bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.FRI.925 Time to look back at NASBO 2017. Have we learned any lessons from NASBO trial in treating patients with small bowel obstruction?
Authors: Majeed Talal , Thapa Anjali , Sommereux Lauren , Patten Alan , Pourikkou-James Marriane , Ishak Rafik
Published: October 2021

Introduction

SBO is a common surgical presentation but despite advancements in surgical and diagnostic skills, patient’s outcome remains poor. SBO need multidisciplinary approach and needs careful decision making at each step of its management. There were no standard protocols to treat these patients until NASBO report 2017 1, with guidelines for step-wise approach to diagnose, treat and follow up patients presenting with SBO.

Aims

This study is an assessment of our local services to evaluate if we are compatible to NASBO guidelines and what we need to do to improve patient outcomes.

Study design

A retrospective observational cohort study was done in a busy emergency surgery unit in North West with highest rate of emergency laparotomy (NELA 2019)2, on patients presented with proven SBO during year 2018.

Methods

Clinical, nutritional and radiological assessment, conservative or operative management, clinical outcomes and complications were compared to the national data from 131 hospitals reported in NASBO 2017. 

Results

136 patients (median age 72) with 59% patients treated with non-operative approach while 41% had surgery (almost half of them were treated conservatively initially). 

Imaging and nutritional assessment and complication rate were well within the target range. 

HDU admission rate was 16% and 30-day mortality was 8% of which 3% were treated palliatively for malignancy and severe comorbidities. 

Conclusions

Our results are similar in clinical performance and management when compared to national average. Certain areas like laparoscopic approach, ERAS, nutritional assessment and elective HDU/ITU admissions have been identified as areas to improve.
EP.FRI.960 USS appraisal in females of child bearing age presented with possible appendicitis
Authors: Hatem Fady , Mostafa Samir , Chamali Basel , Ivanov Andrea , Ross Rebecca , Sonsale Aniket , Kaldas Foad
Published: October 2021

Aims

Appendicitis remains the most common acute surgical condition.  No standard guidelines for the use of imaging studies, and there is a discrepancy between the published data regarding accuracy of these modalities and our practical findings. Yet the growing number of USS reported as “appendix not visualized” has led us to rethink about the value of USS in acute appendicitis. 

Methods

A retrospective single centre study for all females (15-45 years) underwent emergency appendectomy for suspected acute appendicitis. Analysis of preoperative clinical, radiographic and postoperative histopathological data was done.

Results

632 cases analysed over 18months, out of those 238 (37%) were females (15-45 years). USS was done in 129(54%) cases. 25(10.5) cases had both USS and CTAP. 32(13%) cases had only CTAP. The mean rate of appendix visualization in the USS was 30%(71cases) two thirds reported by radiologist versus one third by sonographers. Our negative appendectomy rate dropped from 25 to 15% after a positive scan. 

Conclusions

Traditional preference for ultrasound in the UK compared to CTAP in young population is mostly due to the potential hazards of irradiation, but USS commonly does not visualise the appendix in our practice (70%), and has low sensitivity and specificity for appendicitis.  However, following a positive USS, NAR dropped to 15%. Radiologists had a higher visualization rate of appendix compared to sonographers. Commitment to improve the performance of ultrasonography by allocating adequately timed sessions to the most experienced radiologists and increasing the use of low dose CT scans are possible solutions.
EP.FRI.976 ERAS after malignant colorectal resections: A single centre experience
Authors: Gok M A , Smart C J , Sadat M M , Ward S J , Khan U A
Published: October 2021

Aims

ERAS employs a multi-modal rehabilitation aids post-op recovery following colorectal resections. ERAS applied in both laparoscopic + open surgery. This study aims to assess effectiveness of ERAS at a single centre.

Methods

A retrospective study at East Cheshire NHS Trust, since 2008. Descriptive demography & post-operative features were collected for all elective colorectal resections.

Results

Conclusion

ERAS associated with longer operative time (p < 0.05) (laparoscopic surgery), a shorter hospital stay was achieved (p < 0.05). Delayed ERAS occurred in 26.2 % of cases & can result in delayed discharge. Early ERAS deviations occurred in the presence of major surgical complications (ileus, anastomotic leaks, collections). Despite post-operative cardiac & pulmonary events, ERAS was maintained. A targeted rehabilitation programme especially in the elderly patients can lead to earlier recovery.
EP.FRI.986Life threatening bleeding duodeno-jejunal flexure GIST successfully managed with surgery- Case report
Authors: Atkins William , Perera Duranka , Ayantunde Abraham
Published: October 2021

Introduction

Gastrointestinal stromal tumours (GISTs) are sarcomas and the most common non-epithelial cancers of the GI tract.

Patient

A 77-year old man with life threatening melaena, drop in haemoglobin from 109 to 71 in 24 hours and hypotension. Co-morbidities included COPD, chronic microcytic anaemia, type 2 Diabetes mellitus and hypertension. Anaemia for 9 years had been investigated with OGD and colonoscopy showing no pathology. Calculated Rockall score was 6. An Urgent Oesophagogastroduodenoscopy showed normal findings with no source of bleeding identified.

An urgent CT angiography demonstrated a vascular blush at duodenojejunal (DJ) flexure identified as the source of bleeding. Four units of was blood transfused preoperatively. The bleeding source was not embolisable.

He underwent an initial diagnostic laparoscopy to confirm the site of the lesion and ascertaining whether resection and anastomosis would be visible. Findings at laparoscopy included a DJ flexure lesion. A midline mini-laparotomy, wedge resection of the lesion with a hand-sewn anastomosis was performed. He had a prolonged hospital stay with gastroparaesis and high nasogastric tube output.

Histology showed a well-demarcated, lobulated bland spindle cell lesion. The tumour is composed of cells with mainly blunt ended nuclei. There is strong positive staining to CD117 and DOG-1. There is focal positive staining to Desmin and SMA. The tumour is negative for S100 AND but Pankeratin.

Overall, MDT felt that this was a 30mm DJ flexure GIST with less than 5 mitoses per 50mm2. R1 achieved resection but with a low risk (4.3%) of recurrence based on the histological characteristics.
EP.FRI.997 Recognising frailty: the scale of the problem
Authors: Martin Laura , Chapman Susan , Broadbent Elizabeth , Payne Christopher , Beecroft Christina
Published: October 2021

Aim

To assess compliance with frailty scoring in acute surgical admissions.

Method

Data including age, admitting speciality, whether the frailty score was completed and the recorded score if completed, were collected for all admissions to an acute surgical unit over a 7 day period in November 2019.

Results

The average age of the 139 patients was 56.25 years (range 16-89). Frailty scoring was completed in 53 patients (38.1%); 8 patients (15%) met the criteria for frailty. Sixty-four patients (46%) were aged over 65 years, 26 (40.6%) had the score completed and 7 (27%) met the frailty criteria. Of 36 patients (26%) aged 75 or over, 16 (44.4%) were scored and 6 (37.5%) met the frailty criteria. Scoring was most frequently completed in patients admitted under the Vascular Surgery team (52.9% compliance) with a mean score 3.8.

Conclusion

Worsening frailty is associated with increased morbidity and mortality in acute surgical admissions. The 7-point Clinical Frailty Scale has been added our acute surgical admission document and should be completed for every patient. Our compliance with scoring is a long way from our recommended 100%, with compliance with assessing frailty across age groups similar, despite the increased rates of frailty seen in older age groups. Poor compliance with frailty assessment may hamper future progress with the management of the frail, older surgical patient. We are planning documentation changes, staff education sessions and to appoint frailty ‘champions’ with a repeat audit of compliance to assess the effects of these changes.
EP.FRI.999 Case report of a Low Grade appendiceal mucinous neoplasm (LAMN) and review of literature
Authors: Da Costa Kimberly , Sabanathan Sivakumaran
Published: October 2021

A mucocele refers to an appendix that has dilated due to progressive accumulation of mucus within its lumen. Appendiceal mucocele is a rare cause of an acute abdomen. They represent 0.2-0.7% of all appendix specimens. LAMN account for less than 0.3% of appendicectomy specimens. 

We present a 38 year old man with an acute RIF’s pain who went on to have CT scan which revealed a mucocele of appendix but did not show any features of perforation or pseudomyxoma peritonei. He had a laparoscopic converted to open appendicectomy. The proximal 2 cm of appendix was oedematous but normal calibre. Histology revealed a low grade appendiceal mucinous neoplasm (LAMN) that was completely excised. 

The mucocele of the appendix was first described by Rokitansky in 1842. Appendix mucocele may come as a consequence of obstructive or inflammatory processes, cystadenomas or cystadenocarcinomas. Appendiceal mucinous neoplasms commonly presents in the sixth decade of life and our patient was much younger in comparison. Several literatures suggest the value of preoperative CT imaging in obtaining diagnosis and also in planning further treatment. Appendicectomy or a right hemicolectomy is treatment of choice based on presence or absence of following factors 1. Perforated mucocele 2. Involvement of the base of the appendix. 3. Positive lymph nodes of mesoappendix and ileocolic. Patients with malignancy or pseudomyxoma peritonei are likely to require cytoreductive surgery, heated intraoperative intraperitoneal chemotherapy, early postoperative intraperitoneal chemotherapy.
EP.FRI.1020 The necessity of colonoscopy to rule out colorectal malignancy after computerised tomography proven diagnosis of acute diverticulitis
Authors: Barman S , Meney L , Boyle C , Collison C , Shalli K
Published: October 2021

Introduction

The current Royal College of Surgeons commissioning guideline on colonic diverticular disease suggests that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The necessity of routine endoscopic assessment of CT proven diverticulitis remains debatable.

Aim

To establish whether routine endoscopic assessment should be carried out for patients after an episode of acute diverticulitis.

Method

Data was collected retrospectively from all patients diagnosed with acute diverticulitis on CT and who subsequently had follow up endoscopic assessment from January to July 2019.

Results

Total number of patients were 64.Median age of the cohort was 58.Of all patients, 48 had diagnosis of uncomplicated diverticulitis whereas 16 patients had diagnosis of complicated diverticulitis on CT scan. All patients had follow up colonoscopy after an acute attack with following findings: 2 patients had no pathology, 56 patients had diagnosis of only diverticulosis, 4 patients had both diverticulosis and polyps and 2 patients had bowel cancer. All 4 cases of polyps had benign pathology and uncomplicated diverticulitis on CT scan. Two bowel cancer patients, one had complicated diverticulitis with thickening of proximal sigmoid and the other patient had abnormal sigmoid colon suggestive of malignancy on CT scan.

Conclusion

Recent meta-analysis showed no difference between diverticulitis and normal population group in terms of risk of bowel cancer. Routine colonoscopy may not be appropriate in patients with acute uncomplicated diverticulitis but endoscopic assessment after an episode of complicated diverticulitis is necessary.
EP.FRI.1067 Exploring the Patient Journey and Social Care following Emergency Laparotomy in the Elderly: A Systematic Review of Qualitative Studies
Authors: Chan Anthony , Goldsmith Paul , Watson Andrew , Stathakis Panos , Smith Stella , Macutkiewicz Christian
Published: October 2021

Aims

Frailty is associated with high morbidity following emergency laparotomy. Objective scores such as P-POSSUM are well recognised in predicting outcomes such as morbidity and mortality. Qualitative factors affecting recovery and rehabilitation are less established. This review explores the lived experiences of elderly patients following emergency laparotomy to identify factors to improve post-hospital care.  

Methods

A systematic review of the medical and nursing literature was performed using MEDLINE, Web of Science Core Collection and CINAHL Plus in January 2020. Qualitative and phenomenological studies were identified using keywords ‘emergency’, ‘laparotomy’, ‘abdo*’ and ‘surgery’. Cancer studies were excluded. Themes were extracted for ‘lines of argument’ synthesis to build a general interpretation of findings. The review is registered with PROSPERO (CRD42019159751). 

Results

The search identified 569 unique citations of which 551 were excluded after screening and 17 excluded following full-text review. One study was included (Thomsen et al, 2014) exploring postoperative care for 18 patients following emergency abdominal surgery. Thematic analysis was limited to the hospital setting. Patients described Critical Care as a safe environment for recovery and rehabilitation because of higher nursing ratios. Patients placed emphasis on ready access to staff and timely interventions which was particularly poor on surgical wards. Specific barriers, particularly patient concerns regarding recovery, were not explored.

Conclusions

This review highlights the importance of easy access to staff and inpatient services following emergency laparotomy but demonstrates the lack of qualitative evidence exploring the lived experience of the immediate post-discharge period that impacts on rehabilitation back to normal activities.
SP1.1.4The Walking Thread – What happens to fistula-in-ano patients who are lost to follow up? A Service Improvement Study
Authors: Murgitroyd Ellen , Wilson Blair , Kremel Darja , Anderson David
Published: October 2021

Aims

Management of perianal abscess and resultant fistula-in-ano remains controversial. Studies suggest that 1/3 of idiopathic cryptoglandular abscesses can result in fistula-in-ano. Our current practice is to incise and drain primary abscesses and for patients to return as necessary. Known fistula patients will be appointed for Examination Under Anaesthetic (EUA) at 6-12 weeks. Does this result in best management or do they become “elective emergencies”?

Methods

A retrospective audit of management of fistula-in-ano over 4 years was conducted, utilising precollected data of Cryptoglandular abscesses, excluding inflammatory, radiation or malignant causes. Patients lost to follow up were analysed including presentation, fistula diagnosed at first or subsequent attendance, number of operations, number of attendances and seton placement.

Results

512 patients underwent operations for cryptoglandular abscess causing fistula-in-ano between 2013 and 2017. 10% (N = 50) were lost to follow up despite documented follow up plans for 32. Of these, 18 were elective attendances, 14 emergency. 24 of the 32 had a Seton sited prior to being lost to follow up.

Conclusions

The various presentations (emergency, elective, clinic) and waiting lists mean these patients are presenting as emergencies whilst awaiting follow-up. Many are simply lost to follow up, with Setons in-situ.   We propose a fortnightly hot-clinic system, run by second on-call registrars to assess and manage these patients. This would provide an elective clinic to allow single point of access to fistula-in-ano patients ensuring prompt follow-up and reduction in unnecessary EUA, as well as improving senior colorectal trainees exposure to perianal disease and its management.
SP1.1.5Association between prior screening involvement and presentation and outcomes in patients with colorectal cancer
Authors: Mshihadani Afnan , Golder Allan M , Mansouri David , McMillan Donald C , Horgan Paul G , Roxburgh Campbell SD
Published: October 2021

Aims

Population bowel cancer screening (BCS) is well established, however many patients still present acutely or with advanced disease. Within a cohort of patients with colorectal cancer (CRC), this study aimed to analyse the relationship between prior engagement with the screening programme and mode of presentation, disease stage and survival.

Methods

All patients diagnosed with CRC from 2011-2014 in West of Scotland were identified from a regional database and linked into the Bowel Screening dataset for screening participation within two years preceding diagnosis.

Results

6551 patients were diagnosed with CRC, 19% (n = 1217) through screening. 39% of patients were not invited for screening and 29% of patients did not respond to invite. Non-response to invite was associated with male sex, increasing age, socioeconomic deprivation, co-morbidity and smoking (all p < 0.001). 13% had previously returned negative screening tests. Negative screening was associated with female sex, anaemia, right sided, poorly differentiated and EMVI positive tumours, and screening with gFOBT versus FIT (all p ≤ 0.001).  2% did not undergo further investigation of a positive test, and <1% had a negative colonoscopy. Participation in screening was associated with reduced emergency presentations (8%vs22%), lower TNM Stage, and improved 3-year CSS (88%vs74%) and OS (85%vs69%) (all p < 0.001).

Conclusion

Most new cases of CRC are diagnosed outwith the screening programme, predominantly due to non-invite/failure to respond to invite. This has a significant association with adverse outcomes including emergency presentation, advanced TNM stage and poorer survival. Further work is required to increase screening uptake and widen access to BCS.
SP1.1.16Endoscopic evaluation after acute colonic diverticulitis: Review of literature
Authors: Eltyeb Hazim A. , Subramonia Sriram
Published: October 2021

Aim

To compare the current evidence for routine endoscopic evaluation of the colon after an episode of acute diverticulitis against existing guidelines in the United Kingdom.

Methodology

A systematic literature search of Medline, Embase and Cochrane databases was performed using keywords “Diverticular disease”, “Diverticulitis”, “acute”, “Colorectal Cancer” and “endoscopy”. Recommendations from guidelines of specialist medical societies were reviewed. Available literature was explored to assess the risk of colorectal cancer in patients presenting with acute diverticulitis.

Results

The most recent UK guideline (Royal College of Surgeons Commissioning guide 2014 supported by ACPGBI) recommends the routine evaluation of colonic lumen after resolution of an acute attack of diverticulitis. More recent guidelines from specialist medical societies (European Society of Coloproctology 2020, World Society of Emergency Surgery 2020, European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons 2018) do not recommend routine endoscopic evaluation after recovery from uncomplicated colonic diverticulitis. Two meta-analyses as well as three large cohort studies showed no significant risk of colorectal cancer ((1.22% (95% confidence interval 0.63-1.97) and (0.7%; confidence interval 0.3%−1.4%)) following uncomplicated acute diverticulitis.

Conclusion

Existing UK guidance on routine colonic luminal evaluation after resolution of acute diverticulitis should be revised based on current evidence.
SP1.2.3General Surgical Registrar in the Emergency Department: Developing and Evaluating a New Surgical Role
Authors: Aseem Rabiya , Naseem Tariq , Simillis Costas , Pawa Nikhil , Jason Smith
Published: October 2021

Intro

NHS Departments are experiencing unprecedented pressures with exponentially growing patient numbers and severe delays in waiting time. This directly influences bed pressures leading to cancellation of elective surgical lists to aid acute admissions. We introduce the role of a surgical registrar in emergency departments (ED) to review general surgical patients to (i) help reduce ED waiting times (ii) prevent unnecessary admissions and (iii) accelerate management plans.

Methods

This unique role was introduced in our local ED department for 3 months (Nov 2019 - Jan 2020). The shift was trialled Mon-Fri from midday to 8pm. Patient length of stay (LOS), referral times, admissions, discharges and breaches (> 4hrs) were recorded.

Results

The admission rate was 24% (n 681), with a 10% reduction compared with preceding months. 75% patients were discharged following review from which 20% had outpatient investigations arranged. Average LOS at time of referral was 1hr37mins. Peak referral activity was observed on Mondays, Fridays and between 2-5pm. 98% underwent investigations and 79% received active treatments. Feedback from stakeholders, including surgical colleagues was favourable as it allowed more time spent on operative activities.

Conclusion

The NHS has some of the most challenging performance standards in the world. We introduce an innovative solution to help reduce rising clinical and financial pressures. The role of the surgical ED registrar helps reduce waiting times, escalate management and prevent unnecessary surgical admissions. Further studies are being conducted to further evaluate the sustainability of this service and extending it to neighbouring trust hospitals.
SP2.1.10Prescription of regular medications to surgical patients within 24 hours of admission:Is it being done?
Authors: Rai Anil , Singh Rhea , Brown Katherine
Published: October 2021

Aim

Prescription of necessary regular medications to patients within 24 hours of admission to the hospital is vital for better healthcare. Our aim was to analyse whether regular medications were prescribed to all general surgical patients within that time limit, to find the rationale behind the shortcomings and to suggest a more efficient way to overcome them.

Materials and Methods

A retrospective analysis of 186 surgical patients in the month of February 2020 who stayed in the hospital for more than 24 hours in General Surgery (167) and Urology (19) were analysed. Out of these, 100 were females and 86 males with the maximum in age group of 31-60 years (80) and 75 patients were more than 6o years. 11 groups of medications were analysed.

Findings

Conclusion

More attention needs to be paid towards prescribing medications at the earliest. This could be improved by careful history taking and prescribing medications at the time of admission itself; GP to include all the medication history while referring a patient, liaising with pharmacist and family members for confirming the patients’ medications and providing portable bedside computers for doctors while they are seeing patients.
SP2.1.16Prognostic significance of Drivers at Work and Learning Styles in surgical training
Authors: Mellor Katie , Hopkins Luke , James Osian P , Luton Oliver , Egan Richard J , Lewis Wyn G
Published: October 2021

Aims

Drivers at Work (DW) and Learning Styles (LS) refer to a range of contentious theories that aim to account for differences in career progression, yet seldom feature in training assessment. This study aimed to quantify the influence of Core Surgical Trainees’ (CST) DW and LS on career progression.

Methods

Kolb LS inventories were distributed to 168 CSTs during five consecutive induction boot camps in a single Statutory Education Body. Primary outcome measures were MRCS and National Training Number (NTN) success.

Results

Of 108 responses received (response rate 64.3%), 64.8% were male and 35.2% female (p = 0.003). The spectrum of DW was: Please People (25%), Be Perfect (21.3%), Hurry Up (18.5%), Be Strong (13.9%), and Try Hard (0%, p < 0.001). DW was either unequivocal or not provided by 23 CSTs (21.3%). The spectrum of LS was: Converging (34.3%), Accommodating (28.7%), Diverging (23.1%), and Assimilating (13.9%, p = 0.021). MRCS success was not associated with DW (p = 0.703) or LS (p = 0.598). Men were more likely to have Converging LS (29/70, 41.4%), and women Diverging LS (15/38, 39.5%, p = 0.018) and to have team-based LS (Accommodating / Diverging, 26/38 vs. 30/70, p = 0.010). NTN success was associated with LS (p = 0.038) with Convergers achieving most NTNs (65.4%).

Conclusions

LS are associated with important differences in career progression with Converging LS three-fold more likely to achieve NTNs than Diverging LS.
SP2.2.1Improving surgical training: core programme performance related to rotation theme, design, and trainee protocol engagement
Authors: Mellor Katie , Robinson David B , James Osian P , Powell Arfon GMT , Egan Richard J , Lewis Wyn G
Published: October 2021

Aims

Core Surgical Training (CST) and Improving ST (IST) programmes are in flux and their design controversial. This study aimed to evaluate the relative performance of a single Statutory Education Board’s (SEB) CST and IST programmes related to rotation design, theme, and protocol engagement.

Methods

Individual rotations numbering 181 were analysed prospectively over six-years (2014 to 2020). Primary outcome measures were MRCS pass and specialty National Training Number (NTN) appointment.

Results

Overall MRCS pass was 68.5% and NTN appointment 39.2%. NTN appointment related to rotation design varied from zero to 100% (median 40.0%). Conversion to NTN varied by specialty theme and ranged from: General surgery CST 35.6% to General surgery (IST pilot) 87.5% (p = 0.004). Multivariable analysis revealed NTN appointment was associated with: operative logbook caseload >464 (OR 3.02, p = 0.068), scientific article publication (OR 4.82, p = 0.006), and universal ARCP Outcome 1 (OR 37.83, p < 0.001), and IST (OR 55.54, p = 0.006).

Conclusions

Focused rotational design allied to enhanced performance management, and protocol engagement, were associated with improved conversion to higher surgical specialty training.
SP2.2.6An audit on core surgical trainees’ operating theatre experience to improve compliance against JCST training quality indicators
Authors: Khawar Haseeb , Rehman Saad , Nair Nandu , Luke David
Published: October 2021

Aims

The primary aim of this study was to audit the experience of core surgical trainees in operating theatres with a view to devise some interventions to improve the quality of theatre experience.

Methods

This study was a prospective audit that involved filling out a set proforma by all core surgical trainees working in a busy surgical department of a tertiary care university hospital. The proforma included a breakdown of questions to signpost indicators of quality experience and check compliance with the Joint Committee on Surgical Training (JCST) guidelines. It was completed with particular consideration given to the experience while trainees were on their CEPOD week to facilitate accuracy and relevance of feedback.

Results

8 core surgical trainees filled out the proforma. 75% of trainees had the opportunity to reflect the case with the senior surgeon. Lowest compliance was shown for pre-operative discussion of crucial learning points with the senior surgeon. Only 50% of trainees had a chance to do a briefing pre-operatively which is one of the JCST quality indicator for core surgical trainees.

Conclusion

This audit demonstrates the potential for improvement in the operating theatre experience of junior surgical trainees considering JCST Quality Improvement indicators. A checklist may be introduced to achieve maximum utilisation of the finite training opportunities available to current junior surgical trainees. A loop closing audit after the checklist will be able to assess the change in practice and theatre experience.
SP2.2.8Teams, performance, and trust: a perspective from the vanguard
Authors: James Osian , Bowman Chris , Parker Jody , Luton Oliver , Egan Richard , Lewis Wyn
Published: October 2021

Aims

The aim of this study was to determine surgical trainees’ perspective regarding team environment, function, performance, and trust.

Methods

A 44-point, anonymous survey was distributed to all doctors working in surgery in a single UK Statutory Education Body with responses received from 116 (n = 17 Foundation Year 1 (FY1), n = 50 Senior House Officer (SHO), n = 49 Specialist Registrar (SpR)).

Results

Psychological safety was associated with trainee grade; SHO perception of support (60.4%, n = 29), FY1 (88.2%, n = 15), SpR (82.4%, n = 42), p = 0.016; and ability to ask for help: SHO (70.8%, n = 34), FY1 (100.0%, n = 17), SpR (92.2%, n = 47 p = 0.043). Dependability among colleagues was perceived to be poorer by women (69.8%, n = 30) than men (87.5%, n = 63, p = 0.009). Clarity of team structure was associated with grade and perceived to be poor by SHOs (60.4%, n = 29) vs. FY1 (94.1%, n = 16) vs. SpR (78.4%, n = 40), p = 0.014. Meaningfulness and impact of team achievement was associated with grade: SHO (68.8%, n = 33) vs. FY1 (76.5%, n = 13) vs. SpR (94.1%, n = 48), p = 0.005. Inverse correlations were observed between the prevalence of harassment/bullying and markers of psychological safety (rho -0.382, p < 0.001), dependability (rho -0.270, p = 0.003), and clarity of team structure (rho -0.355, p < 0.001).

Conclusion

Important deficiencies in psychological safety impacted two in five of SHOs adversely. Countermeasures (Enhanced Surgical Resilience Training) are needed to protect morale, patient safety, and clinical outcomes.
SP2.2.15MRCS performance predicts surgical career outcomes
Authors: Ellis Ricky , Scrimgeour Duncan , Cleland Jennifer , Lee Amanda , Brennan Peter
Published: October 2021

Aims

Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training.

Methods

All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices.

Results

There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P = 0.001) but no significant variability in Part B pass rates (P = 0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P = 0.010 and P = 0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass.

Conclusion

MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.
SP2.2.16Hospital compound level endoscopy training quality performance: scoping the spectrum
Authors: Eley Catherine , Brown Christopher , Hawkes Neil , Egan Richard , Lewis Wyn
Published: October 2021

Aims

This study aimed to assess the quality of endoscopy training in a single UK Statutory Educational Body (SEB), related to individual hospitals,compared with the Joint Advisory Group on Gastrointestinal Endoscopy Training (JETS) certification standards.

Methods

Training procedures numbering 28,928 recorded by 211 consecutive cross-specialty trainee endoscopists registered with JETS in18 hospitals during 2019were analysed. Data included trainer and trainee numbers, training list frequency, procedures, Direct Observation of Procedural Skills (DOPS) completion and Key Performance Indicators (KPI).

Results

Annual median training procedures per hospital were 1395 (interquartile range (IQR) 465-2365). Median (IQR) trainers and trainees per unit were 11 (6-18) and 12 (7-16) respectively (ratio 0.8 (0.7-1.3)). Annual training list frequency per trainee was 13 (10-17), 35.0% short of JAG standard (n = 20, p = 0.001, effect size -0.56), and median points per adjusted training list were 11 (5-18). Median DOPS completion per trainee and trainer were 3 (1-6) and 4 (1-7) respectively; completing 0.2 DOPS (0.1-0.4) per list and amounting to 6 (2-12) per 200 procedures: less than half of the JAG standard (p < 0.001, -0.61). Median KPI for OGD: J Manoeuvre 94% (90-96), D2 intubation was 93% (91-96); and for Colonoscopy: Caecal intubation 82% (72-90), and Polyp Detection Rate 25% (18-34). Compound hospital training quality score varied 3-fold, the highest performing hospital scoring 26; compared to the poorest performing scoring 9: median 17 (14-20).

Conclusion

Important variation in endoscopy unit performance were apparent with compound hospital training quality varying almost 3-fold. Trainees, Training Programme Directors alike, should be aware of such data when planning educational programmes to focus, optimise the quality of endoscopic training.
SP3.1.3 Use of a Care Bundle to reduce Surgical Site Infection after Emergency Laparotomy
Authors: Swain C , Rogers J , Gane D , Quinn M , Hopkins J , Pullyblank AM
Published: October 2021

Aim

Surgical Site Infection (SSI) is common after abdominal surgery. A care bundle was introduced to sustainably reduce SSI after elective colorectal surgery. This study aimed to implement an expanded care bundle after emergency laparotomy.

Methods

Quality improvement methodology was used. SSI was measured by direct assessment of the wound in patients in hospital at 30 days. For discharged patients, the PHE SSI surveillance questionnaire was used to measure patient-reported SSI 30 days post-operatively. The care bundle included: 2% chlorhexidine skin preparation; dual ring wound protectors; triclosan-coated sutures for wound closure; second dose of antibiotics >4 hours, betadine to the wound and glove change before closure. Bundle compliance was measured and fed back to surgical teams.

Results

Baseline SSI was 13.5% (178 patients) which reduced to 8.5% (118 patients) following bundle introduction. Response rate was 60%. Compliance with antibacterial sutures was measured for patients whose wounds were closed; 10% received negative pressure dressings. Mortality within 30 days was 9%. Length of stay reduced from mean 22.6 to 12.45, median 13.5 to 9 days.

Conclusion

The care bundle reduced SSI after emergency laparotomy. Measuring SSI is more difficult after emergency surgery due to higher death rate, longer length of stay and use of laparostomy. Other challenges include difficulty using wound protectors for some procedures e.g. adhesiolysis and changing practice from use of skin clips.
SP3.1.5 Variation and predictors of emergency surgery in emergency hospital admissions from the Emergency Surgery Or Not (ESORT) study
Authors: Hutchings Andrew , O'Neill Stephen , Zapata Silvia Moler , Smart Neil , Hinchliffe Robert , Grieve Richard
Published: October 2021

Aims

To assess variation in use of emergency surgery (ES) for emergency hospital admissions with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction.

Methods

Cohorts were extracted from Hospital Episode Statistics for 136 acute NHS trusts in England. Clinical panel consensus defined ES for emergency admissions between 1/4/2010 and 31/12/2019. The association of socio-demographic characteristics with ES use was estimated by multivariable logistic regression, with adjustment for comorbidity, frailty, diagnosis and trust.

Results

The cohort sizes ranged from 49,385 (hernia) to 184,777 (appendicitis) patients. ES was less likely for: patients aged over 80, with odds ratios (ORs) across conditions from 0.15 to 0.84 versus those aged under 40; the most deprived, ORs 0.83 to 0.92, versus least deprived; and Asian patients, ORs 0.72 to 0.88, versus White patients. Black patients were less likely to have emergency surgery for appendicitis (OR 0.78) and cholelithiasis (OR 0.78). Females were less likely to have ES for appendicitis (OR 0.94 versus males), but more likely to have surgery for intestinal obstruction (OR 1.29), hernia (OR 1.13) and cholelithiasis (OR 1.22). Unexplained variation in ES across trusts, remained after case-mix adjustment, and was greatest for cholelithiasis (median of 16%, 10 to 90 centile 5%-34%), and hernia (61%, 52%-71%), followed by intestinal obstruction (29%, 24%-36%). appendicitis (93%, 89%-95%), and diverticular disease (15%, 11%-20%).

Conclusions

The socio-demographic characteristics of emergency admissions are associated with the likelihood of receiving ES. Variation in ES use between NHS trusts remained after adjustment for demographic and clinical characteristics.
SP3.1.17 Assessment of the utility of CT to predict the requirement for resection at laparotomy in patients presenting with acute mesenteric arterial insufficiency
Authors: Ng James , Hennessy Martin , Hussey Keith
Published: October 2021

Introduction

Mesenteric ischaemia as a consequence of arterial atherosclerosis is associated with significant morbidity and mortality. Practice has been influenced by the rise in cross-sectional imaging. In Glasgow a policy of laparotomy for patients presenting with acute mesenteric ischaemia at the time of mesenteric revascularisation has been adopted. We have sought to define whether CT can predict visceral necrosis and a requirement for tissue resection at the primary revascularisation.

Methods

This was a retrospective review of interventions performed for mesenteric ischaemia. Radiological variables described in the context of mesenteric ischaemia were defined. The primary CT report was reviewed to define whether these features were recorded and whether a diagnosis of mesenteric ischaemia was suggested. Imaging was then retrospectively reviewed with reference to the dataset by a radiologist. The radiologist was asked to offer a subjective opinion as to whether there was mesenteric infarction. These data were compared with laparotomy findings.

Results

There were 129 interventions performed for mesenteric ischaemia over the study period and 147 laparotomies. There was no specific radiological variable that was consistently reported in the primary or secondary CT review. However when bowel wall thinning, hypoattenuation or portal venous gas reported (independently) they seemed to be specific as in each case there was mesenteric infarction at laparotomy.

Conclusion

Even with retrospective radiological assessment there is no reliable feature that will predict mesenteric infarction and a requirement for tissue resection. As such a policy of laparotomy in patients who considered physiologically well enough would appear to be justified.
SP3.2.4 Creating sub-specialty emergency surgical care and changing consultant working patterns improves consultant morale and stress levels
Authors: Hardy Edward , Smart Thomas , Hatt Jacob , Lund Jon
Published: October 2021

Aims

General surgery consultants have some of the highest rates of burnout. Ever increasing emergency general surgery (EGS) admissions playing a major role in this. A move to create split sub-speciality cover consisting of upper GI/HPB (UGI) and colorectal (CR) consultants has been suggested to improve EGS outcomes. We assessed the impact changing on-call working patterns had on perceived consultant stress levels, manageability of their workload and patient length of stay (LOS).

Methods

Consultant on call patterns changed from an individual consultant covering four consecutive weekdays to two consultants (one UGI/HPB, one CR) sharing four consecutive weekdays. Consultants were surveyed to assess the impact of this change on the manageability of their workload and their perceived stress levels. Admission numbers and LOS were also analysed for all EGS admissions over a 6-month period either side of the rota change.

Results

89% of consultants who responded chose to work the new on call format. 78% felt it had improved the manageability of their workload, decreased perceived stress levels and improved quality of patient care.

There was no change in the number of EGS admissions (862 vs 866) or EGS patient length over the time periods studied (Pre: 0D: 8%, 1 – 2D 38%, 3 – 4D 19%, >4D 34%. vs Post: 0D 8%, 1 – 2D 40%, 3 – 4D 17%, > 4D 35%).

Conclusions

A move to shorter and sub-specialty on call duties reduced stress and improved manageability for consultant general surgeons without adverse impact on patient’s length of stay.
SP3.2.5 Meta-analysis of the incidence of right-sided colon cancer in patients aged over 40 with acute appendicitis: Implications for routine preoperative CT scan and follow up colonoscopy
Authors: Hajibandeh Shahab , Hajibandeh Shahin
Published: October 2021

Aims

To determine the incidence of right-sided colon cancer in patients aged over 40 with acute appendicitis.

Methods

We performed a systematic review in accordance with PRISMA statement standards. A search of electronic information sources was conducted to identify all studies reporting the incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data.

Results

Eight studies, enrolling 4328 patients, were included. The mean age of patients was 59 (95% CI 53-65); 54% were male (2330 out of 4328). The diagnosis of appendicitis and colon cancer were based on histological assessment only. In patients aged over 40 years the pooled incidence of right-sided colon cancer was 1.043% (95% CI 0.762-1.367); the level of between-study heterogeneity was low (I2=0%, P = 0.45). The risk of right-sided colon cancer in patients aged over 40 with acute appendicitis was significantly higher than the risk in general population (standardised risk ratio: 10.65 95% CI 3.83 - 29.66, P < 0.0001). The number needed to treat was calculated as 112 patients (95% CI 83 - 171).

Conclusions

The risk of right-sided colon cancer in patients aged over 40 years with acute appendicitis is 10 times higher than the risk in general population. This suggests a need for routine preoperative CT scans and follow up colonic assessment in all patients aged over 40 with acute appendicitis.
SP3.2.7 Surgical techniques in emergency hernia repair - what are we doing? Findings from the MASH study
Authors: Green Susanna ,   MASH Steering Group,   MASH Collaborators
Published: October 2021

Aims

There is limited evidence to guide the emergency management of acutely symptomatic abdominal wall and groin hernias (ASH) and there is a lack of consensus on optimal surgical technique. This study aimed to explore surgical techniques used to repair ASH.

Methods

A prospective 12-week cohort study (NCT04197271) recruited adult patients with ASH across 23 UK sites. Baseline characteristics, quality of life, management strategy and 30/90-day outcomes were collected. For those undergoing surgery, detailed information was recorded on: time to surgery, anaesthetic technique, grade of surgeon, intraoperative findings, antibiotic use, operative approach, repair technique (mesh vs suture), mesh/suture type and position and whether bowel resection/stoma formation was required.

Results

Of the 264 patients recruited, 214 (82%) underwent acute repair within 48 hours of admission. 95% underwent open repair, with 93% under general anaesthetic. 5% of inguinal and femoral hernias had laparoscopic repair. Mesh was used in 89% of inguinal hernias vs 29% of umbilical hernias. The majority (86%) used a synthetic non-absorbable mesh (94% inguinal, 84% umbilical). Mesh placement varied widely for epigastric and umbilical hernia, with onlay used most commonly (24%). Similar variation was seen in suture choice. 8% developed an SSI by 30 days, the majority of which were in umbilical repairs. One patient developed early hernia recurrence (umbilical) requiring surgery.

Conclusions

This data demonstrates variation in the surgical management of ASH, especially with the use of mesh. Laparoscopic surgery was uncommon. Further studies are required to clarify optimal technique strategies in the emergency setting.
SP3.2.9 The concordance between emergency CT reporting in non-traumatic abdominal pain with surgical findings at laparotomy
Authors: Edwin Claire , Bradley Alice , Liccardo Filomena , Bowman Georgina , Crisford Sophie , Pawa Nikhil
Published: October 2021

Aims

Abdominal CT imaging is commonly used to assess the acute abdomen, and is relied upon by clinicians in decision making, often influencing the timeliness of intervention. Increased demand for CT imaging has led to departments out-sourcing reporting out of hours. The aim of this audit was to evaluate the concordance between emergency laparotomy findings and pre-operative CT reports.

Methods

115 patients underwent emergency laparotomy with a pre-operative CT scan pertinent to the clinical episode (May 2019-October 2020). 2 surgical assessors independently assessed the CT reports and laparotomy findings to determine discrepancies. Using published audit standards, discrepancies were defined as major-felt to affect patient treatment- and further classified as false positive, false negative, misdiagnosis, indeterminate; or minor and unlikely to change course of patient care.

Results

32/115 had discrepancies, 28/32 major (16/28 misdiagnosis, 4/28 false negative, 3/28 false positive, and 5/28 indeterminate). 71/115 reported by in house radiology. 19/71 discrepancies reported in house (16 major, 3 minor), 13/32 discrepancies reported by out of hours service (12 major, 1 minor). Relative risk of major discrepancies between in house radiology and out of hours service was 1.2 (p = 0.5).

Conclusions

Published audit standards are that CT reports should have >90% concordance with laparotomy findings; this audit found concordance in 76%. Further analysis comparing gastrointestinal vs. non-gastrointestinal specialist radiologist to assess the impact on concordance will be performed. We aim to explore the discrepancies, and seek to identify if our imaging and operating practices can be improved.