bluuebunny/crossref_metadata_2025 huggingface dataset:
657 A Retrospective Cost Analysis of Group and Save Samples Performed Prior To Vascular Procedures
Authors: Akula B , Vijaynagar B
Published: October 2021

Aim

To assess if routine group and save is indicated prior to all vascular procedures.

Method

A retrospective review of all patients who were admitted to vascular ward between 1st to 30th June 2020 was performed using our hospital database. The following data was retrieved: admission diagnosis, preoperative haemoglobin, number, and type of vascular surgeries performed, number of G&S sent and total number requiring transfusion.

Results

Total 81 patients were admitted, all had a G&S on arrival with routine bloods. All preoperative patients need 2 G&S prior to surgery as per trust policy.69 patients underwent surgery.111G&S were processed.51 patients had 1 G&S on admission as they had a previous sample.28 patients had 2 G&S either because they had no previous records or had postoperative complications.2 patients required multiple transfusions so had >3 G&S each. 8 out of 81 patients needed peri-operative blood transfusion. 7 of them had undergone limb or toe amputations and 1 patient had ruptured AAA. The cost of single G&S sample is £30.8. Patients undergoing angioplasty, bypass, carotid endarterectomy (n = 46) did not require transfusion, but the expenditure incurred by performing g&s in these patients was £1570.8

Conclusions

Peri-operative blood transfusion rates were 9.8%. Judicious use of G&S could have saved £1570.8 to the trust. Rationalising preoperative G&S policy would lead to substantial financial savings.
752 Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?
Authors: McCabe R , Davis J , Grainger M
Published: October 2021

Aim

To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging.

Method

A retrospective review of 101 ACDF patients from a single neurosurgical centre. 78 had an in-hospital post-operative radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’. All patients had intra-operative imaging of completed instrumentation. Any post-operative complications were noted, and the length of hospital stay (LOS) recorded. Study parameters also included: levels operated on, whether or not a plate was used with a cage, additional costings to the hospital.

Results

There was one post-operative complication relating to the metalwork in the 101 patients. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year.

Conclusions

In patients who undergo ACDF surgery with an uneventful post-operative course and satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.
774 Paediatric Appendicitis Score (PAS): A Local Trial of a Risk Prediction Pathway
Authors: Darwich A , Lim J , Malik A , Paul S , Verma K
Published: October 2021

Aim

Right iliac fossa (RIF) pain remains the commonest acute general surgical presentation in children. Our centre had been an outlier compared with the national average in terms of negative appendicectomy rates. Thus, we designed and implemented a local pathway for risk stratification and management of children with RIF pain.

Method

The first phase was a retrospective analysis of all appendicectomies performed between April 2018 and March 2019, in children aged five to seventeen years old. Pre-operative inflammatory markers, clinical signs, and histology findings were analysed. Second phase involved designing a pathway utilizing Paediatric Appendicitis Score (PAS), a ten-point scoring system when assessing children with RIF pain. The final phase was a prospective analysis of appendicectomy results performed between August and November 2019, after implementing PAS pathway.

Results

92 cases were recruited in the first phase (mean age 12.3). 22 cases were analysed in the final phase after implementing PAS pathway (mean age 10.9). Our negative appendicectomy rates had reduced from 25% to 15.4%. In addition, we found that 96% of positive appendicectomies had either raised inflammatory markers (WCC or CRP), raised PAS (Score of ≥ 4), or both.

Conclusions

There is noticeable difference in our negative appendicectomy rates since the introduction of PAS pathway. A diagnosis of appendicitis in a child with normal inflammatory markers and PAS score seemed unlikely. Our goal is to continue utilizing the PAS pathway in our department in order to reduce unnecessary surgeries in children.
865 Reducing Delays in Cholecystectomy Surgery of Patients Admitted with Gallstone-Related Disease Within Gold Standard Time Frame Set Out By NICE
Authors: Adnan A , Ahmed M , Vaz O , Sultana A
Published: October 2021

Introduction

As per NICE guidelines, Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) aims for 80% of eligible patients with gallstone-related disease to receive their cholecystectomy within 8 days of presentation1. Only 63.6% of eligible patients at East Lancashire Hospitals NHS Trust (ELHT) had their surgery within the target time. This project was done to identify the reasons behind ELHT not achieving the set target and to implement changes to overcome this.

Method

This was a retrospective review of a prospectively collected data of 444 patients from the ELHT Chole-QuIC database (July 2019-November 2020). Data were analysed in three periods: initial period (July 2019-November 2019), pre-COVID-19 period (December 2019-February 2020), COVID-19 period (March 2020-November 2020). Time to surgery was established. If the 8-day target was not met, reasons behind the delay were recorded.

Results

During the first cycle, the main reasons delays included the patients being temporarily unfit (13.8%), insufficient theatre capacity (13.8%) and variations in treatment plans (11.32%). 8% of patients had re-admissions related to their gallstone disease. Changes were implemented forward included a clear local gallstone disease management pathway and CholeQuIC referral system, increasing theatre capacity, and allocating pre-operative assessment slots. Gold standard cholecystectomy target period improved from 63.6% to 67.4% within three months of changes. However, the figure drastically reduced during the COVID-19 pandemic (36.3%) as elective surgeries were temporarily suspended.

Conclusions

The implementation of a gallstone disease management pathway, a coordinated referral system and additional theatre capacity contributed to the increase in cholecystectomies that were performed within the 8-day national target period.
919 Surgical Voice Restoration – Improving Out of Hours Management: A Multidisciplinary Quality Improvement Project
Authors: Wallace J , McCord J , Roberts B , Browning S
Published: October 2021

Aim

Swansea Bay University Health Board have a caseload of 37 surgical voice restoration (SVR) laryngectomies. These patients are excellently managed during working hours, by a SALT-led service. Concerns were raised regarding the quality of out of hours management: the aim of this project was to identify and address the factors contributing to the difference in care received.

Method

A questionnaire was sent to current junior doctors to assess knowledge and confidence when managing SVR patients. Phone interviews were conducted with SVR patients to discuss the issues from a patient’s perspective. The junior doctor team and SALT team liaised to identify contributing logistical issues.

Results

The junior doctor survey indicated both experience and confidence were low, including amongst senior trainees. 58.3% were unfamiliar with equipment used to change a speech valve. Patient interviews revealed several issues, such as delays to treatment and unnecessary admissions. Logistical concerns included inability to access equipment out of hours and an absence of departmental guidelines.

Conclusions

This project demonstrates a collaborative approach between junior doctors and SALT, to improve the quality of care for a sub-set of patients with highly specialised needs. We identified the contributing factors for the disparity in services and tailored interventions to provide the junior doctors responsible for out of hours care, with the knowledge and skills to provide a better standard of care.
944 Outliers: The Forgotten Patients
Authors: McConaghie G , Osei-Bordom D C , Charan M
Published: October 2021

Aim

It was recognized that surgical wards often have a large number of patients outlied to them. Unfortunately, it was also noted that they often were not regularly seen and so had no daily medical plan. Evidence shows outliers have:

The aim was to develop a means of increasing outlier reviews, plans and awareness of outlier parent speciality.

Method

Medical outliers and outliers from other surgical specialties were included looking at how often care plans were updated and if the nurses knew who and how to contact the patient's named consultant/team. Brightly coloured posters were created to highlight the importance of a patient plan and how to escalate a request. Stickers were created for the notes to highlight outliers and their last plan and their named consultant/team. The effect of the interventions was tracked for just under 6 weeks.

Results

Initial assessment showed care plans were only updated twice a week and nurses were largely unsure who to contact for an individual outlier. With the increased awareness the nurses achieved three reviews a week with patient plans. Importantly, during the review period there were no adverse events, and the nurses reported increased confidence in who to approach. Patients were also discharged earlier and not moved to another ward.

Conclusions

The nurses were empowered, and the patients benefitted from more regular reviews and up to date plans, importantly resulting in fewer adverse events and quicker discharges.
961 ROSE's Proforma: A Tool to Improve Quality and Safety of Surgical Handover
Authors: Mancuso R
Published: October 2021

Aim

Accurate and rigorous handover is paramount in surgery. Human factor can unfortunately affect handovers resulting unsafe for patients. The ROSE’S handover proforma is a structured methodology which has been created according to the RCSEng guidelines to facilitate communication ensuring an effective delivering of information concerning the care of surgical patients.

Method

ROSE is the acronym for REASON, OBSERVATION, SHIFT, ESCALATION and it is made of multiple subparts that cover the majority of the information that need to be shared between team members such as wound care, NEWS score, medications, diagnostic tests, assessments of lines (catheter, cannula, drain, CVC), social situation, deterioration, medical history as required by guidelines of RCSEng. The timing of 40 handovers has been recorded, of these 20 were performed by using the ROSE’s form. A questionnaire has been administered before and after the implementation of the Rose’s handover.

Results

The average time for handover a surgical patient increased from 1.07 to 3.26 minutes with ROSE’s form. The 82.14% of the staff who tried it thought that the form resulted easy to navigate, brief and complete in details. It is a safer practice for the 71.43% of the staff. The quality and the accuracy of the handover given was perceived as improved by the 96.46% of the staff that used it.

Conclusions

A structured surgical handover performed with a written form can be an easy and safe tool that can minimize human factor and technical errors especially out of hours. Clearly further research is needed; however, the preliminary results look encouraging.
1161 Streamlining the Patient Journey for Operative Management During COVID 19
Authors: Skinner H , Williams P , Greenlees G , Ilyas C , Schofield C , Lotia S , Amtul N
Published: October 2021

Aim

Leeds, UK is a high-volume acute surgery unit. Emergency operating was drastically affected by the pandemic and time from admission to definitive procedure significantly increased. This intervention aimed to streamline the patient journey from acute admission to the operating theatre.

Method

An audit considering delays to transfer, theatre access and recovery discharge, along with the criteria used for ‘Hot’ theatre was undertaken. Data was collected prospectively between 02/06/2020-06/07/2020 via a standardised proforma. Preliminary results suggested a geographically remote ‘hot’ theatre was associated with multi-factorial delays so was relocated to more familiar surroundings. This was re-audited between 06/07/2020-06/08/2020 aiming to characterise factors contributing to delay. A dedicated in-hours acute theatres porter was introduced for a trial period. Data was collected retrospectively between 24/08/2020-14/09/2020 and prospectively between 14/09-05/10/2020 via hospital electronic systems.

Results

Initially the average time from patient transfer to leaving theatre recovery was 4h6m55s (N = 52). Relocating theatres reduced this to 2h48m04s (N = 74)- an average reduction of 1h18m51s. The greatest reduction was seen in anaesthetic time between 1h17m54s to 41m29s. The introduction of a dedicated porter reduced the average transfer time to theatre from 36 minutes (N = 53) to 21 minutes (N = 68) (p < 0.05).

Conclusions

Delay to theatre has a high cost financially and in its effect on patient outcomes. Delays are often multifactorial and robust systems are essential to minimise delays. Patients are best served by well-trained, dedicated ‘Acute’ team in familiar surroundings. Long-term implementation of dedicated portering service will save time, money and improve patient care.
1212 A Novel Approach to Alleviating Surgical Anxiety: QI Study in a Primary Care Government Centre
Authors: Peri H
Published: October 2021

Aim

Surgical Anxiety is a challenging problem in the peri-operative care of a patient often leading to poor surgical outcomes and repeated visits by the patient to the hospital. Despite being well documented, in practice, it still remains the most neglected and haphazardly adopted part of patient care. This study aimed to make the overall experience of surgery, safer and pleasant to the patient by instituting a novel, multimodal and easy to follow protocol.

Method

A self-made questionnaire formed the source for data collection from 43 patients listed for elective surgery in a government setup, throughout the duration of their admission and review period. Patient satisfaction rate was assessed by re-audits, post implementation of changes via a Plan-Do-Study-Act (PDSA) cycle. The ease of protocol administration and sustainability were assessed from staff via an audit and it was further simplified to ensure adoption was easy and patient satisfaction rate remained high as well.

Results

Initial audit showed only 49% (n = 21) of patient satisfaction rate at the time of admission. Significant variations of > 90% (n = 39) patient satisfaction rate was noted post implementation of changes after the first PDSA cycle. A second PDSA cycle was instituted to simplify the protocol and post audit >90% acceptance rate from staff were noted.

Conclusions

Shared Decision Making, Peer Support Groups, Adequate knowledge of the treating surgeon, the disease, treatment modalities and complications instituted via a proper protocol helped to alleviate surgical anxiety and prepare a positive patient for surgery.
1255 Crowdedness and Consequences of Long Waiting Time in Public and Private Health Centers Among Patients in Khartoum State, Sudan - 2016
Authors: Ibrahim A , Elkhidir O , A’lam Elhuda D , Elhassan A , Salman M , Ali A , Elkhidir I , Abuzied A , Elhassan M , Mohammed O , Noureddin A
Published: October 2021

Aim

Waiting time (WT) reflects quality of services delivered by Primary health care level. Long waiting time is due to various causes, among which crowdedness is a main cause. This prolonged time has negative impacts on PHC services utilization as well as patients’ outcomes. The aim of this study is to measure the total WT, assess the crowdedness in PHC centers, and to determine the possible consequences of this long waiting time.

Method

Descriptive cross sectional– health institution-based study done in 40 Health centres across Khartoum state using randomized multi-stage sampling. Patients, doctors and lab technicians were interviewed using three different pre-tested structured questionnaires.

Results

A total of 477 patients were included in the study. The average waiting time was found to be 168 minutes. Crowdedness was one of the main causes of delay in waiting time. The lab was the most perceived crowded service (74.4% of the respondents). This long WT had health consequences on patients, ranging from backache, joint pain, and headaches to hypoglycemic symptoms. These symptoms affected patients' willingness to return to the same center. 36.4% of the affected patients were unwilling to revisit the same center.

Conclusions

WT in this study is longer compared to studies from other countries. Crowdedness is one of the main causes of long WT. Due to this prolonged time, patients experienced physical symptoms. It also affected their future attitude regarding PHC centers utilization. There is a need to understand the underlying causes of this issue and address them appropriately.
1270 Secondary Survey Documentation in Trauma Patients - A Review Following Implementation of a Dedicated Trauma Ward
Authors: Blacklock C , Jones K , Baker G , Kealey D
Published: October 2021

Introduction

A secondary survey is a detailed head to toe assessment performed in trauma patients following initial primary survey and patient stabilisation. It forms part of the ATLS guidelines and is an important tool in the recognition of patient injury. We performed an audit within the Regional Trauma Unit to assess the standard of documentation of secondary surveys in trauma admissions. We then repeated this audit following staff teaching and the implementation of a dedicated Trauma Ward, with an aim of improving secondary survey documentation and the early recognition and management of associated injuries.

Method

Admission notes for all trauma patients admitted in the three months prior to the opening of the dedicated Trauma Ward were reviewed for documentation of a secondary survey (n = 30), with the incidence of any missed injuries on follow up recorded. A further audit loop was then performed on all trauma admissions following the opening of the Trauma Ward and trauma staff teaching (n = 52).

Results

Complete documentation of a full secondary survey improved from 10% to 98% for trauma patient admissions. This also improved early identification of initially missed injuries from the primary survey including extremity fractures, chest trauma, and multi-ligament knee injuries.

Conclusions

Secondary surveys are an important tool in assessing trauma patients and can help identify significant injuries. The implementation of a dedicated Trauma Ward along with teaching to the trauma staff has led to an improvement in performance of secondary surveys with a direct improvement in identifying associated injuries in trauma patients.
1323 Assessment of The Appropriate Use of Imaging and Reporting in Acute Pancreatitis in A Secondary Care Setting
Authors: Kirchhoff C , Omokehinde T J , Achunine P , Marshall C , Ikechi C , Shah A
Published: October 2021

Aim

Acute pancreatitis is the world's most common gastrointestinal disease requiring hospital admission. Our audit aim was to assess the timeframe within which Abdominal Ultrasound Scans (USS) and Computerised Tomography (CT) were performed, reported indications for CT and the prognostic factors noted in imaging reports.

Method

A retrospective search included admissions with acute pancreatitis between 01/09/19 to 30/11/19, collecting demographics, admission time & date, time and date of both radiological investigations and imaging reports. Patients under the age of 18 were excluded.

Results

This search identified 75 patients (M:F, 40:35) with a median age of 53 (18-95) years. USS were performed within 24 hours of admission in 40.0% (n = 30) of cases. Out of the patients (n = 44) who received a CT scan, 15.9% (n = 7) were scanned after more than 72 hours of onset of symptoms and 84.1% (n = 37) were scanned within less than 72 hours. Furthermore, 88.6%(n = 39) of CT request indications were in keeping with our standards. The average length of hospital stay was 6.1 days when scanned within 72 hours and 11.8 days when scanned after more than 72 hours.

Conclusions

Only 17.3% (n = 13) of the patients audited met all our standards and were managed according to the guidelines. The average length of hospital stay was half in those who had a CT scan after more than 72 hours of admission and this was also used to monitor disease progression/regression.
1352 BMJ Military Health Webinar Series – Continued Professional Development for Medics and General Duties Medical Officers
Authors: Herron J
Published: October 2021

Aim

The UK DMS delivers military CPD at a local level. Medics are taught at the regimental level and GDMO’s can vary from local teaching, regimental teaching, or no teaching. GDMO’s are GMC mandated to have CPD covering all areas of practice. Due to the nature of the deployable role of both staff groups it is difficult to deliver consistent teaching that can be revisited. We aimed to deliver regular, consistent, high-quality teaching delivered by SMEs on military relevant topics.

Method

A Plan, Do, Study, Act approach was used with predefined measures such as structure, process and outcome elicited via a participant survey. Virtual teaching via MOD Zoom monthly for each group was arranged. Teaching focused on medic portfolio competencies, the GDMO syllabus. Teaching was delivered by tri-service SMEs, the sessions were recorded and edited and subsequently uploaded to the BMJ Military Health website at no cost.

Results

16 webinars, 8 to Medics and 8 to GDMOs have been delivered. Maximum attendance has been 130 tri-service participants including reservists. Feedback from 111 SP been positive with 65% and 28% of participants rating the teaching as excellent or very good respectively. 98% stated the teaching is relevant to their practice, and 89% agreed the teaching will change their practice going forward.

Conclusions

We have demonstrated that it is possible to deliver sustainable high quality, relevant, and practice changing sessions across all three services. This teaching has had active engagement from the user community and senior SMEs within the DMS for minimal cost.
1376 Latex Allergies: Seeking an Alternative to Minimise Risk in The Operating Theatre
Authors: Zargaran A , Zargaran D , Ashraf M , Khanal P , Srivastava A , Mosahebi A
Published: October 2021

Introduction

Natural Rubber Latex (NRL) gloves have been ubiquitously used in surgical practice. Over the past few decades, there have been many reports of NRL allergies associated with their use presenting a safety hazard to both patients and healthcare workers. Powder-free and latex-free gloves have been shown to offer reductions in incidence of allergic reactions, as well as cost savings.

Method

We performed a literature search to identify the rates of reaction to latex across the population in addition to the associated costs including litigation costs, costs of admission, and lost work time associated. We further looked at the rates of perforation of alternatives and the costs associated with such a transition.

Results

The UK prevalence of sensitisation amongst healthcare workers has been estimated to be 10%. The average cost of litigation to the employer was found to be $21,402 per claim. The mean cost of inpatient care for anaphylaxis has been cited as £469.88, with additional costs such as follow-up representing approximately £400. A 14-month study found cost savings of $10,000pa with a switch to non-latex gloves. Furthermore, an overall perforation rate of 80% in a latex-free glove compared to 34.4% in a latex glove.

Conclusions

From a business perspective, there is evidence of cost-savings arising from a switch to latex-free gloves, however, formal cost-effectiveness analyses would inform future decisions. Furthermore, comfort and reducing the chances of allergic reactions through removing the offending allergen all represent benefits of switching to latex-free gloves, however, non-inferiority analyses will inform future strategies both locally and nationally.
1549 Patient Perception on Hand Trauma Management Through a Plastic Surgery Trauma Clinic
Authors: Khan M , Iqbal A
Published: October 2021

Aim

We assessed patient perceptions of hand trauma management through a plastic surgery trauma clinic. We also assessed effects of educating patients about outcomes of their condition on their desire to have prompt surgery.

Method

A prospective survey review was conducted at our plastic surgery trauma clinic. Patients included were those referred due to simple hand trauma. Any patients needing urgent admissions were excluded. An anonymous survey assessing patient perceptions before and after education about delay in surgery was distributed.

Results

Of 100 patients, there were mixed expectations regarding trauma clinic; 38% (n = 38) expect an operation, 32% (n = 32) expect no operation and 30% (n = 30) expect either option. 90% (n = 90) expect surgery within a week (50% n = 50) or within a day (40% n = 40); 10% expect it (n = 10) within a few weeks. After educating patients about no negative effects on their condition from surgical delay, 43% (n = 17) fewer patients desired surgery within a day, and 8% (n = 3) fewer patients desired surgery within a week. 190% (n = 19) more patients were willing to have surgery within a few weeks. 79% (n = 79) would rather come back at a guaranteed surgical slot than stay in hospital until a slot is available. 72% (n = 72) considered knowledge about long-term outcomes associated with surgical delay to influence their decision more than anaesthetic type (12% n = 12) and personal circumstances (16% n = 16).

Conclusions

If appropriate patients are assured that their condition will not be affected by surgical delay, fewer patients may stay in hospital with financial benefits of reduced bed occupancy and reduced covid risks.
727 Robotic Assisted Versus Fluoroscopic Guided Approach in Pedicle Screw Insertion: A Systematic Review and Meta-Analysis
Authors: Tan T K , Tan J Y , Ng K T , Ahuja S
Published: October 2021

Aim

The robotic assisted surgery has become prevalent in most of the surgical subspecialty. The adaption of such technique in spine surgery has resulted in minimising several issues encountered with fluoroscopic guided approach. The aim of this study is to compare the outcomes of robotic assisted approach and fluoroscopic guided approach in pedicle screw insertion.

Method

PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All the studies comparing robotic assisted surgery and fluoroscopic guided approach in pedicle screw insertion were included for quantitative and qualitative analysis.

Results

Twenty-eight studies enrolling 2105 patients (robotic group: 1027, fluoroscopic: 1078) and total screws of 8668 screws (robotic group: 4217, fluoroscopic group: 4451) were eligible for inclusion, these studies consisted of 19 observational studies, 7 randomised controlled trials (RCTs) and 2 cadaveric study. Robotic assisted approach was associated with significantly higher accuracy (Grade A+B) (OR = 2.34; P < 0.0001) and distance between pedicle and screw (MD: 1.69; P = 0.001), lower incident of facet joint violation (OR = 0.22; P < 0.00001), screw revision (OR = 0.38; P = 0.009), intraoperative blood loss (MD: -116.95; P = 0.0006), shorter pedicle screw placement time (MD: -4.66; P < 0.00001), radiation exposure time (MD:-5.27; P = 0.0001), radiation dose (MD:-22.30; P = 0.0002) and postoperative hospital stay (MD: -0.79; P = 0.02) compared to fluoroscopic guided approach. There was no significant difference in operative time and wound infection.

Conclusions

In this meta-analysis, robotic assisted approach is more effective in achieving better clinical outcomes compared to fluoroscopic guided technique in pedicle screw insertion. However, future adequately powered RCTs are warranted to generate standardised outcomes.
1441 Real-World Comparison of Curative Open, Laparoscopic and Robotic Resections for Sigmoid and Rectal Cancer - Single Center Experience
Authors: Ansari S. Akhter , Ahsan Javed M , Hedayat F , Harris C , Sheikh A
Published: October 2021

Aim

There is an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. The aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer.

Method

One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons, using a standardized technique, between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield.

Results

Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups.

Conclusions

Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.
465 Split-thickness Skin Graft Harvest under Local Anaesthetic: A Single Pass Technique
Authors: Begaj A , Asher C , Hamilton A
Published: October 2021

Adequate local anaesthetic, in harvesting a split thickness skin graft (SSG), involves multiple passes of a needle across the length and width of the marked donor site.

We describe a technique using hyaluronidase to uniformly anaesthetise an SSG donor site with one injection, in one pass of one needle. Mix 10mls 1% Lidocaine solution with Adrenaline 1:200,000 with 1 vial Hyaluronidase 1 Unit/ml solution. The mixture is buffered with 1 ml NaHCO3 to neutralise acidity and minimise pain.Mark out the SSG donor siteUsing a 27G long needle (sterican), enter perpendicular to the skin in the middle of the proximal aspect of the donor site. Inject some local anaesthetic subdermally, creating a mound.Change the angle of the needle to 180 degrees and continue to inject the remaining anaesthetic along one half of the width of the donor site.Using a rolled 4x4 swab, apply firm advancing pressure to distribute the mound across the remaining width and length of marked donor site.As the mound advances, the hyluronidase/anaesthetic mixture will distribute uniformly across the donor site within the same plane. The skin blanches secondary to the adrenaline during its distribution.

The technique described is a fast, reproducible way to improve patient comfort through the elimination of repeated passes of a needle, distribute the anaesthetic uniformly across the donor site, and facilitate the acquisition of an SSG of uniform thickness

The technique described is a fast, reproducible way to improve patient comfort through the elimination of repeated passes of a needle, distribute the anaesthetic uniformly across the donor site, and facilitate the acquisition of an SSG of uniform thickness
584 Novel Methods of Detecting Tumour Margins in Gastrointestinal Cancer Surgery
Authors: Perrott C , Patil A , Elson D , Peters C
Published: October 2021

Aim

Gastrointestinal (GI) cancers account for 26% of global cancer incidence with prevalence projected to rise exponentially due to the ageing population and lifestyle choices. Surgical resection is the mainstay of treatment to remove the cancer in its entirety to achieve an R0 resection. Positive margins, when cancerous tissue has been left in situ, is associated with increased morbidity and mortality. Current margin assessment involves histopathological analysis, after resection of the specimen. Diffuse Reflectance Spectroscopy (DRS) and Hyperspectral Imaging (HSI) are novel imaging techniques that have the potential to provide real-time assessment of cancer margins intra-operatively to reduce the incidence of positive resection margins and improve patient outcomes. The aim of this review is to assess the current state of evidence for the use of novel imaging techniques in GI cancer margin assessment.

Method

A literature review was conducted of studies using DRS and HSI in GI cancers in adult patients, published from inception to October 2020.

Results

A total of 15 studies were analysed, nine of which used DRS and six used HSI and the majority of studies were performed ex-vivo. Current image acquisition techniques and processing algorithms vary greatly. The sensitivity and specificity of DRS ranged from 0.90-0.98 and 0.88-0.95 respectively and for HSI 0.63-0.98 and 0.69-0.98, respectively across five types of GI cancers.

Conclusions

DRS and HSI are novel imaging techniques, currently in their infancy but the outlook is promising. With further research focused on standardising methodology and in-vivo settings, DRS and HSI could transform intra-operative margin assessment in GI cancers.
783 Digital Weekend Handover an Effective Documentation
Authors: Chowdhury S , Bhandari M , Quake S , Ahmed I , Ibrahim B
Published: October 2021

Aim

To assess quality of completion for weekend handover for surgical weekend and to plan and design a Digital handover, the implementation and effect of which is studied.

Method

Data collection from TRAKCARE for documentation completion criteriae including diagnosis, further investigations to chase (e.g., bloods, imaging), discharge plans, escalation and DNAR status identified.

First cycle collected in August 2020 for pre-implementation status and standard. Second cycle was collected after implementation and raising awareness about new system in October 2020.

Exclusion criteria: patients discharged prior to weekend

Results

32 (10f 22m) and 22 (9 f 13m) patients were studied in first and second cycle with a respective median length stay of 243 hours and 161.5 hours. Handover entries had improved from 40.6% completion rate to 77.3% these included a diagnosis and management plan. Required blood investigation plans were recorded in 54.5% patients (previously 9.4%). Escalation plans including DNACPR and ceiling of care were improved from 25% to 31%.

Conclusions

Digital Medical recording left a gap in documentation for weekend ward rounds when personnels are thinned and busy. To optimize clinical care, the use of a E weekend handover has improved documentation greatly. Future Ongoing project includes improving escalation plans further.
980 Technological Innovations in The Management of Pressure Ulcers: A Systematic Review and Discussion
Authors: Srivastava A , Khanal P , Zargaran D , Zoller F , Zargaran A , Mosahebi A
Published: October 2021

Aim

Pressure ulcers (PUs) affect over 700,000 patients per annum and are associated with an up to fourfold increase in mortality rate in older populations with complex pathologies. NICE guidelines for PU management involve a combination of low-grade technological interventions, including dressings and foam mattresses, while technology-centric therapies are not offered. The aim of this systematic review is to evaluate the effectiveness of any novel and high-grade technological PU interventions.

Method

The PubMed, Embase (via Ovid), Web of Science and CINAHL databases were electronically searched using free-text and MeSH search strings. Results evaluating the type of technological intervention, outcome measures and wound healing rates, duration of hospital stay, requirement for surgical debridement, infection and mortality rates were methodically assessed.

Results

An initial search identified 900 articles. Using the PRISMA guidance, 25 studies were included, encompassing 845 patients. 28 novel modalities of high-grade innovations were identified, with distinguished technologies including smart wireless bandages and 3D-printed wound repair scaffolds. Overall, 92.8% of devices demonstrated an improvement in wound healing (P < 0.05). A novel framework was created from the different innovations identified to approach adopting innovation in PU management.

Conclusions

The majority of high-technology innovations identified in this systematic review significantly improve PU healing, thus offering an additional pathway to standard care. Given the annual cost of PUs (£531 million), it is vital innovative technologies are considered as the NHS transitions into a digital age. Therefore, further studies are essential and recommended to evaluate the potential benefit of the promising, innovative technologies identified.
1113 Surgical Innovators or Spin Doctors: Reporting of Expectations for Robotic Gastrointestinal Surgery
Authors: Dixon L , Biggs S , Turner B , Embury-Young Y , Wood F , Leandro L , Lok P , Scroggie D
Published: October 2021

Introduction

The use of robotics in gastrointestinal surgery is an increasingly popular area of surgical innovation. Despite uncertainty regarding clinical benefits, gastrointestinal surgery centres continue to introduce robotic services. This may be motivated by perceived benefits, in lieu of substantial empirical benefits. We aimed to summarise the expected advantages and disadvantages of robotic techniques in gastrointestinal surgery, as reported by study authors.

Method

A systematic review was undertaken by the trainee led RoboSurg Collaborative. Searches were conducted on of Embase, Medline, the Cochrane Library and Web of Science. Articles were double screened by abstract, then full text. All primary studies reporting outcomes following robotic cholecystectomy or oesophagectomy were included. Reports of expected benefits and disadvantages or robotic techniques were extracted verbatim, and summarised using descriptive statistics.

Results

We included 192 studies. An expected benefit was reported in 161 (84%). Of those, 127 (79%) expected robotics to have an intra-operative advantage, such as reduced operative time, improved dexterity and improved visualisation. Post-operative benefits, such as reduced recovery time and shorter length of hospital stay, were expected in 72 (45%). Expected disadvantages were reported in 96 (50%) of the included studies. Of those, 74 (77%) expected robotics to have intra-operative disadvantages such as increased operative times and lack of tactile feedback. Increased cost was another commonly expected limitation.

Conclusions

Study authors reported perceived benefits more frequently than disadvantages. Perceived benefits were more commonly advantageous to the surgeon rather than the patient. There were directly conflicting perceptions of how robotic techniques affect operative times.
1172 Maggot Debridement Therapy (MDT) In Treating Group A Streptococcus Necrotizing Fasciitis of The Lower Limb as A Part of Multimodal Therapy
Authors: Haroon M , Alsahaf O , Asure A , Eguare E
Published: October 2021

Background

Medical-grade maggots have been commercially available recently and today there is a resurge interest in MDT. They are approved for debridement of wounds with necrotic tissue, including pressure ulcers, venous ulcers. However, for necrotising fasciitis, it has been used with precaution due to the complexity of the disease. In our practice, Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections. Worldwide, Case reports on the results of 15 patients with necrotizing fasciitis treated with MDT have been reported. However, in current practice, Maggot Debridement therapy has not been widely applied.

Case presentation

A 63-year-old lady admitted to a general surgery ward with uncomplicated cellulitis of the right leg. After 2 days, the patient then was diagnosed with Necrotising fasciitis which was treated with wound debridement. Postoperative histopathology specimen confirmed necrotizing fasciitis V.A.C. VERAFLO™ Therapy was used postoperatively followed by two more debridement sessions. To reduce the need for further surgical debridement Maggot Debridement Therapy was started. Over the next 3 weeks, six sessions of Maggot Debridement therapy were applied to the infected area. Skin grafting then was performed 3 months later. The patient then discharged home with regular surgical fellow up.

Conclusions

NF is a complex disease, associated with high morbidity and mortality. Multimodal therapies are essential to achieve aggressive yet conservative wound debridement with preservation of viable tissue. This case report showed that MDT is a feasible, safe, cost-effective option that to be added to the other treatment modalities
309 Does Anaesthetic Type Effect Positive Excision Margin Rate for Non-Melanoma Skin Cancers?
Authors: Page D
Published: October 2021

Aim

Australia has the highest incidence of Non-melanoma skin cancers (NMSC) in the world estimated to be 2448/100,000 population with the state of Queensland carrying the highest burden. Surgical excision is the primary treatment and makes up a large proportion of general surgical lists in regional Queensland where they are typically removed using either local anaesthetic (LA) alone, local anaesthetic and sedation (LAS), or general anaesthesia (GA). There is little in the literature to suggest if anaesthetic type effects the rate of involved margins. The purpose of this study is to establish if anaesthetic type impacts the rate of positive excision margins in regional hospitals in Queensland.

Method

A retrospective audit was performed, incorporating a total of 194 squamous and basal cell carcinoma lesions excised between October 2019 and October 2020 at two hospitals in regional Australia. Data was recorded for the type of anaesthetic used and the histopathology of the lesions including type of lesion and microscopic margin involvement.

Results

Of the 194 excised lesions 39 of them had involved margins (20.1%). The rate of involved margins under LA, GA and LAS were found to be 19.79%, 18.52% and 22.73% respectively. When comparing these modalities with each other: LA vs GA, LAS vs GA and LA vs LAS no significant difference was found in involved margins for excision of NMSC with p-values (<0.05) of 1, 0.624 and 0.8225 respectively.

Conclusions

Modality of anaesthetic used for excision of NMSC does not affect the outcome of margin involvement.
498 Improving Surgical and Non-Surgical Oncological Outcomes in Patients with Head and Neck Cancer
Authors: Atkinson B , Wilson J
Published: October 2021

Introduction

Treatment of head and neck cancer is complex and involves a multi-disciplinary approach between surgeons and oncologists. Radiotherapy often leaves patients with debilitating side effects such as mucositis, sialadenitis and dysphagia. Radiation induces double strand breaks (DSBs) in DNA within both normal squamous cells and squamous cell carcinomas (SCCs) that, if left unrepaired, initiates programmed cell death. Like normal squamous cells, SCC’s have an effective DNA repair pathway to protect against apoptosis by repairing DSBs through proteins such as FanD2-S331. This study aims to show that mild hyperthermia inhibits FancD2, therefore having the potential to increase the susceptibility of SCCs to radiotherapy and subsequently reducing the side effects.

Method

Head and neck cancer cell line UMSCC47 was cultured, then irradiated with 2 Gray before washing with an anti γH2AX antibody, used as a biomarker for DSBs. Fluorescent antibodies against FacD2-S331 were then used to assess the levels present within the nucleus of cells exposed to mild hyperthermia (39 °C) and then compared to untreated cells and cells exposed to radiation only.

Results

A γH2AX fluorophore intensity score of 58 following radiation compared to 20 in the control confirmed the presence of DSBs. A FancD2-s331 fluorophore intensity score of 76 was observed in cells exposed radiation. Cells exposed to heat prior to radiation showed a FancD2-s331 fluorophore score of 21.

Conclusions

Exposure of SCCs to mild hyperthermia before radiotherapy reduces activation of DNA repair protein FancD2-S2331. A reduction in DNA repair increases the susceptibility of SCCs to radiotherapy and apoptosis.
561 Metastasectomy for Stage IV Melanoma in the Effective Systemic Treatment Era
Authors: Corbetta Machado M J , Gourlay R , Majid A , Van der Westhuizen A
Published: October 2021

Aim

Historically, a diagnosis of Stage IV melanoma was a dire one, with low survival rates and ineffective treatment. The only beneficial treatment option was metastasectomy in very selected cases. The recent introduction of the effective systemic therapy agents (EST) (immunotherapy and BRAF inhibitors) dramatically changed this. This research’s aim is to determine if EST + Metastectomy significantly improves OS. And if so, should be considered as the main therapeutic approach to stage IV melanoma patients.

Method

Single-centre retrospective cohort study from the Melanoma Unit at Calvary Mater Hospital in Australia was conducted, approved by the ethics committee. Inclusion criteria was Stage IV Melanoma patients who received EST from 2009-2019. OS of those who received EST alone are compared to EST + Metastasectomy. The 2 groups were compared retrospectively based on their disease characteristics, using probability score weighting analysis and survival curve.

Results

This is a preliminary analysis for the first 200 patients, data collection is ongoing. Mean OS is 2 years. Several combinations of immunotherapy treatments were identified. Of the 200 patients, 35% underwent metastasectomy. Mean survival for those who had surgery is 3 years, as oppose to 2 years for those who had EST alone. OS in the Metastasectomy group was higher than those who had EST alone, of 47.1% and 42.3% respectively. The Kaplan Meier curve also shows increase survival in the metastasectomy group, up to year 6 post diagnosis.

Conclusions

Metastasectomy for stage iv melanoma in the EST era appears to offer a survival benefit in selected patients