bluuebunny/crossref_metadata_2025 huggingface dataset:
WE2.6 Procedural outcomes of laparoscopic caudate lobe resection: A systematic review and meta-analysis
Authors: Anwer Amal Azhar , Hajibandeh Shahab , Kotb Ahmed , Evans Louis , Sams Emily , Hajibandeh Shahin , Satyadas Thomas
Published: November 2022

Aims

to evaluate the procedural outcomes of laparoscopic caudate lobe resection.

Methods

We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting the outcomes of laparoscopic resection of caudate lobe of liver. The population of interest included adult patients with benign or malignant lesions located in caudate lobe of liver. The intervention of interest included laparoscopic resection of caudate lobe of liver. Random-effects models were applied to calculate pooled outcome data.

Results

196 patients from 12 studies were included. The mean operative time, volume of intraoperative blood loss, and length of hospital stay were 225 mins (181–269), 134 ml (85–184), and 7 days (5–9), respectively. The pooled risks of need for intraoperative transfusion was 2% (0–5%), conversion to open surgery was 3% (1–6%), need for intra-abdominal drain was 6% (0–19%), postoperative mortality was 1% (0–3%), biliary leakage was 2% (0–4%), intra-abdominal abscess was 2% (0–4%), biliary stenosis was 1% (0–4%), postoperative bleeding was 1% (0–3%), pancreatic fistula was 1% (0–4%), pulmonary complications was 2% (1–5%), paralytic ileus was 1% (0–4%), and need for reoperation was 1% (0–4%).

Conclusions

Evidence from case series suggests that laparoscopic approach may be safe, feasible and promising for resection of lesions located in caudate lobe of liver. The findings of current study can be used for hypothesis synthesis in future studies and can be used to inform surgeons and patients about the estimated risks of perioperative complications until a higher level of evidence is available.
WE2.7 Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy
Authors: Hajibandeh Shahin , Hajibandeh Shahab , Patel Ishaan
Published: November 2022

Aims

To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

Method

s. A systematic search of electronic information sources and bibliographic reference lists were conducted. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases was applied. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters.

Results

Nine comparative studies were included which reported 1061 patients of whom 630 patients underwent Roux-en-Y hepaticojejunostomy (IS:281, CS:309) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS:168, CS:263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD:9.82 minutes, p<0.00001) compared to CS, there was no significant difference in overall biliary complications (OR:1.34, p=0.19), bile leak (OR:1.73, p=0.26), biliary stricture (OR:0.77, p=0.64), cholangitis (OR:1.54, p=0.35), or liver abscess (OR:0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR:0.92, p=0.90), bile leak (OR:1.70, p=0.28) or biliary stricture (OR:1.07, p=0.92) compared to CS.

Conclusions

Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable outcomes although the former may be associated with a longer anastomosis time. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high quality research is encouraged to report the outcomes with respect to duct diameter and suture material.
WE2.9 Quality of ultrasound report in patients with biliary symptoms in the context of surgical diseases
Authors: Mateescu Daniela Ioana , Hakeem Abdul , Chedid Youssef , Chattopadhyay Dipankar
Published: November 2022

Aim

The diagnosis of surgical pathology in patients presenting with biliary symptoms is highly reliant on a good quality ultrasound report, our aim was to identify if there are any deficiencies in reports of ultrasound which are important diagnostic parameters of upper GI abnormalities.

Methods

Patients presenting to our hospital with biliary symptoms who require an ultrasound of biliary diseases were included, 8 parameters from the guidelines of Society and College of Radiographers were taken and analysed, means of missing data was calculated, CBD diameter was considered as a significant parameter. Quality of report for CBD was further scrutinized with patients who required 2nd investigations like MRCP and CTAP using crosstabs.

Results

A total of 278 patients were included in the study, 97.9% were due to gallstone diseases and 2.1% were for post-cholecystectomy. 89.7% had mentioned the normality of CBD while only 21.1% mentioned the actual value of CBD. 93% reports mentioned flow of portal vein, 7% did not mention portal vein flow. Interestingly 2.1% of ultrasounds were for post cholecystectomy but during scans, 4.6% of patients had absent gallbladder. 98 (34.5%) patients had one or more secondary investigations. 22.9% of normally reported CBD on ultrasound had positive CBD findings on MRCP.

Conclusions

This audit demonstrates the importance of a good quality ultrasound report. A good quality ultrasound can aid in clinical diagnosis and guidance of further investigations. Important factors to consider are the value of CBD Diameter, portal vein flow and quality of biliary stone/sludge.
WE3.3 Discharge delay-A pitfall for NHS; Can we improve?
Authors: Nessa Ashrafun , Ghazanfar Mudassar , Pawlay Karola , Purewal Ramandeep , Ganeshmoorthy Kajenthiny , Tayo Oluwasegun
Published: November 2022

Aim

Identify reasons for discharge delays from hospital and areas of improvement and any scope for trainees to make a difference – Trainee lead intervention.

Method

All inpatients including Elective and Emergency admissions were included from all 3 teams over 1 week. Data were collected on Microsoft Excel and analysis done with SPSS.

Result

Total 102 patients were included (Purple 44, Yellow 40, Red 18). Mean age was 60.5 years. 54 (52.9%) patients were Female. 57.4% data were missed for clinical frailty score (CSF). 46.5%patients had polypharmacy. 61 patients did not have any Expected date of Discharge (EDD). Mean Length of Hospital stay (LOS) is 18.01 days and median 10 (1–161) days. Total 27 patients were delayed. 1 stayed for 161 days awaiting rehab bed. Mean Duration of delay was 4.93 days and Median 1 day (1–42).4 patients were waiting beds outside of hospital for 3, 6,10, >30 days;6 patients were delayed for Stoma nurse review for average 1 day. Delayed discharges do not seem to be affected by polypharmacy (p=0.067), DNACPR (p=0.926), frailty score (p=0.761) or gender (p=0.518), or which team they were on (p=0.801). Discharges are however affected by age(p=0.037).

Conclusions

Our recommendations were to Identify patient at risk of discharge delay by trainees on admission by CSF, early identification of care requirements with OT/PT, regular EDD review, pre-emptive discharge letter preparation. We also recommended increased resources like training of senior nurses to assess stoma training, phlebotomists/ new clinical support worker to collect early morning bloods, increased Surgical bed capacity.
WE3.4 Nutrition in the Surgical Patient: Evaluation of the Current Knowledge and Practice in a Tertiary Centre
Authors: Procter Alice , Murdoch Jodie , Shah Shaneel , Curran Finlay
Published: November 2022

Aims

Methods

We performed a multi-cycle assessment using the PDSA format. To establish current knowledge a quiz was designed in consultation with local dietitians.

The following domains were evaluated against NICE guidelines:

A pass mark of 80% was established to aid data collection.

Cohort 1 consisted of 47 foundation year 1 doctors undertaking surgical rotations.

With the analysis of results from the first cohort a teaching session was designed. Following delivery of the teaching session, the cohort re-attempted the quiz.

Results

Cohort 1

Conclusions
WE3.6 The effect of the Covid pandemic on operative experience of laparoscopic appendicectomy
Authors: Kenber Melisa , Cheetham Stephanie , Doughty Alice , Smellie Eloise , Saha Arin
Published: November 2022

Aims

The Covid-19 pandemic has led to many changes in the delivery of surgical services; perhaps the greatest of these, for the long-term sustainability of surgery at least, is that on training. This study aimed to describe the effect of these changes on operative experience of laparoscopic appendicectomy

Methods

All patients who had surgery for suspected appendicitis from 2016 to 2021 were identified from a prospectively maintained database of surgeries. Data for 2020 and 2021 were compared with preceding years.

Results

Conclusions

In 2020, there were fewer operations performed for appendicitis and markedly reduced opportunities for trainees. This may reflect a fall in acute admissions, greater reliance on pre-operative imaging and reployment of surgical juniors. With a focus on returning to ‘normal’ in 2021 and a commitment to preserving surgical services, training opportunities have returned for laparoscopic appendicectomy despite the impact of Covid.
WE3.7 Cognitive computing in minimally invasive surgical training
Authors: Schaffer Sierra , Lo Justine JS
Published: November 2022

Aims

Research on Cognitive Computing (CC) in surgery is exponentially developing, however is only just starting to be investigated in minimally invasive surgical skills training. The technology is being underutilized, especially when compared with technical skills training in other industries. This review aimed to establish how CC is currently being used in minimally invasive surgical training and evaluate how this is projected to evolve.

Methods

A literature review was done of Pubmed, MedlineOvid, and PapersWithCode using the MeSH search terms CC (including machine learning, artificial intelligence, and neural networks), and minimally invasive surgical training and education.

Results

AI and NN were the most common CC technologies applied to minimally invasive surgical training. Basic laparoscopic training followed by general surgery robotics procedures were the most common skill sets studied.

The majority of studies focused on the assessment of skills and rating of participants after the training was complete. Overall CC was found to be effective and accurate at this task.

Few studies evaluated CC use for real-time feedback in order to improve participants’ training. Those that did found the technology capable of image tracking within 1–5 seconds. They were only used to provide feedback on one quality within the skill, most commonly economy of movement.

Conclusions

The application of CC to minimally invasive surgical training has only just started to be explored. Further interdisciplinary research with a focus on database development is needed in order to accelerate the wider utilization of CC within minimally invasive surgical training.
WE3.9 Operative competence should be assessed on a procedure-specific basis: analysis of submitted Supervised Structured Assessments of Operative Performance (SSAOPs) by Core Surgical Trainees in Ireland using Generalisability Theory
Authors: Toale Conor , Morris Marie , O'Keeffe Dara , Ryan Donncha M , Boland Fiona , Kavanagh Dara O
Published: November 2022

Introduction

Competency-based training programmes require reliable summative assessment methods. The aim of this study is to assess the reliability of the Supervised Structured Assessment of Operative Performance (SSAOP) tool in determining the operative competence of core surgical trainees in Ireland.

Methods

SSAOP scores from April 2016 - February 2021 were analysed. Reliability analyses for assessment of laparoscopic appendicectomy were compared to those across all submitted procedural assessments. Generalizability and decision studies determined the number of assessments and observers needed to achieve a reliability coefficient (G) of ≥0.7 and ≥0.8 (appropriate for low- and high-stakes assessment respectively).

Results

2,294 SSAOPs were analysed; 85 were completed for laparoscopic appendicectomy. G ≥0.70 is achieved using a single assessor observing a minimum of 3 laparoscopic appendicectomy cases, though G ≥0.70 cannot be achieved for assessments across a wider group of procedures without large numbers of assessors and cases. G ≥0.80 can be achieved with a minimum of two random assessors each observing 3 cases using the Overall Performance rating, or by two assessors and 6 assessments using the ‘Total Checklist’ score. Reliable assessment of a trainee's skill across all procedures, regardless of sub-specialty, could only be achieved using 89 cases and 7 assessors using the Overall Performance rater, or 67 cases and 9 assessors using the Total Checklist.

Conclusion

Operative competence should be assessed on a procedure-specific basis. Assessing overall competence across procedures is not feasible in practice. Trainers and trainees should focus on repeated assessments observing index procedures suitable for a given trainee's stage of training.
WE3.10 The Impact of Simulation Training on Junior Doctors Managing Surgical Emergencies
Authors: Wang Liyang , Morton Jonathan , Powar Michael , Davies Justin , Fearnhead Nicola , Wheeler James , Panagiotopoulou Ioanna
Published: November 2022

Aim

The use of simulation for the training of junior doctors in surgery usually involves either practicing technical skills or exercising communication skills. We have identified a gap in crisis resource management training of junior surgical trainees with scenario-based simulation. We have developed a one-day simulation course on general surgical emergencies and evaluated its impact.

Methods

The course included a human factors presentation and several scenarios of acute surgical emergencies. It was aimed at core surgical trainees, but other junior doctors were invited. High fidelity human simulator (SimMan®) was used and controlled by faculty. Surgical scenarios were selected in order to provide insight for the appropriate resuscitation for acute surgical patients. The impact of the course was evaluated with a post course questionnaire.

Results

Ten courses were completed between 2015 and 2021. A total of 58 doctors attended, 45 were core surgical trainees. All 51 participants who responded to the questionnaire rated the course “Good (4/5)” or “Excellent (5/5)”. Following the course, of 51 participants, 50 felt better prepared and 51 were confident in recognising unwell surgical patients; 42 felt better prepared and 50 confident in providing resuscitation; 46 felt better prepared and 51 confident in escalating care. During debriefs and on free text feedback, participants frequently reported the course helped develop their non-technical skills.

Conclusion

The General Surgical Emergencies simulation courses were rated useful by the learners. The course has positively impacted on the preparedness and confidence of junior surgical trainees in recognising unwell surgical patients, providing initial resuscitation and escalating care.
WE3.11 Inguinal hernia repair operation; review of the consent and the supported decision-making in the out-patient department
Authors: Abbakar Malaz , Ahmed Salma , Stojkovic Stevan
Published: November 2022

Introduction

In 2015, the ruling of the UK Supreme Court in Scotland in the case of Montgomery v Lanarkshire fundamentally changed the practice of consent. According to the Judges, doctors are no longer the sole arbiter of determining what risks are material to their patients. In this study, the RCS CONSENT: SUPPORTED DECISION-MAKING guide was used to evaluate our practice in regards to consent taking for inguinal hernia repair.

Methods

OPD letters to GPs were reviewed between 01/01/2019 to 30/12/2019. For risks with its percentages, alternative management exploration with the patient and whether information leaflets supplied to the patients.

Results

There were 63 patients. 19/63 letters had different options of treatment documented. 37/63 letters showed risks and complications documented and only 4/63 letters had percentages of the risks written. 25/63 patients signed consents in OPD. 0/63 letters indicated a signed consent copy was given to patients. Only 10 patients had been given an information leaflet.

Conclusion

Overall quality of letters was: 36/63 were poor, 21/63 were average and 5/63 were good. Therefore, to improve our practice leaflets shall be made easily accessible in all clinics. A prompt notification, if consent has been signed when booking a patient. workshops with feedback for middle grades.
WE3.12 A Closed Loop Clinical Audit on The Implementation of WHO Surgical Safety Checklist at a Tertiary Level Hospital in India: Where do we stand?
Authors: Sinha Akatya Vidushi , Kadam Sameer
Published: November 2022

Aim

To complete an audit on the level of compliance to the WHO surgical safety checklist in surgical operating theatres at a Tertiary level hospital in India.

Method

A total of 40 general surgeries were observed at the operating theatres at a tertiary level hospital in India to confirm the practice of the WHO surgical safety checklist. The study was conducted for a period of 2 months starting from July to August 2021. The results were compared with standard guidelines and further analyzed. Interventions were carried out by a series of rigorous departmental meetings and discussions with the medical and nursing staff. A re-audit was conducted after 2 weeks.

Results

Of all the operations audited, 45% Sign-In and only 1% Sign-Out were performed in the first cycle. After the re-audit, a significant change was reported as the Sign-In improved to 80% and a 55% Sign-Out was conducted. The Time-Out was observed to increase from 15% to 65%.

Conclusion

Though in the first cycle of our audit the compliance to the SSCL was found to be suboptimal, significant improvement was demonstrated in the second cycle after rigorous awareness programs and training sessions. Compliance was seen to be greater in major surgeries than in minor surgeries. Compliance with all items in the checklist and active participation by all medical and nursing staff is mandatory for successful implementation of the Surgical safety checklist.
WE4.1 A Prospective Observational Study on Quality of Life Pre and Post Gastrojejunostomy for Benign Disease
Authors: Black Rebecca , McCance Angus , Ainger Ellen , Fernandes Mr
Published: November 2022

Background

Benign disease leading to gastric outlet obstruction is a major cause for morbidity and malnutrition. Surgery in the form of a gastrojejunostomy is aimed at improving quality of life by bypassing the obstructing lesion and restoring adequate oral nutrition.

Methods

Patients undergoing an open gastrojejunostomy for benign disease at a district general hospital operated by the same surgeon over a 3 year period were recruited. Based on the HRQoL SF-12 questionnaire, the pre-operative physical component summary (PCS) score were recorded together with pre-operative albumin levels and weight. The post operative PCS score, post-operative albumin and post-operative weight were recorded at 90 days. Differences were investigated using univariate comparisons.

Results

The mean ± SD pre-operative PCS score were 33.9 ± 8.1, postoperative score were 42.7 ± 7.8 9 (p= 0.003) in 6 patients. Mean ± SD pre-operative serum albumin levels were 27 ± 4 and postoperative levels were 32 ± 3 (p=0.04). There was a 3.7 ± 1.2 kg increase in weight over the 90 day period (p=0.03). There were no complications nor returns to theatre. The mean length of stay was 6 ± 3 days.

Conclusions

Gastrojejunostomy for benign disease causing gastric outlet obstruction has been shown to improve quality of life, serum albumin and weight over a 90 day period. It can therefore be concluded that beneficial patient outcomes can be achieved in a relatively short time span post-surgery.
WE4.3 Complete versus partial excision of an infected mesh following abdominal wall hernia repair: A systematic review and meta-analysis
Authors: Bodkhe Komal , Qayum Mohammed Kaif , Kar Irfan , Hajibandeh Shahab , Hajibandeh Shahin
Published: November 2022

Aims

We aimed to evaluate comparative outcomes of complete and partial excision of infected mesh following abdominal wall hernia repair.

Methods

A systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Surgical site infection (SSI), chronic sinus formation, recurrent hernia and need for reoperation were the evaluated outcome measures.

Results

Six comparative observational studies were identified, reporting a total of 317 patients of whom 193 underwent complete mesh excision and the remaining 123 patients underwent partial mesh excision for an infected mesh following abdominal wall hernia repair. The complete mesh excision was associated with significantly lower rates of SSIs (OR: 0.36; 95% CI, 0.16–0.81, p=0.01), chronic sinus formation (OR: 0.11; 95% CI, 0.02–0.71, p=0.02), and reoperation (OR: 0.10; 95% CI, 0.03–0.33, p=0.0001) compared to the partial mesh excision. There was no significant difference in hernia recurrence rate (OR: 3.96.16, 95% CI 0.62–25.44, p=0.15) between two groups.

Conclusions

Our meta-analysis demonstrated that complete mesh excision may be associated with lower SSI, chronic sinus formation and need for reoperation when compared to the partial mesh excision in an infected mesh event. However, the available evidence has failed to report the outcomes with respect to the main confounding factors which, together with other important outcomes such as fistula formation, should be considered by future high quality research.
WE4.4 Robotic versus laparoscopic splenectomy in management of non-traumatic splenic pathologies: a systematic review and meta-analysis
Authors: Hajibandeh Shahin , Hajibandeh Shahab , Bhattacharya Pratik , Phelan Liam , Patel Ishaan
Published: November 2022

Aims

We aimed to evaluate comparative outcomes of robotic and laparoscopic splenectomy in patients with non-traumatic splenic pathologies.

Methods

A systematic search of electronic databases and bibliographic reference lists were conducted and a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in electronic databases were applied. Intra-operative and post-operative complications, wound infection, haematoma, conversion to open procedure, return to theatre, volume of blood loss, procedure time, and length of hospital stay were the evaluated outcome parameters.

Results

Eight comparative studies reporting a total of 560 patients comparing outcomes of robotic (n=202) and laparoscopic (n=258) splenectomies were included. The robotic approach was associated with significantly lower volume of blood loss (MD:-82.53 mls, 95% CI-161.91–-3.16, p=0.04) compared to the laparoscopic approach. There was no significant difference in intra-operative complications (OR:0.68, 95% CI 0.21–2.01, p=0.51), post-operative complications (OR:0.91, 95% CI 0.40–2.06, p=0.82), wound infection (RD:-0.01, 95% CI -0.04–0.03, p=0.78), haematoma (OR:0.40, 95% CI 0.04–4.03, p=0.44), conversion to open (OR:0.63; 95% CI, 0.24–1.70, P=0.36), return to theatre (RD:-0.04, 95% CI -0.09–0.02, p=0.16), procedure time (MD: 3.63; 95% CI, -16.99–24.25, P=0.73) and length of hospital stay (MD:-0.21; 95% CI, -1.17–0.75, P=0.67) between two groups.

Conclusions

Robotic and laparoscopic splenectomy seem to have comparable perioperative outcomes with similar rate of conversion to an open procedure, procedure time and length of hospital stay. The former may potentially reduce the volume of intra-operative blood loss. Future higher level research is required to evaluate the cost-effectiveness and clinical outcomes
WE4.9 Complete versus partial excision of an infected mesh following abdominal wall hernia repair: A systematic review and meta-analysis
Authors: Bodkhe Komal , Qayum Mohammed Kaif , Kar Irfan , Hajibandeh Shahab , Hajibandeh Shahin
Published: November 2022

Aims

We aimed to evaluate comparative outcomes of complete and partial excision of infected mesh following abdominal wall hernia repair.

Method

A systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Surgical site infection (SSI), chronic sinus formation, recurrent hernia and need for reoperation were the evaluated outcome measures.

Results

Six comparative observational studies were identified, reporting a total of 317 patients of whom 193 underwent complete mesh excision and the remaining 123 patients underwent partial mesh excision for an infected mesh following abdominal wall hernia repair. The complete mesh excision was associated with significantly lower rates of SSIs (OR: 0.36; 95% CI, 0.16–0.81, p=0.01), chronic sinus formation (OR: 0.11; 95% CI, 0.02–0.71, p=0.02), and reoperation (OR: 0.10; 95% CI, 0.03–0.33, p=0.0001) compared to the partial mesh excision. There was no significant difference in hernia recurrence rate (OR: 3.96.16, 95% CI 0.62–25.44, p=0.15) between two groups.

Conclusions

Our meta-analysis demonstrated that complete mesh excision may be associated with lower SSI, chronic sinus formation and need for reoperation when compared to the partial mesh excision in an infected mesh event. However, the available evidence has failed to report the outcomes with respect to the main confounding factors which, together with other important outcomes such as fistula formation, should be considered by future high quality research.
WE5.1 Review of acute referrals to Surgical SDEC at a DGH
Authors: Chidambranath Rajesh , Thomas Pradeep , Flatt Janette
Published: November 2022

Aim

We intend to interpret the pathway that patients attending Surgical SDEC followed in this journey, at first contact point, their experience at each stage of contact with emergency services and reasons for taking the final pathway.

Method

We formed an anonymised questionnaire for patient pathway to SDEC, filled on arrival at SDEC. First 53 patients were included from 1 week data. This included the reason for their visit, duration of their presenting problem and whom they called before attending or being directed to SDEC and patient experience with each provider such as 111, 999 and GP in brief. Finally, we observed who they contacted and how urgent they thought their problem was.

Result

There were 53 patients, 50 responding for themselves. 51 of 53, agreed that they would contact GP or 111 for non-urgent queries. 41/53 77.35% approached their GP initially and we found that 58.5% were referred to SDEC. Of the 32 (37.7%) patients seen by GP, 24 (58.5%) were referred to SDEC. 20% thought they were too urgent for GP. We found that GPs were managing most urgent referrals (38%) and the majority of these were referred to SDEC as in the case of 111 responders.

Conclusion

Changes introduced by the Long Term Plan were well received by patients with majority of patients being seen in SDEC. The first patient contacts also resulted in SDEC referrals from the community and it would be appropriate for such referrals to be sent directly to SDEC by GPs and 111.
WE5.2 Safety of in-hospital delay to appendicectomy in acute appendicitis: a retrospective study
Authors: Claydon Oliver , Down Billy , Kumar Sidharth
Published: November 2022

Aims

In many hospitals the availability of operating theatres and access to senior surgical and anaesthetic support diminishes during night hours. Therefore urgent surgery is sometimes postponed until the following morning rather than performed overnight, if judged to be safe. We aim to determine if a delay to laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, is correlated to worse patient outcomes. Our primary outcome was delayed discharge from hospital. Our secondary outcomes were appendicitis severity, conversion, and post-operative complications.

Methods

We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient clinical and demographic information; and times of hospital admission, surgery, and discharge; were collected. Delayed discharged was defined as ‘time to discharge’ >24 hours.

Results

506 patients were included. In 144 patients (28.5%) ‘time to surgery’ was under 12 hours; in 362 patients (71.5%) ’time to surgery’ was over 12 hours. 362 patients (71.5%) had a delayed discharge. 303 patients (59.9%) had simple appendicitis; 143 patients had severe appendicitis (28.3%); 60 patients had a macroscopically normal appendix (11.9%). No statistically significant association between ‘time to surgery’ and delayed discharge, appendicitis severity, conversion or 30 day re-presentations was observed.

Conclusions

Time from admission to start of appendicectomy did not affect patient outcomes. Short in-hospital delays to appendicectomy, for example an overnight delay, may be safe in certain patients, taking account of clinical judgement.
WE5.3 Emergency laparoscopic “hybrid” IPOM+ repair of incarcerated umbilical hernia in patient with BMI 62 and small bowel obstruction; a case study
Authors: Clyde Danielle , Healey Andrew , Damaskos Dimitris
Published: November 2022

Background

Large abdominal incisions in obese patients are associated with considerable rates of systemic and wound complications. Recently published European Hernia Society guidelines recommend laparoscopic intraperitoneal on-lay mesh (IPOM) repair for large hernia defects and patients at higher risk of wound morbidity, ideally with closure of the defect and a 5 cm overlap.

Case Presentation: We report on a 69-year-old, morbidly obese (BMI 62), comorbid woman who presented as an emergency with a 5-day history of vomiting and abdominal pain. A pre-operative computed tomography (CT) scan confirmed small bowel obstruction secondary to a ventral abdominal wall hernia. Operative findings confirmed an obstructed paraumbilical hernia containing small bowel and omentum. A laparoscopic “hybrid” IPOM+ repair was performed, with a generous overlap. She recovered uneventfully with no surgical complications.

Discussion: Minimally-invasive surgical techniques are preferred for obese patients with evidence suggesting lower perioperative complications and recurrence rates compared with open repair. However, additional challenges must be taken into consideration including; surgeon expertise, timing of operation, surgeon ergonomics, distortion of surface anatomical landmarks, need for higher pneumoperitoneum pressures and the physiological effects of this on the patient.

Conclusion

With preoperative planning, our case study demonstrates that IPOM ventral hernia repair remains a viable option for severely obese patients even in emergency presentations. The closure of the defect is recommended whenever feasible. Addition of the hybrid approach (excision of the sac with a limited incision after the laparoscopic closure) reduces the risk of postoperative seromas.
WE5.4 The Successful Resurrection of NELA in a District General Hospital
Authors: Gohil Bhavesh , Sarodaya Varun , White Alastair , Garg Arti
Published: November 2022

Introduction

The NELA requirements of data collection is known to be mandatory. Our DGH had three years of non compliance. We present an executed plan in the collection of retrospective and prospective process to achieve national standard.

Method

A new structural setup with anaesthetic and surgical teams was formalised.

A recruitment of 13 foundation doctors was made and each were induced to NELA with a teaching session. Allocation of 15–20 hospital numbers with a primary deadline of seven days to achieve full entry was expected. A formal NELA certificate and recognition for taking part from the divisional director was issued.

A prospective strategy was initiated with patient ownership from the joint anaesthetic and surgical team involved. A NELA login with local access was setup, plus paper format readily available for rare access situations. A two email reminder system with further escalation process was introduced if entry was incomplete. The escalation being contact from the clinical lead / divisional director. This information was highlighted at a local meeting plus a familiarity of the NELA database was ensured.

Results

A large proportion of the retrospective data has been collected over a short time period due to a clear incentivised scheme. Prospectively there has not been any escalation emails needed since the new setup.

Conclusion

Areas of problems were identified with a wide range of solutions being put forward.

A multi collaborative approach was needed plus positive cooperation from the clinical lead, clinical director and the divisional director to ensure the successful new era.
WE5.6 Hajibandeh index is more accurate than NELA score in predicting mortality following emergency laparotomy in patients aged over 80
Authors: Anwer Amal Azhar , Hajibandeh Shahab , Hajibandeh Shahin , Waterman Jennifer , Miller Bethany , Evans Louis , Maw Andrew
Published: November 2022

Aims

To compare performance of the Hajibandeh Index (HI) and National Emergency Laparotomy Audit (NELA) score in predicting mortality following emergency laparotomy (EL).

Methods

In compliance with STROCSS guidelines for observational studies a cohort study was conducted. All patients who underwent EL between January 2014 and January 2021 in our centre were included. The performance of HI and NELA score in predicting 30-day and 90-day postoperative mortality were compared. The discrimination of each test was evaluated using ROC curve analysis, classification using classification table and calibration using a plotted diagram of the expected versus observed mortality rates.

Results

Analysis of 700 patients showed that the predictive performance of the HI and NELA models were comparable (AUC: 0.86 vs 0.87, P=0.557). HI was significantly better than the NELA model in predicting postoperative mortality in patients aged over 80 (AUC: 0.85 vs 0.72, P=0.0174). The performances of both tools were comparable in patients with ASA status above 3 (AUC: 0.82 vs 0.82, P=0.9775), patients with intraperitoneal contamination (AUC: 0.77 vs 0.85, P=0.0728) and patients who needed a bowel resection (AUC: 0.85 vs 0.88, P=0.2749). Both tools were comparable in terms of classification and calibration.

Conclusions

Hajibandeh index is better than the NELA score in predicting mortality following EL in patients aged over 80. Its performance is comparable to NELA for all patients, patients with ASA status above 3, patients with intraperitoneal contamination or patients who need a bowel resection. We encourage other researchers to validate HI in predicting mortality following EL.
WE5.7 A Comparison of Small and Large Bites Closure of Fascia in Midline Laparotomy Wounds: Experience in a District General Hospital
Authors: Heard Rachel , Darbi Elmahdi , Soh Coreen , Barker Jonathan
Published: November 2022

Aims

Small bites (SBC) laparotomy closure (5mm fascial bites, 5mm apart) is thought to decrease incisional hernia rates compared to large bites (LBC) closure (1cm bites, 1cm apart). A colorectal surgeon in our centre changed practice following the STITCH trial. We aimed to assess whether this change affected outcomes.

Methods

All midline laparotomy patients immediately before and after the change in practice in 2017 were considered for inclusion. Data on demographics, co-morbidities, operation details, length of stay (LoS), complications and outcome were gathered from operation notes and electronic patient records. Follow up was censored at 12 months to make groups comparable.

Results

80 patients were included (38 SBC; 42 LBC), undergoing laparotomy from August 2014-December 2020. Age, gender and ASA grade were comparable between groups. 58% SBC; 71% LBC were emergency cases. LoS was 7 days (range 3–166) for SBC; 11 (5–369) LBC. Overall wound complication rates were similar (23.7% SBC; 19% LBC, p=0.61). There were 4 (10.5%) burst abdomens following SBC and 2 (4.8%) following LBC (p=0.21). 1 (2.6%) SBC and 3 (7.1%) LBC developed incisional hernia at 12 months.

Conclusions

SBC did not result in decreased wound complications: although incisional hernia rate and LoS were reduced, there was a (non-significant) higher rate of burst abdomens in SBC. The latter may reflect a learning curve effect of a new technique. This study suggests SBC is feasible in a DGH, but long-term outcomes of SBC are yet to become apparent, which may have affected results in this cohort.
WE5.8 Length of stay in Emergency General Surgery – Time for a Comprehensive Look at Our Elderly Population
Authors: Howie Emma , Helley Michael , Box Emma , Watt David
Published: November 2022

Aims

Patients’ Length of stay (LoS) has increased due to increasing age and co-morbidities. The British Geriatric Society 2020 Position statement states patients >65 being considered for laparotomy should have a documented Clinical Frailty Scale (CFS) within 72hrs of admission and, if >5, should receive Geriatrician lead Comprehensive Geriatric Assessment (CGA) which improves patient outcomes.

We sought to quantify CFS documentation in Emergency General Surgery (EGS) patients in a District General Hospital before implementing a new CGA to improve elderly EGS patient care.

Methods

Planning

Business intelligence records of all adult EGS admissions over 1-year were retrospectively interrogated – comparing LoS between age groups, comorbidity number, discharge destination and whether a procedure was undertaken.

EGS admissions were prospectively reviewed over 1-month, noting patients >65 and CFS documentation.

Results

Retrospective: 3962 patients >16 were admitted January-December 2019. 1317 patients (33%) were >65. Average LoS was 3.9 days, overall highest LoS was ages 75–84 (8.5 days). Highest average LoS were >75yr olds requiring supported care at home (15.5 days). LoS varied directly with number of diagnosis codes and increased if undergoing a procedure.

Prospective: There were 130 EGS admissions in 1 month, 53 (40%) patients were >65. No patients >65 had a CFS documented.

Conclusions

Increased LoS in EGS is associated with increasing age and comorbidities - particularly patients > 75 awaiting home-care. BGS statement concordance to establish prompt frailty assessment is imperative to improve patient outcomes. Staff education and surgery-specific CGA note-stickers may improve concordance. Subsequent analysis to evaluate effectiveness in patient and economic outcomes is paramount.
WE5.9 Management of acute abdominal pain in children at District General Hospital (DGH)
Authors: Jalali Uzma , Alam Imran , Fani Mazyar
Published: November 2022

Introduction

Children with acute abdominal pain are frequently seen in paediatric A&E at DGH. Acute appendicitis is the most common surgical cause of acute abdominal pain in children. Diagnosis and management can be a problem in the absence of paediatric surgical unit

Methods

A retrospective study was conducted at a busy DGH where general surgical department is routinely involved in the management of acute abdominal pain in children. 6 months data was collected from 01/06/21 to 30/11/21.

Results

381 patients (5–16 years) attended paediatric emergency with complaint of abdominal pain. 24% referred to surgeons (females 53%, mean age 10.9 years). All Presented with pain in RIF, migratory pain was in 42%. Nausea and vomiting were reported in 38%, loose stools in 10.8% and loss of appetite in 21.7%. Duration of pain vary between 24 hours to 3 weeks. WCC was raised in 32% patients, US was performed in 21.7%, CT scan in 5.4%, MRI 1%, and 1% had both Ultrasound and MRI. 46.7% did not have any radiological investigations. Appendectomy was performed in 21% (19) patients including laparoscopic in two. Duration of stay range from less than 24 hours to 5 days. 46.7% were discharged within 24 hrs of review, 21.7% stayed for one and only 2% stayed for five days. 1 patient was readmitted following a post operative collection that was managed conservatively. 2 referred to tertiary paediatric unit for complicated appendicitis.

Conclusion

This data proves that paediatric patients with suspected appendicitis can be safely managed in a surgical unit at DGH.
WE6.2 The true cost of pre-operative investigations
Authors: Dholoo Farzan , Shabana Amanda , Burrows Abigail , Horsnell Jonathon
Published: November 2022

Introduction

Pre-Operative Assessment (POA) is an integral part of surgery. It is essential for pre-operative investigations including bloods and COVID-19 swabbing. There was concern within the Breast-Unit that patients may be having unnecessary blood-tests as part of their POA. This was likely due to POA not having one unified resource to refer to. Guidance suggests POA uses the patient's American Association of Anaesthesiologist's (ASA) grade, type of surgery they are undergoing and additional conditions for determining pre-operative investigations.

Methods

This QIP consisted of 2 cycles. During cycle-1 data was audited against national guidance to see which blood tests were performed unnecessarily. After developing a universal-guidance poster and teaching sessions, a second cycle was performed. Cycle-2 assessed whether there was a reduction in unnecessary blood tests being performed.

Results

During cycle-1, 216 pre-operative blood tests were undertaken. Of these only 99 were required. Therefore 54% of the tests were unnecessary. This equates to £690.77 over 2-months and if extrapolated £4144.62 spent, unnecessarily per-year. This represents a significant cost to the trust and puts needless pressure onto the laboratory. During cycle-2, after our intervention, there were 57 fewer tests and 40 fewer, incorrect blood tests. Our intervention therefore resulted in a £183.46 saving, which over a year equates to £1110.76 saved.

Conclusion

The potential benefits of improving POA include financial savings, patient autonomy, increased appointment availability and reduced pressure on the laboratory. In these unprecedented times, trying to tackle the COVID-19 backlog; we advise all departments to ensure that clear guidance exists.
WE6.3 This isn't going to hurt - an ambulatory model of management of patients with subcutaneous abscesses reduces use of general anaesthetic and bed days
Authors: Dru Rebecca , Ermiah Asem , Amr Bassem , Barton Jessica , Williams Lian , Hollyman Marianne
Published: November 2022

Aim

Management of patients with subcutaneous abscesses is challenging. Once in hospital, the majority require incision and drainage (I&D), often under general anaesthetic (GA). Patients placed on emergency lists are frequently superseded, due to being systemically well, often staying overnight in hospital.

We assessed how the establishment of a nurse-led, ambulatory service for I&D of abscesses reduced the need for GA, and impacted inpatient stay.

Method

Multiple digital sources were used to retrospectively collect data for all patients attending our centre for I&D of subcutaneous abscess during two time periods: August-October 2019 (prior to establishment of the ambulatory service) and August-October 2021 (a year after implementation of the service). Location I&D performed, mode of anaesthesia and length of stay were collected.

Results

In 2019, 102 patients underwent I&D; 87(85%) were drained under GA. In 2021, 73 patients were managed with I&D, but only 41(56%, p<0.001) required GA; 6(15%) cases were accommodated on a day surgery list.

In 2019, 37(36%) patients were managed without overnight stay; in 2021 this rose to 46(63%, p<0.001).

Extrapolating if an average of one patient requiring I&D attended each day, estimated bed days used per year dropped from 440 in 2019, to 215 in 2021.

Conclusion

Establishment of a nurse-led ambulatory pathway for I&D of skin abscesses safely and effectively reduces the number of general anaesthetics and inpatient bed days, potentially by half. Patients requiring anaesthetic support should be accommodated on planned day case lists where possible.
WE6.6 Does Nexobrid improve healing outcomes in treatment in adults with partial thickness burn compared to standard of care? A meta-analysis
Authors: Imsirovic Anja , Butler Ceri , Drake Paul
Published: November 2022

Aims

Burns are usually associated with significant morbidity and mortality due to dysfunction and disfigurement. Non-fatal burns usually contribute to morbidity via burn wound infection, systemic sepsis, multiple organ failure, pneumonia etc. leading to prolonged hospitalization. The objective of this study is to present a systematic review of the role of enzymatic debridement in healing outcomes compared to standard of care (debridement and skin grafting) in adult patients with burns.

Methods

A systematic review of randomized controlled and case-control studies reporting and comparing healing outcomes of Nexobrid with the standard of care, published on Embase, Medline, PubMed, Google Scholar and Cochrane databases in the period from 1946 until August 2021 was performed. Relevant studies were extracted and analysed with the help of Review Manager.

Results

The database search identified thirteen articles that met inclusion criteria. A combined number of 441 patients were included. Nexobrid application average time was one day. The combined mean of total body treated mean surface was 6.5%. Studies investigating Nexobrid mention the combine average success of debridement of 82.8%. The forest plots favour the current evidence of Nexobrid shortens time from injury to intervention, reducing the need for surgery, hence shortening the length of hospital stay.

Conclusions

This systematic review provides the current results of Nexobrid usage for enzymatic debridement of partial thickness to deep dermal burns. Further randomized controlled trials or feasibility studies are warranted to open new horizons for this modality of burns treatment.
WE6.8 An audit to look at the current practice of treating ureteric stones and compare it to NICE/ BAUS guidelines
Authors: Minhas Avneet , Moss Basil
Published: November 2022

Aim

An audit to look at the current practice of treating ureteric stones and compare it to NICE/ BAUS guidelines.

Methods

A retrospective audit looking at treatments given to patients presenting to the emergency department with renal colic. We looked at the time it took for patients to get a CT scan from the time of admission, the treatments provided to them as an inpatient, the subsequent outpatient follow-up, and the timescale within which these were provided.

Results

A total of 50 patients were included. The average time it took for patients to get a CT scan from the time of admission was 16hours and 31 mins. Only 6% (3) of patients received definitive surgical treatment during their inpatient admission. 62% (31) of patients were treated conservatively, 26% (13) were treated with a ureteric stent, and 4% (2) with a nephrostomy. At follow-up, in patients managed conservatively, stone had passed spontaneously in 58% and remained in 35.5% of patients. Patients treated with interim measures like stent or nephrostomy had to wait approximately 7 weeks on average after their inpatient treatment for definitive management.

Conclusion

Majority of patients were able to get a CT scan within the 24-hour target. Reasons for delayed definitive management could be not having access to suitable operating theatres or lack of trained staff to use the laser or assist with emergency stone treatments. Overcoming these obstacles could potentially lead to substantial cost savings on a population level and avoid subjecting patients to unnecessary second procedures and longer waiting periods.