficulties in contacting SAU staff.

Methods

During the study, referral calls were diverted for triage by the hospital switchboard. Three outcomes were offered: Clinical advice, ‘Hot Clinic’ (HC) appointment or urgent SAU review.

Prospective referral data (15/6-31/7/2020) and retrospective non-triage data (15/6-1/7/2019) were gathered. Triage effects were measured by outcome comparison with non-triage data and the associated financial implications calculated.

Stakeholder feedback questionnaires were distributed.

Results

Non-triage data showed 56% of patients reviewed in SAU were sent home and 44% admitted, compared to 23.6% and 28.1% of referrals during the 2020 study period. Furthermore, 28.4% of admissions were avoided by triage.

Only 3.1% of triaged patients presented to Emergency Department within 7 days of the triage conversation. Almost half of these had been reviewed in SAU following triage and discharged the same day.

HC availability was limited during the triage study. In view of reduced admissions and overall cost savings of £8330.62/week, expanding these clinics may prove cost neutral.

Triage was universally popular with stakeholders.

Data will inform future development of Urgent and Emergency Care at our hospital.

Conclusions

Traditional ways of working should be challenged. Novel approaches can be cost effective & positively impact patient care.
SP10.1.9 Delay to Elective Colorectal Cancer Surgery and its Potential Implications: A Systematic Review and Meta-analysis
Authors: Whittaker Thomas , Abdelrazek Mohamed , Fitzpatrick Aran , Froud Joseph , Williamson Jeremy , Williams Gethin
Published: October 2021

Aim

The ongoing Covid-19 pandemic has interrupted surgical treatment of colorectal cancer (CRC). This systematic review will assess literature concerning the risk of delay of elective surgery for CRC patients, focusing on overall survival (OS) and disease-free survival (DFS).

Methods

A systematic review was performed as per PRISMA guidelines (PROSPERO ID: CRD42020189158). Medline, EMBASE and Scopus were searched. Patients over 18 with a diagnosis of colon or rectal cancer who received elective surgery as primary treatment were included. Delay was defined as the period between CRC diagnosis and day of surgery. Metanalyses of the outcomes OS and DFS were conducted. Forest plots, funnel plots, tests of heterogeneity, and estimated Number Needed to Harm (NNHs) were produced.

Results

Of 3753 articles identified, seven met the inclusion criteria. Encompassing 314560 patients, three of the seven studies showed a delay to elective resection was associated with poorer OS or DFS. OS was assessed at a one-month delay, the HR for six datasets was 1.13 (95%CI 1.02-1.26, p = 0.020) and at three months the HR for three datasets was 1.57 (95%CI 1.16-2.12, p = 0.004). Estimated NNHs for a delay at one month and three months were 35 and 10 respectively. Delay was non-significantly negatively associated with DFS on metanalysis.

Conclusions

This review recommends elective surgery for CRC patients is not postponed longer than four weeks, as evidence suggests extended delays from diagnosis are associated with poorer outcomes. Focused research is essential so patient groups can be prioritized based on risk-factors for future pandemics.
SP10.2.8 Trainee led Emergency Laparotomy operating; does it impact on outcomes?
Authors: Boyd-Carson Hannah , Doleman Brett , Lockwood Sonia , Tierney Gillian , Lund Jon
Published: October 2021

Introduction

To achieve completion of training in general surgery, trainees are required to demonstrate competency in common procedures performed at Emergency Laparotomy (Em Lap). We describe the patterns of trainee led emergency laparotomy operating and the association between post-operative outcomes.

Methods

All patients who had an Em Lap were extracted from the National Emergency Laparotomy Audit database from December 2013 to November 2017. Patients were grouped by grade of operative surgeon; trainee (speciality registrar) or Consultant (including Post Certificate of Completion (CCT) fellows). Trends in trainee operating by education deanery, hospital size and time of day of surgery were investigated. Adjusted regression analysis for the outcomes of 90-day mortality and return to theatre in operative subgroups of segmental colectomy, Hartmann's procedure, adhesiolysis and repair of perforated peptic ulcer disease were performed.

Results

The study cohort contained 95 520 patients. There were no increased odds of death by 90 days or of return to theatre across any of the operative groups when a trainee was listed as the most senior surgeon present in theatre. Trainees were more likely to operate independently in the Welsh deanery, high volume centres and at night (all P < 0.001).

Conclusion

There is significant variation in trainee led operating in Em Lap cases by deanery, hospital size and by time of day. However, this involvement in cases required for CCT in general surgery does not appear to impact on mortality or return to theatre in patients when adjusting for various pre-operative features.
SP10.2.11 Horses for Courses – do surgical courses exist outside of the Royal Colleges?
Authors: Ali Roshneen , Bera Katarzyna , Hassan Maleeha , Lewis Christopher
Published: October 2021

Aims

Educational courses supplement deanery-led teaching, and may be mandatory for training progression. The Royal College websites are the first contact for trainees to search for courses, with other courses identified by word of mouth. This project aimed to collate a first comprehensive database of courses available for core and higher general surgical trainees and to identify areas requiring development.

Methods

A snowballing approach was used to systematically search all online available resources. This includes, but was not limited to, websites of the Royal Colleges, sub-speciality societies, trainee organisations, regional centres, deaneries and surgical technology companies. Course target grade, price, provider and dates were collated into a database. Conferences and symposiums were excluded.

Results

47 sources yielded 173 courses, priced between £50 to £1600 (median £450).

Technical skills (89/173) and clinical courses (45/173) entailed the majority; only 3 courses developed non-technical skills and 4 developed surgical leadership. Other categories include revision (11.6%), teaching (5.2%), and research skills (1.7%). The Royal Colleges provided 27.7% of all available courses, with the majority developed and delivered by other institutions. There was significant variability in available course information.

Conclusions

There are a wide variety of courses available for surgical trainees, however this information is fragmented, duplicated and incomplete. A central database requires maintenance, but would provide a reliable source of information. Leadership, research and non-technical skills are critical skills for surgeons – the lack of courses in these areas was surprising and require development as only 4 courses are endorsed by the Royal Colleges.
SP10.2.13 Theatre-team meeting start times during the COVID-19 pandemic: An audit of elective orthopaedic theatre practices at a high volume elective orthopaedic centre during the COVID-19 pandemic
Authors: Bishi Habeeb , Getachew Fanuelle , Kader Nardeen , Kader Deiary
Published: October 2021

Aims

The estimated cost of running an NHS theatre is 20 pounds per minute therefore it is essential that theatres runs as efficiently as possible to reduce waste.

After elective services were restarted a disproportionate increase in late theatre start times was observed.

An audit was carried out to evaluate whether team meetings were beginning on time (08:00) and if not; the length of and reason for the delay. These findings were presented at Clinical Governance and a re-audit was done to see if there had been any improvement.

Method

Data was recorded on an audit proforma in each theatre before the first case. This was done for 2 weeks over 12 days of theatre sessions and subsequently analysed to evaluate if practice was compliant with local theatre protocols.

Results

First cycle – average team brief start time of 08:05 with 17/18 (94%) of late starts due to surgeon/anaesthetist lateness.

Second cycle - average team brief start time of 08:08 with 10/22 (45%) of late starts due to surgeon/anaesthetist lateness.

Conclusions

Late starts led to further delays to the patient being sent for and arriving in theatre; late starts were usually caused by doctors/surgeons. The proportion of late starts due to the surgeon/anaesthetist (45%) decreased compared to the first cycle (94%) suggesting that theatre team members successfully adapted their practices following changes to local protocols during the COVID-19 pandemic.

A number of extraneous factors were also attributed to the later average start times in the second cycle.
TP1.2.3Oncological Outcomes of Organ Preservation Strategies - Local Excision Procedures and ‘Watchful Waiting’ In Management of Low Rectal Cancers – A Systematic Review And Meta-Analysis
Authors: Aspari A R , Ramesh V , Kumar G , Narayanasamy S N , Gumber A O , Thomas P F
Published: October 2021

Objective

To evaluate local recurrence, metastases, and survival outcomes of `wait and watch’ (WW) strategy and local excision (LE) of tumours, in comparison to the present standard practice of total mesorectal excision (TME) for locally advanced rectal cancers.

Data Sources

MEDLINE, EMBASE, PubMed databases, and sources of Grey literature.

Study Selection

Randomised and non-randomised prospective studies, retrospective studies with propensity-score-matched analyses.

Data Extraction and Synthesis

These were carried out independently by two reviewers. A random-effects methodology was used for meta-analyses. Data was presented keeping with the 27-item PRISMA checklist.

Main Outcomes

The primary outcomes of interest were local recurrence, distant metastases, disease-free-survival and overall-survival, which were assessed in comparison to those associated with radical surgeries (TME).

Results

7 of the 16 studies in the systematic review were included for the quantitative synthesis and meta-analysis. Local recurrence rates were comparable amongst patients in WW group and LE group to those undergoing TME. [Risk ratio (RR) 3.07/1.41; 95% Confidence Interval (CI) 0.86-10.95/0.66-3.01; P = 0.08/P=0.89 respectively]. Rates of distant metastases in the WW group and LE group were comparable to those undergoing TME [RR = 0.71/0.94; 95% CI 0.22-2.30/0.55-1.61; P = 0.56/ P = 0.83 respectively]. The median 3-year disease-free survival among patients undergoing WW, LE procedure, and TME were 88%, 80%, and 78.2% respectively; and the median 3-year overall survival among the three groups were 96%, 93%, and 89.5% respectively.

Conclusions and Relevance

Organ-preservation strategies appear to be a viable treatment option in the management of rectal-cancers. Further research is warranted to provide stronger levels of evidence on organ-preservation strategies.
TP5.2.1 Duplex ultrasound should be interpreted with caution in vascular access
Authors: Wicks Andrew , De Siqueira Jonathan , Bailey Marc , Troxler Max , Scott Julian
Published: October 2021

Aims

Dysfunctional vascular access in haemodialysis has varied clinical presentations, including prolonged bleeding, pain, loss of thrill, difficulties needling and ineffective dialysis. We aimed to establish whether specific presentations correlate with a higher frequency of adverse imaging findings and intervention.

Methods

Duplex ultrasound scans (DUS) of surgical AV fistulae and grafts performed in a teaching hospital trust between 01/07/2019 and 31/01/2020 were analysed. Referral reasons, diagnostic findings, onward imaging and interventions to salvage fistulae and grafts were cross-referenced from electronic patient databases.

Results

359 scans of AV fistulae were performed in the period studied, of which, 220 were performed on men. Median age was 63 years (IQR 49-72). The most common referral reasons were loss of thrill and difficulty needling (n = 46, both). 185/359 (52%) scans lead to subtraction angiography and 46/359 (13%) to open surgical intervention. Median time from DUS to angiography was 21 days and 21% (39/185) of DUS did not match with angiographic results. When assessing outcomes based on presentation, 16/19 (85%, p < 0.01) patients who had high venous pressures on dialysis and 23/31 (74%, p < 0.01) of those with dialysis recirculation required endovascular intervention. Pain on dialysis correlated poorly with future intervention (6/30).

Conclusions

A substantial proportion of DUS of dysfunctional vascular access do not correlate with subtraction angiography. Referral for DUS prior to angiography may delay intervention. Patients with objective signs of dialysis dysfunction (recirculation and high venous pressure) are highly likely to need intervention. Such cases may benefit from proceeding directly to angiography and on-table intervention.
TP5.2.5 The utility of ‘kissing’ common iliac artery stents in the management of occlusive atherosclerotic arterial disease of the aortic bifurcation
Authors: Delaney Jenna , Templeman Joshua , Hussey Keith
Published: October 2021

Introduction

A systematic review published in 2017 concluded that ‘kissing’ iliac stents to treat occlusive disease of the aortic bifurcation was associated with high technical procedural success and good medium-term patency. We have explored this in a regional vascular unit.

Methods

Retrospective review of patients managed with endovascular treatment of aorto-iliac segment (March 2015 to September 2020). The median follow-up was 2-years. Key outcome variables included the patency of the reconstruction and requirement for secondary intervention.

Results

There were 1,348 iliac endovascular procedures performed for occlusive atherosclerotic arterial disease of the aorto-iliac segment of which 56 were ‘kissing’ iliac stents. Intervention was performed for chronic limb threatening ischaemia in 29 cases. In 37 cases patients had unilateral symptoms only and in 41 cases patients had either TASC A or B lesions. Technical success was achieved in 55 cases and the median duration of admission was 1-day. At follow-up there was clinical patency in 54 cases, although there were 3 major extremity amputations performed (all on the index admission).

Conclusion

As with much of the work on ‘kissing’ iliac stents the number of patients is small and the group of patients variable in terms of medical co-morbidity, presenting clinical features and morphology of iliac disease. The procedure appears to have high technical success and can be achieved with little in the way of major morbidity. Medium term durability is good.
TP5.2.12 30-Day mortality in vascular surgery during the COVID pandemic: 1st wave outcomes
Authors: Stocco Fabio , Michel Martin , Khaliq Farihah , Sahl Abdullah Bin , Foster Joseph , Parry Duncan
Published: October 2021

Aims

To assess the 30-day mortality rate in patients undergoing vascular procedures in a single vascular centre during the first wave of the Covid-19 pandemic.

Methods

Retrospective analysis of all vascular operations undertaken at our unit from 11th March 2020 to 16th November 2020. Thirty-day mortality rate, ASA grade, 30-day Covid-19 PCR test positivity and cause of death were assessed. Mortality rate was compared to previous five-year average with a Chi- Square test.

Results

Within the observed period, 237 vascular operations were performed (49% operative reduction). 57 patients (24%) were operated electively through the “Green pathway” (day case) and there were no perioperative positive Covid-19 tests. 180 patients were operated through the “Amber” (elective Inpatient) or “Red” (emergency) pathway. Eight inpatients (4.4%) died within 30 days from surgery, similar to the average 30-day mortality observed in the previous years (5.9% p > 0.05). Three patients (1.42%) tested positive preoperatively but were all asymptomatic from Covid-19. One patient who died tested positive for Covid-19 but was asymptomatic from a respiratory aspect and died of cardiovascular disease.

Conclusion

We found no difference in 30-day post-operative mortality rate during the initial wave of Covid-19. Only 3 patients undergoing emergency operations tested positive. This study does reinforce the “Green pathway” strategy for elective patients to ensure minimising exposure to Covid-19 but we also did not witness any difference in mortality rate in the “Amber” or “Red” pathway. The impact of the second or third “wave” on current numbers will need to be studied further.
TP6.1.8 Meta-analysis and trial sequential analysis of three-port versus four-port laparoscopic cholecystectomy (Level 1 Evidence)
Authors: Hajibandeh Shahab , Finch David A , Hajibandeh Shahin , Satyadas Thomas
Published: October 2021

Aims

to compare the outcomes of three-port and four-port laparoscopic cholecystectomy.

Methods

In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port versus four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of the available evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data.

Results

Analysis of 2524 patients from 17 studies showed that three-port and four-port laparoscopic cholecystectomy techniques were comparable in terms of operative time (MD:-0.13,P=0.88), conversion to open operation (OR:0.80,P=0.43), gallbladder perforation (OR:1.43,P=0.13), bleeding from gallbladder bed (OR: 0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD:-0.00,P=0.81), bile or stone spillage (OR:1.67,P=0.08), port site infection (OR:0.90,P=0.76) and need for reoperation (RD:-0.00,P=0.94). However, the three-port technique was associated with lower VAS pain score at 12 hours (MD:-0.66,P<0.00001) and 24 hours (MD:-0.54,P<0.00001) postoperatively, shorter length of hospital stay (MD: -0.09, P = 0.41), and shorter time to return to normal activities (MD:-0.79,P=0.02).

Conclusions

Robust evidence (Level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.
TP6.2.13 A PEG insertion pathway for Motor Neurone Disease patients improves efficiency and patient outcomes
Authors: Rossi Benjamin , Salem Rola , Andrews Stuart , Bowling Kirk
Published: October 2021

Aims

Patients with Motor Neurone Disease (MND) often require a Percutaneous Endoscopic Gastrostomy (PEG) as a palliative procedure during the later stages of their illness, due to swallowing difficulties. More recently these are being inserted earlier before the inevitable decrease in nutritional intake and subsequent fall in albumin levels. This allows patients to eat food they enjoy rather than concentrating on maintaining intake.

Insertion has traditionally been done with local anaesthetic and OGD, which can be difficult and traumatic. We propose a method of insertion using TIVA (Totally Intravenous Anaesthetic) in theatre with no intubation, performed by the surgical team, with a pathway including pre-operative anaesthetic assessment.

Methods

Data was collected from all PEG insertions performed in theatre from 1/1/2011 to 1/9/2019. MND patients following our pathway were compared to all other indications for PEG insertions. Length of stay (LOS), 30-day re-admission rates, 30-day, 90-day and 1-year mortality were analysed.

Results

98 patients were identified. Median LOS was 3 days (mean 12.2) with a 3% 30-day mortality, 12.2% 90-day mortality and 34.7% 1-year mortality. In the MND group there were 27 patients. Median LOS was 2 days (mean 8.6) with a 7.4% (2 patients) 30-day mortality, which remained 7.4% at 90 days. There were 13 re-admissions (13.3%) overall compared to 0% in the MND group (p = 0.04 (Chi-squaredtest)).

Conclusions

PEG insertion under TIVA for MND patients is safe. A set pathway for admission and pre/post-insertion care increases efficiency with reduced length of stay and improves patient outcomes with no re-admissions.
TP7.2.1 Outcomes of Modified Karydakis flap in the surgical management of sacrococcygeal pilonidal disease: A single surgeon’s experience
Authors: Alam Fahreyar , Farooq Dilawar , Theofilis Aris , Wooler Harry , Payne Richard
Published: October 2021

Aim

To determine the incidence of post-operative complications of patients with sacrococcygeal pilonidal disease who were treated with the Modified Karydakis flap with a specific management bundle. Primary outcomes assessed included the post-operative incidence of seroma, haematoma, SSI, deep SSI, wound dehiscence, re-admissions, return to theatre and flap necrosis. Secondary outcome evaluated was recurrence at 6 month follow up.

Method

It was a retrospective analysis of a single surgeon’s (FA’s) practice results of Modified Karydakis flaps on patients with sacrococcygeal pilonidal disease who were managed according to a specific protocol. Data was collected between June 2017 and June 2020. 96 patients were analysed, of which 9 were excluded as they had excision without closure. Pre, per and post-operative management for the remaining 87 patients was according to a standardised protocol. Data was collected from patient’s notes and from prospectively and retrospectively maintained patient data bases (Theatre System, Medway).

Results

Primary outcomes:

• Seroma: 8/87 (9.2%)

• Haematoma: 1/87 (1.2%)

• SSI: 10/87 (11.5%)

• Deep SSI: 4/87 (4.6%)

• Superficial dehiscence: 7/87 (8.0%)

• Re-admission: 4/87 (4.6%)

• Return to theatre: 0 (0%)

• Flap necrosis: 0 (0%)

Secondary outcome:

• Recurrence at 6 months: 2/87 (2.3%)

Conclusions

Good surgical results can be obtained with Modified Karadakis flap, provided meticulous surgical technique is applied. Placement of a suction drain for a minimum of 72 hours reduces incidence of post-operative haematoma and seroma formation. Three post-operative doses of broad spectrum intravenous antibiotics followed by 5 days of oral antibiotics helps reduce post-operative infections.
TP7.2.6 Frequency of Obstructed Inguinal Hernia in Infants
Authors: Abdullah Farooq , Gulnaz Nadia , Saeed Khawar
Published: October 2021

Inguinal hernia in children is the result of the failure of obliteration of processus vaginalis or weakness of the abdominal wall. The incidence of inguinal hernia ranges from 0.8-5%. It is more common in preterm babies with an incidence of up to 30%.There is disagreement concerning the management of inguinal hernia in infants worldwide with few in favor of early repair of the hernia due to fear of incarceration while some are against it.

This study was conducted to determine the frequency of intestinal obstruction in infants with an inguinal hernia for the development of a proper protocol for the management of inguinal hernias.

Methods

A total of 112 patients were included in the study. The patient’s gender and age were recorded. The presence of hernia was confirmed clinically and by performing an ultrasound. All the relevant data was recorded in a pre-designed printed proforma.

Results

In this study, 112 children were included. 73% of children were in the age between 1-6 months and 27% children were in age between 7-12 months. The mean age was 5 months ±5.87. Male children were 86% and female children were 14%. An obstructed inguinal hernia was observed in 11% of children while 89% of children didn’t have obstructed inguinal hernia.

Conclusion

Our study concludes that the frequency of incarcerated inguinal hernia was 11% in infants mostly occurring at a younger age and in male children.
TP8.1.6 Why do people remain in hospital after mastectomy?
Authors: McLellan Morag , James Karen , Burrah Rajaram , Poonawala Shabbir , Callaghan Callaghan , Vinayagam Raman
Published: October 2021

Aims

Mastectomy is established as a safe day-case procedure. Amidst the ongoing COVID-19 pandemic it is essential to find ways to continue elective surgery with greater efficiency. The aim of this study is to establish factors associated with overnight admission after simple mastectomy, enabling more effective pre-operative planning.

Methods

All patients undergoing simple mastectomy in our unit between January and October 2020 were included. Those undergoing immediate reconstruction were excluded. The electronic case notes were reviewed to include procedure performed and patient characteristics. Basic statistical analysis was performed.

Results

95 patients underwent simple mastectomy (28 with axillary clearance and 58 with sentinel node biopsy). 56% of procedures were day-case. Axillary clearance was more common in the inpatient compared to the day-case surgery group (24% vs 45%). Both average age and ASA were significantly lower in the day-case compared to the inpatient group (p < 0.05). There was no significant difference in BMI or specimen weight between groups. 16 patients underwent simple mastectomy without drain insertion, none required admission. Of the patients admitted overnight following surgery, 50% were pre-planned admissions. 57% of these were for patients identified as high surgical or anaesthetic risk at pre-operative assessment. Overall 5 patients stayed in hospital due to patient preference.

Conclusions

In addition to axillary surgery performed, age, ASA and perceived pre-operative risk are associated with overnight admission following simple mastectomy. Knowledge of these factors can better inform pre-operative planning. Providing enhanced post-operative support at home may enable more patients to be discharged on day of surgery.
TP8.2.1 Quality Improvement Project: Improving the percentage of patients receiving their consent form copy
Authors: Hamid Mohammed , Elserafy Amr , Anis Karim , Dilworth Mark
Published: October 2021

Aim

Good practice set out by the GMC and DoH is to acquire written informed consent for surgery, despite it not being a legal requirement. Baseline data of 50 consecutive surgical cases, undertaken in the UK’s largest trust, found that only 12% of patients were being offered their consent form copy prior to surgery. We constructed a SMART aim to increase this percentage by 20% each month on the general surgical wards of a city hospital.

Method

On analysing the patients’ physical notes, the three primary drivers identified were factors intrinsic to the department, consent form and our patients; signifying there was a lack of standard awareness, education and safety-net to ensure sustainability. To tackle this in-turn, we designed three PDSA cycles: Departmental seminar and poster, legal education session, and theatre checklist adaptation.

Results

Following our first PDSA cycle, the mean percentage increased from 12% to 44%. Using projection analysis, we anticipate this to increase to 76% after the second PDSA cycle, and 100% after PDSA3, with 100% sustainability 1 year later.

Conclusions

Overall, our results to-date show that the proportion of patients receiving their consent form copy has improved following our first PDSA cycle, indicating that awareness plays an important role in the consenting process. We predict that education plays an equal role; and given the research supporting the implications of checklists, we forecast that this later element will be the ultimatum leading to 100% sustainability of patients receiving their consent form copy prior to surgery.
TP8.2.5 Taking the virtual plunge: delivering an intensive curriculum at the 'St Thomas' MRCS course' in the COVID era
Authors: Davis Heather , Patel Ashish , Wythe Odile , Chan Shirley
Published: October 2021

Aims

The Covid-19 global pandemic changed the world. Disruption to teaching and training has been felt across medicine, but more acutely in craft specialities such as surgery. The Royal College of Surgeons has raised concerns and started a campaign: ‘no training today, no surgeons tomorrow’. Innovation and adaptation are required in this new normal.

We assess the effectiveness of adapting an intensive face-to-face revision course covering essential skills and knowledge required for the Membership of the Royal College of Surgeons (MRCS) examination to the virtual world.

Methods

Over five days interactive lectures, small-group teaching (clinical examination, communication, procedural skills), and a complete mock examination were delivered by a faculty of expert lecturers, consultants and actors live over Zoom. Feedback was collected on all aspects of the course by online survey. Sessions were marked for presentation, clarity, relevance and overall quality.

Results

19 participants attended 35 sessions and six mock stations, with a total of 597 candidate sessions and 108 candidate mock stations. 94% of ratings were at least very good; 63% were excellent. Participants reported significantly improved levels of skill and knowledge (p < 0.001). Most felt skills improved from fair to very good. All candidates felt the course was well organised and allowed full participation.

Conclusion

Increasingly, medical education is occurring in the virtual world. Whilst this poses difficulty in craft specialities, particularly for skill acquisition, our data demonstrate high participant satisfaction. Moreover, significant improvements were seen in self-assessment of skills and knowledge as a consequence of this unique course.
TP8.2.6 The effect of checklists on the surgical performance during laparoscopic cholecystectomy: A systematic review
Authors: Boghdady Michael El , Tang Benjie
Published: October 2021

Aims

Laparoscopic cholecystectomy (LC) is known to be one of the most widely performed general surgical operations. However, it is still associated with an increased incidence and severity of complications especially during the period of a surgeon’s proficiency-gain curve. Certain complications could be prevented by decreasing the incidence and consequences of surgeon errors. We aimed to systematically review the use of checklists during LC and their effect on the surgical task performance.

Methods

A systematic review was performed in compliance with the PRISMA guidelines. A search was carried out on PubMed, ScienceDirect and the Cochrane-Library databases. English language articles published to November 2020 were included in this study. The terms included: ‘Checklist and laparoscopic cholecystectomy’, ‘checklist and laparoscopic surgery’, ‘checklist and cholecystectomy’ and checklist and minimally invasive surgery’’. MERSQI score was applied for quality assessment. The research protocol was registered with PROSPERO register (CRD42021209118).

Results

The results of the systematic search resulted in 8862 citations, of which 23 relevant citations were assessed for eligibility. A final 9 articles were included in this study. The endpoints were equipment-related-risk events, numbers and types of adverse events, rate of conversion to open cholecystectomy, team communication and coordination, the number of consequential and inconsequential errors. The positive effect of checklists on the performance during LC was supported with 5 high-quality studies.

Conclusion

The effect of checklists application during LC showed a significant improvement of the surgical task performance by decreasing the number of surgeons’ errors. We envisage the routine use of checklists during LC.
TP8.2.10 Impact of COVID-19 on General Surgery Training in a University Hospital with Ring Fenced Elective Centre
Authors: Gala Tanzeela , Ain Quratul , Obasi Chekwas , Rashid Hajar , Radha Sarkhell , Vig Stella
Published: October 2021

Aim

Higher Surgical training was decimated by the COVID-19 pandemic with cessation of elective care. Trainees raised concerns that the elective restart and need for higher theatre activity to clear backlogs would impact on training opportunities. This study evaluated the resumption of training associated with a ring-fenced elective centre (EC).

Methods

The EC was established in July 2020 and three time periods were determined: pre-COVID (10/19-2/20), 1st wave of COVID (3/20-7/20) and post EC go-live (8/20-12/20). Data was collated from the E-Logbooks of General Surgery Registrars.

Results

The normal all-speciality pre COVID theatre-activity averaged 1052 cases/month. During the first wave elective activity decreased to 254 cases/month (24% of normal activity). Within 5 weeks of establishment of the EC, theatre activity was near normal despite a reduced number of theatres (with higher theatre utilisation).

Pre COVID, trainees accessed 22.9 cases per month which then dropped to 7.7 cases during the first wave of COVID. Post the go live of the EC, trainees were able to operate on 20 cases per month almost back to normal training levels.

Prior to the impact of the second wave, each trainee had developed a deficit of 90 cases during the 5 months pause.

Conclusion

The ring-fenced elective centre has protected training opportunities for higher surgical trainees. However, the pause in training requires a targeted training recovery plan to overcome the deficit secondary to the first and subsequent waves of COVID to ensure that the JCST target of 1200 cases can be met for CCT.