bluuebunny/crossref_metadata_2025 huggingface dataset:
170 Primary Breast Lymphoma-Mimicking Inflammatory Breast Disease: A Case Report
Authors: Alam R , Basak B , Ahsan A , Gupta A S , Islam S , Akther S M Q
Published: May 2021

Primary breast lymphoma (PBL) is an unusual clinical entity accounting for 0.4–0.5% of all breast neoplasms. The usual presentation includes a painless palpable mass similar to that of breast carcinoma. Diffuse large B-cell lymphoma (DLBCL) is the most common identifiable type of PBL based on the histopathological examination.

We report an unusual case of 22 years old Bangladeshi woman presented with a 6-month history of a lump on left breast. Although the lump was initially small, it began a rapid growth after 4 months. The swelling was localized and did not show any skin involvement or discharge and as she didn’t have any positive familial history of breast carcinoma her primary attending physician diagnosed it as a case of breast abscess. When local incision and drainage proved ineffective, she was referred to us. After doing an immunohistochemistry from incisional biopsy the diagnosis was confirmed as Diffuse Large B-cell Lymphoma. The patient was treated initially by chemotherapy with CHOP therapy followed by wide local excision.

Early and accurate diagnosis of PBL is crucial for selecting the appropriate MDT treatment strategies to avert potentially harmful surgical interventions.
207 Laparoscopic versus Open Surgery for Locally Advanced Colon Cancer: A Retrospective Cohort Study
Authors: Tay P W L , Xiao J L , Lim W H , Wong N W , Chong C S
Published: May 2021

Introduction

While an increasing number of studies substantiate the non-inferiority of laparoscopy to open surgery for pT4 colon cancer, studies investigating its value specific to the subgroup pT4a in right hemicolectomies remain scarce.

Method

We performed a retrospective cohort analysis in National University Hospital of Singapore of patients who underwent a right hemicolectomy for pT4 colon cancer. Statistical analysis was performed using Wilcoxon rank sum test and chi square/fisher exact.

Results

In total, 65 patients had T4 colon cancer. 55 underwent right hemicolectomy and 10 underwent extended right hemicolectomy. Baseline demographics were similar in laparoscopic (n = 27) and open (n = 38) groups, with no significant difference in proportion of pT4a patients (p = 0.724). For pT4, 30-day mortality (7%, 5% respectively, p = 0.723), overall survival (p = 0.1903) and disease-free survival (p = 0.3476) did not differ significantly between laparoscopic and open groups. R0 resection rates were significantly higher in laparoscopic group (p = 0.039). pT4a subgroup analysis found similar observations. Other complications including postoperative wound infection and anastomotic bleed were not significantly different for both T4 and T4a analysis.

Conclusions

This study presented comparable safety and oncological outcomes between the two surgical methods for right hemicolectomy, suggesting laparoscopy to be a viable alternative approach for locally advanced right colon cancer.
226 Management of Liver Trauma: Outcomes at One of Europe's Most Active HPB and Liver Transplant Centres
Authors: Edwards M , Laing R
Published: May 2021

Introduction

The management of liver trauma (LT) has gradually moved away from surgery and more towards conservative or interventional radiological management. Positive outcomes depend upon careful selection for non-operative management, and to avoid surgical intervention in all grade I-III injuries unless haemodynamically unstable following resuscitation. This study investigated the management of all LT patients over a 12-month period at our institution.

Method

We undertook a retrospective study of all patients admitted with LT in 2019 (n = 60). We assessed records to determine the grade of LT (I-VI), concurrent injuries, their management, length of stay and outcomes.

Results

Of the 60 patients admitted with LT, 43 were male (72%) and 41 patients (68%) sustained injuries to multiple organs. 53/60 patients (88%) sustained injuries classified as grade 3 or below. In patients with multiple organ injuries, 7/41 (17%) underwent intervention compared to 7/12 (58%) in those with isolated LT. No deaths were recorded in patients with LT, and 6 people died in the multiple injury group (mortality 10%). Any form of intervention was associated with a doubling in average length of stay.

Conclusions

Non-operative management underpins most isolated LT care; if this fails or is associated with multiple organ traumas, morbidity and mortality rise dramatically.
846 Are Patients with Higher BMIs Requiring A Prolonged Inpatient Stay After Elective Arthroplastic Hip and Knee Operations?
Authors: Okoye E , Asumu T
Published: May 2021

Introduction

Obesity affects an increasing proportion of orthopaedic patients. Arthroplasties on this sub-population are associated with increased complications(anatomical issues to peri-operative complications/infection).

It is postulated patients with increased BMI have longer inpatient stay. Is this the case in our elective orthopaedic department at Fairfield General Hospital? Is there a basis to implement a BMI cut-off for arthroplasties?

Method

A single centre case-control study in our elective unit including patients who had primary total hip and knee arthroplasties (unicompartmental knee arthroplasties were excluded). Patients were analysed over a 3-month period(January 2019 – March 2019) collating data including their BMI, date of procedure, and discharge date.

Results

227 patients included with BMI ranging from 14.4 to 57.6

Inpatient days for the separate BMI classes :

Pearson’s correlation coefficient R = 0.134 - a weakly positive correlation between BMI and inpatient stay.

Conclusions

Interestingly, these results suggest there is no basis to implement a cut-off value for BMI.

Further research would be useful, detailing the pre-operative, intra-operative and post-operative issues those with an increased BMI may face.

Further research would be useful, detailing the pre-operative, intra-operative and post-operative issues those with an increased BMI may face.
308 A Qualitative Study Evaluating the Uses, Benefits and Barriers of Tele-Consultations in The Pre-Operative Pathway for Elective Orthopaedic Surgery at A Major London Teaching Hospital
Authors: Haq I , Abbass R , Sharif F , Asinger S , Ahmed H , Tonner E
Published: May 2021

Introduction

Digital healthcare technology is becoming a prodigious tool in healthcare management, supporting efforts for effective demand management and personalised, user-centred care. One example is tele-consultations, clinical consultations conducted remotely using technology such as telephones or videos. However, there is slow adoption of such technology and lack of literature supporting its use, particularly within the pre-operative surgical pathway, where communication, patient education and planning is vital to post-surgical outcomes. This study aimed to evaluate the uses, benefits and barriers of tele-consultations in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders.

Method

16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway before conducting a thematic analysis.

Ethical approval was received from Imperial College Research Ethics Committee on 05/02/2019.

Results

HCPs suggested use-cases for tele-consultation use in pre-assessment consultations with lower risk patients, information delivery, physiotherapy, and occupational therapy pre-assessment. Benefits cited were reduced overall costs and time, increased workflow efficiency with barriers noted as accessibility challenges, lack of holistic examination of patient and digital illiteracy.

Conclusions

Future studies should be conducted in other NHS trusts to identify greater uses within the entire surgical pathway.
430 A Review of Artificial Intelligence Solutions for Hepatocellular Carcinoma
Authors: Kawka M , Dawidziuk A M , Jiao L R , Gall T M H
Published: May 2021

Introduction

Hepatocellular carcinoma (HCC) is a significant cause of morbidity and mortality worldwide. Despite significant advancements, the diagnosis and management of HCC remain a challenge. This review aims at exploring artificial intelligence (AI) solutions applied to HCC.

Method

A review of the literature from Embase, MEDLINE and Cochrane Library was conducted to determine the role of AI in HCC, across three domains: detection, characterisation, and prediction. 56 relevant original research studies were identified and included in a qualitative synthesis.

Results

AI models can be implemented into detection of HCC, as they excel at analysis and integration of large datasets. Moreover, AI outclasses traditional statistical models at tumour characterisation based on radiological and pathological images. Predicting treatment outcomes and survival using AI can shape future HCC guidelines and support clinical decision making, especially treatment choice. AI in HCC has limitations, hindering its clinical adoption. Small sample size, single-centre data, non-transparent reporting, lack of external validation, and overfitting all results in low generalisability of findings.

Conclusions

AI has immense potential; however, interdisciplinary collaboration is needed to improve, validate, and implement it across all aspects of HCC. AI has a multifaceted role in HCC and its importance can increase in the future, as more sophisticated technologies emerge.
612 Uterus Transplantation: An Overview
Authors: Yao S L , Hammond-Browning N
Published: May 2021

Introduction

Uterine transplantation (UTx) allows women with abnormal uterine factor infertility (AUFI) to have their own biological children. UTx use both living and deceased donations (LD and DD), and once transplanted, embryos fertilised through IVF are implanted. The aims of this review are to summarise the history of UTx and discuss the ethical issues surrounding immunosuppression and living donations for a ‘life enhancing’ transplant.

Method

Data on UTx, clinical trials and resulting births was found by conducting a literature search on PubMed and other medical databases. Additionally, newspaper articles, institutional press releases and conference proceedings were used as some of the data is yet to be published.

Results

72 UTx have been performed which have resulted in 29 live births. The first LD UTx was performed in 2000 but was removed due to graft thrombosis. The first live births from LD and DD UTx were achieved in 2014 and 2017 respectively.

Conclusions

Live births provide proofs of concept of UTx. Graft rejection, vessel thrombosis and infection are amongst reasons for graft failure. Development of an international registry for UTx is important to monitor the progress of all transplants in the long term to determine its medical and ethical feasibility as a treatment for AUFI.
878 Comparing Treatment Outcomes for Unruptured Brain Arteriovenous Malformations: A Retrospective Cohort Study
Authors: Taweel B , Gillespie C , Ali T , Islim A , Hannan C , Chavredakis E
Published: May 2021

Background

Unruptured brain arteriovenous malformations (bAVMs) carry a lifetime risk of haemorrhage. Treatment strategies include conservative management, microsurgical excision, endovascular treatment (EVT) and radiosurgery (SRS). Optimal treatment selection remains unclear.

Method

A single-centre retrospective cohort study of adult unruptured bAVMs (2007-2019). Patients who underwent intervention were propensity matched using baseline features (age, sex, size, deep drainage, eloquence, and Spetzler-Martin grade) with patients conservatively managed. Rates of neurological disability and mortality due to intervention or bleed were compared.

Results

137 patients (mean age 48 years [SD = 16], males 64) were included; 34 (25%) EVT, 20 (15%) surgery, 31 (22%) SRS and 51 (37%) conservative. After a median follow-up of 49 months (IQR 23-75), rates of disability were as follows: surgery 35%, EVT 21%, SRS 13% and conservative 8%. Matched cohorts (intervention/conservative) were: surgery-19/18, SRS-30/22 and EVT-33/34. Comparison of disability rates across matched cohorts revealed no statistically significant differences (surgery p = 0.07, SRS p = 0.65 and EVT p = 0.11). Three conservatively managed patients died.

Conclusions

Unruptured bAVMs carry a significant risk of neurological morbidity, regardless of intervention choice. Treatment choice may have an impact on patient outcomes but requires investigation of stratified cohorts. Findings are consistent with the nuances of AVM treatment selection.
31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)
Authors: Nathan A , Shukla S , Sinha A , Sivathasan S , Rashid A , Rassam J , Smart S , Patel K , Shah N , Lamb B
Published: May 2021

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.
57 The Use of a Hemi Glabella Flap for Reconstruction of Medial Canthus Defects
Authors: Tan P , Agilinko J , Khalil A
Published: May 2021

Background

Medial canthal reconstruction is a challenging task due to the complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum and horizontal scarring which is aesthetically displeasing. The senior author in this paper has developed an intuitive modification to the technique.

Method

A rotational advancement flap involving the upper lateral nasal wall with the hemi glabella was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients.

Results

Reconstruction using the Hemi-Glabellar technique was performed on 12 patients following resection of BCC in or near the medial canthus area. Superficial cellulitis was noted in 2 patients, they were managed oral antibiotics. There was bruising in 7 patient which resolve spontaneously in 4-7 days. All patients had a good outcome at 2 months and 6 months follow up. There was no flap loss and all patients were satisfied with the aesthetic outcome.

Conclusions

The technique highlighted can be performed easily and is applicable to reconstruction to defects of the medial canthus with excellent aesthetic outcomes with an inconspicuous scar and supple skin with matching colour
59 Should The ‘Normal’ And ‘Ideal’ Nipple Position in A Male Influence the Surgeon When Planning Severe Gynaecomastia Correction?
Authors: Tan P , Dhaliwal K , Khanna A
Published: May 2021

Background

The ideal nipple position of the male chest following gynecomastia surgery is well documented however with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we feel these measurements need to be applied to the patients build and take into consideration the patient's future fitness goals.

Method

We have analysed photographs of 3 groups of men: super- athletes, athletes and severe gynaecomastia. We assessed the proportions of the chest in relation to the NAC and the degree of ptosis.

Results

There is wide variation in the position of the nipple to the chest wall between each group with minor variation within each group. Based on this research we believe that surgeons should be circumspect when considering breast reduction with a Wise pattern in patients with severe gynaecomastia.

In patient with increased development of the pectoralis major muscles, the NAC placement can change, leading to medial displacement of the nipple and ptosis and poor aesthetic result.

Conclusions

We suggest a two-stage procedure, carried out on two separate occasions wound be more ideal than a single stage as this allows better long-term better positioning of the nipple.
62 Is Weight Loss Alone an Appropriate Indication for Urgent Gastroscopy?
Authors: Pickard C , Komolafe S
Published: May 2021

Aim

To assess if patients with weight loss alone have significant pathology identified at gastroscopy.

Method

94 consecutive Urgent Suspicion of Cancer (USOC) referrals undergoing gastroscopy were studied over a 6-month period. General, and specific upper GI symptoms, as well as endoscopic findings, were recorded.

Results

68% of patients were female. 98% of referrals mentioned weight loss, 94.5% of these patients had concurrent symptoms. 77.5% of patients had a positive finding. 5% (n = 5) had a diagnosis of malignancy. Of the 5 diagnosed with malignancy, none had presented with symptoms of weight loss alone.

Conclusions

Our practice is in accordance with NICE guidelines. Despite perception, OGD for weight loss alone does not occur commonly. In the current COVID-19 pandemic, it is even more important to vet patients appropriately to prevent unnecessary aerosol generating procedures. We cannot extrapolate from this pilot study whether weight loss alone, is a good indicator for detecting upper GI malignancies, though all cases of malignancy had other specific alarm symptoms.
63 Chronic Femoral Osteomyelitis Case Series: Outcomes and Economic Impact at A United Kingdom Based Tertiary Centre
Authors: Lau E , Arshad Z , Aslam A , Thahir A , Krkovic M
Published: May 2021

Introduction

Osteomyelitis refers to an inflammatory process affecting bone and bone marrow. This study reviews chronic femoral osteomyelitis treatment and outcomes, including economic impact.

Method

We retrospectively collected data from a consecutive series of 14 chronic femoral osteomyelitis patients treated between January 2013 and January 2020. Data collected include patient demographics, comorbidities, pathogens, complications, treatment protocol and costs. Functional outcome was assessed using EuroQOL five-dimensional interview administration questionnaire (EQ-5D-5L™) and EuroQOL Visual Analogue Scale (EQ-VAS™).

Results

Of these, 92.9% had one or more osteomyelitis risk factor, including smoking and diabetes. Samples from 78.6% grew at least one pathogen. Only 42.9% achieved remission after initial treatment, but 85.7% were in remission at final follow-up, with no signs of recurrence throughout the follow-up period (mean: 21.4 months). The average treatment cost was £39,249.50 with a net mean loss of £19,080.10 when funding was considered. The mean-derived EQ-5D score was 0.360 and the mean EQ-VAS score was 61.7, lower than their values for United Kingdom’s general population, p = 0.0018 and p = 0.013 respectively.

Conclusions

Chronic femoral osteomyelitis treatment is difficult, resulting in significant economic burden. With previous studies showing cheaper osteomyelitis treatment at specialist centres, our net financial loss incurred suggests the need for management at specialised centres.
79 The Effect of The C3 And C3ar On Adult Hippocampal Neurogenesis
Authors: Marei O , Westacott L
Published: May 2021

Introduction

Adult hippocampal neurogenesis (AHN) is the process whereby new neurons are added to the dentate gyrus to support cognition. This process is disrupted in neurological disorders such as mesial temporal lobe epilepsy and there is significant involvement of the complement system. Research suggests that C3/C3aR affects AHN, although the manner remains unclear.

Method

15 2-months-old male mice (WT, C3-/-, C3aR-/-) were used. They were injected with an intraperitoneal injection of BrdU (100mg/kg), culled 8 hours later, and perfused with paraformaldehyde. Brains were sectioned using a microtome at 40um and stained for BrdU/Ki67. Fluorescent microscopy was used to view and count the number of cells that contained BrdU and/or Ki67, from 5 sections per animal.

Results

Significant increase in markers of proliferation (BrdU/Ki67) in the dentate gyrus of C3aR mice only. Differences were observed in both blades of the dentate gyrus, although BrdU+ cells were significantly increased in the dorsal blade of the dentate only.

Conclusions

Data suggest that C3aR may influence proliferation in a C3a-independent manner since effects were not seen in C3-/- mice. The increase in cells, in the absence of the receptor, suggests the anti-proliferative effects of the receptor. Results show the potential to identify therapeutic targets to be used clinically.
80 Defunctioning Stomas the Answer to Avoid Anastomotic Leaks – Mere Precaution or A Necessity?
Authors: Jayawardena P , Peris R , Hany T
Published: May 2021

Introduction

Anastomotic leaks account for one of the major complications following Colorectal Surgery. One of the surgical procedures to help avoid this complication include providing a defunctioning stoma. Evidence surrounding the provision of a defunctioning stoma has been supported extensively in the field of Colorectal Surgery.

Method

A retrospective study was performed using a cohort of patients from a single teaching hospital between 2014 and 2019. 559 who had undergone elective bowel resection with primary anastomosis were identified and followed up. Data was captured using the hospital’s electronic medical records; Quadramed and Evolve.

Results

From the 559 patients 167 received a defunctioning stoma, out of which 114 were successfully reversed. 2 patients out of the 114 were deceased at 6 months following the reversal (p = 0.332). Furthermore, 15 patients of the 167 went on to develop complications at the anastomotic site (chi-square 25.37, p = <0.00001). 8 patients had anastomotic leaks and 9 patients developed strictures of which 2 patients developed both strictures and leaks.

Conclusions

Although written literature points in favour of providing a defunctioning stoma; it is important to consider such a decision in a case-by-case manner, due to the complications involved instead of routinely providing a stoma as a prophylactic measure.
96 Mixed Adenoneuroendocrine Carcinoma in Crohn's Disease: A Case Report and Literature Review
Authors: Cuthbert M , Cuthbert R , Karamsadkar S , Minicozzi A , Chan C
Published: May 2021

Introduction

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare neoplasm with dual adenocarcinomatous and neuroendocrine differentiation. Subgroup analysis demonstrates an increased frequency of both adenocarcinomas and neuroendocrine tumours in patients with Crohn’s disease (CD), though the incidence of MANEC is unknown.

Method

A 58-year-old male with a 31-year history of CD presented with small bowel obstruction. After failed conservative management, the patient underwent right hemicolectomy, with subsequent histology demonstrating MANEC.

A literature search was performed to identify further cases of patients with concomitant MANEC and CD.

Results

11 cases were identified. The mean duration of CD before presentation was 19.5 years, and 58% of cases involved the terminal ileum. 60% of cases demonstrated nodal spread and metastatic disease was evident in 25%. 42% of patients with MANEC were initially treated for an exacerbation of CD.

Conclusions

MANEC is a rare tumour of uncertain aetiology. The terminal ileum is commonly affected, with most cases exhibiting a longstanding CD history. Diagnosis is challenging, with symptoms of MANEC mirroring exacerbations of CD. Future research should strive to identify imaging modalities or biochemical markers which aid in distinguishing the two pathologies, preventing futile medical management of MANEC, and reducing the risk of metastatic spread due to delayed diagnosis.
126 White-Eyed Blowout Fracture in The Paediatric Patient Thought to Be A Head Injury – A Missed Diagnosis
Authors: Dattani A , Chauhan A , Dave R , Messahel A
Published: May 2021

White eyed blowout fracture or ‘trapdoor fracture’ is an orbital floor injury caused by blunt force trauma directly to the orbit causing ocular muscle entrapment between fractured bones of the floor of the orbit. It is most commonly encountered in the paediatric patient population and presents acutely with little to no periorbital signs of injury. This serious diagnosis is frequently missed at initial presentation due to a lack of obvious soft tissue pathology, termed “White Eyed” blow out fracture. It is frequently misdiagnosed as a head injury due to presenting nausea and vomiting and failure to examine eye movements.

The authors present a case of a 15-year-old male who suffered blunt force trauma to the orbit and a white eyed blowout fracture ensued. This was not identified in the emergency department and the patient consequently suffered permanent motility deficit of the globe. We outline recommendations for emergency department practitioners to help identify such presentations and see their timely surgical management.
131 Concerns of The Unheard: A Qualitative Systematic Review on The Preoperative Concerns of General Surgery Patients
Authors: Cheng J Y J , Chin Y H , Wong B W Z , Ong Z H , Ng C H , Tham H Y , Samarasekera D D , Dev K M , Chon C S
Published: May 2021

Aim

Preoperative care is important for patients and healthcare professionals (HCPs), and greatly influences patients’ postoperative outcomes. This review aims to provide an in-depth understanding of the concerns general surgery patients have in the preoperative period and discover solutions to improve their care.

Method

CINAHL, Medline, PsycINFO, and Web of Science were searched, and articles related to patients’ preoperative concerns were included. Key quotes were extracted, coded, and thematically analyzed according to Thomas and Harden’s methodology.

Results

Three themes were generated from the 27 included articles; lead-up to surgery, the postoperative recovery process, and HCP care provision. Patients were uncertain and concerned about the impact the surgery or disease may have on them while they waited for their surgery to occur. Additionally, perceived inadequate provision of care by patients led to them doubting their HCPs’ ability, heightening their preoperative anxiety. Lastly, postoperative recovery processes were often unclear, leading to increased distress as patients wonder if they could recover from the disease and/or surgery.

Conclusions

Unresolved preoperative concerns increase patients’ anxiety and uncertainty, negatively affecting their postoperative recovery. A combination of individualized preoperative education and complementary therapy can be implemented by HCPs to alleviate these concerns, leading to better postoperative outcomes.
148 Acute Renal Infarcts from Spontaneous Intra-Renal Dissection
Authors: Daga K , Chua B , Taneja M
Published: May 2021

Spontaneous renal artery dissection and acute renal infarcts are rare occurrences and often misdiagnosed in clinical practice. We present four male patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension, or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were all treated with endovascular stenting. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram, a rare pathology which is reported in literature to mostly affect women. All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti-platelet therapy for two years and did not experience any post-procedural complications at their 24-month follow up. Classically visceral artery dissection can be managed by anti-platelet therapy alone, however fibromuscular dysplasia can cause spontaneous dissection with renal infarcts and this requires urgent treatment with endovascular stents. Further research is needed on the post-procedural medical management guidelines.
157 A Rare Case of Cutaneous-Urachovesicoenteric Fistula in a Patient with Crohn’s Disease
Authors: Ghanem Y K M , Clarke J , Jacob T , Ahmad N Z
Published: May 2021

Background

Entero-Uracho Vesicle fistulae are a rare sequelae of aggressive Crohn’s disease with only a small number of case reports being available in the literature. Such cases are most often managed via “SSNAP” principles with many Crohn’s fistulas requiring complex surgical intervention to definitively deal with the offending fistulous tracts. We present a case with an even rarer consequence of uncontrolled Crohn’s disease despite immunomodulatory therapy in a 34-year-old male who presented with a Entero-Uracho Vesicle fistula. We discuss the presenting symptoms and management protocol involved in this case.

Case:

A 34-year-old male with known Crohn’s disease presented with an entero-uracho vesicle fistula, which further developed into a cutenaous-urachovesicoenteric fistula while awaiting surgery during his index admission. The fistula tract was confirmed via Computed Tomography with evidence of significant inflammation. Bowel rest, antibiotics, and nutritional support with Total Parenteral Nutrition preceded total excision of the fistulous tract with ileo-caecal resection of the diseased bowel with primary anastomosis, and resection of the urachus and closure of the cutaneous fistula site with desirable outcome. Patient completed a full-recovery with return of normal bowel function and nutritional status, with no delayed complications at 6-month follow-up.
175 Open vs MIS Lumbar Surgery: A Systematic Review of Cost Effectiveness
Authors: Oduoza U , Eseonu K , Monem M , Tahir M
Published: May 2021

Introduction

Minimally invasive surgery has benefits over open surgery for lumbar decompression and/or fusion but there is no established consensus regarding its cost effectiveness.

Method

A systematic electronic search of databases (MEDLINE, EMBASE and Cochrane Library) and manual search from the Cost Effectiveness Analysis (CEA) database and NHS Economic Evaluation Database (NHS EED). Two authors reviewed abstracts against exclusion criteria. Studies including adult populations undergoing surgery for degenerative changes (lumbar stenosis, lumbar radiculopathy, spondylolisthesis) of the lumbar spine, reporting outcomes of costing analysis, CEA or Incremental cost effectiveness ratio (ICER) were included.

Results

Two of the 5 studies comparing open vs single level MIS fusion surgery (TLIF) reported a statistically significant reduction in direct cost for MIS compared to open surgery. The mean non-inflation adjusted cost was $31,626, and $34757 for the MIS and open TLIF groups respectively.

One paper comparing open versus MIS two level TLIF reported a statistically significant difference in costing but not in QALYs.

Conclusions

Generally, studies reported a reduced cost associated with MIS versus open surgery. One study reported a statistically significant change in QALY. The majority had a high risk of bias. This review was unable to recommend MIS over open surgery from a cost effectiveness perspective.
196 A Rare Case of Chemical Burn: Dithranol With Salicylic Acid
Authors: Raj D R S , Adjei B , Kamil M L , Al Nahhas O
Published: May 2021

A 16-year-old female with psoriasis was admitted to our Plastic Surgery department with a significant chemical burn to the neck, upper torso, and left cheek (TBSA 6%). She applied a concoction of cream prescribed by her dermatologist in her native country, Poland when she returned to the United Kingdom. A few hours after application she developed a burn with pH of 5.

A review of the cream revealed a mixture of 19% Dithranol and 5% Salicylic acid. This combination is recognized for managing psoriasis, however the strength of dithranol in the combination given is of a high concentration (normally <3%). This alone can cause a burn to the skin if left for a prolonged period of time.

Salicylic acid is an enhancer which augments the stability of dithranol and increases its penetration and efficacy. The concentration of 5% is also on the higher end.

Our patient was admitted for pain relief and further irrigation till normalization of the pH which was achieved after 3 days.

A worrying aspect in our patients’ case is that she was given the cream to commence at home. High concentration preparation is normally commenced in a controlled setting under medical supervision.
205 Internal Herniation of The Caecum and Ascending Colon Through the Foramen of Winslow: A Case Report
Authors: Lasheen O , Amin A
Published: May 2021

Introduction

An internal hernia occurs when part of the bowel protrudes through a mesenteric or a peritoneal orifice which could be either normally present or acquired. These hernias usually represent a challenge to diagnose. Of the natural anatomical orifices is the Foramen of Winslow through which the caecum and the ascending colon could herniate.

Case

Report

An 85-year-old gentleman presented with a one-day history of abdominal pain. His pain had a sudden onset, an intermittent course and was limited to the epigastric region. He was nauseated but not vomiting. He had opened his bowels a day before presenting to the hospital. CT scan of the revealed herniation of the caecal pole through the foramen of Winslow and into the lesser sac. The decision was made to perform a laparotomy where it was revealed that the caecum and part of the ascending colon had herniated through the foramen of Winslow. Content of the hernia, which was viable, was carefully reduced and right hemicolectomy was performed.

Conclusions

With the scarcity of similar cases, we currently have no consensus of management. Dealing with the hernia at laparotomy would be usually the choice of the surgeon depending on tissue viability and other operative findings.
231 Breast Lymphedema After Breast Conservative Surgery; An Up-To-Date Systematic Review
Authors: Abouelazayem M , Elkorety M , Monib S
Published: May 2021

Background

While arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema,

Aim:

We aimed to provide a systematic review to help avoiding or management of breast lymphoedema

Method

The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative and surgery to search Embase database. All papers published in English were included with no exclusion date limits

Results

A total of 2155 female patients were included in this review; age ranged from 26 to 90. Mean BMI was 28.4, most of the studies included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as body mass index (BMI), breast size, tumour size, tumour site, type of surgery and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including Manual lymphatic drainage (MLD), self-massaging, compression bras or Kinesio taping.

Conclusions

Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.
232 To Report A Rare Case of Fungal Necrotising Otitis Externa (NOE) Centred on The Left Temporomandibular Joint (TMJ)
Authors: Khan A , Omakobia E , Smith I , Hasnie S , Barton R , Oktseloglou V , Gopalan P
Published: May 2021

Introduction

NOE is a rare life-threatening complication of otitis externa, affecting the skull base, mastoid and temporal bones. Pseudomonas aeruginosa account for 95% of cases, making fungal NOE unusual. Complications secondary to NOE include cranial neuropathies, meningitis and dural sinus thrombophlebitis.

Case-study

A 67-year-old man with stage-5 chronic kidney disease presented with left otalgia and otorrhea. He was treated with antipseudomonal topical antibiotics and microsuction for months as an outpatient. Aspergillus flavus was grown on an initial swab, but subsequent cultures were negative. Computerised Tomography scans revealed inflammatory changes in the left masticator space with mastoid bone involvement suggestive of left NOE. He received three months of intravenous anti-pseudomonal antibiotics, microsuction and topical aminoglycosides. Despite interventions symptoms persisted and magnetic resonance imaging scanning revealed disease progression into the left TMJ, prompting maxillofacial surgical opinion. Following washout of the TMJ, a tissue biopsy was positive for DNA on pan-fungal PCR, and the sequence identified as Aspergillus flavus group. The patient was successfully treated with oral posoconazole and topical amphotericin and discharged home.

Conclusions

Fungal NOE remains poorly treated as there is limited guidance on antifungal choice and duration of treatment. It should always be considered, particularly in immunocompromised patients with intractable cases of NOE
241 Have We Learnt Any Lessons from the 2018 NASBO Report?
Authors: Osuji J , Majeed T , Sommereux L A , Aiynattu S
Published: May 2021

Introduction

Small Bowel Obstruction (SBO) is a common presentation requiring a multidisciplinary approach to its management. However, patient outcomes remain poor. Until the NASBO 2018 report1, there were no standard protocols. This study is an evaluation of our local service, assessing our compatibility to NASBO guidelines and identifying areas to improve patient outcomes.

Method

A retrospective cohort study was carried out on patients with SBO during 2018-19. In a busy emergency surgery unit in North West England, with the highest number of emergency laparotomies (NELA 2019)2. Clinical assessment, management, outcomes, and complications were compared to the national data reported in NASBO 2018.

Results

Of 200 patients (median age 73), 60% were treated conservatively and 40% surgically, of which <50% were initially treated conservatively. 59.5% had a nutritional assessment on admission, of which 33.5% were at nutritional risk and started on TPN. Complications during stay were within the target range (<5%). 16% were admitted in HDU. The 30-day mortality was 8%, with 3% requiring palliative care for malignancy and severe comorbidities.

Conclusions

When compared to the national average, our department had a similar performance in management. Use of laparoscopic approach, ERAS, nutritional assessment and elective HDU/ITU admissions were identified as areas for improvement.
243 Thromboprophylaxis In Elective Arthroplasty Patients: Assessing DVT Rates
Authors: Maki S , Baskaradas A , Smith J
Published: May 2021

Introduction

Deep vein thrombosis (DVT) in elective hip and knee arthroplasty range from 1-25%. The NICE Guidelines for Venous Thromboembolism (VTE) advise offering chemical prophylaxis with anti-embolism stockings (AES) as VTE prophylaxis. The aim of this study was to assess the role of anti-embolism stockings, by analysing the rates of DVT in patients who had chemical VTE prophylaxis in combination with anti-embolism stockings compared to patients who had chemical prophylaxis alone.

Method

Retrospective data analysis of patients who underwent elective primary hip or knee replacements from April 2018 to April 2019. Patient records were reviewed for each patient to identify any subsequent DVT diagnosis.

Results

759 patients were identified. 595 patients had combined chemical VTE prophylaxis and AES. 164 patients did not have AES. 12 patients who received the combined therapy presented to A+E with suspected DVT, which was confirmed in two patients. Of the patients who did not receive AES, there were no cases of DVT.

Conclusions

There was no increase in DVT rates in patients who were not offered anti-embolic stockings. Taking into account the risks associated with AES and the costs incurred, the routine prescription of stockings must be carefully reviewed by orthopaedic departments.
270 Spontaneous Trans-anal Evisceration of Small bowel: A Case Report
Authors: Lasheen O
Published: May 2021

Introduction

Trans-anal evisceration of small bowel is a very rare surgical presentation. The first case ever reported was in 1827. The exact mechanism of how this develops remains poorly understood. Majority of the cases recorded there was a perforation in the anterior wall of the rectum.

Case Report:

A 70-year-old female patient with a history of multiple strokes, presented with multiple small bowel loops eviscerated through the anus. The bowel was covered with warm saline soaked packs and the patient was transferred to theater. Abdominal exploration through was done. The bowel was carefully reduced. There was a longitudinal defect on the anterior wall of the rectum at the recto-sigmoid junction. There was also a large mesenteric defect and thrombosed mesenteric vessels compromising blood supply to part of the bowel, so resection of 50 cm of ileum, jejunostomy and a mucous fistula were performed.

Conclusions

Several pre-existing pathologies, like diverticular disease or rectal prolapse can result in thinning out of the wall of the rectum. That combined with increased intra-abdominal pressure can explain trans-anal evisceration of the bowel. This condition is typically managed by surgical intervention. The operation will depend on the extent of viability, contamination, and patient’s general condition.
271 Factors Affecting the Decision to Perform Same Admission Cholecystectomy Following Biliary Pancreatitis: A Comparative Study
Authors: Dick L , Young J
Published: May 2021

Introduction

Same admission cholecystectomy is recommended following biliary pancreatitis to prevent recurrent attacks. However, delaying surgery may be appropriate in certain cases. We aimed to compare patient and admission factors between those undergoing same admission and delayed cholecystectomy.

Method

Admissions with confirmed biliary pancreatitis over a 5-year period were included. Demographics, co-morbidities, need for intensive treatment unit (ITU) admission and endoscopic retrograde cholangiopancreatography (ERCP) were analysed to determine differences between those undergoing same admission and delayed cholecystectomy.

Results

55 and 46 patients underwent same admission and delayed cholecystectomy respectively. There was no difference in age (59 vs 59.2 years, p = 0.947), history of cardiovascular disease (38.2 vs 34.8%, p = 0.724), diabetes (7.3 vs 8.7%, p = 0.792) anticoagulation (7.3 vs 6.5%, p = 0.882) or previous abdominal surgery (0 vs 6.25%, p = 0.05) between groups. Only need for ITU admission (5.5 vs 21.7%, p = 0.01) and ERCP (9.1 vs 28.3%, p = 0.01) were found to be statistically different between groups.

Conclusions

Severity of pancreatitis, rather than patient factors, alone seems to influence the decision to perform same admission cholecystectomy in those with biliary pancreatitis. Further work is needed to understand surgeon factors in the decision-making process.
310 Management of Anterior Penetrating Abdominal Injuries and the Role of Computerised Tomography
Authors: Sanchez-Thompson N , Frith D
Published: May 2021

Introduction

Optimal management of anterior penetrating abdominal injuries (A-PAI) is an area of ongoing debate. Randomised controlled trials are missing and guidelines are based on expert opinion. The accuracy of computerised tomography (CT) is challenged, and hence diagnostic laparoscopies are still widely used.

Method

We retrospectively reviewed the TARN database identifying patients presenting with A-PAI to a London Major Trauma Centre between 01/19/2015-31/03/2018 and reviewed their clinical notes.

Results

143 patients were identified (79% male, mean age = 30). Non-operative management (NOM) took place without complication in 15% (n = 12) of cases, despite 38% (n = 8) showing a potential peritoneal breach on CT, and 19% (n = 4) a definitive intra-abdominal injury. Of the 37% (n = 53) of patients undergoing laparoscopy, half revealed no intra-abdominal injury. When comparing CT consultant reports to intra-operative findings, the accuracy of CT in identifying peritoneal breach was calculated to be 93% and sensitivity at 95%. Negative predictive value was 62%.

Conclusions

We concluded that a significant number of patients have unnecessary laparoscopies, which are not without risk. CT is an excellent resource, but negative predictive value is poor. NOM with serial abdominal examination remains a valid clinical option in the stable non-peritonitic patient and in the absence of definitive viscous perforation on CT.
324 Outcomes of the Exeter V40 Cemented Femoral Stem at a Minimum of 10 Years in a Non-designer Centre
Authors: Mahon J , McCarthy C , Sheridan G , Cashman J , O'Byrne J , Kenny P
Published: May 2021

Introduction

The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018, with excellent results at a minimum of 10-years for the first 540 cases performed at the designer centre in the Exeter NHS Trust. The aim of this current study is to report long term outcomes and survivorship for the Exeter V40 stem in a non-designer centre.

Method

All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between January 1st 2005 and January 31st 2010 were eligible for inclusion. Outcome measures included data on all components in situ beyond 10 years, death occurring within 10 years with components in situ and all-cause revision surgery.

Results

A total of 829 stems were included in the data set. Of these, 808 (97.5%) had no further surgery within the follow-up period; 648 stems (78.1%) were in situ beyond 10 years, and 165 (19.9%) were in situ at death before 10 years. The mean preoperative WOMAC score was 61±15.9 with a mean postoperative score of 20.4±19.3.

Conclusions

The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high-volume non-designer centre.
327 Rare Synchronous Volvulus of Sigmoid Colon and Caecum, Management of Two Cases
Authors: Butt M A , Lee A , Smith J
Published: May 2021

Colonic volvulus accounts for approximately 5% of cases of large bowel obstruction. Sigmoid volvulus is commonest (75%), followed caecal volvulus (15%). Synchronous volvulus of the caecum and sigmoid is rare, with five reported cases in the literature. We report two cases in a London teaching hospital managed within 6 months. Both male patients (aged 72 and 79 years) had presented to the emergency department on multiple occasions (2-5 times in the preceding 1-8 months), with obstructive symptoms including tender abdominal distension and constipation. On all occasions, sigmoid volvulus was diagnosed based on plain abdominal films and flatus tubes were inserted, with initial clinical resolution. On their final presentation, both patients were admitted for definitive surgery. CT scans of the abdomen and pelvis were consistently reported as showing only sigmoid volvulus. Only intra-operatively was the diagnosis of synchronous caecal and sigmoid volvulus appreciated. Complete symptom resolution was achieved with subtotal colectomy and ileostomy formation. The key learning points from these cases are: 1) synchronous large bowel volvulus is a rare and easily missed diagnosis, 2) conservative management is unlikely to be successful, 3) radiological appearances may only suggest one type of large bowel volvulus and 4) definitive diagnosis is made intra-operatively.