bluuebunny/crossref_metadata_2025 huggingface dataset:
EP-534 Review of Types of Intravenous Fluid and Rate of Administration in Resuscitation of Acute Pancreatitis Patients
Authors: Rakhimov Iskandar , Badawi Marwa , Lee Sara , (Allenis) Mak Tsz Lun
Published: November 2022

Aim

Acute pancreatitis even in its mildest form leads to dehydration that requires correction by intravenous fluid in timely fashion. The pathophysiology of fluid deficit is caused by fluid shift as a result of severe inflammation in the abdomen, lung damage and compromise to renal functions.

The evidence behind choice of fluid used for resuscitation is limited, but delayed resuscitation is linked to increased mortality, however overly aggressive fluid administration could lead to lung injuries.

Aggressive fluid resuscitation is defined as 15ml/kg/hour or >3.1L in the first 24 hours while conservative administration is defined as 5–10ml/kg/hour.

Methods

We reviewed our admissions with acute pancreatitis in August & September 2021. The age range was 24–94 years, diagnosis was confirmed by raised amylase, clinical symptoms and radiological evidence.

55.5% received Hartman's solution, 18.5% of patients received normal saline and 26% received both. The mean amount of fluids was 3Litres and the mean rate of first, second and third Litres was 4hours, 3.4 hours and 3.7 hours/Litre respectively in the first 24 hours.

Results

The mean LOS was 3.2 days, none of our patients were re-admitted for complications related to pancreatitis within 90 days, 1 patient had complicated necrotising pancreatitis and 1 patient deceased during their stay.

Conclusion

NICE guideline NG104 did not specify clear guidance on rate of fluid resuscitation, low quality evidence suggested possible benefit of aggressive therapy comparing mortality and systemic complications. We recommend individual assessment of rate of fluid administration for every patient to ensure absence of contraindications to aggressive therapy.
EP-546 Management of breast cancer in different age groups during pandemic single institute review
Authors: Muhibullah Nazli , Ng James , Cuffolo Giulio , Whisker Lisa
Published: November 2022

Introduction

Covid 19 has huge impact on healthcare in general and challenges in cancer services in particular. In breast cancer prioritization strategies for management have been introduced at start of pandemic by different medical associations.

Aim

We aim to see impact of prioritization strategy in treatment of premenopausal and postmenopausal breast cancer patient. This is further stratified as under 50, 50 to 70 and over 70.

Methods

A prospectively collected database from March 2020 to March 2021 analysed. This include patient demographic, tumour characteristics, Neoadjuvanct endocrine NAET), Neoadjuvanct chemotherapy (NACT), primary endocrine (PE), type of surgery: breast conservation surgery (BCS) with or without oncoplastic procedure, Mastectomy with or without reconstruction and utilization of private sectors.

Results

Total 454 patients reviewed. Mean age 61 yrs (26–97yrs).

Total patient less than 50 years were 116. BCS 66 (57%), Simple mastectomy 26 (22%), Mastectomy with reconstruction 24 (20%).In this group 45 patients were offered NACT and 6 patients had NAET.

Total patients older than 50 years were 236. BCS 191 (80%), Simple mastectomy 38 (16%) and Mastectomy with reconstruction 7(3%) patients. In this group 69 patients had NACT and 13 had NAET.

Patients over 70 years were 102. BCS 57(56%), Simple mastectomy 25(24%), 1 (1%) had mastectomy and reconstruction. 8 patients had NACT, 13 had NAET and 30 had primary endocrine.

Conclusion

Due to swift guidelines in pandemic times breast cancer services were largely intact and provide standard care.
EP-553 A Review of feedback for the Surgical department teaching for foundation doctors
Authors: Gulnaz Nadia , Tasleem Sadia , Siddique Khurrum
Published: November 2022

Aims

To assess the usefulness of departmental teaching for the foundation doctors.

Methods

Teaching sessions are arranged every Friday covering the most common surgical problems and the management steps appropriate for their level. A feedback questionnaire was sent out to the foundation doctors at the end of their rotation and the data was analyzed for the period of August 2020 to November 2020.

Results

The feedback completion rate was 93%. 18 sessions were planned 14 of which went ahead. 1 session was canceled due to junior doctors shortage. Maximum attendees in any session were 10/14 (mean 7) Almost all of them found these sessions useful to and agreed to recommend attending (6–10 on Likert score of 0–10) 75% rated these sessions as “excellent” and all the rest as “very good”. 76% showed satisfaction with the time and space allocation. 84% agreed that the session length of 1 hour was adequate. 91% were happy with the adequacy of communication from the organizer. A vast majority suggested flexibility in session timings and relief from ward jobs for improved attendance.

Conclusion

Overall Positive Response. Most suggested the timings/ days be changed.

The topics covered were appropriate for their level and helped them in their daily practice.

Interactive and simulations sessions were the most appreciated ones.

Some necessary changes to rota were suggested in order to make these sessions more accessible and useful.
EP-555 The telescoping sigmoid – a rare presentation of acute large bowel obstruction
Authors: Al-Sabbagh Ali , Alseifi Shaker , Kaur G
Published: November 2022

Background

Adult bowel intussusception is a rare cause of bowel obstruction (1–5%) and requires urgent treatment, usually emergency surgery.

Aim

We wish to highlight the diagnosis and management of the rare entity of acute bowel obstruction secondary to intussusception with our adult patient with sigmoid colon intussusception.

Case presentation

We present a 65 years old male who attended with constipation, abdominal discomfort and per-rectal bleeding. Clinical examination revealed multiple subcutaneous lipomas, mild LUQ tenderness and large ‘lump’ 10 cm from anal verge on rigid sigmoidoscopy. CT abdomen/pelvis showed intussusception of the sigmoid into the rectum with a large ‘polyp’ as the lead point. On- table Flexible sigmoidoscopy was unsuccessful in reducing the intussusception. We proceeded to laparotomy with reduction of intussusception, high anterior resection with end- to- end stapled anastomosis. He made an excellent recovery. Post-operative histology which was reviewed in detail in MDT did not reveal any neoplastic/lipomatous lesion to account for the intussusception. The patient was very well on outpatient review.

Conclusion

Adult bowel intussusception is rare (5% of all intussusceptions), especially in the left colon. When it does occur, it is usually secondary to lipoma, neoplasm, or nodal mass acting as a lead point. These patients can be diagnostically challenging due to lack of clear obstructive symptoms on presentation. Early diagnosis (via a CT scan) and treatment of adult colonic intussusception (usually via surgery) is necessary to avoid serious complications such as bowel perforation/peritonitis. Postoperative histology review is also imperative to plan any appropriate further management.
EP-567 Stress Thrombosis - A case of spontaneous DVT of upper extremity
Authors: B M Darshan , Somasekhar Kasa
Published: November 2022

Background

Primary spontaneous upper extremity deep vein thrombosis is rare with an estimated annual incidence of 1 to 2 cases per 100,000 population. The majority of cases are secondary and related to central venous cannulation (eg, central line, pacemaker) or prothrombotic states. On the offset of COVID-19 pandemic such cases could become a common entity.

Case Report

An elderly diabetic and hypertensive female patient presented with a history of acute onset swelling, heaviness, tingling and numbness of left upper limb since 1 week. Examination revealed, diffuse swelling of left upper limb extending to neck with small dilated veins in left upper chest. A provisional diagnosis of left upper limb DVT was made based on Constants criteria and was confirmed on Duplex scanning.

The patient was started on LMWH for anticoagulation. Evaluation for occult cancers was unremarkable. Patient showed symptomatic improvement and recanalisation of thrombosed veins was noted on repeat duplex scan.

Conclusion

Upper extremity DVT (UEDVT), once a rare entity, can be seldom thought of, due to widespread interventions and ongoing COVID-19 pandemic. Focus on evaluation of occult malignancy rather for hypercoagulable states which do not change the management. This case report highlights the importance of early recognition of UEDVT and stresses on the evidence that no added benefit is achieved by performing expensive tests to rule out prothrombotic states. Early diagnosis based on Constants criteria and anticoagulation would save time and prevent grave complications.
EP-568 A prospective study on single layer bowel repair
Authors: B M Darshan , Somasekhar Kasa
Published: November 2022

Aim

To determine the efficacy of single layer bowel repair with respect to postoperative complications such as leakage rates, duration of repair, overall length of hospital stay, cost effectiveness, to assess the morbidity, mortality and outcome.

Methods

This prospective study was done on 21 patients admitted under department of surgery from the period of January 2020 to September 2021. All the patients under bowel repair in continuous single layer extramucosal fashion for various etiology, follow up data was collected and analysed.

Results

In our study, 81% (17 cases) of the single layer bowel repair were done in an emergency setting. The study consisted of 42.9% (9 cases) of perforation repair and 57.1% (12 cases of resection and anastomosis of large or small bowel). The average time duration of anastomosis was 14.45 minutes with the average hospital stay of 13.2 days. Our study showed an anastomotic leak rate of 9.5% (2 cases) with an overall mortality of 19.04% (4 cases) which included 2 cases with COVID-19 related ARDS.

Conclusion

Our study was determined to analyse the effectiveness of single layer bowel repair and found that it is a quicker and theoretically better technique for bowel repair which avoids unnecessary tissue ischemia. The leakage rates within the study was comparable with other studies published and the studies with double layer bowel repair technique in terms of leak rates and mortality. A meticulously done single layer repair will best double layer repair and surgical trainees must be trained early to perfect the art of bowel anastomosis.
EP-573 Does type of surgery influence recurrence of breast cancer in younger patients?
Authors: Farrugia Alexia , Green Matt , Brookes Phil , Kasana Iqbal
Published: November 2022

It is well established that young age is a risk factor for outcome of breast cancer, and younger women are more likely to have adverse prognostic factors. Our aim was to investigate whether type of surgery (wide local excision vs mastectomy) had any effect on local or distant recurrence in women under the age of 35.

All women with breast cancer under the age of 35 treated between 1st January 2010 and 31st December 2020 were included. Data including age at diagnosis, comorbidities, type of surgery, neoadjuvant/adjuvant treatment, histology, lymph node positivity, expression of receptors, local/distant recurrence was collected.

There were 34 patients included, age range 21–34. Ten patients had a wide local excision (WLE) while the rest had a mastectomy. Four patients had local recurrence while nine patients had distal recurrence. In WLE group 1 out of 10 had local recurrence and 2 out of 10 had distant metastasis (one of these patients had both). In mastectomy group 2 out of 24 had local recurrence and 7 out of 24 had distant metastasis (two patients had both). The average recurrence time was 1.7 years after initial diagnosis. Using a Chi-square test, there was no significant difference found for local, distant or overall recurrence between patients having wide local excision or mastectomy (p=0.719, p=0.554, p=0.462 respectively).

Type of surgery did not affect the local or distant recurrence rate. The sample size is small, and a larger series is required to determine whether it is equally safer to offer WLE to younger women.
EP-575 Exhaled volatile organic compounds in the detection of colorectal cancer: A systematic seview and meta-analysis
Authors: Alsaadi Daniah , Clements Nicolle , Gabuniya Natiya , Chand Manish , Nader Francis
Published: November 2022

Aims

There is an apparent need for novel non-invasive colorectal cancer (CRC) screening tests that are more acceptable to patients and can reliably detect CRC or reduce the number of unnecessary colonoscopies performed in cancer-free patients. An emerging number of studies demonstrate the potential value of exhaled volatile organic compounds (VOCs) as a diagnostic and triaging test for CRC. A systematic appraisal and meta-analysis of the published evidence was done to determine whether exhaled VOCs can be used in the detection and screening of CRC.

Methods

Nine electronic databases were searched from inception of the databases until August 2020. Quantitative and descriptive data of CRC patients and healthy control (HC) participants who underwent VOCs breath analysis was extracted. In addition, where possible, sampling methods, analytical platforms, processors, and specific breath biomarkers found in each study were recorded.

Results

Fourteen articles were included in the systematic review with 491 colorectal patients and 754 HC participants (n=1245). Sub-group meta-analysis was conducted on nine of those articles and the pooled sensitivity was estimated to be 0.89 (95% CI = 0.80–0.99) whereas specificity was 0.83 (95% CI = 0.74–0.92). Heterogeneity of pooled sensitivity and specificity was estimated as I2=11.11%.

Conclusions

Although this study was limited by small sample size and different analytical platforms, the proposed future framework resolves such limitations and standardizes future research. It is reasonable to deduce that VOCs breath analysis is certainly a field of research that can progress to replace traditional methods within the framework of CRC screening and diagnosis.
EP-581 Prophylactic onlay mesh at emergency laparotomy: Promising early outcomes with long-acting synthetic resorbable mesh
Authors: Alsaadi Daniah , Stephens Ian , Simmons Lydia O , Bucholc Magda , Sugrue Michael
Published: November 2022

Background

Careful surgical strategy is paramount in balancing the prevention of fascial dehiscence, incisional hernia (IH) and fear of additional mesh-related wound complications post-laparotomy. This study aims to review early outcomes of patients undergoing an emergency laparotomy with prophylactic long-acting resorbable synthetic TIGR® mesh, used to reduce early fascial dehiscence and potential subsequent IH.

Methods

A retrospective, ethically approved review of 24 consecutive patients undergoing prophylactic TIGR® mesh placement during emergency laparotomies by a single surgeon between January 2017 and June 2021 at a University Hospital. A standardised approach included onlay positioning of the mesh, small-bite fascial closure, and a wound bundle. We recorded patient demographics, operative indications, findings, degree of peritonitis, postoperative complications, and mortality.

Results

The study included 24 patients; 16/24 (66.6%) were female and mean age was 66.5 (range 31–86); 14/24 patients were ASA grade III or greater; 4/24 patients (16.6%) developed six complications and 3/6 occurred in a single patient. Complications included subphrenic abscess, seroma, intrabdominal hematoma, enterocutaneous fistula leading to deep wound infection and small bowel perforation. Five (20.8%) patients died in hospital; central venous catheter sepsis (n=1), fungal septicaemia (n=1) and multiorgan failure (n=3). Surgical site infection and seroma rates were low, occurring in 2/24 patients (4% each).

Conclusions

This small study has identified that prophylactic onlay mesh in patients undergoing an emergency laparotomy is not associated with significant wound infection or seroma when used with an active wound bundle. The wider use of TIGR® to prevent fascial dehiscence and potential long-term IH prevention should be considered.
EP-582 Giant bilateral intrathoracic involvement from pseudomyxoma peritonei
Authors: Hunduma Gabriel , Kukreja Roy , Veres Lukacs , Tamburrini Alessandro
Published: November 2022

A 46 year old male never smoker was referred to the unit for investigation of progressively worsening shortness of breath, 9 months after being treated for pseudomyxoma peritoneum. He had completed 3 cycles of CAPOX chemotherapy followed by total colectomy and hyper-thermic intraperitoneal chemotherapy (HIPEC).

Computed tomography showed very extensive and bulky bilateral intrathoracic disease with large infiltrations in the parietal and visceral pleura, pericardium and diaphragm, suggesting significant intrathoracic extension of pseudomyxoma peritoneum.

Following MDT discussion, pleurectomy and decortication with cytoreductive intent was performed. A pleural mass measuring 5cm was resected, along with drainage of copious amounts of yellow gelatinous material. Extra-pleural dissection was continued up to the apex from the mediastinum and diaphragm. Pericardial tissue was also resected and reconstructed with a vycril mesh. He was discharged home on postoperative day 6 and found to have significant improvement in his symptoms 3 months after surgery.
EP-583 Review of lower limb orthoplastic flap monitoring protocol
Authors: Dastidar Anannya Ghosh , Gardner Earl , Abdelrahman Mohamed
Published: November 2022

Aim

To improve upon the existing muscle and fascio-cutaneous flap monitoring protocol. The objective is to follow the patient's journey from the time of admission up to discharge and then follow up, in a tertiary care hospital in the Northern region of England, United Kingdom.

Method

The patients were selected from the online plastic surgery audit tool regularly used for documentation, handover and maintaining continuity of care. We looked at the patients requiring free muscle flaps, pedicled muscle flaps and fascio-cutaneous flaps, following fractures sustained to the lower limb, from April 2016 to April 2021. The exclusion criteria were elective free flaps or pedicled flaps and open fracture with no wound management concerns.

The parameters being evaluated were patient observations, flap observations, urine output, bloods, intravenous fluids, patient-controlled analgesia, oxygen, dressing, nutrition, mobility and follow up. Following analysis of the results, a more standardised protocol was distributed across the wards. The response to the new monitoring protocol was measured based on continuity of care, staff satisfaction and outcomes.

Results

There was an initial need for standardisation of monitoring protocols and elimination of multiple charts. This included the nutrition status, use of blood products, dressings and physiotherapy, in addition to the previously mentioned parameters.

Conclusion

The staff feedback was positive and felt better equipped. It removed the ambiguity and patients were aware of their follow up dates prior discharge. The collaboration with the physiotherapy team was well coordinated. This led to an organised recovery period.
EP-592 Hepatic abscess secondary to intrahepatic migration of ingested foreign body: A Case Report
Authors: White Annabelle , Badawi Marwa , Cruikshank Naomi , Rakhimov Iskandar
Published: November 2022

Introduction

Cryptogenic liver abscesses present a unique diagnostic and therapeutic challenge, especially in patients with delayed presentation. Presence of a foreign body, not always immediately apparent on imaging, can explain treatment failure of presumed cryptogenic liver abscesses, often requiring surgical or endoscopic removal for abscess resolution.

Case

We described the case of a 20-year-old female patient, previously fit and well with no surgical or medical history of note. She initially presented to a DGH A&E department following ingestion of a pen, and was discharged clinically stable following review of an inconclusive chest x-ray. She represented 5 months later with ongoing epigastric pain and nausea, and underwent a CT scan showing the foreign body perforating her duodenum and continuing up to the right lobe of the liver where it lay within an abscess. She was immediately started on intravenous antibiotics, and referred to a local hepato-pancreato-biliary unit where she underwent a laparotomy and removal of the object.

Conclusion

This was an unusual case due to the duration of foreign body being in situ, and the patient remaining haemodynamically stable throughout and systemically well. Upon review of the literature, we found 60 cases reported of liver abscesses secondary to foreign body ingestion, and key areas for right lobe abscesses originate from perforation of either first or second part of the duodenum, pylorus or antrum of stomach. Due to the diagnostic challenge presented by these patients, diagnostic algorithms including indirect evidence of FB migration including of fistula tracts or adhesions have been suggested.
EP-593 Blind loop mucocele of a side-to-end colorectal anastomosis as a rare cause of large bowel obstruction
Authors: Peacock Luke , Pangeni Anang , Prakash Samip , Sontenam Venkata , Shrestha Ashish , Allu Veera
Published: November 2022

Background

Large bowel obstruction (LBO) after colorectal surgery draws wide differentials. Very few reports of LBO secondary to closed loop mucocele have been published. To our knowledge, LBO due to mucocele of the blind colonic limb of a side-to-end colorectal anastomosis has not been described.

Case Details

A 57-year-old man presented with pain, gradual abdominal distension and one week history of constipation. He had extensive surgical history – colo-vesical fistula takedown, sigmoid resection and Hartmann type end colostomy followed by reversal, and mesh repair of incisional ventral hernia among others. Notably, a side-to-end configuration was fashioned as a descending colo-rectal anastomosis. CT, followed by MRI scans, of the abdomen and pelvis respectively suggested a mucus-filled short blind colonic bowel segment compressing the anastomotic site as the cause of large bowel obstruction proximal to the site. On flexible sigmoidoscopy under general anaesthesia, external compression of the rectum with narrowing of the lumen was noted. Transrectal needle aspiration of the blind colonic segment yielded 145 mL of mucoid fluid and allowed proximal examination. Anastomotic site was of normal calibre.

The patient's symptoms improved and he was discharged with scheduled outpatient follow-up. Gastrografin enema post-discharge demonstrated an end-to-side rectosigmoid anastomosis with local rectal stenosis and showed the blind loop had emptied.

Conclusion

This case highlights that blind colonic loop mucoceles in colorectal anastomosis can rarely cause obstruction and endoscopic management is feasible when accurate diagnosis is confirmed on imaging.
EP-595 The Use of Scrotal Compression Following Large Open Inguinoscrotal Hernia Repairs
Authors: Jesuyajolu Damilola , Jesuyajolu Paul
Published: November 2022

Aims

Large inguinoscrotal hernias are endemic in Sub-Saharan Africa, and scrotal edema is a common complication following surgery. The use of scrotal compression has been advised, especially in tropical regions, to reduce its incidence. We aimed to determine the rate of usage of scrotal compression following large inguinoscrotal hernia repairs as recommended.

Method

A review of all herniorrhaphies done for large inguinoscrotal hernias over one year in the hospital was carried out to evaluate the application of scrotal compression post-op.

Results

Out of the 22 large inguinoscrotal hernia repairs done, 12 of them did not have a scrotal compression post-surgery.

Discussion/ Conclusion

Due to the deep dissection needed during open hernia repairs, as well as the potential space left after surgery, there is a tendency for fluid to collect in the space, leading to an edematous scrotum. Although not mandatory, the use of scrotal compression confers some benefits in preventing the occurrence of scrotal edema. Following the presentation of the findings to the department and a re-audit, there was increased usage of scrotal compression and a reduced incidence of post-operative scrotal edema. The use of scrotal compression is a useful tool in reducing the incidence of scrotal edema.
EP-602 The impact of COVD-19 on the surgical management of acute cholecystitis
Authors: Leiberman Christopher , Kizis Georgis , Leipner Anna-Marie , Hendry Julianne
Published: November 2022

Aim

The Association of Upper Gastrointestinal Surgeons (AUGIS) recommends performing a laparoscopic cholecystectomy within 72 hours of admission for acute cholecystitis. COVID-19 has drastically affected the way healthcare is able to be delivered worldwide. This project was designed to audit the impact of COVID-19 on the surgical management of acute cholecystitis against AUGIS guidelines.

Methods

All general surgical admission from November 2020 were retrospectively analysed. Admission records were screened for those presenting with acute cholecystitis. Those identified had their records analysed for laparoscopic cholecystectomy. Patients who died before surgery, had an alternative procedure performed, or who were unfit for surgery, were excluded.

Results

During this time, 28 patients were admitted with acute cholecystitis. In total, 3 patients were excluded: 1 died before any possible intervention, 1 was unfit for surgery, and 1 received a cholecystostomy. Of the 25 included patients, only 11% (n=3) patients received a laparoscopic cholecystectomy within seven days from their hospital admission. The remaining 89% (n=22) of patients were managed conservatively with fluids, analgesia, and antibiotics.

Conclusion

It can be concluded that COVID-19 has severely impacted the surgical management of acute cholecystitis as only 11% of those patients presenting were managed in accordance with AUGIS guidelines. Whether conservative management is an alternative long-term option for management remains to be seen as further long-term studies are needed.
EP-603 What a difference a year makes: Long-term follow-up of non-operative management in acute cholecystitis
Authors: Leiberman Christopher , Kizis Georgis , Leipner Anna-Marie , Hendry Julianne
Published: November 2022

Aim

Surgery is currently the recommended treatment for acute cholecystitis and the Association of Upper Gastrointestinal Surgeons (AUGIS) recommends that laparoscopic cholecystectomy be performed within 72 hours of admission. However, given the impact of the COVID-19 pandemic on healthcare delivery, this is not always possible. So, what happens to those who are managed conservatively?

We observed the long-term impact of conservative management of patients admitted with acute cholecystitis over the course of one year.

Methods

Twenty-eight patients were admitted with acute cholecystitis to a large tertiary hospital in November 2020; twenty-three were discharged without having had a cholecystectomy. These patients were followed up for one year and observed for the development of any gallstone-related admissions and surgical procedures.

Results

Of the 23 patients observed, 30% (n=7) were admitted for gallstone-related complications. Biliary colic was responsible for 43% of these admissions with pancreatitis (14%), cholangitis (14%), choledocholithiasis (14%), and cholecystitis (14%) causing the rest. Only 9% (n=2) received a laparoscopic cholecystectomy. In both cases, it was in an emergency setting during admission for biliary colic.

Conclusion

Long-term observation of conservatively managed acute cholecystitis was possible in around two-thirds of patients as no gallstone-related hospital admissions were observed. Biliary colic was the most common cause of gallstone-related admissions. Longer observation is required to assess the feasibility of long-term non-operative management in acute cholecystitis.
EP-604 The Golden Patient Pathway - Improving Efficiency of Emergency General Surgery Theatres and Bed Management
Authors: Rizkallah Nayer , Smith Katherine
Published: November 2022

Aim

This closed loop audit aimed at improving efficiency of time management with good utilisation of the first hour of the day in emergency theatres. This was reflected on bed management and patient service.

Methods

Patients who required simple emergency operations were the target population. Retrospective data of patients’ demographics, time of attendance to surgical admission unit, time waiting for an operation, anaesthetic start times, surgical start times and postoperative inpatient stay were collected. Then the Golden patient pathway was implemented via a list of agreed criteria for the Golden patient (simple procedure, non-septic, non-diabetic, etc.). The chosen patient was labelled as Golden on the booking form. A precise time scale for anaesthetic review and theatre sending time was agreed. This pathway was tried for a month followed by data collection to compare outcomes.

Results

After starting the Golden patient pathway in our emergency surgery service, the mean anaesthetic start time (+/- standard deviation) improved from 09:12 +/- 0.11 to 08:32 +/- 0.01. Consequently, the mean operation start time improved from 09:45 +/- 0.10 to 08:53 +/- 0.01. The percentage of patients with same day discharge after simple procedures increased from 57% to 100% thus providing better use of hospital beds.

Conclusion

The Golden patient pathway provides a good utilisation of the first hour of the day in emergency theatres. It has a positive impact on patient service and bed management via reducing the waiting times. The Golden patient pathway is an asset to the emergency general surgery service.
EP-605 Perineal Partial Myocutaneous Gluteal (PMG) Flap Reconstruction after Extra Levator Abminoperineal Excision (ELAPE): Recent Experience and Outcome
Authors: Patil Sangram , Bowers Ciara , Chandrashekhar Bhargavi , Mohammed Paul , Sivakumar Rangasamy , Bashir Abdul Mohamed
Published: November 2022

Background

Extra Levator Abminoperineal Excision (ELAPE) is widely performed surgery for low rectal cancers. A large defect in the perineum adds significant post-operative morbidity. There is no clear unanimity about the closure of the defect. The aim of the study is to evaluate our experience and outcome of the perineal wound management after ELAPE with partial myocutaneous gluteal (PMG) flap reconstruction in a large series of 81 patients at a single centre in the United Kingdom (UK).

Method

Retrospective review of all patients undergoing ELAPE and primary PMG flap reconstruction between January 2012 and December 2021 in a large district general hospital. Patient demographics, 30 days morbidity and mortality were studied.

Results

Total 81 patients (male 52, female 29) had ELAPE (laparoscopic 65, open 11, converted to open 5) and PMG flap closure for low rectal cancer. Mean age of patients was 67.2 years (SD+- 10.7). Length of stay was average 19 days (range: 6 to 168 days). Half of the total patients had neoadjuvant chemoradiation. 18.5% patients developed minor perineal wound complications, whereas only 2.5% patients needed to return to theatre for major wound complications. None of patients had perineal hernia or mortality in 30 days. All flaps were viable during the follow-up.

Conclusion

PMG flap provides safe and reliable method for perineal closure after ELAPE perineal defect without any additional morbidity compared to conventional closure offering overall good patient outcome and experience.
EP-606 An audit to assess the requests for plain abdominal radiographs for surgical conditions for the patients admitted in SAU are appropriate
Authors: Ravindran Sharanya , Sarveshwaran Janahan
Published: November 2022

Aim

To ensure that requests for plain AXR for surgical conditions for the patients admitted in SAU are performed appropriately as advised by Royal College of Radiologists guidelines.

We intend to reduce the radiation dose and early access to more appropriate investigations.

RCR iRefer guidelines for AXR

Methods

Patients admitted in SAU with abdominal pain in the month of October 2020 were taken. Total number of patients audited 50.

22 patients had AXR whereas 28 didn't have any.

In this 28 patients (56%); 16(58%) of them directly underwent higher imaging CT scan as they were quite unwell on arrival. Remaining 12 (42%) did not have abdominal x ray in line with the guidelines.

Out of 22 patients who had abdominal Xray, we noted that 15 were not indicated which are shown in the table below.

Group 1. – 28(56%) did not have an x-ray, in that 12 (42%) met the guidelines

Group 2. – 22(44%) patients had an x-ray 15(68%) of these were not indicated

Conclusion
EP-608 Robotic surgery in Inflammatory Bowel Disease: single centre experience
Authors: Banaskiewicz Karolina , Madurska Marta J , Randhawa Neena
Published: November 2022

Aims

Minimally invasive surgical approach has been shown to be beneficial especially with its utilization in the rectal dissection for the management of malignant disease. There has been growing interest in robotic approach in the surgical management of diverticular disease and inflammatory bowel disease (IBD). The aim of this study is to present our local institutional experience following implementation of a robotic service for surgical management of benign colorectal disease.

Methods

Data on patient demographics, intraoperative details, length of hospital stay (LOS), and postoperative complications were collected prospectively with a 30 day follow up. Patients included those who underwent robotic ileocaecal resection, subtotal colectomy, anterior resection, panproctocolectomy or proctectomy between April and December 2021, for benign disease including diverticular disease, IBD, or chronic constipation.

Results

Seventeen patients were included. 35% were male, median (IQR) age was 38 (22) years and BMI was 23 (2). Procedure duration was 181 (125) minutes, and one patient underwent conversion to open surgery. LOS was 9 (6) days and one patient required admission to HDU for one day. N=3 (18%) had ileus, and n=1 (6%) had an anastomotic leak, acute renal failure, or a chest infection. Two patients had collection requiring percutaneous drainage. No return to theatre or deaths were recorded.

Conclusions

Our early experience demonstrates encouraging outcomes as well as feasibility and safety of robotic approach in managing benign colorectal disease. Future studies with larger samples will allow to draw more definitive conclusions.
EP-609 Doctor-led Straight to Test Service: Streamlining the Colorectal 2ww referral pathway
Authors: Nunn Rebecca , Hassan Adil , Allgrove Carol , Vivekanandan Shanmugam , Vijay Vardhini
Published: November 2022

Aims

Since its introduction in 2000, the Two-week wait referral pathway (2ww) has become entrenched in NHS practice to fast-track the investigation, diagnosis and management of suspected cancer. Straight-to-test (STT) routes further expedite this process: staff screen referrals and offer a diagnostic test within 2 weeks where appropriate. Our Trust has provided a doctor-led STT service for the Colorectal Department since January 2021. We hypothesize that physician-led strict scrutiny of referral proformas, with incomplete forms being returned to GPs, has led to improved compliance with the referral process.

Methods

A prospectively maintained database consisting of 2ww Colorectal referrals from primary care was analysed over a 12-month period (January 2021- December 2021). Agreed key referral criteria required to make an STT decision were identified as ‘complete’ or ‘incomplete’. Incomplete referrals were returned to GPs, with a request for complete information (usually provided within a median period of 2 weeks).

Results

There were 1112 referrals during January-April 2021, 1140 during May-August 2021 and 1158 during September-December 2021. The proportion of referrals containing incomplete datasets fell from 28% (January-April 2021) to 17% in the latter two 4-monthly time intervals.

Conclusions

Our data is promising- the proportion of incomplete referrals has reduced since the introduction of our doctor-led STT triage service. These figures may reflect a positive change in the referral practises of local GPs. Submission of complete referral forms improves communication between primary and secondary care, enabling our doctors to make timely informed decisions about STT pathways.
EP-617 Early vs delayed laparoscopic cholecystectomy for acute cholecystitis: A systemic review
Authors: Gibson Jamil , Allen Neill , Viswanath Yks
Published: November 2022

Background

Gallstones are present in approximately 10% to 15% of the adult western population with 1% to 4% of patients becoming symptomatic each year. Laparoscopic cholecystectomy for acute cholecystitis is usually performed after the acute cholecystitis episode settles because of the perceived fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery may expose the individual to gallstone-related complications.

Aims & objectives

To compare early laparoscopic cholecystectomy, defined as less than seven days of clinical presentation with acute cholecystitis, versus delayed laparoscopic cholecystectomy more than six weeks after index admission and conservative treatment for acute cholecystitis.

Search Criteria

Clinical databases were searched for suitable studies. Randomised and non-randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis published after 1994 were included.

Results

16 studies were identified for this review and the outcomes measured were operation time, conversion to open surgery, postoperative complication, post operative pain and analgesia use, length of hospital stay, and duration of antibiotic therapy. For all but one of the criteria it has been found that early and delayed laparoscopic surgery were equivalent for these end points. The endpoint antibiotic duration post-surgery still remains an area of contention.

Conclusion

Early and delayed cholecystectomy for the treatment of uncomplicated acute cholecystitis is both safe and feasible. Early laparoscopic cholecystectomy is preferred over delayed laparoscopic cholecystectomy mainly because of decreased length of hospital stay in the early laparoscopic cholecystectomy group. This is a clear advantage.
EP-623 Can we count on serum hyperbilirubinemia to predict acute complicated appendicitis?
Authors: Jaskani Sadia , Al-Hamid Zaid
Published: November 2022

Introduction and Aims

Acute appendicitis (AA) is usually a clinical diagnosis and surgical intervention is typically a preferred choice to avoid potentially lethal complications. The aim of this study was to evaluate hyperbilirubinemia as a predictor of complicated acute appendicitis (CA).

Material and Methods

A retrospective analysis of patients who underwent surgery for AA in a district general hospital in the UK from Jan 2018 to April 2019. It includes White cell count (WCC), C- reactive proteins (CRP), and liver function tests (LFTs).

Results

A total of 236 (Median age = xx, IQR , F: M = 1:1.4). The frequency of normal, uncomplicated, and complicated appendicitis was 25(10.6%), 161 (68.2%), and 50 (21.2%), respectively. There were significant differences in the rate of negative appendicectomy in females (9.3% F vs 1.3% M, p-VALUE=0.0001). The bilirubin levels mirrored the CRP levels and showed statistically significant difference in patients with normal versus uncomplicated/complicated appendicitis (Bilirubin = 8.36 in normal versus 12.39 in uncomplicated and 16.44 in complicated appendicitis, p value=0.0001; CRP= 34.09 in normal versus 44.38 in uncomplicated and 114.34 in complicated appendicitis, p value=0.0001). The Neutrophil count showed increased differences between normal and uncomplicated/complicated appendicitis (Neutrophil 8.4 vs 11.2, p-value0.016; WCC 11.8 vs 14.1, p-value=0.003).

In the negative appendicectomy group, 17/25 had preoperative imaging. In 7/25 (28%) imaging was suspicious of appendicitis, 10/25 (40%) had normal findings and 8/25 patients did not have any prior imaging.

Conclusion

SB had low sensitivity and high specificity as compared to CRP and WCC for AA.
EP-631 Left Ovarian Teratoma Containing Follicular Thyroid Carcinoma: A case Report
Authors: Rezkallah Emad , Elsaify Wael
Published: November 2022

Introduction

A mature cystic teratoma of the ovary is composed of well-differentiated derivatives of the three germ layers, the ectoderm, the mesoderm and the endoderm. About 20% of ovarian teratomas contain thyroid tissues. When thyroid tissue comprises more than 50% of the ovarian teratoma, it is termed; struma ovarii. Patients are usually asymptomatic or predominantly presented with a pelvic mass in 45% of cases or abdominal pain.

We represent a rare case of stuma ovarii containing follicular thyroid carcinoma.

Case presentation

A 56 years old patient presented with a left ovarian mass. The patient had no history of any thyroid abnormalities and no family history of thyroid malignancy. The patient underwent total hysterectomy (TH) and bilateral salpingo-oophrectomy (BSO). Mature cystic teratoma of the left ovary containing highly differentiated follicular carcinoma with omental deposits was discovered.

The case was referred for thyroid MDT for discussion of further management. Thyroid US and CT scans showed slightly small thyroid containing multiple hypoechoic nodules with no evidence of distant metastasis.

Management

The patient had total thyroidectomy and the final histopathology reported incidental multifocal papillary microcarcinomas of follicular variant; stage pT1a. Post-operatively the patient had Radio-iodine ablation. TSH suppression with thyroxin was initiated. The patient had regular radiological and thyroglobulin checks and no recurrence was detected on 5 years of follow-up.

Conclusion

The treatment for malignant struma ovarii depends on the tumor stage. The initial surgery includes TH and BSO with omentectomy. The adjuvant treatment includes thyroxine, total thyroidectomy with RAI ablation. Long-term follow-up is recommended.
EP-641 ‘Feel Good Factor’: Positive recognition impacted staff morale, encouraged juniors and led to the overall departmental development during the COVID-19 pandemic
Authors: Zarsadias Prizzi , Burford Charlotte , Rai Sujata , Vigneswaran Natali , Shah Ankur
Published: November 2022

Aims

Low doctor morale and mental well-being is associated with poor patient care, especially during the COVID-19 pandemic. We report on a local initiative, Feel Good Factor (FGF), and its impact on doctors and the department.

Methods

FGF is a monthly presentation at the departmental meeting implemented at WHH, started in December 2019; where kind acts are applauded. A 10-item questionnaire was distributed to doctors working in two Surgery Departments (WHH and QEQM) in May 2021. Questionnaires collected demographic data, awareness of both positive/negative events and mental well-being using Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Data was collected on audits, QIP's, sickness due to mental health, junior progression and publications.

Results

48 doctors responded (58.3% QEQM). There was no significant difference in overall WEMWBS score. Doctors in the WHH department were more decisive (70% vs 25%, p = 0.043); positive incident reporting was higher at WHH (25.0% vs 0.0%, p = 0.025). A trust-wide record number of 45 audits, 22 publications, 6 national studies and 11 juniors progressed in 2020. Patient clinical marker of NELA mortality was one of the least. There was no sickness leave due to mental health. FGF was also shortlisted for the annual BMJ awards.

Conclusion

FGF is associated with increased awareness of positive events. Improved doctor morale led to widespread participation in projects and departmental output leading to national recognition. Initiatives such as FGF should be encouraged and advertised to other departments, to improve the hospital rating.
EP-642 Case Report: Using the Novel Flamingo Device for Endoscopic Treatment of Buried Bumper Syndrome in high risk patients
Authors: Asnani Kusum , Fernandes Roland
Published: November 2022

Aim

Buried Bumper Syndrome is a rare, major late complication of percutaneous endoscopic gastrostomy (PEG) occurring in 1% of cases. It occurs when the internal bumper of the PEG tube erodes into the gastric wall. This lead to a loss of patency, leakage and inability to change the tube endoscopically. Until recently, the treatment was surgical removal under general anaesthesia. However, patients with BBS are likely to have significant co-morbidities thus deeming the procedure high risk.

Method

We present a case report demonstrating successful treatment of BBS completed endoscopically using the Flamingo device with a good patient outcome. The Flamingo device is a new endoscopic tool that acts like a sphincterotome. Appropriate consent was taken from the patient. This was performed on a 56 year old patient suffering from multiple sclerosis causing dysphagia for which a PEG tube was inserted in 2018 for nutrition. Over time, his care home noticed significant leakage from the site. At gastroscopy, he was diagnosed with BBS. Due to his risk for surgical intervention, the Flamingo device was trialled to remove the buried bumper and allow insertion of a new PEG.

Results

As demonstrated in the photos, the mucosa was successfully cut allowing the buried bumper PEG to be retrieved. A new PEG was inserted without complication. The patient was discharged the following day and no complications have arisen 3 months later.

Conclusion

The Flamingo device has proven to be a safe and minimally-invasive method to treat BBS endoscopically in this patient.
EP-653 Diagnosing Acute Appendicitis using Machine Learning: A Systematic Review
Authors: Chan Anthony , Yau Christopher
Published: November 2022

Introduction

Acute appendicitis is a surgical emergency that usually presents in the younger population. The mortality risk for uncomplicated acute appendicitis is less than 0.1%, but this rises to 0.6% should gangrene or a perforation develop during its disease course. The clinical diagnosis of acute appendicitis remains challenging, with systems such as the Alvarado score not specific enough to exclude a diagnosis. The aim of this study is to review the literature on the use and effectiveness of machine learning (ML) in the clinical diagnosis of acute appendicitis, with a particular focus on the parameters used to train the ML models.

Methods

A systematic review was conducted using PubMed and OvidSP using search terms ‘appendicitis’, ‘artificial intelligence’ and ‘machine learning’.

Results

There were 255 articles identified, which after excluding duplicates and screening, 14 articles were reviewed in detail and 6 articles included in the final review. Parameters used to train ML machines included patient demographics such as age and gender, clinical assessment such as temperature, presenting symptoms and examination findings, and biochemical and haematological results such as white cell count and C-Reactive Protein.

Discussion

The parameters used to train ML models are based on limited clinical and biochemical components from established scoring systems such as the Alvarardo score. Despite this limitation, ML models were generally better in predicting acute appendicitis in terms of sensitivity and specificity and positive- and negative-predictive values. Future ML models should use more contemporary markers to further improve diagnostic accuracy.