bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.TU.182Surgical Serendipity: The Accident that Exposed an Autoimmune disease
Authors: Sultana Emiko
Published: October 2021

Objectives

IgG4 related disease is an autoimmune condition that often leads to diagnostic challenges which can often delay timely treatment. It rarely presents with pulmonary findings which can radiologically mimic cancer. We describe a unique case of an incidentally diagnosed IgG4- related lung disease (IgG4-RLD).

Case description

A 32-year-old healthy female suffered a car accident and had a CT Trauma. This revealed an indeterminate soft tissue lesion in the middle lobe of the right lung with an endobronchial component of uncertain histology which had central extension into the right inferior hilum. She had a bronchoscopic biopsy revealing that the mass was an Inflammatory Myofibroblastic Tumour (IMT). Due to the close relationship of this tumour with the root of her right lung, she was planned for a right pneumonectomy. However, it was agreed for that she underwent another bronchoscopy with biopsy to obtain more histology before proceeding with a pneumonectomy for the uncertainty about the diagnosis of an IMT and due to the absence of distinct clinical features from this mass. This revealed that the mass was highly suggestive of IgG4-RLD. Her blood tests revealed high serum IgG4 levels which confirmed the diagnosis of IgG4-RLD.

Conclusion

IgG4-RLD is a rare condition which can seldom be diagnosed incidentally. Patients with biopsies suggestive of IMT should undergo a repeat biopsy before proceeding to surgical resection of the tumour. Alternatively, a serum IgG4 level can also be deemed a useful tool for screening such patients.
EP.TU.200Improving variable rate insulin infusion compliance in general surgery
Authors: George Jayan , Jackson Samuel , Orsi Andrew , Ardley Rohan
Published: October 2021

Aims

1. Audit the current variable rate insulin infusion (VRII) practice per local guidelines.

2. Understand barriers to good VRII practice to create an intervention.

3. Re-Audit the VRII practice following intervention.

Methods

Junior doctors were surveyed using Likert scales (1 to 5: not at all confident to very confident) as well as closed and open questions. Chain action reaction (CAR) theory was used. Six domains were identified against a local proforma. Initial audit and questionnaire were collected from November 2019 to January 2020 and analysed using Microsoft Excel. Intervention consisted of a condensed one-page algorithm with group teaching. Re-audit data was collected between June 2020 to August 2020 for comparison.

Results

Questionnaire – 53.6% (15/28) of juniors responded. Challenges included conversion oral hypoglycaemics and complexity of the guidance. Group teaching and a condensed portable format were the most popular modalities for delivery of further education.

Initial Audit – 12 VRII charts were audited. 33.3% (4/12) were completed correctly. Areas of significant need for improvement were as follows: ensuring long-acting insulin is prescribed, transferring from a VRII back to oral medications and appropriate fluid prescribing.

Re-Audit – 18 charts were audited following intervention. Of these, 66.7% (12/18) were completed correctly. There was a significant improvement in appropriate fluid prescribing and long-acting insulin prescriptions.

Conclusions

Understanding the factors involved throughout the chain of how VRIIs are prescribed has helped to implement a positive intervention in our department. The improvement has been significant (100% better) however there is still further work required to improve compliance.
EP.TU.226Removal of a pepper shaker from the rectum using a Foleys catheter, a novel technique of balloon trawling
Authors: Mewse Jacob , Liyanage Aloka Suwanna Danwaththa , Smith Richard
Published: October 2021

Background

Foreign bodies inserted into the rectum often pose a challenge to the emergency surgical teams due to the unforthcoming nature surrounding the object inserted. Its shape, size and the position within the rectum and the associated bowel and sphincter injuries often determine the route of extraction and the need for further intervention. Trans-anal extraction risks anal sphincter injury, however, circumvents the need for a laparotomy and a potential stoma.

Case history

Here we describe a case of a ceramic pepper shaker inserted into the rectum of a 41-year-old male. Removal was undertaken under general anaesthesia and required evaluation of the matching salt shaker in theatres to creatively design a manoeuvre to extract the shaker via trans-anal route without risking it breaking inside the rectum.

Methods

A 20 French Foleys catheter was of an appropriate size to be able to thread through the opening at the bottom of the salt shaker. Under optical sigmoidoscopic guidance, the catheter was inserted into the rectum and passed through the hole in the bottom of the pepper shaker. The balloon of the Foleys catheter was then inflated with 30ml of saline and trawled out of the rectum intact.

Conclusion

Extraction of foreign bodies via trans-anal route in most instances avoids prolonged morbidity. Successful removal of these difficult foreign bodies with minimum morbidity often requires strategic planning and creative thinking.
EP.TU.269Management of preoperative anemia with Iron Therapy in colorectal cancer patients- a Systematic Review and Meta-Analysis
Authors: Narayanasamy Sangara Narayanan , Gumber Ashutosh , Kumar Gautham , Aspari Ajay Raghunath , Ramesh Vibha , Thomas Pradeep
Published: October 2021

Background

Nearly half of colorectal cancer (CRC) patients are diagnosed with anemia at the initial assessment (Ferlay et al., 2015). Anemic patients require blood transfusion, which increases cancer recurrence (Acheson et al., 2012). Hence iron therapy for anemia correction reduces postoperative morbidity and mortality.

Aims

To review randomized controlled trials on iron therapy for preoperative anemia in CRC patients.

Methodology

Includes formulating a review question, analyzing, quantifying the inclusion and exclusion criteria, literature search, quality assessment, data extraction and data synthesis, bias rectification, results interpretation and summarizing the evidence. Cochrane Handbook of Systematic Reviews and acronym PICO has been used for formulating review questions and study design (O’Connor et al., 2011).

Selection Criteria

Systematic reviews and RCTs with higher level of evidence were included in this review

Data Extraction

Quality assessment and data collection were done using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Analysis) checklist. Data extraction and analysis done by REVMAN Manager (Higgins et al., 2011).

Results

Two trials reported that iron therapy reduces the need for blood transfusion, but with insignificant result. All three studies showed that hemoglobin rise occurs with iron therapy postoperatively. None of the studies analyzed the quality of life.

Recommendations

RCTs with larger sample size to be done for more relevant and accurate reports, aiming at the primary and secondary outcomes like morbidity, mortality and quality of life. Oral iron with fewer side effects has to be experimented for best efficacy.
EP.TU.281Mind the Gap: Improving the Quality of Neurosurgical Discharge Summaries
Authors: Esemen Yagmur , Uberti Micaela , Singh Navneet , Karamitros Andreas
Published: October 2021

Aims

A discharge summary is a permanent record of a patient’s hospital visit and the primary means of handover between care providers. Studies show they often lack precision and omit important information. This may compromise quality and continuity of care yet they are frequently written by the most junior clinicians on a ward with little guidance or formal education on how to write one. The aim of this study was to develop some specific guidelines to improve the quality of discharge summaries in a busy neurosurgical unit.

Methods

A survey was designed to identify the challenges faced by junior medical staff in writing discharge summaries. The essential components of a good neurosurgical discharge summary were identified by group of senior neurosurgeons. Summaries were retrospectively audited against these components. We then designed a simple visual aid and placed it above computer stations in the junior doctors’ offices. Formal departmental teaching session followed. After three months we re-audited the discharge summaries retrospectively to measure any effect of our intervention.

Results

Half of the neurosurgical team rated summaries as below expectations. Challenges included poor ward round documentation and a lack of clear expectations regarding structure and essential components. After the intervention, ward round documentation and discharge summary quality improved dramatically.

Conclusions

Although various recommendations about writing good discharge summaries exist, they are generally vague and not specific to neurosurgical practice. The development of a simple specialty specific discharge summary guide can improve discharge summary quality and should be encouraged in all specialties.
EP.TU.304The Role of the Surgical Senior House Officer: A Quality Improvement Project
Authors: Boardman Charlotte , Klein Martin , Saunders Michael
Published: October 2021

Aim

The role of the surgical Senior House Officer (SHO) is very variable and evidence reports that many surgical SHO posts do not meet national quality standards. SHO is an active training role in which the doctor should be exposed to all aspects of General Surgery to prepare them to become a registrar. However, in a busy surgical department this can be difficult to achieve whilst ensuring that acute inpatient care is not compromised. A quality improvement project was undertaken to increase the quality and quantity of training opportunities available for the surgical SHOs in a district general hospital.

Methods

All of the SHOs in the general surgery department were asked to complete a survey about their experiences as an SHO. A timetable with personalised allocations to on-call cover, theatre sessions, clinics and ward work was introduced. After one month, further survey data was collected to re-assess.

Results

Prior to the implementation of the new timetable, the SHOs did not understand their role within the department and had minimal exposure to the elective aspects of General Surgery. One month after implementation, job satisfaction was greatly increased and attendance in clinics and theatres had doubled.

Conclusion

The implementation of this timetable resulted in a significant improvement in training for the surgical SHOs and clarification of their role within the department. By specifying activities within a formal rota, overcrowding of SHOs in theatre sessions and clinics was avoided and it ensured that all SHOs were provided with equal and adequate training opportunities.
EP.TU.310Dancing in the rain: early experience of Enhanced Stress Resilience Training
Authors: Luton Oliver , James Osian , Mellor Katie , Eley Catherine , Egan Richard , Lewis Wyn
Published: October 2021

Aim

Core Surgical Training (CST) programs are associated with a 60% risk of burnout and failure to progress. This study aimed to assess the influence of a novel Enhanced Stress and Resilience Training (ESRT) course delivered alongside a focused induction at the start of CST in a single UK Statutory Education Body.

Method

All CST1s were invited to participate in a six-week ESRT course teaching mindfulness-based exercises to develop tools to deal with stress at work and burnout. Primary outcome measures were compliance with ESRT programme and degree of burnout measured using Maslach Burnout Inventory (MBI) scoring.

Results

Of 43 boot camp attendees, 38 trainees completed questionnaires, with 24 choosing to participate (63.2%; male 13, female 11, median age 28 yr.) Burnout was identified in 23 trainees (60.5%) with no evident difference in baseline MBI scores between participants or not (p = 0.77, median 4 [0-11] vs. 4 [1-11]). MBI scores were comparable before and after ESRT in the intervention cohort (p = 0.63, median 4 [0-11] vs. 4 [1-10]). Qualitative data reflected challenges delivering ESRT because of arduous and inflexible clinical on-call rotas and time pressures related to academic curriculum demands. Despite these challenges, 22 (91.6%) considered the course valuable, 14 (58.3%) continued to use the techniques in daily clinical work there was and unanimous support to continue the program in future.

Conclusion

ESRT was feasible and further research is warranted to determine its medium-term efficacy.
EP.TU.435A Rare Case of Granulomatous Appendicitis
Authors: Alhabsha Osama , Kudchadkar Shantata J. , Sagar Jayesh
Published: October 2021

Granulomatous appendicitis is a rare form of appendicitis due to a variety of causes such a foreign body, fungi, parasites, mycobacteria, Yesinia, Crohn's pathology and delayed appendicectomy. Definitive diagnosis necessitates histopathological analysis.

We present an unusual case of granulomatous appendicitis in a young gentleman, incidentally detected at histopathology, along with a brief literature review.

Patient presented with a classical clinical history and examination findings suggestive of acute appendicitis and underwent an emergency laparoscopic appendicectomy, followed by an uneventful post-operative recovery. Histopathological examination showed features of acute on chronic transmural inflammation with epithelioid granuloma, confirming diagnosis of granulomatous appendicitis.

We hereby, aim to emphasize the significance of increased awareness required among general surgeons and pathologists, as patients with granulomatous appendicitis needs to be investigated further due to the likelihood of them having an underlying Crohn’s disease or developing it in future.
EP.TU.440Managements of blood thinning medications in elderly populations presenting with rectal bleeding: Are we doing it right?
Authors: Prasannakumar A Bavikatte , Uwaoma S , Zahid M , Herath D , Olugbemi M , Sebastian B
Published: October 2021

Purpose

Rectal bleeding is a common adverse effect of blood thinners in elderly patients resulting in admission. Our aim is to review the management of bold thinning medications in populations.

Methods

A retrospective analysis of patients admitted with per-rectal bleed from 2018 to December 2020 was performed. All patients above the age of 60 years on blood-thinning medications were analyzed in terms of management and discharge.

Results

A total of 93 (54.71%) patients out of 170 were included in the study. The median age was 83 years. The majority of them were on Direct Oral-Anticoagulants (DOAC) (35.4%), Clopidogrel (26.8%) and Aspirin (32.5%) with remaining on warfarin (14%) and dual anti-platelets (3.2%). On admission DOAC and warfarin was stopped in all the patients and antiplatelets was stopped in 76% of them. Identical percentage of patients in all the groups required blood transfusion. At discharge, DOAC was restarted in 33% of the patients with similar percentage discontinued. 6% were switched to alternative and the rest were due to outpatient review. Warfarin and antiplatelets was restarted in 61% and 62% of the patients respectively. Alternative medications were initiated on 7.6% of patients on warfarin and 5.4% on antiplatelets. Readmissions were mainly seen in patients on antiplatelets (10%). No patients in the study developed thrombotic complications.

Conclusion

Individual patient circumstances lead to variations in the management of blood thinning medications with per-rectal bleed. Larger trials are needed to ensure uniformity. Readmissions were mostly seen in patients on antiplatelets.
EP.TU.520ISC0Re Begins: An independent research group for junior doctors
Authors: Cheah Hock Ping , Wong Kenneth
Published: October 2021

Research is often a difficult component of training for many surgical trainees and junior medical officers (JMOs) wanting to apply for surgical training in Australia. In 2014, we established an independent research group called Institute of Surgical Collaboration for Research (ISCoRe) to develop a research culture amongst surgical trainees and junior medical officers (JMOs). The group was chaired by an unaccredited surgical registrar with a strong interest in surgical research and a general surgeon with a wealth of experience in presentations and publications in an advisory role.

Being a small independent research group allows us to work very closely with JMOs and surgical trainees to identify their career interests, coming up with research topics and ideas and guiding the research group members through the process of data collection, analysis, writing up abstracts and submitting abstracts to conferences.

We have had a good initial success with the research output from the group, with multiple research abstracts accepted and presented in various international conferences in our first two years of the formation of the group.

However, being an independent group does have its disadvantages. The biggest challenges we face involve manpower and financial support. We are hopeful that by training up JMOs who have been with us for one or two years, they will in turn be able to help us guide new group members.
EP.TU.575One Man's Meat: Nutritional guidance for ileostomy care should consider pre-existing comorbidities
Authors: Tan Yan Yu , Subramonia Sriram
Published: October 2021

Aims

(1) To assess the prevalence of comorbidities which can be influenced by dietary changes in a cohort of our patients with ileostomies and (2) To compare the standard dietary recommendations for these conditions against nutritional advice for patients with ileostomies.

Methods

We performed a cross-sectional study of patients with ileostomies identified from a prospectively maintained database in January 2020. Patient demographics, comorbidities and records of formal nutritional advice were analysed. Dietary recommendations for common chronic illnesses were obtained through a literature review.

Results

Twenty-one patients (15 men, 6 women) were included. Median (IQR) age was 63 (51-73) years. The median (IQR) length of time for which patients had ileostomies was 60 (24-144) months. The most common chronic illnesses include hypertension (38%), diabetes (24%) and chronic kidney disease (14%). All patients received standard dietary advice for ileostomy management without consideration of pre-existing comorbidities. Literature review revealed a lack of high-quality evidence for dietary recommendations in patients with ileostomies and conflicting advice for those with comorbidities.

Conclusion

Existing nutritional guidance for patients with ileostomies lacks a firm evidence base and does not consider the potential modifications required for pre-existing comorbidities.
EP.TU.673Optimising the referral process to the Surgical Emergency Clinic through mutual education of primary and secondary care teams: an audit cycle
Authors: Cheung Tiffany , Muneer Faiza , Freeborn Michael , Cross Katie
Published: October 2021

Aims

The Surgical Emergency Clinic (SEC) in our Hospital facilitates access to General Surgical consultant-led emergency assessment. Anecdotally, referrals are often (likely inadvertently) inappropriate and / or incomplete, which may delay assessment by the correct specialist.

We audited the quality of GP referrals to the SEC against four standards:

Methods

Retrospective analysis of 50 GP referrals to the SEC between November - December 2017, after recording data pertinent to the above standards in a spreadsheet. Results were presented at a local GP development day, a re-designed referral form incorporating GP feedback received was uploaded onto the Trust’s intranet and an email inbox created for e-referrals. 50 further referrals between September - November 2018 were analysed.

Results

Full completion of the referral form increased from 0% (initial audit) to 29% (re-audit), and appropriateness of referrals from 62% to 90%. The proportion of patients having had specified blood and urine tests in advance improved overall also.

Conclusions

Our experience demonstrates that primary and secondary care teams actively communicating and working closely together can improve the referral process for both parties, and most importantly enhance patient access to timely, appropriate specialist care.
EP.TU.701Colon Capsule Endoscopy versus Computed Tomographic Colonography for identifying Colorectal Cancer and Polyps: a systemic review and meta-analysis
Authors: Gumber Ashutosh , Kumar Gautam , Narayanasamy Sangara Narayanan , Ramesh Vibha , Aspari Ajay , Shalli Kawan
Published: October 2021

Aim

Early diagnosis and treatment of Colorectal Cancer can improve outcomes. Polypectomy with colonoscopy has failure and incompletion rates with risk of aerosol-generation. Computed Tomographic Colonography, second investigation, is limited by radiation exposure and aerosol generation. Colon Capsule endoscopy is a novel technique without gas insufflation, therefore avoiding the discomfort and aerosol-generation.

Our aim is to compare the yield of the CCE with CTC in CRC and polyps in patients with positive stool tests or diagnosed colorectal lesions.

Methods

Review followed PRISMA standards. Electronic database (EMBASE, MEDLINE, PubMed, CINAHL) searched for RCTs and Observational studies. MedCalc Statistical Software used for the synthesis of results. Primary (Per-Lesion and Per-Patient sensitivity analysis) and secondary (Other lesion and completion rate sensitivity analysis) outcomes measured using a random-effect model.

Results

We found one RCT and three observational studies. Per-Lesion Sensitivity Analysis of CCE versus CTC showed overall effect of 1.903 (0.990- 1.937), p-value-0.057. Per-Patient Sensitivity Analysis of showed overall effect of 1.928 (0.995-1.892), p-value-0.054. Other lesions Sensitivity Analysis showed overall effect of 0.810 (0.121-161.995), p-value-0.418. Completion Rate Sensitivity Analysis showed overall effect of -0.419 (0.526-1.516), p-value-0.676.

Conclusion

CCE had a better detection rate for colorectal cancer and polyp than the CTC, but this was not statistically significant. Therefore, this study failed to prove CCE's superiority over CTC. A careful decision can be made in current COVID-19 pandemic since its advantage of zero aerosolisation. Researchers should focus on innovation in techniques and simultaneous high-quality studies to evaluate them.
EP.TU.740Implementing a departmental handbook to improve induction for FY1s during COVID-19 pandemic
Authors: Annett Jessica , Neminathan Tabitha , Fisher Simon , PhD Barney Stephenson
Published: October 2021

Aims

The 2020 cohort of FY1s qualified during the COVID-19 pandemic; most prequalification placements were cancelled. Induction provides crucial information for new FY1s. We assessed the impact of redesigning the General Surgery induction handbook at Hereford County Hospital.

Methods

A 40-question survey, designed against standards in ’Recommendations for safe trainee changeover’ published by the Academy of Medical Royal Colleges, was sent to all FY1s commencing General Surgery in August 2020 two weeks following induction. The survey contained 5 sections: introduction; testing your knowledge parts A and B; team atmosphere; and demographics. Answer modalities included: binary answer; multiple choice; Net Promoter Scores (NPS); and free text. Submissions were made electronically via Microsoft Forms.

Feedback guided redesign of the induction handbook which was sent to FY1s rotating December 2020. Information included: how to contact seniors; requesting investigations; referring to specialties and expected duties. A repeat survey was sent to FY1s 4 weeks following induction.

Results

10/11 FY1s responded during the first rotation; 9/11 during the second. FY1s felt more confident requesting bloods (NPS +50 to + 90), requesting imaging (NPS –20 to + 70), completing discharge summaries (NPS +30 to + 80) and referring to specialties (NPS –40 to + 60). There was a better understanding of different shift types (NPS –40 to + 30). More FY1s correctly recalled on call bleeps for the medical registrar (from 56% to 75%) and the anaesthetic registrar (from 50% to 78%). Most (78%, NPS +78) felt they had enough support from other FY1s which remained the same (NPS +78) through the second rotation. As a result of the COVID-19 pandemic, prequalification experience varied greatly between individual FY1s.

Conclusion

Overall, FY1s were more confident requesting investigations, referring to other specialties and completing discharge summaries after redesign of the induction handbook. Considering disruptions in pre-qualification training as a result of the COVID-19 pandemic, a thorough departmental induction handbook can be an invaluable resource tool to aid rotation into a new specialty.
EP.TU.833The F2 Cohort of COVID19: The impact on Career development – a survey analysis
Authors: Whitton Charlotte
Published: October 2021

In March 2020 the coronavirus outbreak was announced as a global pandemic by WHO, in response to the pandemic the NHS underwent huge changes. This included recalling foundation doctors and cancelling the changeover into their final rotations. There have been studies into the impact of the pandemic on junior doctor training and wellbeing, however none looking specifically at their career development. An online survey was distributed to a cohort of Foundation Year 2 Doctors (F2s) in one NHS trust. This specifically asked about the impact of not rotating, specialty tasters, courses and the overall impact of the pandemic. The results of this study show that F2 doctors report weaker specialty applications alongside missed career development opportunities. However, the main influence of COVID-19 was reported to be on the cohort’s personal lives. This study concluded that the COVID-19 pandemic negatively affected both F2 doctor’s professional and personal lives, and it would be useful to follow up the cohort’s career development in the long-term as well as investigate the impacts in other NHS foundation trusts in the country.
EP.FRI.8 Hajibandeh index predicts nature of peritoneal contamination and risk of postoperative mortality in patients with acute abdominal pathology: A multicentre cohort study
Authors: Hajibandeh Shahab , Hajibandeh Shahin , Shah Jigar , Mansour Moustafa
Published: October 2021

Aims

To develop and validate intraperitoneal contamination index, Hajibandeh Index (HI), derived from combined levels of CRP, lactate, neutrophils, lymphocytes and albumin in predicting the nature of peritoneal contamination and risk of postoperative mortality in patients with acute abdominal pathology.

Methods

A multicentre cohort study was conducted to develop and validate an index to predict presence of purulent and feculent contamination and risk of postoperative mortality in patients with acute abdominal pathology. All adult patients with acute abdominal pathology requiring emergency laparotomy between 2014 and 2020 were included. The index was developed in a primary cohort and was validated in retrospective and prospective validation cohorts. ROC curve analysis was performed to determine discrimination of the index and cut-off values of HI that could predict nature of peritoneal contamination and postoperative mortality.

Results

737 patients were included (234 in primary cohort, 234 in retrospective validation cohort, and 269 in prospective validation cohort). The analyses identified HI of 24.76 as cut-off value for purulent contamination (AUC:0.78,P<0.0001;sensitivity:82.4%,specificity:60.9%); HI of 33.84 as cut-off value for feculent contamination (AUC:0.78, P<0.0001;sensitivity:82%,specificity:67.8%), and HI of 33.47 as cut-off value for postoperative mortality (AUC:0.70,P<0.0001;sensitivity:72.7%, specificity:58.47%). The results of the primary cohort and validation cohorts were comparable.

Conclusions

HI predicts presence of purulent and feculent contamination in patients with acute abdominal pathology and risk of postoperative mortality in patients undergoing emergency laparotomy. Future studies should investigate the effect of HI on accuracy of preoperative prognostic scoring tools and on patient selection for operative or non-operative management of underlying abdominal pathology.
EP.FRI.12Meta-analysis of demographic and prognostic significance of right-sided versus left-sided acute diverticulitis
Authors: Hajibandeh Shahab , Hajibandeh Shahin , Smart Neil J , Maw Andrew
Published: October 2021

Aims

To compare the demographic and prognostic outcomes of right-sided versus left-sided acute colonic diverticulitis

Methods

We performed a systematic review in accordance with the PRISMA statement standards to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis. We used the ROBINS-I tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data.

Results

Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients (MD:-14.16,P<0.00001) and more male patients (OR:1.33,P=0.02) compared with left-sided diverticulitis. Smoking (OR:2.23,P<0.0001), alcohol consumption (OR:1.85,P=0.002) and co-morbidity (OR:0.21,P<0.00001) were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group (OR:0.21,P=0.001). More patients in the right-sided diverticulitis group had modified Hinchey stage I disease (OR:10.21,P<0.0001) while more patients in the left-sided group had stage II (OR:0.19,P<0.00001), stage III (OR:0.08,P=0.009) or stage IV disease (OR:0.02,P<0.00001). Right-sided diverticulitis was associated with a lower risk of recurrence (OR:0.49,P=0.04), failure of conservative management (OR:0.14,P=0.0006), the need for emergency surgery (OR:0.13,<0.00001) and shorter length of hospital stay (MD:-1.70,P=0.02).

Conclusions

Right-sided acute colonic diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence, and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.
EP.FRI.57 Audit of Medical Records on Structure and Content of T&O Documentation
Authors: Yoganathan Sanjeevan , Raghavendra Ram , Joseph Ignatius , Sharma Ajay
Published: October 2021

The aim of the audit was to assess if Trauma & Orthopaedic admission documentation and record-keeping met the national standards. Standards used included the ‘Royal College of Physicians-Generic Record Keeping Standards 2, 4, 6, 10’ and ‘Professional Records Standards Body, Section 2 Admission Record’. Seventeen admission criteria and eight documentation criteria where audited from the respective standards.

Retrospective data were collected using A&E clerking documents, GP referral letters, admission clerking proformas and continuation notes from hospital admission.

Initial data showed that only 41% of pages of documentation had appropriate patient identification details listed. Of the 17 admission criteria audited, only 7 criteria scored above 90%. The major downfalls were in vital signs (38%) and assessment scales i.e. Abbreviated Mental Test Score (18%) and venous thromboembolism assessment (32%). With regards to subsequent separate entries, the main failure was entries not listed in chronological order (48%), with only two criteria scoring above 90% (entries dated and legibility). Following the implementation of an updated admission proforma and education on documentation; only 5 of the 17 admission criteria scored 90% or above. However, 46% of pages had the correct patient identification details on admission. On subsequent ward entries, 7 out of the 8 sections had improved, with 62% of notes in chronological order. Furthermore, 4 out of the 8 documentation criteria scored above 90%.

Informing staff on correct documentation helped improve doctors’ entries in patients’ notes. Improvements in the admission proforma need to be made to help meet record-keeping standards.
EP.FRI.75 Are 100% of VTE assessments being completed correctly and implemented as planned?
Authors: Elsllabi Mohamed
Published: October 2021

Aims

Methods

Results

Conclusion

Recommendations
EP.FRI.77 What proportion of pyelonephritis admissions under urology care have surgical pathology
Authors: Elsllabi Mohamed
Published: October 2021

Aims

Methods

Results

Conclusion
EP.FRI.147 Abdominal Variant Lemierre’s Syndrome: A Case Study and literature review
Authors: Rawes Catherine , Badas Vanessa , Aylward Kathryn , Whittle Annika , Brown Peter , Andreou Alexandros
Published: October 2021

Background

Lemierre’s Syndrome (LS) is a rare condition with a prevalence of around 0.6-2.3 cases per million of population. Typically, LS starts with a Fusobacterium Necophorum oropharyngeal infection which spreads rapidly causing infective thrombophlebitis, classically of the internal jugular. This is a life-threatening condition which left untreated has a mortality of 90%.

In less than 10% of LS cases thrombophlebitis occurs outside of the internal jugular vein. These atypical presentations can result in delay in diagnosis thus treatment and hence have an increased risk of mortality.

Case Report

Here we present a case report of a patient with Abdominal Variant Lemierre’s syndrome. A 47-year-old female with no past medical history was admitted to the emergency department with severe epigastric abdominal pain. The patient was stable, her National Early Warning Score (NEWS) was 2, blood tests on admission showed thrombocytopenia (Hb 121g/dl, Platelets 50x109/l, WCC 17.1x1012/l), raised CRP 299mg/l and deranged Liver Function Tests (Total protein 56g/l, Bilirubin 45mg/dl, ALT 94U/L, AlkPhos- 121U/L). A Venous Blood Gas was abnormal with Lactate 2.1mmol/l. A sepsis pathway was initiated. The blood cultures grew Fusobacterium Necophorum. MRI Imaging confirmed the diagnosis of Abdominal Variant Lemierre’s Syndrome. Haematology and Microbiology were consulted. The patient was treated with antibiotics and anticoagulation and was discharged 29 days later, she has made a full recovery.

Conclusion

This case highlights the importance of sepsis vigilance in Acute General Surgery admissions and emphasises that multidisciplinary teamwork is essential to achieve effective and prompt treatment for patients.
EP.FRI.175 Outcomes from the introduction of routine Geriatrician review for General Surgical patients over 65 years old undergoing Emergency Laparotomy at a large District General Hospital
Authors: Shamsiddinova Amira , Kiang Joanne , Jegard James , Bajracharya Abhijit , Himpson Rebecca , Bafadhel Leila
Published: October 2021

Aims

The National Emergency Laparotomy Audit (NELA) results show that only 28.8% of all patients over 65years having emergency laparotomy had Geriatrician input. Advancing age predisposes to more complex medical needs due to a higher prevalence of co-morbidities, polypharmacy, cognitive impairment, and physiological frailty. Introduction of perioperative geriatrician input has been demonstrated to significantly reduce post-operatively mortality (national average 9.5%, rising to 20-40% in older age). We introduced a Geriatrician led liaison team with the initial aim to reduce 30-day mortality in older patients undergoing emergency laparotomy.

Methods

Prospective database was maintained of all eligible patients reviewed by the new service. Data on Rockwood Clinical Frailty Score (CFS), NELA risk prediction score, length of stay, mortality and complications were analysed. In this service development pilot we specifically assessed age and frailty demographics, expected mortality, and actual mortality in the cohort.

Results

All NELA patients 65 and over were reviewed by the service between September and December 2020, 35 in total. Median age 77 years; Median CFS 3 (range 2-6); Median NELA mortality risk 12% (range 0.9%-55.8%). Inpatient mortality was 2.9% and 30-day mortality 2.9% during this study period, compared to 18% in the previous year. 

Conclusion

Our pilot study demonstrates that development of an embedded Geriatrician liaison service for patients undergoing emergency laparotomy is achievable in a district general hospital. Consistent with other larger scale studies we demonstrated significant mortality reduction in older adults undergoing emergency laparotomy with the new service offering enhanced inter-disciplinary Surgical, Critical Care and Geriatrician team-working.
EP.FRI.253 Outcomes of treatment of anal squamous cell carcinoma over a 10-year period
Authors: Ayantunde Abraham , Noureldin Khaled , Edison Daniel , Haq Hafizul , Praveen Bandipalyam
Published: October 2021

Background

We evaluated our 10-year experience with the treatment and outcomes of patients with anal squamous cell carcinoma (ASCC).

Patients and Method

Clinical and pathological data of patients with ASCC were analysed between January 2011 and December 2019. All patients underwent the standard workup according to the anal cancer network guidelines and treated accordingly. Patients were followed up clinically and with imaging according to the network protocol. The outcome measures were clinicopathological characteristics, treatment modalities, recurrent disease, disease-free and overall survival.

Results

117 patients were diagnosed with ASCC over the 10-year period. 14 patients with adenocarcinoma(11), melanoma(1), Paget disease(1) and carcinoid tumour(1) were excluded. Median age of 103 patients included was 68 (38-101) years with a Male to female ratio of 1:2. Four patients were HIV positive and 42.7% of the patients had AIN of varying degree of dysplasia. 66% (68/103) of the patients had radical chemoradiotherapy with curative intent while 9 patients with tumour ≤2cm underwent wide local excision. Six patients underwent palliative therapy and the remaining 20 were on supportive palliative care. 61.2% of the patients treated with radical chemoradiotherapy had complete response while 10.7% had partial response. Four patients with incomplete response underwent salvage APER. 13% (10/77) of the patients treated with curative intention developed recurrence. 

The overall mean survival time was 77.9 (95% CI 66.73-89.06) months with 5-year survival rate of 59%. The overall mortality rate was 42.7% and disease-specific mortality was 26.2%.

Conclusion

ASCC responds well to radical chemoradiotherapy with enhanced survival rate.
EP.FRI.265 Laparoscopic Right Hemicolectomy with Complete Mesocolic Excision for a T4 Caecal Tumour with Associated Phlegmon
Authors: Afzal Zeeshan , Stupalkowska Weronika , Davies Richard , Wheeler James , Saverio Salomone Di
Published: October 2021

A 67-years-old female presented with right lower abdominal pain and raised inflammatory markers. A computed tomography scan showed marked inflammatory changes with collections adjacent to terminal ileum. Patient was managed with intravenous antibiotics initially. Subsequent colonoscopy showed a bulky 8cm caecal pole tumour involving ileocaecal valve. Histopathology confirmed a diagnosis of moderately differentiated adenocarcinoma. Staging CT was negative for distant metastases. The patient subsequently proceeded to laparoscopic right hemicolectomy with complete mesocolic excision (CME). Intraoperatively the ileocolic vein was clipped just at the level of its confluence with superior mesenteric vein. The ileocolic artery was divided at its origin form superior mesenteric artery followed by division of right colic artery. The caecal mass was dissected off the abdominal wall. Proximally small bowel was resected 25cm form the ileocaecal valve and distally colon was divided up till mid transverse point. The specimen was extracted through a 9 cm Pfannenstiel incision. An intracorporeal isoperistaltic ileocolic side to side anastomosis was performed using a novel technique.1 The patient made full recovery and proceeded to adjuvant chemotherapy. Histology showed moderately differentiated T4 adenocarcinoma with tumour free lymph nodes. This case demonstrates intraoperative steps of laparoscopic complete mesocolic excision. CME is now becoming a standard due to improved oncological outcomes as it yields higher number of resected lymph nodes and better tumour clearance margins. This approach can be challenging due to variability in vascular anatomy, however, in experienced hands it is feasible and safe resulting in extensive lymphadenectomy and better oncological radicality. 1.https://www.ncbi.nlm.nih.gov/pubmed/28833963/
EP.FRI.271 The impact of Surgical Assessment Unit on emergency and ambulatory surgical care in a district general hospital
Authors: Liyanage Aloka Suwanna Danwaththa , Apter Philip , Causer Gemma , Gokul Krishnan , Ainsworth Paul
Published: October 2021

Aims

There has been a paradigm shift in the delivery of emergency and ambulatory surgical care necessitated by paucity of beds, improved expedited diagnostics and delayed transit in Emergency departments. The objective of a surgical assessment unit (SAU) is to reduce the number of semi-urgent admissions, provide direct access to urgent surgical admissions bypassing the ED, expeditious assessment by senior clinicians and to reduce the number of OPD follow up. In our setting, the SAU came into existence on all 5 working days at 12-hour daily schedule and its impact was evaluated retrospectively. 

Methods

Prospectively maintained data base over a 2-month period was examined. Pre and post SAU figures were compared to judge any quantitative improvement in surgical services. 

Results

During the audit period of 2 months there were 156 emergency patients and 190 ward attenders for follow up care. Majority of these patients were assessed within 4 hours and discharged or ambulated. Numbers being admitted overnight purely to facilitate investigations showed a decrease of 44.6% post SAU establishment. There was a reduction in post discharge outpatients appointments when compared to a similar time period pre SAU (14% difference).  

Conclusion

The SAU, although initially conceived and designed purely to cope with increased admissions and to minimise breaching of emergency department targets, has shown quantitative and qualitative improvement in emergency and ambulatory surgical care delivery.
EP.FRI.274 Nasogastric decompression in small bowel obstruction
Authors: Ayeni Adewale , Rajebhosale Ramprasad , Ravi Prabhu , Thomas Pradeep
Published: October 2021

Aim

The aim of this study is to review the surgeon’s compliance and efficacy of nasogastric decompression in management of small bowel obstruction.

Method

This is a retrospective 6 months study from 1st January 2020 to 30th June 2020.

Results

73 patients were managed for SBO during this period. Adhesions (43.8%) was identified as the most common cause of small bowel obstruction followed by hernias (27.4%). 

51 (70%) patients had nasogastric decompression planned on admission, although there was history of vomiting in 85% of patients at admission. Forty two patients (58%) had nasogastric decompression. Majority (71%) of these patients had NG inserted within 24 hours, only 2 of these patients had it inserted on admission.

Of the 44 patients managed conservatively for their SBO, 19 had NG decompression. Two patients died during admission (both managed with palliative intent). 

Conclusion

The routine use of nasogastric decompression in SBO is still common despite the lack of randomized control trial. Its use is associated with an increase in duration of hospital stay. Although the optimal timing of placement of NG tube is not known, our study shows that placement within 6 hours of admission may shorten the duration of hospital stay.
EP.FRI.337 Active management of the open abdomen in non-trauma catastrophes, including use of negative pressure wound therapy, is associated with high primary fascial closure rates
Authors: Nair Dheepa , Banks Jessica , Guy Richard
Published: October 2021

Aims

Deliberate use of the open abdomen (OA) following emergency laparotomy (EL) may be life-saving in the non-trauma abdominal catastrophe (NTAC) and damage control surgery (DCS) can reduce the risk of abdominal compartment syndrome in compromised patients. Controversy exists over optimum management of the abdominal wall. An audit was undertaken of negative pressure wound therapy (NPWT) in OA patients.

Methods

All patients who underwent OA management of NTAC from 1st Jan 2019 to 31st Dec 2020 were identified. Data on patient demographics, indication for OA and clinical outcomes were analysed.

Results

Eighteen patients (median age 65.5 years; M:F9 each) underwent OA  following EL. The indications were: bowel ischaemia (8), intra-abdominal sepsis (5), grossly distended bowel (3) and intra-abdominal haemorrhage (2). In all cases, ABTHERATM dressings (KCI/Acelity) were used. Mean ICU stay was 7.4 days (range 1-15) and mean hospital stay 33 days (range 2-61). Four patients died, 3 within 24 hours of initial EL. Relook laparotomy was performed within 48 hours in the remaining 15 patients; 3 patients required 2 relooks and 1 patient had three. Primary fascial closure (PFC) was achieved within five days in 13/14 (93%) survivors. Eight patients had SSIs with 2 intra-abdominal collections and all were treated conservatively. One patient developed an enterocutaneous fistula.

Conclusions

The use of commercially-available NPWT dressings in OA management is associated with high PFC rates within one week of initial EL. This practice is consistent with World Society of Emergency Surgery guidance recommending planned re-look laparotomy within 48 hours.
EP.FRI.368Impact of Covid 19 on Urgent Suspicion of GI Cancer Referral in a District General Hospital
Authors: Barman Sowrav , Ng Hwei Jene , Teo Serene , Blaney Eimear , Mansfield Olivia
Published: October 2021

Aim

Endoscopy services across United Kingdom were affected significantly since March 2020 due to Covid-19 pandemic. Services were reduced and were more selective. We aim to compare the impact on duration between referral to colonoscopy and the detection rate of pathology between February (pre- Covid) and August (Covid-impacted) 2020.   

Methods

Data was analysed from a prospectively maintained database of patients referred for colonoscopy to Royal Alexandra Hospital, Scotland. Patients underwent colonoscopy in month of February and August 2020 were included. Bowel screening patients were excluded. Positive findings included diverticulosis, colitis, polyp and adenocarcinoma. P value of < 0.05 was considered significant.

Results

Total number of patients included was 97 (55 in February, 42 in August). Median age was 61 and 69 years respectively. Mean duration from referral to colonoscopy were 4 weeks in February and 7 weeks in August. qFIT test were found raised in 50.9% in February and 57.1% in August with positive findings of 47.3% in February and 66.7% in August. 46.4% in February and 16.7% in August had raised qFIT but normal findings (p < 0.05). Two high grade dysplasia polyps and two adenocarcinomas were identified in February, none found in August.  

Conclusion

Covid-19 pandemic has disrupted the endoscopic services prolonging the duration from referral to colonoscopy. qFIT test is more heavily relied to prioritise urgent colonoscopies resulting in more positive findings on colonoscopy. Cancer detection rate has reduced which is a consistent finding as the UK national endoscopy study. Massive efforts are needed to restore endoscopy services.