bluuebunny/crossref_metadata_2025 huggingface dataset:
232 The inGuinal heRnia OperatIon Notes (GROIN) Quality Improvement Project
Authors: Kapsampelis Panagiotis , Prce Daniela , Saunders Jada , Bezzaa Sabrina , Gerogiannis Ioannis
Published: August 2023

Aims

Accurate and comprehensive operation notes are crucial for patient safety, quality assurance and medico-legal purposes. Inguinal hernia repair is one of the most common surgical procedures. Thus, operative documentation should be precise and standardised. The GROIN project aims to improve the quality of inguinal hernia operation notes using evidence-based proformas and an operation note composition software.

Method

We retrospectively reviewed operation notes of inguinal hernia repair performed at our institution between August and November 2022. Operation notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items.

Results

The operation notes from 89 cases were reviewed. High-scoring items included: operation name (100%), operative findings (99%), surgeon's name (99%), closure technique (98%), operation date (90%) and signature (90%). Postoperative instructions were sufficiently detailed in 79% of cases. Regarding mesh placement, 63% of notes described mesh size and type, whereas 30% documented only the mesh type. The lowest-scoring items were: venous thromboembolism prophylaxis (31%), designation as elective or emergency (22%), operative diagnosis (6%), and estimated blood loss (2%).

Conclusions

We identified several areas for improvement in inguinal hernia operation notes based on our results. The next step of the GROIN project is to standardise operation note creation by implementing an evidence-based template, which will be delivered through a novel operation note composition software. This will allow accurate record-keeping and efficient operative data extraction analysis. Efforts to standardise operative notes and enhance their quality on a national and international level are imperative for patient safety.
235 A case of Painless Palpable Gall bladder - a rare Exception of the Courvoisier's Law
Authors: Pal Shreya , Pusalkar Aditya , Choudhry Mazhar , Pangeni Anang , Shrestha Ashish K
Published: August 2023

Introduction

The Courvoisier's law states that a painless palpable enlarged gallbladder with jaundice is unlikely to be caused by gallstones. There are however various exceptions to the law. We report a rare case of such an exception to make us aware of the clinical condition.

Case Description

72-year-old male, otherwise fit and healthy, presented to the Emergency department with epigastric discomfort, along with dark urine and pale-coloured stool. He was clinically examined to have jaundice, and a painless globular palpable gall bladder, with blood results confirming obstructive picture i.e. raised bilirubin (70 μmol/L), ALT (103 U/L) and Alkaline Phosphatase (590 IU/L). Ultrasound abdomen showed acute cholecystitis. CT chest-abdomen-pelvis showed cholelithiasis and choledocolithiasis with dilated common bile duct (CBD), as well as asymmetric gallbladder wall thickening. The MRCP showed concentric and uniform thickening of the entire gallbladder wall, with minimal pericholecystic fluid reflecting acute inflammation. Multiple calculi were noted to be present within the CBD and gall bladder, resulting in dilation of CBD (15.8mm).

The patient had ERCP with sphincterotomy and retrieval of multiple stones by balloon trawl. He was discharged the following day and is planned to undergo laparoscopic cholecystectomy as an elective procedure. His liver function test markedly improved at discharge bilirubin of 18 μmol/L and ALP of 364 IU/L.

Conclusion

This is an unusual case of painless jaundice with palpable gall bladder due to stones impacted in the CBD and not due to periampullary carcinoma, which is an exception to the Courvoisier's Law.
270 The Liberal Use of Magnetic Resonance Cholangiopancreatography (MRCP) can be switched over to its Selective use to detect choledocholithiasis
Authors: Haji Altaf , Elhassan Ali , Elkadi Mahmoud , Sivakumar Naveen , Piramanayagam Bala , Syed Ijlal Haider
Published: August 2023

Background

Gallstone disease is known in 10-15% of adults in Western populations. Cholangiopancreatography is the investigation of choice for choledocholithiasis; however, its use is varied, and guidelines are not well-defined. The NICE guidelines recommend MRCP be done when common bile duct dilatation ≥ 8mm or liver function tests) are abnormal but do not quantify this further. The liberal use of MRCP is gaining popularity as a roadmap prior to cholecystectomy, aiming to assess primarily for the presence of migrated gallstones within the cystic duct or common bile duct, as well as providing information regarding the anatomical features of the extrahepatic biliary tree on an individualized basis. Due to these reasons, MRCP is at times done unnecessarily which creates an economic burden and restricts access to patients in real need of imaging slots.

Method

It is a hospital-based retrospective observational study. The time frame was July 2021 to July 2022. The sample size was 230 patients.

Result

Our Study showed that isolated elevated Alanine Aminotransferase levels should not be a reason to evaluate patients for Choledocholithiasis. It concluded that elevated serum bilirubin levels, Alkaline Phosphatase, and Gamma Glutamyl Transferase are the strongest predictors of CBD stones in patients with gallstone disease and hence can be used to triage patients for undergoing MRCP.

Conclusions

To conclude elevated serum bilirubin levels, ALP and GGT are the strongest predictors of CBD stones in patients with gallstone disease and hence can be used to triage patients for undergoing MRCP. Isolated elevated ALT should not be a reason to evaluate patients for CBD stones.
279 Quality and Prognostic Value of Colorectal Cancer Pathology Reports
Authors: Papalois Zoe-Athena , Nash Daniel , Howard Mark
Published: August 2023

Aim

Comprehensive pathology reports are essential to inform clinical decision-making. An internal audit was conducted to determine whether the Trust Histopathology department fulfilled histopathological reporting standards for colorectal cancer (CRC) by the Royal College of Pathologists (RCPath).

Methods

Pathology reports for CRC surgical resection specimens between 2018-2021, were reviewed. Resections were from symptomatic (non-screening) patients, with no preoperative treatment. Benign or endoscopically obtained specimens, and non-primary CRC were excluded. Reports were reviewed for compliance with the CRC categories: I. median number of lymph nodes attained (≥12 per specimen) II. cases showing extramural venous spread (≥30%) III. cases showing peritoneal/serosal involvement (≥20%).

Results

277 reports were included. Median lymph node yield was consistently >12, throughout. >30% of specimens demonstrated venous invasion between 2018-2020, however, 24% of specimens in 2021. Nearly all reports commented on the depth of venous invasion (e.g. ‘intramural’/‘extramural’) by 2021. >20% specimens demonstrated peritoneal involvement between 2018-2020, however this was 16% in 2021.

Conclusions

The quality of reports was high and consistent. There was overall compliance with the RCPath requirement. Results from 2021 may be affected by changes to pre-COVID CRC treatment pathways, with more patients presenting at a more advanced stage and receiving initial neoadjuvant treatment. As venous invasion is an independent prognostic indicator, documenting the extent of invasion is a quality assurance factor.
309 Comparison of Lichtenstein Procedure with and Without Mesh Fixation for Inguinal Hernia Repair in Terms of Postoperative Pain
Authors: Riaz Ilyas , Rauf Sidra , Ayubi Azaz , Ajaz Hamda , Mujahid Sheeza , Sakhizada Fahim
Published: August 2023

Aim

Although advanced techniques have been adopted in inguinal hernia repair parallel to those in developing medical technologies, currently no consensus has been reached on the best method among all existing methods. Post-operative pain is the main reason far longer hospital stay and delay in return to daily routine work. Aim of study was to compare the mean post operative pain of Lichtenstein procedure with and without mesh fixation for inguinal hernia repair.

Methods

Randomized control trial was conducted for six months after approval of synopsis. After permission from the concerned authorities and ethical committee and informed consent, patients were selected from indoor-patient department. All patients were assessed by consultant surgeons with more than 2 years of experience after fellowship, and the patients were prepared for hernia repair. Two groups were formed, Group-A included those managed by without mesh fixation and Group-B who were managed withmesh fixation. All the patients were assessed for postoperativepain at 24 hours by visual analogue scale (VAS).

Results

In our study, comparison of mean post operative pain score in both groups shows 3.23+0.77 in Group-A and 3.98+0.76 in Group-B, p value was 0.0001.

Conclusion

We concluded that post-operative pain is less in patients managed by Lichenstein repair without mesh fixation as compared to patients managed with mesh fixation.
314 Comparison of hemorrhoidectomy by LigaSure and conventional Milligan Morgan's Technique
Authors: Akhtar Fahad , Rauf Sidra , Noor Aiman , Ayubi Azaz , Sakhizada Fahim
Published: August 2023

Aim

To compare outcomes of hemorrhoidectomy by LigaSure and conventional Milligan Morgan’s hemorrhoidectomy.

Methods

In this randomized controlled trial, we enrolled a total of seventy adult patients of either gender between age 17-80 years. All the enrolled patients presented with 3rd or 4th degree haemorrhoids and were planned for hemorrhoidectomy. The patients were assigned to two treatment groups. Group A (Milligan Morgan’s) patients were enrolled from one hospital and Group B (LigaSure) patients were enrolled form second hospital. Post-operative pain was assessed in both groups using VAS at 6, 12 and 24 hours along with amount of blood loss during the surgery. Duration of surgery (min) was estimated and compared in both the groups.

Results

There were 62.9% males and 37.1% females in group A and 80.0% males and 20.0% females in group B (P=0.112). Mean age in group A and group B patients was 43.3 years ± 11.3 SD and 46.4 years ± 8.2 SD respectively. In group A, there were 68.96% patients having grade III and 31.4% patients having grade IV haemorrhoids and in group B, 57.1% patients had grade III and 42.9% patients had grade IV haemorrhoids (P=0.322). Mean VAS at 6 hours, 12 hours 24 hours, mean amount of blood loss during the surgery and mean duration of surgery was significantly shorter (P=0.001) in patients of group A as compared to patients of group B.

Conclusions

The LigaSure method had significantly lower degree of post operative pain, lesser amount of blood loss during the surgery and shorter duration of surgery as compared to Milligan-morgan method.
342 The NHS in crisis; assessment of the impact of litigation trends over 20 years in general surgery
Authors: Wallace-King Sabina , Musbahi Aya , Coates Rachael , Mofidi Reza
Published: August 2023

Introduction

A rising proportion of the NHS annual budget is being spent on medico-legal costs, with over 1.6% of total UK healthcare spending on litigation in the year 2018/19. This is a risk to both patient care and public opinion of the NHS. Despite this, surgical litigation is a relatively understudied subject. This paper aims to assess the scale of the litigation crisis to fuel further work into mitigating it and improve value for patients and staff alike.

Method

Data was obtained via a Freedom of Information request from NHS resolution for all claims relating to General Surgery between January 2000 and December 2020.

Results

17,542 claims were made against General Surgical units in England with a gradual increase in claims per year. The successfully closed claims cost £1.3 billion. This was out of proportion to both inflation and case volume. The three most common causes for claims were intra-operative problems, failure/delay of treatment and failure/delay of diagnosis.

Conclusion

The NHS is threatened by a litigation crisis, with case volume and cost rising out of proportion to surgical workload and inflation. The most common causes for claims against surgical units are known complications discussed as part of a standard consenting process, indicating that current practice may fail to achieve adequate patient understanding of surgical risk. More research is required to design methods to improve the current consenting process, and to identify specific demographics that may increase an individual’s propensity to make a claim and establish modifiable risk factors.
364 Surgical confidence over a rotation in foundation year one doctors in a busy district general hospital
Authors: Savage Daniella , George Jayan , Wafai Ahmad Hisham , Samuel Nehemiah , Yeluri Sashidhar
Published: August 2023

Aims

Methods

FY1 doctors were surveyed in December 2022. Ten questions used Likert scales (1 to 5: not at all confident to very confident) to assess general surgical patient management. One question focused on education methods and one open question. Data was initially inputted using Google Docs and analysed in Microsoft Excel.

Results

10 FY1 doctors (10/10) completed the pre-questionnaire and post-questionnaire.

Confidence levels were greater across all Likert scale questions at the end of the rotation.

Confidence levels at the start of the rotation had a modal score of 1 in managing the deteriorating surgical patient, end-of-life care and prescribing pre-emptive medications.

The lowest confidence levels at the end of the rotation were for speaking to a dying patient’s family and speaking to a patient about their management when their condition is unknown.

Common concerns of FY1 doctors were not being able to contact a senior in theatre and the busyness of the specialty.

Most FY1 doctors felt that case-based discussions would be the preferred method to increase understanding of general surgery.

Conclusions

Confidence levels improved by the end of the rotation. Targeted case-based discussions may support increasing confidence before and through the rotation.
381 A Rare Case of CBD obstruction secondary to Endometriotric cyst
Authors: Nadeem Tehmina , Lim Jieqi , Lykoudis Pavlos
Published: August 2023

Background

Bile flow obstruction due to bilary tree pathology is well documented. Intramural causes include gallstones and infections such as clonorchis sinensis and Ascaris Lumbriocodes1 mural causes include autoimmune diseases e.g Sclerosing cholangitis. Extrinsic compression are usually due to malignancy e.g Cholangiocarcinoma or pancreatic head carcinoma. we encountered a rare case of common bile duct (CBD) obstruction cause by large endometriotic cyst.

Case report

A fit & well, 85 year old female presented with gradual onset of Obstructive jaundice. admission Liver function tests indicated a Bilirubin of 485 subsequent Ct scan revealed a large endometriotic Cyst (15cm x10 cm) indenting the CBD and stomach. Endoscopic ultrasound confirmed the presence of a large cystic fluid collection. Patient`s biliary system was indirectly decompressed with AXIOSTM via gastric wall into cyst Copious dark brown non-viscous fluid was drained into stomach. Cytology results reported benign cyst contents without mucin or neoplastic epithelial cells. Fluids Amylase was 121 U/L. the patient recovered well, with resolution of Bilirubin.

Discussion

Endometriotic cyst have been reported to cause organ obstruction such as CBD and ureter1,2 patient's from previously reported cases had to endure major surgery to achieve symptomatic relief.

AXIOSTM stent is a device commonly utilized for drainage of pancreatic pseudocyst and we report the use of it as a Novel and minimally invasive technique in this rare case of CBD obstruction.

References:

1-A clinical pathway on endoscopic retrograde cholangiopancreatography for common bile duct stones. World J Gastroenterol. 2019 Feb 28;25(8):1002-1011.

2-Liver Tumours Due To Endometriosis And Endometrial Stromal Sarcoma".
420 Parathyroid surgery outcomes - 2 surgeons outcomes for the past 9 years in a teaching hospital
Authors: Kho Jason , Kuan Jen Yee , Turner Paul , Shetty Vinutha
Published: August 2023

Aim

The success of parathyroid surgery in hyperparathyroidism is defined by the sustained improvement in calcium levels without the need for re-exploration. Reoperation rate in the United Kingdom currently sits at 1.6%. It has been shown that the need for repeat parathyroid surgery is related to surgeon annual volume. We aimed to review the outcomes of parathyroid surgery for hyperparathyroidism performed by two upper gastrointestinal surgeons experienced in parathyroidectomies.

Methods

Retrospective review of consecutive parathyroidectomy cases performed by VS and PT in a teaching hospital was conducted between April 2013 and December 2022. Data was obtained from local hospital database. Primary outcome was re-exploration within one year of index procedure. Secondary outcomes included methylene blue uptake by adenomas and postoperative vocal cord palsy.

Results

211 parathyroidectomies were performed during the study period. Patient cohort was predominantly female (n=153, 72.2%). Mean age of study population was 57±13 years. Histopathology confirmed 171 (81.0%) parathyroid adenomas, 34 (16.1%) multiglandular hyperplasia and 6 (2.8%) normal glandular tissue. None were malignant adenoma. 4 (1.9%) patients required re-exploration within one year of index procedure, three of which were found to be ectopic adenomas. Preoperative methylene blue infusion was used in all cases to assist identification of adenoma; uptake was evident in 169 (80.1%) cases. 2 (0.9%) patients developed permanent recurrent laryngeal nerve damage, resulting in mild voice hoarseness.

Conclusion

Our dedicated parathyroid service led by experienced surgeons was associated with comparable re-exploration rates and high cure rates. Preoperative methylene blue infusion helps in intraoperative identification of parathyroid glands.
425 Appendicular Endometriosis- A rare presentation
Authors: Kaur Mandeep , Singh Anurag , Tonsi Alfredo
Published: August 2023

Endometriosis is a known gynaecological condition in young women of reproductive age group. It presents with many different symptom complexes, most common presentation being pain abdomen especially during menstruation. Pelvis is the most common site for endometrial deposits. Gastrointestinal endometriosis is rare. Appendicular endometriosis is rarer. There have been only a few case reports of endometriosis causing appendicitis.

We came across a case of perforation peritonitis in a young girl with a background history of endometriosis. Patient presented with sign and symptoms of acute appendicitis and on USS was found to have inflamed appendix. During diagnostic laparoscopy she was found to have gangrenous perforated appendix and a hard caecal nodule, which on histopathology revealed endometriosis. Another important fact revealed on histopathology is bleeding into the endometrial tissue. This patient underwent laparoscopic right hemicolectomy. Post – operative recovery was well and uneventful. Patient was discharged from the hospital on 5th day post operation.

We did a literature research to find out that there have been only two cases of perforated appendicitis mentioned in literature. While endometriosis is a common disease and may lead to appendicitis but it is not very common for it to present it as perforation peritonitis.
426 Litter's Obturator hernia- A Rare presentation
Authors: Singh Anurag , Kaur Mandeep , Abogabel Sameh , Khera Goldie
Published: August 2023

We are reporting this case of Obturator hernia with Meckel’s diverticulum as content.

Obturator hernias are one of the rarest hernias accounting for 0.07-1% [1] of all the hernias. Litter’s hernia, as described by Alexis De Litter in 1700s, is the protrusion of a Meckel’s diverticulum through a potential abdominal opening [1]. It is also a rare phenomenon [2]. After thorough review of literature we were able to find only 4 papers regarding similar occurrences, which make this case extremely rare [3] [4] [5] [6].

In this case report we will be presenting a case of 77 year old lady who presented with symptoms of small bowel obstruction. CT scan abdominopelvic was suggestive of small bowel obstruction due to obturator hernia. It was intra-operatively diagnosed as to be Obturator hernia with Meckel’s diverticulum as content i.e. a Litter’s Obturator Hernia
437 Migrated tubal sterilisation clip presenting as a subcutaneous gluteal foreign body 24 years later: A case report and literature review
Authors: Lakha Adil Siraj , Ang Andrew , Salih Sarmad Mohammed , Lewis Christopher
Published: August 2023

Introduction

The incidence of sterilisation clip migration is reportedly 25%. However, less than 1% of those who experience clip migration will present with pain, an abscess, or spontaneous extrusion. Here we present a rare case of sterilisation clip migration through the entire pelvic floor.

Case

A 66-year-old female was referred from community to the Surgical Emergency Unit with a possible metallic foreign body under the skin following an attempted routine gluteal cyst excision. The patient first noticed a lump under the skin 2 years ago which gradually became more apparent and tender over the previous 2 months. The patient denied recent trauma, had no co-morbidities and had a sterilisation procedure 24 years prior. Examination revealed a non-mobile solid structure just beneath the skin 5cm laterally from the anal verge. Inflammatory markers were normal and an ultrasound confirmed a 15x7mm foreign body in the subcutaneous tissues. The foreign body was excised easily under local anaesthesia, revealing a closed Filshie sterilisation clip. The wound was closed primarily, and recovery was uncomplicated.

Discussion

This is the first reported case of sterilisation clip migration to the subcutaneous gluteal region. A literature review revealed 35 case reports of sterilisation clip migration, mostly to the bladder.

Patients with a previous sterilisation procedure and suspected subcutaneous foreign body without trauma should elicit a high index of suspicion for migrated sterilisation clips. These clips can migrate through multiple layers of muscle and fascia, including the pelvic floor.
439 A review of the management of Anti-coagulation and anti-platelet medication in surgical patients in a University Hospital
Authors: Lee Chloe , Findlater Hannah , Ghazanfar Mudassar , Ganesh Radhakrishnan
Published: August 2023

Management of surgical patients on anti-coagulation and anti-platelet medication can be challenging. Balance between discontinuation, with thrombotic risk, and continuation or early re-initiation with risk of bleeding should be considered. In emergency setting patients are managed depending on clinical situation.

Aim

To review the management of anticoagulant or antiplatelet therapy in acute and elective surgical patients.

Methods

Method: Electronic data was retrospectively reviewed for both elective and emergency admissions to surgical ward during two weeks period. Data including age, sex, admission diagnosis, indication and nature of anti-thrombotic or antiplatelet medication, and thromboembolic or bleeding complications were collected.

Results

30 patients (19 male, 11 female) with a mean age of 74 (54-90) were reviewed. 22 patients were emergency admission and 8 were elective.

All elective cases had their medication withheld. Three patients developed complications including 1 rectal bleeding, 1 post liver biopsy bleed and 1 internal jugular vein thrombosis.

17 emergency patients had their medication withheld. 5 patients underwent surgery and 7 patients had endoscopic invasive procedures (ERCP). One patient developed bowel ischemia from arterial thrombosis following emergency open cholecystectomy. Among the 5 patients who continued the medication one patient had ERCP and others did not receive any intervention.

Conclusion

Patients on anti-coagulation and anti-platelet medication undergoing invasive procedure can develop thrombo-embolic or bleeding complication.
445 Endovascular treatment of acute mesenteric ischemia: An option to consider in patients unfit for major surgery
Authors: Philip Ken , Uzoma Chukwuebuka , Cota Allwyn , Rogers Angie
Published: August 2023

Introduction

The number of embolectomies for superior mesenteric arterial occlusion has increased over the years. Endovascular embolectomies in acute mesenteric ischemia continue to be performed only in a smaller proportion of cases despite multiple studies reporting promising results.

Case description

An 85-year-old lady presented to the emergency surgical unit with an acute onset of severe abdominal pain and vomiting.

She has a background of atrial fibrillation and hypertension and has been a chronic smoker for the past 50 years. One month before her presentation, she stopped taking her anticoagulation due to intermittent per-rectal bleeding attributed to diverticular disease.

Initial CT demonstrated an SMA embolus extending from the first bifurcation approximately 4.5cm distally. In addition, there were features of bowel ischaemia with abnormal thickening of the small bowel loops in that vascular territory. She was deemed too frail for a laparotomy by the surgical and anaesthetic team, and the patient preferred to explore a non-operative approach.

Despite treatment dose anticoagulation, her clinical condition deteriorated, with a rise in inflammatory markers, intolerance of food, and worsening abdominal pain. Unfortunately, thrombolysis was not an option because of the large size of the embolus and PR bleeding.

She underwent an endovascular vacuum-assisted thrombectomy. The procedure achieved near-complete revascularisation, and the patient sustained a good recovery and was discharged on day 8 of admission.

Discussion

Available literature has shown promising results with endovascular treatment of acute mesenteric ischemia. The successful revascularisation, in this case, confirms that endovascular techniques are a viable option to consider in acute mesenteric ischemia.
452 Impact of COVID-19 on the closure of temporary ileostomies following colorectal surgery
Authors: Hughes Rebecca , Massie Eleanor , Renwick Andrew , Vella Mark , Moug Susan
Published: August 2023

Aims

Temporary defunctioning ileostomies are created in emergency general surgery and elective colorectal surgery with the aim of reversal in the near future. Ileostomies come with associated morbidity. There is a nationwide delay to closure of ileostomies in the UK for a variety of reasons and Covid-19 has had a further significant impact on surgical waiting lists. We aim to assess the length of delay to reversal of ileostomy and whether there is greater morbidity associated with delayed reversal.

Methods

All reversal of ileostomy patients referred to the National Waiting Times Centre over a one year period between November 2021 and November 2022 we included. Demographics and details of index surgery were collected, as well as reversal peri-operative details, complications and length of stay.

Results

Twenty-three patients underwent reversal of ileostomy. Mean age 60.4 years. Mean number of days from index procedure to reversal was 648 days (range 99 – 2136). Reasons for delay were; adjuvant chemotherapy (n=6), waiting list/Covid-19 delays (n=13), patient preference/no reason documented (n=4). There were 7 end ileostomies who underwent laparotomy and 16 loop ileostomies reversed. Mean length of stay was 7.04 days (range 2-19 days). 7 patients had ileus following reversal, 3 had an anastomotic leak requiring return to theatre, 1 returned to theatre for bleeding and 1 developed Clostridium difficile.

Conclusion

Half of this cohort of patients who were referred as ‘long-waiters’ to the National Waiting Times Hospital developed a complication following reversal of ileostomy. This cohort of patients waited on average 377 days longer than pre-Covid-19 waits (Close-IT).
491 Quality of Operation notes - Fit for purpose?
Authors: Vinodkumar Narayanan , Amin Dylan , Rajasingh John , Opaluwa Abdu , Abdelwahed Ahmed , Sharma Abhay
Published: August 2023

Aims

Every doctor should maintain accurate and contemporaneous records. Operation notes with accurate documentation are crucial for providing good medical care. This responsibility lies with the primary surgeon. The aim was to assess the quality of operation notes in accordance with standards by RCS guidelines ‘Good surgical Practice.’

Methods

120 General Surgery operation notes (Electronic and handwritten) were randomly identified over a period of 2½ months. This covered both elective and emergency operations. Reviewers collected the data from the operation notes and the analysis was completed by clinicians. The parameters that were evaluated were Name, Hospital number, Date, Time of the operation, Elective/Emergency, Procedure, Name of the surgeon, Assistant, Anaesthetist, Incision, Operative diagnosis, Findings, Complications, Details of tissue removed, Additional procedures, Name/serial number of prostheses, DVT prophylaxis, Antibiotics, Blood loss, Details of closure/suture material, Post-op instructions and signature.

Results

Of the above parameters, 6 met a standard of 100%, 7 a standard of ≥ 90%, 7 a standard of 50-89% and 2 achieved a standard of < 50%.

Conclusions

There are certain parameters that need improvement to achieve a standard of 100%. Actions have been taken to raise awareness of the essential requirements of operation notes, to facilitate compliance to the guidelines as well as reminders to ensure adherence to the process. This will further improve the quality of the operation notes. A re-audit subsequent to these above measures will furnish us with more information.
520 The role of abdominal drains in Laparoscopic Appendicectomy: a prospective study of 260 patients
Authors: Hume Grace , Burford Charlotte , Shah Ankur
Published: August 2023

Aims

Guidance regarding the use of antibiotics and drains following laparoscopic appendicectomy remains unclear. We aim to describe current practice at our unit with the view to forming a local guideline.

Method

A prospective review of all adult patients undergoing laparoscopic appendicectomy at our unit between July 2021-July 2022 was performed. Data was collected from electronic patient records and theatre software, including patient demographics, blood and imaging results and drain and antibiotic details where applicable.

Results

260 patients underwent laparoscopic appendicectomy (53.1% female) with a median age of 38 years (IQR 30.75). 87.7% were positive for appendicitis on histology.11.2% were discharged within 23 hours from admission. The median length of stay was 2 days (IQR 2). 70.7% received postoperative antibiotics with a median duration of 5 days. 25.4% had a drain inserted and had a significantly longer inpatient stay (3 vs 2 days, p<0.001). Those with drains had a higher median CRP compared to those who did not (137 vs 38, p=<0.001) and this association remained significant on multivariate analysis when controlling for white blood cell count and lactate (p<0.001). Patients who had post-operative antibiotics or a drain were not more likely to re-present following discharge (p=0.586 and p=0.169 respectively).

Conclusions

In our cohort drains did not reduce likelihood of complications but increased length of time in hospital. Further research is needed to identify specific patients, if any, who would benefit from drain use.
557 Laparoscopic versus robotic cholecystectomy: a meta-analysis to differentiate between postoperative outcomes
Authors: Singh Anurag , Kaur Mandeep , Swaminathan Christi , Sains Parv , Singh Krishna , Shafique Muhammad
Published: August 2023

Objective

Robotic cholecystectomy (RC) may be an option to replace conventional laparoscopic

cholecystectomy (LC) due to several reported advantages. The objective of this study is to compare the postoperative surgical outcomes in patients undergoing RC versus LC.

Materials and methods

RCTs reporting postoperative outcomes in patients undergoing RC versus LC were selected from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.

Results

Two RCTs on 196 (113 patients in RC group and 83 patients in LC group) patients were found suitable for meta-analysis according to the inclusion criteria. In the random effects model analysis, the duration of operation [standardised mean difference -15.83, 95%, CI (-22.99, -8.67), Z = 4.33, p < 0.0001] was shorter in the LC group. However, the risk of bile leak [standardised mean difference 3.15, 95%, CI (0.69, 14.44), Z = 1.48, p = 0.14] and postoperative complications [standardised mean difference -0.48, 95%, CI (0.10, 2.33), Z =0.91, p = 0.36] were statistically similar between RC and LC groups. There was no heterogeneity (Tau 2 = 0.09; Chi 2 = 1.06, df = 1; (p = 0.30; I 2 = 6 %) between included RCTs.

Conclusion

RC failed to prove any clinical advantage over LC for postoperative outcomes including longer duration of operation. These findings are insufficient to draw a stronger conclusion due to the paucity of RTCs and a major multicentre RCT is required to strengthen the existing evidence.
563 Retrospective analysis of the role of intravenous fluids in the prevention of Post-ECRP pancreatitis
Authors: Johnston Magnus , Apollos J , Dhaif A , Alexander L
Published: August 2023

Background

Recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommend the ‘conditional’ use of intravenous fluids in prevention of those at moderate to high risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

The aim of this study was to appraises the rates of post-ERCP pancreatitis following the administration of procedural and post procedural ERCP intravenous fluids (Hartmans) within a years period in a large district general hospital.

Conclusion

Intravenous fluids may have benefit in reduction of post-ERCP pancreatitis rates however further study is required. On balance, given the relative potential benefit vs harm, cost effectiveness and feasibility we would recommend the routine use of procedural and post procedural ERCP intravenous fluids.
566 The compliance of the surgical unit with regards to the NICE guideline recommendation for extended VTE for post-operative colorectal cancer patients in both elective and emergency settings
Authors: Elwes Caitlin , Arun Chokkalingam , Oyewole Bankole
Published: August 2023

Aims

This audit assessed the compliance of the surgical unit with regards to the NICE guideline recommendation for extended VTE for post-operative colorectal cancer patients in both elective and emergency settings. The audit reviewed the various factors for non-compliance and posits action plans to improve compliance.

Methods

Data was collected over a 3 month period for all consecutive elective and emergency colorectal cancer resections. The operation notes, discharge summaries, drug charts and clinical notes were reviewed and data collated and analyzed with the Microsoft Excel application.

Results

30 cases met the inclusion criteria, 25 elective and 5 emergencies. Within 24 hours of admission, only 47% of all cases were prescribed mechanical prophylaxis but 93% prescribed pharmacological. Whilst 70% of cases had VTE prophylaxis written in operation notes, only 10% of these stated the 28 day extended VTE requirement. Cases that had received the recommended 28 day extended VTE post operatively was found to be 83% with 17% of cases receiving fewer than 28 days post operatively.

Conclusions

The deficits found in this study could be due to a number of factors that include but are not limited to lack of education of post operative VTE requirements for colorectal cancer, lack of clear documentation of requirements and incorrect prescribing at admission and discharge.
595 Audit of IV fluids prescription and administration on adult surgical in-patients
Authors: Babiker Mohammed , Garnett Joseph , Dawson Angus , Hassoun Omar , Jones Keira , Apollos Jeyakumar , Johnston Magnus
Published: August 2023

Aim

Is to measure the conformity of the practice with the guidelines issued by NICE (National Institute for Health and Care Excellence), GIFTASUP (Guidance on Intravenous Fluid Therapy for Adult Surgical Patients) and the local hospital policies.

Methods

NICE guidelines and GIFTASUP recommendations were reviewed. Data collected from medical records of 40 in-patients on surgical wards. The records with incomplete information were excluded from the analysis. The data was then analyzed using Excel sheets, and the results were reviewed and compared against the guidelines mentioned above. The variables measured during the audit were the level of prescriber, indications, type of fluid, rate of administration, pre-checking of U/Es, and complications.

Results

The results showed that the majority of the IV fluids were prescribed by FY1s (40%) and ANPs (20%). The majority of the prescriptions were for maintenance purposes (63%). The most commonly used fluid was 0.18% NaCL/4% Dextrose (35%) followed by Hartmann's (30%). The most common rate of administration was 150ml/hr (35%) and only 10% of the U/Es were pre-checked. The commonest complication recorded was hypo-natraemia (15%), followed by hypo-kalaemia (5%) and total 25% of patients suffered complications.

Conclusion

The audit revealed that there were issues with documentation, type of fluids used and the rate of administration and complications. These findings can be used to improve the practice of IV fluid prescription and administration, ensuring that it is in line with the guidelines and policies, resulting in better patient outcomes.
600 Longer than expected stay in elective general surgical patients - understanding the dynamics
Authors: Arifuzaman Mohammed , Bhattacharya Sayan , Hammad Ahmed
Published: August 2023

Aims

To find the number of patients listed as elective day case or elective inpatient in general surgical department. To understand the dynamics of the day case surgeries and the predictors of lengthy stay.

Methods

Retrospective analysis of all the elective patients listed in general surgery from December 2021 to May 2022. The age, sex, list number of the patient in the theatre list, surgical time, anaesthetic time and ASA grade were compared against the length of stay. A total of 181 patient studied. Type of surgery listed and reason for longer stay collected from the evolve notes of the patients. Elective surgical patients were included and emergencies excluded. Statistical analysis done on StatsDirect 3.

Results

A total of 181 patients studied and 163 (90 %) were listed as day case (DC) and 18 (10%) as inpatient (IP). Median post-op day (POD) discharge for IP was 1 and DC was 0. Median age for IP was 57.5 years and DC was 49 years. Median surgical time was 85.5 minutes for IP and 72 minutes for DC. Median anaesthetic time was 34.5 minutes for IP and 31 minutes for DC.

Discussions

Overnight observation is the most common reason for the patients to stay in longer seen in 71.4 % patients. Late presentation to ward is the second most common reason, seen in 25 % patients. Median POD discharge for patients with overnight observation and drain is 2. Patients with documented overnight observation + drain + weekend results in POD 4 discharge. Drain – median POD 2 (min 1 max 12). NG – median POD 5 (min 2 max 6).
626 To assess the appropriateness of colonoscopy in patients below the age of 60 in a District General Hospital
Authors: Zaidi Syed , Zaidi Abbas
Published: August 2023

Aim

To assess the indications of colonoscopy on the basis of symptoms in patients below the age of 60 using Epage 2 guidelines. Correlate them with colonoscopic and pathologic findings to determine the appropriateness to improve patient selection in district general hospital.

Methods

This is a retrospective study including 296 patients below the age of 60. They were referred from Gastroenterology and Surgical department. Data includes age, sex, indications, colonoscopic and pathologic findings. The Epage 2 online guidelines were used.

Results

43% of patients were male and 57% were female. The most indication for colonoscopy was abdominal pain and bleeding PR (20% each) and diarrhoea (19.6%). Colitis was found in only 14.9%, with diverticulosis 11%, polyp 4% and haemorrhoidal disease 6%. Using the EPAG 2 Criteria 80.5% were appropriate indications, 12.5% were uncertain and only 7% were inappropriate indications.

Conclusion

This study confirmed that the majority of indications for colonoscopy were appropriate. Cancer was only found in 2% of patients and majority of the colonoscopy findings were normal. The most common diagnosis in this age group was colitis (14.5%).
634 Dehisced Functioning Stoma Healed with Novel use of Negative Pressure Wound Therapy
Authors: O'Malley Paula , Shields Conor
Published: August 2023

Background

Three years following bowel resection and colostomy formation for colorectal cancer a 62 year old man developed a parastomal hernia. On Day11 following laparoscopic repair and stoma formation the midline and stoma wounds dehisced. The stoma had a superficial wound extending 1cm but the lateral edge of this wound had a cavity 4x5x10cm. This wound presented challenges regarding the adherence of both dressings and the stoma bag.

Aim

During an exploration under anaesthesia, no purulent fluid or mesh was located in the cavity. Initially dressed with betadine wick and a JVAC drain, however, the moisture led to repeated stoma bag detachment and leakage of faeces into the wound.

Method

Consequently, to speed up healing and contain the faeces, negative pressure wound therapy (NPWT) was used around the stoma. The peristomal area was dressed with hydrofibre and hydrocolloid to provide a base, the cavity with polyvinyl alcohol foam, the stoma protected with Fistula Funnel (3M, San Antonio, Texas) and polyurethane granufoam applied around the wound with a pressure of -150mmHg. Following application of the NPWT a hole was cut to allow stoma contents to be evacuated and a stoma bag applied.

Result

Within three weeks the cavity was 3x4x1cm and NPWT discontinued.

Conclusion

The use of NPWT is contraindicated over exposed organs and the need for an occlusive dressing presents active outflow of contents. However the use of a soft, flexible silicone funnel allowed a complex wound to be healed in weeks, when conventional treatment wound have taken months.
Executive decision-makers: a scenario-based approach to assessing organizational cyber-risk perception
Authors: Parkin Simon , Kuhn Kristen , Shaikh Siraj A
Published: August 2023

The executive leadership in corporate organizations is increasingly challenged with managing cyber-risks, as an important part of wider business risk management. Cyber-risks are complex, with the threat landscape evolving, including digital infrastructure issues such as trust in networked supply chains, and emerging technologies. Moreover, engaging organizational leadership to assess for risk management is also difficult. This paper reports on a scenario-driven, workshop-based study undertaken with executive leadership to assess for cybersecurity and cyber-risk perception related to preparation for, and response to, potential incidents. The study involves leadership members at a large public–private organization. Our approach utilizes scenarios, which are structured in their design to explore and analyse aspects of business risk, risk ownership, technological complexity, and uncertainty faced by an organizational leadership. The method offers a means to engage with leadership at real-world organizations, capturing capacity and insights to manage business risks due to cyberattacks.
Epilepsy and long-term risk of arrhythmias
Authors: Wang Jie , Huang Peiyuan , Yu Qingwei , Lu Jun , Liu Pinbo , Yang Yiping , Feng Zeying , Cai Jingjing , Yang Guoping , Yuan Hong , Tang Haibo , Lu Yao
Published: August 2023

Background and Aims

Previous evidence has mainly supported transient changes in cardiac function during interictal or peri-ictal phases in people with epilepsy, but the long-term risk of cardiac arrhythmias is poorly described. This study aimed to assess the long-term association of epilepsy with cardiac arrhythmias, considering the potential role of genetic predisposition and antiseizure medications (ASMs) in any associations observed.

Methods

This population-based study evaluated UK Biobank data for individuals recruited between 2006 and 2010. Cox proportional hazards models and competing risk models were used to examine the association of epilepsy history with the long-term incidence risk of cardiac arrhythmias and arrhythmias subtypes. Polygenic risk scores (PRS) were calculated to investigate the effect of genetic susceptibility. The role of ASMs was also evaluated by integrating observational and drug target Mendelian randomization (MR) evidence.

Results

The study included 329 432 individuals, including 2699 people with epilepsy. Compared with those without epilepsy, people with epilepsy experienced an increased risk of all cardiac arrhythmias [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.21–1.53], atrial fibrillation (HR 1.26, 95% CI 1.08–1.46), and other cardiac arrhythmias (HR 1.56, 95% CI 1.34–1.81). The associations were not modified by genetic predisposition as indicated by PRS. Competing and sensitivity analyses corroborated these results. Individuals with epilepsy using ASMs, especially carbamazepine and valproic acid, were at a higher risk for cardiac arrhythmias. This observation was further supported by drug target MR results (PSMR < .05 and PHEIDI > .05).

Conclusion

This study revealed the higher risk of cardiac arrhythmias persists long term in people with epilepsy, especially among those using carbamazepine and valproic acid. These findings highlight the need for regular heart rhythm monitoring and management in people with epilepsy in order to reduce the risk of further cardiovascular complications.
Introducing Myth to Foreign Policy Analysis: The Blair Poodle Myth and Its Impact on Constructions of the “Special Relationship”
Authors: Eason Thomas
Published: August 2023

This article introduces the concept of political myth to foreign policy analysis. It explains how myth can influence the construction of foreign policy events and decisions and creates a new lens that analysts can use to study this. To do that, this article draws upon conceptual literature on political myth to explain what myth is and how it shapes discursive constructions of the world. Adopting an interpretivist approach, it then uses the concept as a lens to analyze the impact that the Blair Poodle myth has had on the construction of the US–UK “special relationship” from 2002 to 2022 and considers how this has influenced the diplomatic behavior of five UK prime ministers. It finds that the myth has been integral to negative constructions of the “special relationship” over the past twenty years and has inspired political action, including protests, resignations, and more formal diplomatic engagement with the United States.