bluuebunny/crossref_metadata_2025 huggingface dataset:
EP-86 Preventable errors in hand surgery: analysis of data from NHS England
Authors: Hafez Ahmed , Omar Islam , Ang Andrew , Mahawar Kamal
Published: November 2022

Background

Avoidable medical errors and never events represent a significant problem with negative consequences on the patient, the healthcare professionals, and the healthcare facilities. Hand surgery is a unique multidisciplinary speciality in which orthopaedics, plastic and general surgery are usually involved in the care of their patients, which makes this speciality prone to medical errors. The study highlights these preventable errors in hand surgery in NHS England.

Methods

We analysed hand surgery-related preventable medical errors published by the NHS England during the last ten years from 2012 till July 2021.

Results

Out of 3742 never events during the review period, only 50 never events related to hand surgery were found, representing (1.3%).

The majority were under wrong-site surgery category 30 (60%), which included 17 (57%) wrong finger or digit surgery followed by five wrong digit or thumb injections, three wrong K wire placement, and three scaphoid bones were mistakenly removed during trapeziectomy.

The second most common category was wrong incision 15 (30%), with 13 wrong finger incisions, two wrong carpal tunnel incisions for trigger finger release.

Four patients had wrong procedures, including CTR rather than trigger finger or Dequervain release or an unnecessary carpal tunnel release in addition to one wrong hand tendon transfer. Lastly, only one patient had a wrong injection for carpal tunnel that was intended for another patient.

Conclusions

Hand surgery-related medical errors represent 1.3% of the whole Never Events reported.

Awareness of these incidents will help prevent their occurrence in the future.
EP-88 Plastic Surgery Venous Thromboprophylaxis for abdominal and thigh based free flap breast reconstruction surgery
Authors: Bahadori Darab , Eiben Inez , Eiben Paola
Published: November 2022

Aims

Correct Venous Thromboprophylaxis (VTE) assessment and prescription is at basis of patient safety when considering patient hospital admission. Current local Guy's and St Thomas Hospital guidelines are in keeping with National Institute for Health and Care Excellence (NICE) guidelines recommending all patients to be assessed and prescribed VTE prophylaxis within 24 hours of admission. There are no specific local or national guidelines however that would recommend VTE prophylaxis specific to free flap breast reconstruction surgery.

We assessed therefore adherence to VTE prophylaxis guidelines for patients undergoing abdominal and thigh based free flap breast reconstruction surgery. Patient outcomes were reviewed and VTE prophylaxis proforma was recommended.

Methods

Patients who underwent abdominal or thigh based free flap breast reconstruction surgery between October 2017 and February 2019 were identified. Data was collected retrospectively and analysed via SPSS Statistics (IBM, USA).

Results

51 patients were included in the first audit cycle; 50 patients in the re-audit. Overall improvement and 100% of patients received LMWH on admission. The timings of correct prescription versus actual administration of LMWH decreased however from 71% to 49%.

Discussion

There is good adherence to assessment and administration of VTE prophylaxis across the patients. Unfortunately the prescription of VTE prophylaxis itself is mostly incorrect. It is therefore with gratitude to the ward staff VTE is administered correctly. Further improvements in the communication therefore between theatre, ward and surgical staff and implementation of VTE prophylaxis proforma need to be considered.
EP-127 Filling in the Knowledge Gap: Designing the General Surgery/ Orthopaedic Clinical Handbook for NHS Dumfries & Galloway
Authors: Hemadasa Niroshini A , Isles Chris , Apollos Jeyakumar , Sami Sharukh
Published: November 2022

Introduction

The NHS Dumfries & Galloway Clinical Handbook was developed to provide readily accessible and practical guidance when assessing and managing a wide variety of medical conditions for junior doctors. We summarise the relevant NICE and SIGN guidelines and link to other relevant handbooks. Until now the content has been purely medical.

Aim

To expand the Clinical handbook to include topics in General Surgery and Orthopaedics that would be useful for junior doctors.

Methods

Results

Initial survey sent to 15 junior doctors showed everyone stating it would be very useful to have a general surgery and orthopaedics section in the handbook with 80% stating they used the handbook all the time. Free text questions included asking useful topics to be included in the handbook with answers including management of common surgical emergencies/ presentations, analgesia and laxatives, anticoagulation. The handbook was written and published online and can be accessed via https://www.nhsdghandbook.co.uk

Conclusions

The handbook was well received by the junior doctors. A survey has been sent out to junior doctors for feedback and number of online visitors to the site will be collected and reviewed. The handbook will be updated to include more topics.
EP-169 Management dilemma in an unusual presentation of acalculous acute cholecystitis
Authors: Bose Sayantan , Alasmar Mohamed , Doran Helen
Published: November 2022

Acute acalculous cholecystitis is a recognised but seldom encountered entity except in immunocompromised and critically ill patients. Epstein-Barr virus infection, on the other hand, is a common viral illness throughout the world, mostly in the younger age groups. However acute cholecystitis due to EBV infection is very rare to occur and can be difficult to diagnose. Here we present a case of a middle aged adult who presented with upper abdominal pain and non-specific viral illness-like symptoms. LFTs were of a mixed picture and she had marginally raised inflammatory markers. Standard imaging studies excluded gallstones but she had thickened gallbladder wall with pericholecystic oedema and some fat stranding, but normal intra hepatic biliary tree and CBD. Strikingly there were sizable lymph nodes in abdomen and thorax. Suspecting viral aetiology, a viral screen was performed which gave a positive EBV result. However on daily clinical examination she kept on worsening symptomatically and a decision to operate was made following discussion with gastroenterologists and the patient. To note, EBV result was delayed and arrived after she had the operation. This case gives an example of a rare surgical case which may create a diagnostic dilemma amongst clinicians. Whilst understanding that management of acalculous cholecystitis is usually conservative, but in a clinically deteriorating young patient like this there may be a case for cholecystectomy or cholecystostomy. Here the learning point should be to think of other possible diagnoses and consider viral aetiologies earlier which may avoid a procedure on a patient.
EP-191 The effect of surgical case-based discussions in confidence levels in acute kidney injury management
Authors: George Jayan , Rees Chantal Olivia Blanch
Published: November 2022

Aims

Methods

FY1 doctors were surveyed throughout July 2021 and December 2021 across two sites. Six questions used Likert scales (1 to 5: not at all confident to very confident) to assess managing AKI. Data was initially inputted using Google Docs and analysed in Microsoft Excel.

Results

44 FY1 doctors completed the initial questionnaire.

19 FY1 doctors completed the questionnaire post rotation. (8 attended teaching and 11 did not.)

Confidence levels in managing AKI were greater in FY1 doctors who had received CBD for recalling the common classes of drugs that cause AKI, explaining the significance of lactate and bicarbonate and managing the surgical patient with AKI, as opposed to those who did not.

Confidence levels for managing AKI, categorising the causes of AKI and assessing a patient's fluid status, were similar between those who had received CBD and those who did not.

Conclusions

Confidence levels in managing AKI were mostly higher in those FY1 doctors who received surgical CBD teaching. Further research is required for the use of CBD in its potential to improve FY1 doctor education.
EP-213 An Audit on the Initial Management of Acute Cholecystitis: A Single Centre Experience
Authors: Stoll Sarah , Doherty Rachel , Sedighi Tina , Davidson Christopher , Modi Hemel
Published: November 2022

Aim

Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates.

Method

All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (>38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour.

Results

Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p<0.001). Age, gender, temperature, inflammatory markers and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription.

Conclusions

Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.
EP-216 Case Report: A Fishy Case of Flexor Tendon Injury
Authors: Mactier Mhairi , Davies Kerry , Gilmour Adam
Published: November 2022

Introduction

We describe the first documented case of a flexor pollicis longus (FPL) tendon injury occurring secondary to a fish bite.

Case Report

A 52-year-old right hand dominant male was referred with inability to flex his right thumb following a pike bite whilst fishing in a nearby Loch. Clinical examination revealed superficial abrasions to his right thumb with two deeper puncture wounds over the volar pulp. He had no active flexion of the interphalangeal joint. Radiographs showed no fracture/foreign body. Given deep animal bite, intravenous antibiotics and operative exploration were indicated. Intraoperative findings revealed 100% division of the FPL tendon (zone II); this was repaired using a modified Strickland method. The patient completed 48 hours intravenous antibiotics and was discharged with physiotherapy-led follow up.

Discussion

Animal bites are a common presentation to the Emergency Department however non-domesticated animals account for <5% cases. We are not familiar with managing marine animal bites and the literature is lacking. Only 2 cases of sting-ray injuries have been described, both of which were associated with delayed presentation and poor functional outcome. Aquatic injuries also contain unique bacterial flora including Vibrio, Aeromonas and Pseudomonas which merits consideration.

Conclusion

This case highlights the importance of managing innocuous wounds with caution in case of underlying structural damage. Unusual animal bites should be closely monitored with low index for surgical exploration to avoid delayed complications. Discussion with microbiology specialists should also be considered.
EP-238 Challenges of delivering a tertiary breast cancer service during the COVID-19 pandemic
Authors: Mehta Anjali , Whisker Lisa , Oni Georgette
Published: November 2022

Introduction

Delivering a breast service during the COVID-19 pandemic has been challenging. At our tertiary referral centre, we have had to coordinate care across multiple sites in order to maintain provision of services. This study looks at how this was achieved at the Nottingham Breast Institute (NBI) by a team of 6 Consultant Surgeons.

Methods

This was a retrospective review of a prospective data base (managed by one Consultant Oncoplastic surgeon) of all patients treated at the NBI over a period of 18 months, at the start the pandemic from March 2020 to October 2021. Data collected included patient demographics, hospital site, and type of surgery.

Results

Over the 18 months 1191 patients were operated on. The average age was 57.8 years (range 17 to 86); as expected the commonest indication was cancer (93.1%). 11.3% of those patients (125/1109) received neoadjuvant chemotherapy. Of these 37.4% of patients (N=446) were operated on at our usual operative base site (NBI). 49.5% and the majority of cases (N=589) were performed across two independent hospitals and a smaller proportion (12.9%) was conducted at a fourth hospital which offered 23 hour stay facilities.

Conclusions

Despite the challenges of securing operative capacity, thus far, we have been able to deliver over 1000 breast cancer surgeries during the COVID-19 pandemic. This is due in part to multisite working, surgeon flexibility, and oversight of all the patient pathways collated on one database by a dedicated surgeon.
EP-244 A “missed” nasal button battery in a child during the COVID-19 pandemic
Authors: Anastasiadou Sofia , Chan Jacqueline , Janjua Ah
Published: November 2022

A 5-year-old boy was referred acutely to the on-call ENT doctor following multiple remote consultations with his general practitioner with 2 months history of worsening left-sided foul-smelling nasal discharge and bleeding. He underwent examination under anaesthesia and removal of nasal foreign body which was subsequently identified as a button battery (intra-operative as well as imaging pictures included). This case highlights the challenges posed to clinicians during the COVID-19 pandemic but also serves as a reminder to keep a high index of suspicion and low threshold for clinical examination in suspected cases of nasal foreign body. It also highlights that since COVID19 omicron variant has emerged it is more than significant to evaluate cases that are assessed remotely with increased care to avoid any further misses or mistakes.
EP-257 A case report of Furuncular myiasis affecting the glans penis of a young boy caused by the larvae of Cordylobia anthropophaga (The Tumbu Fly)
Authors: Jesuyajolu Damilola , Jesuyajolu Paul
Published: November 2022

Introduction

Cutaneous myiasis is endemic in West Africa, and it is most commonly caused by the larvae of Cordylobia anthropophagia. In English literature, recorded cases of this cutaneous myiasis affecting the glans penis are rare. This rarity calls for a need to consider this as a differential when looking at furuncular lesions of the glans penis. This awareness is important for practitioners who may come across this case.

We report a case of furuncular myiasis of the glans penis due to the larvae of C.anthropophaga of an 11-year-old boy living in Lagos, Nigeria.

Case presentation

We present an 11-year old boy who presented to the surgical emergency department with a lesion on his glans penis, initially thought to be a boil. Upon examination, the lesion contained a single larva of C.anthropophaga. After sedation of the patient, It was extracted in the mini-theatre with a non-toothed forceps and dressed, and the area healed well.

Discussion

Although endemic, furuncular myiasis of the glans penis is a very rare condition, likely related to the living circumstance of the patient. An awareness of the clinical features is important to prevent misdiagnoses of foruncular lesions that occur on the glans penis, especially in people with identified risk factors.

Health education and promotion of good hygiene are important in reducing the incidence of Cordylobia anthropophagia infestation in endemic regions as well as among frequent travelers to and from endemic areas.

Keywords

myiasis, cutaneous myiasis, Cordylobia anthropophagia, glans penis, Tumbu fly
EP-306 Management of acute sigmoid diverticulitis in a district general hospital – a retrospective audit
Authors: Egbe Azelle
Published: November 2022

Aim

Acute sigmoid diverticulitis is one of the most common emergency general surgery conditions. Guidelines from the European Society of Coloproctology published in 2020 outline best practice in management, including a move away from routine antibiotic therapy. This audit aims to assess compliance with these guidelines.

Methods

Electronic records of all patients admitted under the emergency general surgery team with acute sigmoid diverticulitis in 2021 were analysed to obtain information on management. These data were compared against the 2020 guidelines to assess compliance.

Results

99 patients were admitted with acute sigmoid diverticulitis in 2021. 97% of patients underwent an abdominal CT scan and 100% received IV antibiotics.

65% of cases were classified as uncomplicated and 35% were classified as complicated (i.e. abscess formation or perforation).

The mean length of stay for all patients was 5.7 days. The length of stay for patients with uncomplicated diverticulitis was 3.7 days compared to 9.3 days for complicated diverticulitis. 10% of patients underwent surgical intervention and no patients underwent radiological intervention.

Only 57% of patients were referred for an outpatient lower GI endoscopy.

Conclusion

These results raise three main insights for further consideration. Firstly, it appears that the evidence against routine antibiotic therapy for acute diverticulitis is not yet being reflected in clinical practice. Secondly, patients admitted with uncomplicated diverticulitis have a relatively short length of stay, indicating a role for ambulatory management of this common condition. Lastly, referral rates for outpatient endoscopy must be improved to ensure that patients with an underlying malignant lesion can be identified.
EP-319 Evaluating the outcomes of patients treated with surgical vs IR cholecystostomy during the COVID-19 pandemic
Authors: Gunn Christopher , Alam Imran
Published: November 2022

Aims

We evaluated the outcomes of patients treated with laparoscopic cholecystostomy versus percutaneous (IR) cholecystostomy during the COVID-19 pandemic.

Methods

Electronic records of patients undergoing cholecystostomy during the COVID-19 peak in 2020 were analysed. Our primary outcomes were the number of readmissions and subsequent completion of laparoscopic cholecystectomy.

Results

6 patients underwent laparoscopic cholecystostomy between January and December. 3 were performed following failure of cholecystectomy, 2 were unfit for cholecystectomy and one underwent surgery due to lack of radiologist availability. 9 IR cholecystostomies occured between March and July. 4 were unfit surgical candidates, 5 were due to COVID related restrictions on operating. 6 readmissions came from the surgical cohort, 4 for infection compared to 3 from the IR cohort with only 1 for infection. Notably, of the 4 IR-drained patients deemed unfit, only one had a subsequent gallbladder related admission. 3 surgical patients underwent definitive surgery, 2 subtotal and 1 total cholecystectomy with a mean time to definitive treatment of 27.5 weeks. 4 IR patients underwent surgery with 1 abandoned, 1 subtotal and 2 total cholecystectomies with a mean time to definitive management of 20.25 weeks.

Conclusions

IR cholecystostomy showed reduced readmission rates compared to laparoscopic cholecystostomy, especially related to infection with rates of 11% and 66%, respectively. More patients underwent total laparoscopic cholecystectomy following IR drainage. However, adhesion formation proved troublesome in both methods. IR cholecystostomy showed a reduced time to definitive surgery. Finally, most high-risk patients undergoing IR cholecystostomy had no further gallbladder related admissions therefore proving its utility in such groups.
EP-341 Haemorrhagic Cholecystitis with cystic artery pseudo-aneurysm
Authors: Nessa Ashrafun , Milburn James , Ramsay George
Published: November 2022

Introduction

Haemorrhagic cholecystitis and cystic artery pseudo-aneurysm (CAP) are two very uncommon causes of right upper abdominal pain. However, the development of haemorrhagic cholecystitis induced by ruptured cystic artery pseudo-aneurysm and haemobilia are extremely rarely documented with few occurrences documented in the literature.

Case presentation

A 80year-old frail patient was admitted with RUQ pain, deranged LFTs and melaena. She had known gall stones, hypertension, chronic kidney disease and fibromyalgia. She demonstrated localized tenderness in the right abdomen and bloods showed a significant drop in haemoglobin which required blood transfusion. Abdominal ultrasound showed cholecystitis and MRCP showed CBD dilatation with no choledocholithiasis. She was found to have haemorrhagic cholecystitis and CAP along with a cholecysto-colonic fistula on triple phase liver CT. The patient underwent urgent embolization of the CAP and remained clinically stable. She was discharged home with a plan of further review before consideration for cholecystectomy.

Clinical discussion

Haemorrhagic cholecystitis and CAP are rare. Clinical suspicion is warranted to diagnose the case – the combination of features of cholecystitis with acute anaemia should raise the suspicion. Diagnosis is made primarily by pathognomonic findings on appropriate phase of CT and US imaging. Prompt diagnosis and management is essential in preventing mortality and/or significant morbidity.

Conclusion

A rare consequence of intra-biliary bleeding due to ruptured CAP leading to haemorrhagic cholecystitis is a potential differential diagnosis in patients presenting with right upper abdominal pain and haemoglobin drop. Close liaison with radiologist is warranted to organise appropriate investigation for diagnosis and successfully manage the condition.
EP-343 Compliance of Prescription of Intravenous Maintenance Fluids in Acute Surgical Patients According to NICE Guidelines
Authors: Morsy Hesham , Li Michael , Davidson Chris , Gu Kat , Ali Maryam , Hollingshead James , Patel Dharti
Published: November 2022

Aim

Assess compliance of prescription of for intravenous maintenance fluids in accordance with NICE Guidelines in the acute surgical admissions population.

Method

Total of 158 patients were included. We collected data prospectively for surgical patients admitted between 25/02/21–18/03/21 (first cycle) & 12/09/2021–4/10/2021 (2nd cycle). Maximum of 5 patients daily randomly selected. Data collected in wards after clerking on Day 1 of admission. Surgical Proforma was used to identify feeding plan for patients. Drug charts used to assess volume and types of intravenous fluids prescribed. Admissions by audit authors were excluded to prevent selection bias.

Intervention

Posters in Emergency Assessment Unit and Wards, Teaching to junior doctors, Regular reminder messages to on-call teams.

Results

Prescription of Intravenous Maintenance Fluids in Acute Surgical Patients in compliance with NICE guidelines for IV Fluid maintenance rose from 6% to 22% between cycle 1 and 2, respectively. In non-compliant prescriptions, the issue was due to excess volume (73%), sodium and chloride (88%) as well as inadequate potassium (75%) and glucose (40%).

Conclusions

Most acute surgical admissions require maintenance fluids. Some patients did not have their weight recorded which is necessary for correct calculation of fluid requirements. Some patients were prescribed maintenance fluids although they were not indicated. Most patients received an excessive fluid volume, sodium & chloride. Most patients received inadequate potassium & glucose. Ward based nursing staff are reluctant to give maintenance fluids containing potassium. More teaching and awareness on correct prescription of maintenance fluids is needed.
EP-351 Extended VTE prophylaxis in patients undergoing elective surgery for colorectal cancer in a district general hospital and its Compliance with NICE guidelines
Authors: Elzaafarany Ahmed , Tawfik Ahmed , Igbekele Tosin , Day Andrew
Published: November 2022

Aim

A This audit aims to assess the department's current compliance with guidance, understand reasons for non-adherence and implement a plan of action to improve future compliance and subsequent patient outcomes.

Background

NICE guidance recommends extended VTE prophylaxis for up to 28 days post colonic resection for cancer

Methods

A single centre, retrospective, observational study was performed between January 2018 –January 2019. We included all the Patients who underwent elective colorectal resections for cancer.

Results

A total of 123 patients had elective elective colorectal resections for cancer. 91 (73%) were laparoscopically, 8 (6.5%) laparoscopic converted to open and 24 (19.5%) were done as open operations from the start. The summary of the operations done were as follows; 62 RHC, 25 HAR and 36 LAR. LMWH for extended VTE prophylaxis for 28 days was prescribed for 91% (112/123) of the patients among the studied period. 5.7% (7/123) were already receiving alternative anticoagulation thus the NICE guidance was achieved for 96.7% (119/123). The patients who did not receive VTE prophylaxis were 3.3%, 4/123), there was no clinical reason documented or identified for this omission. A postoperative VTE was experienced in 4.8% (6/123), 3 of them required a hospital admission (50%). There was no VTE related mortality documented

Conclusion

This audit has demonstrated 96.7% of patients who underwent surgery for colorectal cancer received extended VTE prophylaxis as per NICE guidelines. This is a significant improvement from previous audit cycle, though the aim is for 100% compliance with guidelines. We implement plan of action to achieve that
EP-369 Examining EphA2 expression in Colorectal Cancer
Authors: Lyons Nicholas , Hooper John , Kryza Thomas , Clark David , Riddell Andrew
Published: November 2022

Aims

EphA2 is a potential therapeutic target for the treatment of colorectal cancer (CRC), however reports of EphA2 expression in CRC are inconsistent and often lack the context of a normal tissue comparator. The aim of this investigation is to undertake a detailed assessment of EphA2 protein expression across a range of pathological and normal specimens.

Methods

177 patient specimens (100 paired primary and normal colon, 42 paired primary and metastasis and 35 unpaired samples as part of a multi-tumour TMA) underwent immunohistochemical analysis (IHC) probing for EphA2 expression alongside a normal tissue array.

Results

Weak/moderate EphA2 expression was noted in normal tissues of the proximal GI tract (stomach, small intestine) with little expression in the colon/rectum with a significant upregulation of EphA2 noted in primary lesions compared to matched normal tissue controls (p<0.0001). No difference in expression between stage of disease, sex or effect of patient age, location of samples (edge vs centre), stage of disease, T-stage or N-stage. EphA2 expression was significantly higher in primary lesions associated with M1 disease primaries (p=0.03). No difference in EphA2 expression was noted between matched primary and metastatic lesions (p>0.05).

Conclusion

In this study, EphA2 protein expression was significantly higher in CRC lesions compared to healthy tissue (p<0.0001) with no diminution noted across a wide range of stages or lesion types. On this basis, diagnostic or therapeutic interventions targeting EphA2 are likely to be useful across a wide spectrum of disease.
EP-449 Gall Bladder Torsion - A twist in tale
Authors: Jayasankar Balaji , Aal Yasser Abdul , Porte Francois , Saeed Shoaib
Published: November 2022

Introduction

A 90 year old lady presented with history of sudden onset abdominal pain. The pain was continuous, severe with a tender abdomen.

Methods

Blood investigations were not conclusive. A CT of the abdomen revealed a possible torsion of the gall bladder around its axis with impending gangrene. She went on to have a successful emergency laparoscopic cholecystectomy.

Results

A work up and successful surgical intervention with an extremely unusual gall bladder presentation of torsion.
EP-505 Audit assessing compliance with General Medical Council (GMC) guidelines at Whittington Hospital Colorectal Department (NHS Trust)
Authors: Efthymiou Nikolaos , Braithwaite William , Benhimda Rami , Iskandarani Mohamad , Mukhtar Hasan
Published: November 2022

Introduction

The General Medical Council (GMC) released new guidelines titled ‘Decision making and consent’, which came into effect on the 9th of November 2020. It contains guidelines and standards for consenting patients for elective procedures and the documentation of said consent. Within the Colorectal Department of the Whittington Hospital, an audit was conducted to determine how closely the guidelines are being followed and whether that is reflected in the documentation.

Methodology

We evaluated 57 outpatient letters in the first cycle and 36 in the second. Our intervention was a poster of the guidelines in all clinic rooms for all consenting doctors to see prior to talking to patients.

The four criteria were:

Results

Conclusion

We see slight improvement during the second cycle. Still, the numbers are not satisfactory. A third audit cycle will be conducted once another round of interventions is implemented.
EP-524 Implementing Simulation Based Learning (SBL) to Reduce the Gap in Surgical Training, A Theoretical Evaluation Approach
Authors: Badawi Marwa , Sharmin Afroza , Shamardal Aliaa , Shalaby Ahmed
Published: November 2022

Background

The current surgical training is severely affected by COVID-19 pandemic with redeployment and reduced number of elective procedure across NHS hospitals, this has affected both core and higher surgical trainees, rendering the traditional apprenticeship model obsolete. It became evident that the future of Surgical training and innovation will require a combination of simulation and operative exposure to overcome the obstacle of reduced exposure in surgical education and operative training.

Discussion

In our theoretical analysis, we will discuss the efficacy, safety and impact of relying on SBL to fill the gaps in surgical training.

Clinical exposure alone will not be sufficient to train procedure based speciality trainees to their highest proficiency. SBL is one design that is supported by learning theories such as Transformational Learning and Experiential Learning Theory.

In a high fidelity simulation, such as laparoscopic simulation courses, all concepts of facilitated learning are fulfilled which strongly supports our hypothesis.

On balance, given the complexity of skills learnt, it remains difficult to measure the efficacy of transferring the learnt capabilities into practice and standardise this among learners. SBL also leaves non-technical skills un-assessed in depth.

Conclusion

The disruption of training due to COVID-19 affected our procedure based learning, this leaves us with a dilemma to catch-up with these unmet training needs. SBL could be one of the adjuncts that fill in the gaps on the short and medium term. Implementing SBL in surgical training curriculum, should be evaluated for efficacy and cost effectiveness.
EP-565 Four different causes of bowel obstruction in single patient – case report and review of management of small bowel obstruction
Authors: Shah Ugam , Lau Simon , Javed Tasveer , Kaur G
Published: November 2022

Introduction

The most common causes of Small bowel obstruction (SBO) in adults are adhesions, hernias, cancer, Crohn's, Diverticulitis, volvulus, etc; in children, intussusception. Overall mortality is 10%, increasing to 30% with complications. Urgent investigation, aggressive medical management and appropriate timely surgery are key to successful outcome.

Aim

We present a patient with 4 causes of bowel obstruction due to a single pathology, to highlight different causes and management of SBO with the aim of improving patient outcomes.

Case presentation

A 55 year old lady presented with SBO, and mass RIF. CT demonstrated subacute SBO. Four causes of obstruction were found at laparotomy 1. intraluminal lesion proximal jejunum 2. intussuscepting ileal lesion 3. terminal - ileal lesion perforated /adherent to pelvic side wall, and 4. RIF mass lesion from ascending colon. Right hemicolectomy + terminal ileal resection (lesions 2, 3, 4) and jejunal resection-anastomosis (lesion 1) were performed. She made a good post- operative recovery. Histology found the morphological appearances and immunoprofile were soft tissue sarcoma arising in the GIT: gastrointestinal clear cell sarcoma/ malignant gastrointestinal neuroectodermal tumour. She is under review with the specialist regional sarcoma team.

Conclusion

There are over 22 000 admissions for bowel obstruction in England/Wales each year; 6.4% result in death within 90 days. Depending on the cause, SBO may resolve with medical therapy but timely surgery is needed for total obstruction, complications such as bowel perforation, ischaemia, or failure of conservative therapy. Our case report highlights the importance of urgent investigations and appropriate management of SBO.
EP-566 A case series analysis of intestinal ischemia in COVID- 19 pandemic
Authors: B M Darshan , Somasekhar Kasa
Published: November 2022

Aims

To determine the presentation and outcomes of cases of intestinal Ischemia amidst COVID -19 pandemic and to review latest guidelines in its management.

Methods

A case series analysis of 11 patients admitted and managed under Department of Surgery, over a duration of 17 months from September 2020 to January 2022.

Results

Out of the total of 11 cases of intestinal ischemia, 4 were COVID-19 positive, overall mortality was 54.5% and patients with COVID-19 were found to have 100% mortality. Mortality in conservatively managed patients was also 100%, Mortality in surgically managed patients was 55.5%. Preoperative acidosis, hypoxia and hypotension were found to be important determinants of outcome of the disease.

Conclusion

Occurrence of intestinal Ischemia in COVID - 19 patients is a life threatening complication which demands surgical management with significant mortality.

Treatment of COVID - 19 and intestinal Ischemia should go simultaneously and in line with the latest evidence based guidelines of COVID 19, Patients who survive an acute event are likely to die of other complications related to the COVID-19 like ARDS, Disseminated Intravascular Coagulation etc that could have predisposed them to intestinal ischemia
EP-574 Improving gentamicin prescribing for intra-abdominal sepsis on a general surgical firm
Authors: Fardanesh Armin , Koo Hei-Fen , Van den Berghe Christen , Gathercole George , Dilke Stella , Sengupta Neel
Published: November 2022

Aim

Gentamicin is recommended by local guidelines for the empirical treatment of intra-abdominal sepsis. However, severe side effects that can occur through prolonged raised trough levels requires its use through a specific dosing protocol. Challenges of this means it often “falls off” the drug chart, leading to suboptimal drug-levels. The aim of this quality improvement project was to improve the process of gentamicin prescription.

Methods

A two-week retrospective analysis of all patients admitted was performed to obtain baseline data. Information was collected on gentamicin use, if levels were taken at 6–14 hours post-dose, and if subsequently correctly re-prescribed. PDSA 1 involved placing posters in the surgical office, reminding the clerking doctor of the gentamicin protocol. PDSA 2 involved a departmental teaching session to reiterate the above intervention.

Results

At baseline, only 7% (1/15) of patients prescribed gentamicin had a correct post-dose level taken and subsequently received a correct second dose. After PDSA 1, this rose to 67% (2/3). After PDSA 2, this level was similar at 60% (3/5). Furthermore, at baseline 47% (15/32) of patients deemed to have intra-abdominal sepsis received gentamicin. After PDSA 1, this proportion fell to 11% (3/28) and after PDSA 2 this was 38% (5/13).

Conclusion

Education sessions and posters were effective at increasing the proportion of patients that received a safely prescribed second dose of gentamicin, as a result of correctly taken trough levels. However, a reduction in the percentage of patients receiving gentamicin for intra-abdominal sepsis possibly suggests further education on the role of gentamicin is required.
EP-584 An evaluation of plastic surgery operation note documentation in line with RCS standards
Authors: Carhart Benjamin , Khanna Rahul , Mwaura William
Published: November 2022

Aim

To assess the extent to which operation note documentation had been completed accurately, in line with Royal College of Surgeons (RCS) standards, in a local plastic surgery department.

Methods

Using an RCS good surgical practice guideline, operation notes from cases in January 2021 were reviewed. A total of 112 procedures that were undertaken in both theatres and plastics dressing clinic were audited. The results were collated and analysed using Microsoft Excel. As a result of data analysis, interventions were created whereby results were presented at a local meeting and guidelines were disseminated via WhatsApp to members of the surgical team. A re-audit then occurred using all plastic surgery procedures in May 2021, totalling 112 patients again.

Results

The first cycle demonstrated that the majority of the guideline subsections were met well. This included a defined operative diagnosis (96% of notes) and operative findings (97% of notes). However, some guidelines including problems/complications (17% of notes) and DVT prophylaxis (0.01% notes) were not adhered to as appropriately. The re-audit concluded that nine subsections of the guideline improved from the first cycle. This included operative diagnosis (96% first cycle, 100% second cycle) and details of closure technique (81% first cycle, 95% second cycle). Notably problems/complications (17% first cycle, 41% second cycle) also improved.

Conclusions

Initially, the guideline was met to a reasonable standard, however, improvements were made following the intervention. This led to an improvement in the documentation of nine subsections of this guideline.
EP-589 Acute Surgical Referrals from Emergency Department - A Retrospective Audit
Authors: Nordin Mohamad Nazmi M , Sutton Lynne
Published: November 2022

Aim

Emergency Department (ED) is a major source of admission for patients presenting with acute surgical issues. The Royal College of Surgeons of England recommends that a patient requiring an emergency surgical assessment, will receive an appropriate assessment within 30 minutes of referral being made in the case of life- or limb- threatening emergencies, and within 60 minutes for a routine emergency referral. However, there is a huge challenge to achieve this, given the limited time, capacity and resources, in ED and inpatient services. We aim to evaluate abdominal pain referral to general surgery from ED, with an emphasis on the initial diagnosis, admission rate, time from referral to assessment and operative management.

Methods

All patients with abdominal pain who were referred to general surgeons, were retrieved from a local electronic database. Primary outcomes include the diagnosis for abdominal pain, admission rate, time from referral to surgical review and operative management.

Results

81 patients with abdominal pain were referred to general surgeons within a period of seven days. 56 patients (69.1%) had a surgical diagnosis, and 25 patients (30.9%) had a non-surgical diagnosis. 63 patients (77.8%) were admitted as inpatients and 16 patients (19.8%) were discharged. The time from referral to surgical review ranged between 5 minutes to 476 minutes (mean = 103 minutes). 16 patients (19.8%) had surgical intervention.

Conclusion

The mean time from referral to surgical assessment is 103 minutes, which is longer than the standard recommendation from RCS England. Measures should be taken to expedite surgical assessment following referral from ED.
EP-630 Pheochromocytoma Associated with SDHB Mutation: A case report
Authors: Rezkallah Emad , Elsaify Wael
Published: November 2022

Introduction

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors arising from the chromaffin cells of the adrenal medulla or extra-adrenal tissues. 10% to 20% of tumors are detected before age 18 years. Approximately 10%–15% of pheochromocytoma and 20%–50% of paraganglioma are malignant. Up to 24% of the cases are familial where they may be associated with genetic syndromes like MEN 2, succinate dehydrogenase subunit B (SDHB) gene mutations and VHL syndrome. Germline mutations in SDHB gene increase the risk of PGLs/ PHEOs and RCC with 38%-83% risk of malignancy.

We represent a rare case of pheochromocytoma associated with SDHB mutation in a child.

Case presentation

A 17-year old patient presented with repeated vomiting and hypertension. BMI was 14.4 kg/m2, BP was 140/112 mmgh, PR was127 peats/min. The rest of the clinical examination was unremarkable. Plasma and 24-hour urinary metanephrines levels were highly elevated together with Chromogranin A level. Abdominal CT and MRI scans revealed an enlarged right adrenal gland measuring approximately 45 mm, indenting but not invading the posterior aspect of the IVC.

Management

Treatment was initiated with α-blockers; (Doxazosin then phenoxybenzamine); followed by β-blockers. The patient underwent laparoscopic right adrenalectomy. The tumor was 50×30×30 mm and weighting 58g. The tumor was positive with chromogranin, and S100. The PASS score was 2. Genetic mutation was detected at SDGB (c.72+1G>A).

Conclusion

We recommend genetic testing for all suspecting cases of PHEO/PGLs to establish the appropriate follow-up plan.
Sustainability Prize 1 Green Endoscopy to reduce CO2e generated by endoscopic waste – the GECO2e interventional study
Authors: Cunha Neves João A , Roseira Joana , Queirós Patrícia , de Sousa Helena Tavares , Pellino Gianluca , Cunha Miguel
Published: November 2022

Aims

Endoscopy is healthcare's third-largest waste-generating procedure. This study aimed to measure a single unit's waste carbon footprint and to perform a pioneer evaluation applying the principles of green endoscopy towards a more sustainable unit.

Methods

This was a 3-stage, prospective study. Stage 1: 4-week observational audit, during which daily endoscopic waste (landfill, biohazard) was weighed. Stage 2: 1-week intervention with presentation of retrieved data and education of the team towards waste handling. Recycling bins were placed in endoscopy rooms, and landfill and biohazard bins were relocated. Stage 3: 4-week post-interventional period, during which daily endoscopic waste was weighed. An engineer-calibrated scale was used. Equivalence of 1kg of landfill waste to 1kg carbon dioxide equivalent (CO2e) and 1kg of biohazard waste to 3kgCO2e was applied. Paired samples T-tests were used for comparisons before and after the intervention. The opinion of the staff was collected.

Results

Total waste and biohazard waste were diminished by 12.2% (p=0.166) and 41.4% (p=0.010), respectively, whereas landfill waste (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). In terms of CO2e, a total decrease of 31.6% (138.8kgCO2e) was found (mean kgCO2e 109.7 vs 74.9, pre- vs post-intervention, p=0.018). Mean endoscopy load was similar (46.2 vs 44.5, p=0.275). The endoscopy unit may achieve an estimated annual reduction of 1665.6kgCO2e. The personnel agreed “the project did not disturb daily work”.

Conclusions

In this interventional study applying green endoscopy principles to a real-world scenario, biohazard waste reduction and daily recycling were achieved, without compromising endoscopy productivity.
SP1.2.9 Stylish surgical writing: the state of the art surveyed
Authors: Mellor Katie , Luton Oliver , Ling Jerome , Fabre Ismay , Powell Arfon , Lewis Wyn
Published: November 2022

Introduction

Glaring gaps exist between what most readers consider proficient writing and what academics typically publish. This study aimed to assess the writing styles of the 13 journals held in the highest esteem by 11 surgical specialties.

Methods

The first 1,000 words of the initial 10 articles published in January 2018 from the 11 journals affiliated with surgical specialty associations were assessed as well as the BMJ and Lancet. The primary effect measures were Flesch-Kincaid Readability Ease (FRES, range zero (difficult) to 100 (easy)) and Flesch-Kincaid Grade Level (FGL, range -3.40 to infinity), related to journal Impact Factor and article citations.

Results

FRES median was 18.2 (1.4–38.2) and FGL 16.3 (12–26.2). FRES was directly related to the use of be verbs (p=0.004), but inversely proportional to numbers of common abstract nouns, words per sentence, characters per word, authors, references, level of evidence, and Journal Impact Factor (all p<0.04). Citations were inversely related to FRES (rho -0.292, p<0.001; critical value 14.5 (OR 0.20 p<0.001)) and directly proportional to FGL (rho 0.279, p=0.001; critical value of 15.5 (OR 5.04 p=0.05)). The journal with the highest FRES (most readable) was the British Journal of Oral & Maxillo-Facial Surgery (median 30.4; total citations 5).

Conclusion

Big differences in writing style and readability were plain with FRES varying 28- and FGL two-fold. No journals had a FGL of <12 (reading age of >17 yr.). Superior Journal prestige, Impact Factor, and citations were not associated with better Flesch-Kincaid reading ease.
SP2.2.1 Surgical Resection of metastases to the adrenal gland
Authors: Allan Jennifer , Anderson Hannah , Eatock Fiona
Published: November 2022

Aims

The adrenal gland is a common metastatic site for lung, breast, skin, renal, thyroid, and colorectal cancers. Our aim was to review resection of adrenal metastases and their primary pathology and the impact of adrenalectomy on the survival and disease free survival rate.

Methods

Retrospective review of adrenalectomy for adrenal metastases in a single regional centre between June 2010–2020.

Results

34 adrenalectomies in 33 patients were performed. Median age of patients was 70 (39–82). All adrenal lesions were diagnosed on staging or surveillance CT scan. Isolated adrenal metastases were seen in 26 patients.

The most common primary malignancy was renal cell carcinoma (RCC) (n=20), followed by non small cell lung cancer (NSCLC) (n=6), colorectal adenocarcinoma (n=2) and infiltrating ductal breast carcinoma (n=2). Other primaries include malignant melanoma, oesophageal adenocarcinoma, prostate adenocarcinoma and hepatocellular carcinoma (each n=1).

Adrenalectomy was carried out for diagnosis in 5 cases, 4 where no resection of the primary lesion was performed. Median time from resection of primary lesion was 4 years (1–16). 5 patients had synchronous adrenal metastases, 1 with synchronous resection of primary.

At the time of writing, there was a 38% mortality. 84% of deaths were due to disease progression. Median survival from adrenalectomy was 23 months (4–52 months). Of the surviving patients 76% are disease free and under oncological or clinical surveillance. 24% underwent further systemic or localised oncological therapy.

Conclusions

Survival rate following adrenalectomy for metastatic deposits is 62%. Better outcomes are observed in patients with RCC metastases.