bluuebunny/crossref_metadata_2025 huggingface dataset:
635 Giant Paratesticular Liposarcoma Imitating a Recurrent Right Inguinoscrotal Hernia
Authors: Shulman N
Published: August 2023

Case

48-year-old male presented for elective open recurrent right inguinal hernia (RIH) repair due to ongoing right inguinoscrotal swelling; and an ultrasound suggestive of a large indirect inguinal hernia containing peritoneal fat and extending into the scrotum with displacement of the right testis.

Previous open RIH repair with mesh completed 12mths prior found a moderate direct inguinal hernia; and during a post-op phone review (given the COVID pandemic) noted he was healing well. No urinary/obstructive or systemic symptoms identified. Other history included alpha thalassemia trait, ex-smoker and non-English speaking background (NESB).

Intraoperatively there was no evidence of recurrent hernia, and the mesh was intact; however a large right scrotal mass was identified as the cause. An 18x8cm soft lipomatous mass surrounded the right testicle and extended up towards the cord structures at the superficial inguinal ring. Given the concern for malignancy, a right orchidectomy and excision of scrotal mass was performed.

Histology confirmed a well differentiated grade 1 liposarcoma. He recovered well and is undergoing close MRI surveillance - with no sign of recurrence.

Discussion

Liposarcoma is an important differential for scrotal masses and can imitate an inguinoscrotal hernia on ultrasound, MRI is the gold standard investigation.

The above case highlights the importance of physical post-operative examination and barriers to care during the COVID pandemic, particularly in those with NESB. Informed consent was imperative, we could safely proceed with the appropriate surgery as the patient had been explicitly consented for testicular loss due to recurrent nature of the operation.
636 Internal Dislocation of Scapula Following Ivor Lewis Oesophagectomy - a Case Report
Authors: Patel S , Ibrahim M , Tsai Al , Raza M , Moorthy K , Nandi J
Published: August 2023

Internal dislocation of scapula is a known but rare complication following traumatic thoracic injury and lung resection. We report a case and the management in a 69-year-old Caucasian man who underwent a stage two Ivor Lewis oesophagectomy for a T3N1M0 oesophageal adenocarcinoma. Post-operatively, the patient required an FiO2 of 60% and two days later placing on Optiflow to maintain adequate oxygen saturations. A CT thorax on day 5 post-op demonstrated a marked chest well deformity with intrathoracic dislocation of the scapula on the site of thoracotomy, 4th rib displacement downwards into the pleural cavity, left basal atelectasis and a pneumothorax; there was no evidence of anastomotic leak or perforation. Following an unsuccessful trial of conservative management using chest drains, a decision was made for surgical exploration and repair. Intra-operatively, the redo thoracotomy from pervious surgical excision revealed that the initial suture had given way allowing the scapula to dislocate into the thoracic cavity; this was subsequently released, adhesions to the lung dissected and pleural effusion drained. The defect in the posterior section of the 4th rib, was closed using a double-layered 15 x 15 cm prolene mesh, which was further secured to the ribs above and below. Post-operative care with pain management and ionotropic support was required in the intensive care unit, and later ongoing chest physiotherapy for basal atelectasis. This case demonstrated the importance of considering rare thoracic complications after oesophagectomy and early decision for re-operation, with the placement of an inlay mesh shown to be effective.
654 Inflammatory Bowel Disease and Risk of Interval Colorectal Carcinoma: What’s Missing in Surveillance Endoscopy?
Authors: Epanomeritakis I , McGuigan C , Mark D
Published: August 2023

Colorectal carcinomas in ulcerative colitis patients are more commonly missed endoscopically compared to those in other symptomatic patients. They may present as flat lesions on a background of colitis, making them harder to visualise. Those presenting after negative colonoscopies are termed interval cancers, and account for up to 50% of colorectal cancers in patients with inflammatory bowel disease (IBD). Professional bodies recommend the use of chromoendoscopy for IBD surveillance to improve diagnostic yield by allowing targeted biopsies of non-polypoid lesions. We present an asymptomatic missed cancer in a patient with UC following a complete white light surveillance colonoscopy. After the sole endoscopic finding of a small, raised rectal lesion, found to be dysplastic, a CT scan incidentally demonstrated a missed ascending colon tumour. Had chromoendoscopy been used, this cancer may have been detected initially. This case report demonstrates that missed tumours remain a problem during surveillance endoscopy for IBD.
718 Pilonidal Disease: Diagnosis Which Can Be Unexpected
Authors: Kazimirchyk M
Published: August 2023

Background

Pilonidal disease is seen at sacrococcigeal region in prevalent number of cases. We present an unusual case of an abscess at lumbar region which turned out to be a pilonidal sinus.

Case presentation

A 18-year-old male presented to the outpatient clinic with swelling at lumbar area for 1 month. Physical examination revealed an inflammatory infiltrate 1,5*1,5cm, with fluctuation, located in the projection of L4-L5 vertebrae. The initial diagnosis of abscess was made.

Initial management

During incision and drainage of abscess 10 ml of malodorous purulent discharge emerged along with collection of hair. The subcutaneous tract was revealed which run caudally for 8 cm close upon gluteal cleft, where midline pit was discovered.

Diagnosis

Based on clinical presentation and intraoperative findings final diagnosis of pilonidal disease of sacrolumbar region was made.

Investigation

X-ray revealed asymmetric, deformed L5 vertebrae, with a possibility of being a developmental variation. The concurrent diagnosis of osteomyelitis was put into a question, which was rejected based on results of CT that revealed no bone-destructive pathology.

Final management

After healing of surgical wound subcutaneous sinusectomy at gluteal cleft was accomplished in the inpatient setting, no additional surgical interventions regarding the subcutaneous tract at lumbar region were performed.

Outcome

The patient was monitored intermittently after that for 9 months and no signs of recurrence were observed.

Conclusion

Draining sinus tract of a pilonidal cyst is able to spread to an apparently distant location that can markedly complicate the diagnosis.
747 Ten Year Outcomes After Surgical Fixation of Tibial Plateau Fractures
Authors: Khalid A , Nelson C , Howell M , Eseonu O , Doonan J , Blyth M
Published: August 2023

Aim

This study represents one of the largest clinical case series' evaluating long-term outcomes following surgical fixation of tibial plateau fractures over a 10-year follow-up. The primary aim is to evaluate the incidence of TKR and risk-factors associated with poor outcomes.

Method

Patients receiving surgical fixation of tibial plateau fractures between 2008 – 2012 were included. Those requiring arthroplasty or endoprosthesis post-injury were excluded. PACs was used to analyse case notes and radiographic imaging. Articular reduction and alignment (mPTA) were measured using pre-operative radiographs. Comparisons were made with radiographs post-fracture union (6-weeks to 6-months), assessing fracture reduction maintenance. Long-term outcomes were assessed for patients receiving imaging thereafter. Patients were checked using the Scottish National Imaging Archive.

Results

130 patients presented various fractures (Schatzker I-III n = 78, IV n = 12, V n = 9, VI n = 29) and 2 open-fractures. 32 patients required further surgery, 13 required multiple operations - resulting in 47 operations. These included metalwork removal (n = 28, 21.5%), TKR (n = 12, 9.2%), washout for infection (n = 3, 2.3%), osteotomy (n = 2, 1.5%), sequestrectomy (n = 1, 0.8%), and above knee amputation (n = 1, 0.8%). ≥ 2mm articular reduction was maintained in the majority (84%); however, good articular reduction did not prevent progression to arthroplasty (average step 1.4mm in TKR versus 1.8mm in non-TKR). Good alignment correlated with favourable outcomes - average mPTA being 90.8° in non-TKR versus 93.5° in TKR.

Conclusions

These findings support previous literature in this field demonstrating that malalignment, rather than articular depression, increases the risk for post-traumatic arthritis requiring arthroplasty. The incidence of TKR after tibial plateau fracture fixation at 10-years was 9.2%.
813 Management of Massive Air Leak with Persistent Pneumothorax and Pneumoperitoneum in a 1.2kg Preterm Neonate – a Case Report
Authors: Woodun H , Thomas J , Fraser N
Published: August 2023

Pneumothorax is a life-threatening condition with potential iatrogenic causes which can extend to pneumomediastinum and pneumoperitoneum. Risk factors of spontaneous pneumothorax include prematurity, low birthweight, low APGAR scores and caesarean-section delivery. A 1255 grams preterm boy (Twin-2) was born at 28+3 weeks of gestation by emergency lower segment caesarean section. He showed signs of respiratory distress after uncomplicated endotracheal tube insertion which was required due to apnoeic episodes during continuous positive airway pressure ventilation. Recurring tube thoracocentesis and high frequency oscillatory ventilation (HFOV) treated persistent right-sided pneumothorax and nonsurgical pneumoperitoneum, with improvement on day-10, gradual removal of five chest drains by day-19 and extubation on day-24. Transillumination and chest radiography were main diagnostic investigations. Laryngotracheobronchoscopy on day-16 identified erythema and possible old injury at the carina. He was also treated for hypotension, suspected sepsis and pulmonary hypertension and was discharged home on day-66. Identifying pneumothorax promptly is essential to reduce morbidity and mortality. Lung ultrasound would improve diagnosis and monitoring. Management is patient-specific and includes needle and tube thoracocentesis and HFOV. Use of blood patch, fibrin glue or chemical agents, selective bronchial ventilation have been reported. Surgery is usually applied in unstable patients where bridging the defect is not feasible. nonsurgical pneumoperitoneum should be considered in ventilated neonates and those with airway injury to avoid exploratory laparotomy. Our case demonstrates challenges of managing a massive air leak in a premature newborn, who with adequate tube thoracocentesis and HFOV, successfully recovered from presumed iatrogenic persistent pneumothorax and pneumoperitoneum with conservative management.
816 A Benign Diagnosis for Suspected Malignant Differential of a Sacral Lytic Lesion.
Authors: Matthews J , Matthews M , Garcia S
Published: August 2023

49-year-old relatively healthy man presented to the ER with abdominal and associated low back pain. Past history was significant for excision of spinal benign tumor excision and 30-year pack history of smoking. Review of systems was significant for recurrent leg swelling and muscle aches.

Neurological exam was non focal. CT scan of the abdomen and pelvis revealed a lytic sacral lesion with soft tissue component. The rest of the skeletal survey and system evaluation was unremarkable. Patient was referred to Oncology, suspecting the localized plasmacytoma variant of multiple myeloma with an inconclusive sacral mass biopsy report. Full blood count, comprehensive metabolic panel, Beta-2 microglobulin serum protein electrophoresis (SPEP), and free light chains assays undertaken were all within normal ranges. Further second opinion was sought for the biopsy results to undertake special stains which concluded the biopsy as schwannoma. In view of the persisting recurring pain and swelling, further MRI imaging and IR guided biopsy was suggested. However, the patient was with limited insurance coverage. He opted to defer further evaluation and adopted a “wait and see” approach and has since remained stable.

Sacral schwannomas are rare. It is possible that his previous extradural lesion could have been a schwannoma. Schwannomas are slow growing and relatively asymptomatic. As they are typically lytic lesions can easily be mistaken for malignant lesions and have to be considered in the differential of osteolytic lesions as they can grow in close proximity to bony structures.
820 Atypical Presentation of Muscular Metastasis of Melanoma in the Contralateral Limb
Authors: Mondal A , Dingle L , Hough M
Published: August 2023

Case Presentation

A gentleman in his 50s presented to his GP with an asymptomatic, soft, enlarging mass on his left upper arm. He had previously been diagnosed with a 4.5mm cutaneous malignant melanoma (MM) on his right arm, which was treated with an excision biopsy and a further 2cm wide local excision. He further had a sentinel lymph node biopsy (SLNB), which confirmed no residual melanoma. He was subsequently followed up routinely by the skin cancer multidisciplinary team (MDT) for five years with no concern.

The patient subsequently underwent an ultrasound scan, a Magnetic Resonance Imaging (MRI) scan, and a final staging Computed Tomography (CT). Imaging was suspicious for an intramuscular soft tissue malignancy. Core biopsy of this mass suggested a diagnosis of metastatic MM. Excision was performed within three weeks of his core biopsy. The lesion was completely excised, and formal pathology confirmed the diagnosis of metastatic MM. He has been referred to the oncology services for the commencement of Nivolumab (anti PD-1 antibody) immunotherapy according to the genetic analysis.

This case highlights a rare example of muscular metastasis of MM, presenting in a distant site, despite a negative SLNB, over five years from the original diagnosis. Such cases highlight the unpredictable nature of MM, reminding clinicians of the need for a low threshold for investigation of soft tissue masses in patients with a history of cutaneous malignancy.
823 The Dilemma of Managing the Thyroid Gland After Incidental Diagnosis of Malignant Struma Ovarii, Is Radical Thyroidectomy and Radioactive Iodine Necessary? a Case Report and Literature Review
Authors: Batog W I , Riain C Ó , Abu Saadeh F
Published: August 2023

Background

Struma Ovarii is a unique type of ovarian teratoma which occurs when thyroid tissue constitutes 50% or more of the tumour. Most of these tumors are benign, however malignant transformation happens in less than 3%. Thyroid carcinomas can occur as distal metastasis with malignant struma ovarii (MSO) however, their diagnosis and treatment remain debatable.

Case

We report on a case of a 48-year-old woman whose MSO was discovered accidentally during a clinical trial. An ultrasound (US) depicted a complex left adnexal mass, which an MRI subsequently confirmed. The mass measured 4.5cmx 2.5cmx 5.0cm, a strong Doppler blood flow, and nodularity were noted. Salpingo-oopherectomy, omentectomy, appendicectomy, and left pelvic and para-aortic lymph node dissection were performed. The postoperative histopathological assessment of the tumour confirmed the diagnosis of MSO. The patient was then reviewed by a head and neck multi-disciplinary meeting. A 6mm thyroid nodule was located on the left lobe, and the cytology was reported as negative on fine needle aspiration (FNA). Nonetheless, the patient was treated with a radical thyroidectomy and radioactive iodine. Post-operative histopathology reported thyroid carcinoma, despite the negative cytology on FNA. No recurrence was noted.

Conclusions

This case highlights the importance of radical treatment of the thyroid in patients with MSO. Accurate preoperative diagnosis of thyroid carcinoma secondary to MSO is difficult, since pathological diagnosis is the gold standard. Our case showed that a radical treatment of thyroid with surgery and radioactive iodine minimises the risk of local and distal recurrences.
830 Surgical Management of a Patient with Triple Carcinoid Heart Valve Disease
Authors: Holland L , Ghouri S , Sahdev N , Liu G , Punjabi P
Published: August 2023

Background

Carcinoid heart disease is an uncommon manifestation of carcinoid syndrome that can present to a cardiac surgeon as a complex constellation of structural problems. Patients develop progressive valve disease, more commonly of the right-sided heart valves but sometimes involving the left, which will in turn impact cardiac function. Without intervention, carcinoid heart disease portends a dismal prognosis. Given the rarity with which these cases are encountered, in conjunction with their complexity, it is important for the cardiac surgeon to be equipped with the knowledge of how to operate on these patients and the challenges likely to be faced.

Case

A 72-year-old man, who had previously undergone small bowel resection for multifocal neuroendocrine tumours, was referred to our centre with significant symptomatic carcinoid heart valvulopathy affecting the tricuspid, mitral and aortic valves. He successfully underwent triple valve replacement and permanent epicardial pacing system implantation along with coronary artery bypass grafting. He was discharged after an inpatient stay of two weeks and is well at follow-up.

Discussion

Triple valve replacement is infrequently performed in the UK, but all centres ought to be prepared to offer this treatment in a select group of patients. In this report we describe the technicalities of performing such an operation and the relevant surgical anatomy, the rationale and technique of pre-emptive epicardial pacing system implantation, and both the pre- and post-operative management of such patients.
837 A Rare Case of Regional Odontodysplasia in a Young Male
Authors: O'Rorke R , Siddik D
Published: August 2023

Background

Regional odontodysplasia (ROD) is a rare localised developmental disorder affecting the dental tissues. It presents with specific clinical, radiographic, and histopathological features. There have been less than 180 reported cases of ROD in the literature.

Case Report

A 10-year-old boy was seen in the paediatric dental department with a complaint of missing teeth and pain in the left maxilla. Examination revealed retained fragments of primary teeth and a partially erupted upper left first permanent molar (UL6) with an unusual morphology, cavitation, and associated infection. The dental development in the rest of the mouth appeared to be normal. CT scanning of the left maxilla revealed all unerupted permanent teeth were present but had a characteristic "ghost-teeth" appearance suggestive of regional odontodysplasia. The patient underwent surgical exploration of the left maxilla and removal of the UL6. The remaining unerupted teeth in the area showed no signs of infection. Although they have a poor long-term prognosis, they were left in situ in order to preserve alveolar bone whilst the patient is growing. Histological examination showed thin disorganised dental tissues with large pulp chambers, confirming the diagnosis of regional odontodysplasia.

Discussion

ROD presents management challenges, particularly in children. This case highlights the importance of being aware of the clinical and radiographic features of rare disorders in order to aid diagnosis and treatment planning. This case also demonstrates the importance of targeted intervention and monitoring in order to improve outcomes for placement of dental prostheses in adulthood once growth is complete.
859 Bilateral Vocal Cord Palsy Secondary to Rheumatoid Arthritis: A Case Report
Authors: Hyland L , Saville R , Dwiddar N , Sovani M
Published: August 2023

Introduction

Rheumatoid arthritis (RA) affects the larynx in 13-75% of cases and is usually subclinical. Airway obstruction due to vocal cord fixation occurs late in RA and presents as an inspiratory stridor.

Case presentation

An 85-year-old woman presented to A&E Resus with tachypnoea, stridor and drowsiness. An ABG showed hypercapnic respiratory failure. A flexible nasendoscopy was performed which revealed adducted vocal cords with paradoxical breathing. The patient had been admitted with a similar presentation before which was attributed to her longstanding RA. Potential surgical options including tracheostomy, vocal cord lateralisation and vocal cord/arytenoid removal were considered but ultimately, these options were deemed unsuitable for the patient.

Conclusions

Stridor is a late but life-threatening complication of RA that has viable surgical options of tracheostomy and vocal cord lateralisation; however, the appropriateness of such procedures should always be correlated with the patient’s clinical status and background.
913 Role of Botulinum Toxin in the Medical Management of Respiratory Distress Secondary to Suspected Intraabdominal Hypertension After Abdominal Wall Reconstruction
Authors: Adeboye T , Kulkarni G , Atkinson T , Hammond T
Published: August 2023

Introduction

Botulinum toxin (BTX) is a neurotoxin which causes functional denervation of muscles. Botulinum toxin type A (BTX) has been approved for a wide range of clinical applications. In addition, off-label preoperative injection of BTX is increasingly used for chemical component relaxation of the lateral abdominal wall muscles prior to abdominal wall reconstruction.

Rationale

Postoperative intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) with consequent organ dysfunction can be a potential complication after abdominal wall reconstruction. The IAH and ACS clinical practice guidelines suggest improving abdominal wall compliance in their medical management algorithm including neuromuscular blockade.

Method

Following an open retrorectus mesh repair with left component separation via transversus abdominis release of a midline incisional hernia, we report a case of postoperative respiratory distress and acute kidney injury suspected secondary to increasing intraabdominal hypertension due to ileus unresponsive to standard conservative measures including nasogastric tube insertion, use of prokinetic agents and judicious fluid management. We performed Botox A injection under ultrasound guidance to the lateral abdominal wall musculature. This resulted in improved abdominal wall compliance, consequent resolution of respiratory symptoms and reversal of acute renal injury with eventual resolution of ileus and a good post operative outcome. There was an increase in length of stay by 2 days compared to our average. The patient remains well at 3 months post operatively.

Conclusions

Botulinum Toxin A injection can be considered as adjunct in the medical management of IAH and ACS if it has not been used in the pre-operative setting.
929 Case Report -Post Cataract Surgery Fungal Infection Presenting as a Mass Lesion
Authors: Arun Shankar A P
Published: August 2023

Purpose

Fungal endophthalmitis is rare and usually causes poor outcome in untreated patients. It is important to document and be aware of uncommon presentation of fungal endophthalmitis.

Case report

68-year-old male presented with complaints of redness, pain, and blurry vision in the right eye for the past 5 months. He underwent an uneventful cataract surgery in the right eye 5 months ago elsewhere and in the post operative follow-up was found to have high intraocular pressure for which he was started on antiglaucoma medications. Aqueous tap did not reveal growth of any microorganism. On examination his vision in both the eyes were 20/20. Slit lamp examination revealed congested conjunctiva, corneal superficial punctate keratitis, anterior chamber 2+ cells and 1.2mm white mass over the iris which was encroaching towards the pupillary margin. Ultrasound bio microscopy revealed 0.8mm x 1.5mm mass in the iris at 11 -12 o’clock position. Since there was a diagnostic uncertainty, excision biopsy was done which revealed fungal filaments on KOH staining. The patient was started on tablet voriconazole and advised to review in 1 month.

Conclusions

Due to the rare frequency, there is a lack of understanding of presentation of fungal endophthalmitis. Many cases series analysis have suggested that the late fungal endophthalmitis presents as clumpy anterior chamber or posterior chamber inflammation [1], white plaque over the lens [2], peripheral vitreous lesion or as chorioretinitis. Our case report shows a rare presentation of fungal endophthalmitis in the form of mass lesion on the iris.
997 Traumatic Jejunal Rupture Following Gaelic Football Game. Case Report
Authors: Croitoru C , Mallon C , Harron M
Published: August 2023

Aim

Abdominal injury accounts for just 6.3% of injuries in sport. The most common mechanisms are contacts with a player (74.5%), a surface (8.1%) or equipment (0.6%). Only twelve cases of Jejunal rupture are described in the literature.

Method

This case involves a young Gaelic football player who had significant abdominal contact with other players’ knees. He experienced nausea and left flank pain radiating to the groin. At the Emergency Department the heart rate was 95 beats per minute and blood pressure was 120/70 mmHg. There was bruising in the left flank at the impact site and some guarding. Initial investigations showed normal inflammatory markers and a normal Chest X-ray. Nine hours later the white cell count had increased to 17.85x10^9 and CRP to 106mg/L. Abdominal and Pelvic CT scanning suggested a bowel injury with free fluid in the left flank and pelvis.

Management

Exploratory laparotomy identified a jejunal rupture 10cm distal to the duodenal-jejunal flexure. A primary two-layer repair was performed. Antibiotic and anti-fungal cover were prescribed, and he was discharged well on day 5.

Conclusions

Owing to the rarity of bowel injury after blunt trauma, soft peritoneal signs and radiological insensitivity, the diagnosis of small bowel perforation is often delayed and can be associated with marked morbidity and mortality. Serial examinations and a high index of suspicion is required to detect bowel injuries in the case of blunt abdominal trauma in contact sports.
1036 Colonic Erosion of a Laparoscopically Inserted Adjustable Gastric Band
Authors: Saini K , Fakih-Gomez N
Published: August 2023

The popularity of laparoscopic adjustable gastric band surgery has declined over the past decade. This is partly due to concerns about a high rate of long-term complications, including band erosions occurring in over 1% of cases. Erosion into the colon is exceedingly rare, with only three reports in the literature. Our images/video illustrate the case of a 51-year-old female patient presenting in February 2022 with abdominal pain and two chronically discharging sinuses around her port site. She had a gastric band initially fitted in 2010, which was revised in 2018. The port was re-sited in 2021 following port-migration and flipping. On this presentation, a CT scan revealed 16cm of tubing within the lumen of the descending colon. Our procedure began with diagnostic laparoscopy, showing the gastric band tubing entering an inflammatory phlegmon in the left flank involving omentum and descending colon attached to the abdominal wall beneath the port site. The tubing was cut near to the gastric band. The gastric band was freed, divided, and removed. The previous port site incision was extended around the external opening of the fistula, which was excised. The port and tubing were easily removed, though partly covered in faeces. A decision was made, based upon prior discussion with the patient, to leave the colocutaneous fistula in-tact. This avoided the risk of colonic resection and anastomosis in freeing the bowel. Stapling across the phlegmon and tract risked diverting colonic contents into another potential tract headed towards the stomach. Postoperative recovery was uneventful.
1142 Using Lipofilling to Improve Skin Quality Following Severe Radiation Necrosis to Enable Successful Joint Replacement – a Case Report and Literature Review
Authors: Satkunabalan M ri , Cavallaro D , Govindan Srinivasan K , Jagadeesan J
Published: August 2023

Case

A 74-year-old female patient presented with severe osteoarthritis and pathological fracture of the left knee, following treatment with radiotherapy of osteosarcoma over a decade ago. Surgical management of the fracture was initially not possible, due to radiation-induced fibrosis of the skin. She was referred to the plastic surgery department where she underwent a total of three sessions of fat grafting over nine months. The rigotomy approach was applied to the large area of irradiated skin. As a result, her skin quality improved such that a successful total knee replacement was possible. The outcome of this was better mobility and improved quality of life.

Conclusions

Skin quality after radiotherapy can limit surgical options, even decades after treatment. Fat grafting, also known as lipofilling, is a commonly utilised reconstructive and cosmetic adjunct. However, recent reports of its effect on skin quality are gaining popularity. We present a case of successful use of fat transfer to improve irradiated skin quality prior to successful joint replacement; this is a novel use case which we believe to be the first published.
1299 Puerperal Shoulder Pain: A Rare Case of Glenohumeral Joint Septic Arthritis
Authors: Kulkarni K , Khan A , Jump C , Hadi S
Published: August 2023

Introduction

Native glenohumeral joint septic arthritis is a rare manifestation of an occult bacteraemia. Without urgent diagnosis and intervention, septic arthritis can lead to rapid cartilaginous and joint destruction. We report an unusual presentation of postpartum streptococcal glenohumeral arthritis.

Case Description

A fit and healthy 34-year-old woman gravida 2 para 3 developed unremitting shoulder pain, reduced range of movement and tachycardia day 1 postpartum after a vaginal delivery associated with a grade two perineal tear. Initial blood work revealed rising inflammatory markers, CRP 275, WCC 16.2. Initial radiographs showed no significant abnormality. T2 weighted MRI revealed a large glenohumeral joint effusion. All samples from joint aspirate grew Group B streptococcus (GBS), concordant with a high vaginal swab taken in the late third trimester. The patient underwent urgent arthroscopic washout and synovial sampling, growing GBS. Transthoracic echocardiogram revealed no imaging evidence of infective endocarditis. The patient was commenced on an appropriate 6-week intravenous antibiotic course and clinically improved. Physiotherapy and rehabilitation improved shoulder range of movements.

Discussion

There is a scarcity of orthopaedic complications reported with obstetric pathology. Atraumatic joint pain associated with physiological, or biochemical signs of infection should alert the diagnosing surgeon to consider septic arthritis. Haematogenous bacterial translocation can cause atypical presentations of septic arthritis. Routine biochemical parameters and arthrocentesis continues to prove to be the gold standard of diagnosis. A compilation of a case series detailing location, microorganism, complications, and effective treatment would prove useful to tailor management of these rare presentations.
376 Neoplasms of the Appendix- Are They Managed Appropriately?
Authors: Amir A H , Chia T M , Choy M , O'Connell L , Meshkat B , Nugent E , Joyce M , Regan M , Hogan A
Published: August 2023

Aim

Appendix neoplasms are rare. Half are neuroendocrine tumours (NET). Incidence of NET is 0.4 per hundred thousand and of low-grade appendix mucinous neoplasm (LAMN) is 0.2-0.3 per hundred thousand. Most are diagnosed incidentally on appendicectomy specimens. The aim of this study was to ascertain the incidence of appendix neoplasms managed in a tertiary referral centre and to ascertain compliance with international guidelines.

Method

A prospectively maintained gastrointestinal oncology database was interrogated over a six-year period (July 2016-July 2022). Histologically confirmed primary appendix neoplasms were included. Data collected included patient demographics, clinical presentation, management and follow up (median 38 months). Histopathological staging was according to the AJCC 8th edition. Institutional review board permission was not required.

Results

Incidence of appendix neoplasm over the study period is 1.3% (16/1259). These included 8 NET, 5 LAMNs, 2 invasive adenocarcinoma and 1 adenocarcinoid. A majority were managed with definitive appendicectomy. One patient underwent right hemicolectomy following discussion at tumour board meeting. Four patients were enrolled on a surveillance programme. A further four with LAMN underwent appendicectomy only and one had appendicectomy and partial caecectomy. Surveillance was not deemed necessary in any of the LAMN cases.

Conclusions

Incidence of appendix neoplasm in our centre is comparable to that reported in larger series (2%). All cases were discussed at tumour board meeting. Management in all cases was in keeping with current guidelines. While most patients had adequate margin clearance with appendectomy alone, a small number required further surgery and/or surveillance.
824 Complete Mesocolic Excision Is Safe and Results in Increased Lymph Node Harvest: Further Justification for Randomised Trials
Authors: Jones T , Butnari V , Hawkins R , Kung V , Banerjee S , Kaul S , Huang J , Rajendran N , Boulton R
Published: August 2023

Aim

Complete mesocolic excision (CME) for right hemicolectomy encompasses embryonic dissection planes, radical lymphadenectomy and vascular pedicle ligation at the origin. Compared to conventional D2 dissection, CME is associated with increased disease-free survival in population studies. Critics argue that morbidity from CME may be higher. We sought to examine complication rates and specimen oncologic characteristics in a cohort from a single NHS trust.

Method

We conducted a retrospective cohort study of all right hemicolectomies performed for adenocarcinoma between 3/1/2019 and 15/11/2022. The choice of CME or D2 lymphadenectomy was at the discretion of the operating surgeon. Data were collected from paper notes and electronic records. Statistical analyses used non-parametric testing.

Results

CME was performed in 30 patients and D2 resection in 99. The CME group were younger (70 vs. 72 years, p = 0.04) and preoperative nodal staging was higher. There were no differences in duration of surgery, estimated blood loss, postoperative haemoglobin or transfusion requirement. Only 20% patients in the CME group had a significant complication compared to 40% of the D2 group (p = 0.05) and length of stay was reduced (5 vs. 7 days, p = 0.02). Nodal harvest was increased in the CME group (24 vs. 19, p = 0.01) with no difference in R0 resection rate.

Conclusions

CME appears to be safe and does not result in increased complication rates in this single institution cohort. Nodal harvest is increased with comparable margin clearance. Whether this translates to increased disease-free survival is unclear. There is equipoise and randomised studies examining long-term outcomes are justified.
090 Transarterial Haemorrhoidal Dearterialization Versus Open Haemorrhoidectomy for Symptomatic Haemorrhoids- a Meta-Analysis of Randomized Controlled Trials
Authors: Kaur I , Sahebally S
Published: August 2023

Although effective, open haemorrhoidectomy (OH) is associated with significant postoperative pain. Novel non-excisional techniques such as transarterial haemorrhoidal dearterialization (THD) are increasingly advocated due to a lower incidence of pain and complications. We aimed to compare short and long-term outcomes of THD and OH in the present meta-analysis.

A PRISMA-compliant systematic review and meta-analysis was performed including randomised controlled trials (RCTs) from inception until June 2022. The primary objective was recurrence, whilst secondary objectives included complication rates, mean length of stay (LOS), operative time and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. A p-value < 0.05 was considered statistically significant.

6 RCTs encompassing 474 patients were captured. There were 129 (54%) males in the THD group and 142 (59%) in the OH group. On random effects analysis, OH had a lower recurrence rate (OR = 2.76, p = 0.04) whereas THD was associated with a quicker return to baseline (MD = -14.05 days, p < 0.0001). There were no differences in bleeding (OR = 0.58,p = 0.09), urinary retention (OR = 1.01, p = 0.99), incontinence (OR = 0.49, p = 0.41), anal stenosis (OR = 0.14, p = 0.19), number of patients with chronic pain (OR = 1.30, p = 0.40), operating time (MD = 11.79 mins, p = 0.20) or LOS (MD = -0.23 days, p = 0.22).

THD is a safe technique that affords a quicker return to baseline post procedure but is associated with a higher recurrence rate compared to OH.
1179 Analysis of the Staging of Colorectal Cancer Before and During the COVID-19 Pandemic in a UK District General Hospital
Authors: Hussain S , Adhya S , Andelic M , Callan R , Shamardal A , Zaidi S
Published: August 2023

Aim

The COVID-19 pandemic has had significant implications for delays in diagnosis and treatment of colorectal cancer. We set out to investigate the impact of the COVID-19 pandemic on the stage of colorectal cancer in operatively managed patients in our district general hospital in the United Kingdom.

Method

We retrospectively collected data for patients with colorectal cancer who underwent surgery pre-COVID-19 lockdown in the UK (January 1st, 2019 – March 22rd 2020) and compared with those who underwent surgery during the COVID-19 pandemic (March 23rd 2020 to January 2021). Pre-operative and post-operative TNM classification were assessed.

Results

318 patients underwent surgery for colorectal cancer from January 1st, 2019, to 31st January 2021: 136 in 2019, 90 in 2020, and 92 in 2021. There was a rise in proportion of T4 cancers during the COVID-19 pandemic (27%) vs pre-pandemic levels (15.7%). There was an increase in nodal positivity, with 42% of patients presenting with N1/N2 disease during the COVID-19 pandemic, compared to 38.8% in pre-COVID-19. However, we did not see a change in metastatic disease during the Covid-19 pandemic - 91.3% of patients in 2019 had M0 classification, 94% in 2020, and 93.4% in 2021.

Conclusions

There was a large reduction in patients undergoing operative management for colorectal cancer since the start of the pandemic – this may be secondary to late presentations or delays in diagnosis. There is a need for continued research to establish the long-term impacts of the COVID-19 pandemic on the diagnosis and treatment of colorectal cancer.
305 Facial Nerve Outcomes Following Malignant Lateral Skull Base Surgery at a Tertiary Centre
Authors: Prasansapakit K , Fleming J
Published: August 2023

Background

Although a rare malignancy, lateral skull base tumours often present a challenge to head and neck surgeons due to complex neurovascular anatomy. Patients also tend to present late with advanced disease. With lateral skull base tumours being a rare occurrence, there is limited knowledge on facial nerve outcomes following surgery.

Method

Data from 44 patients were collected and analysed. The main outcome collected in this study was facial nerve function at presentation and post op (both immediately and long-term) according to the House-Brackmann scale.

Results

90% of patients presented without signs and symptoms of facial nerve involvement. Patients who had no facial pain or paralysis at presentation are more likely to maintain normal facial functions after surgery (20 out of 26 that scored House-Brackmann 1 pre-op maintain a score of 1 in long term post-op review). 80% of those who presented with signs and symptoms of facial nerve involvement required intraoperative nerve sacrifice.

Conclusions

Patients who presented with facial pain or paralysis tend to have more advanced disease. The majority (80%) of those presenting with facial deficits pre-operatively underwent nerve sacrifice. The purpose of this study is to offer insight into facial nerve outcomes of patients who underwent lateral skull base surgery at a tertiary centre. We collected and analysed the outcomes of surgery for 44 patients, with main outcome measures including facial nerve functions based on the House-Brackmann scale, as well as any postoperative complications, recurrences, types of adjuvant therapy required and survival after the operation.
410 Is a Single Dose, Single Agent Peri-Operative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 14-Year Review of 574 Cases
Authors: Tan J Y , Mahmood A , Nix P
Published: August 2023

Post-operative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. As endonasal approaches to the skull base are clean-contaminated procedures, peri-operative antibiotics are routinely used. We sought to analyse the safety and efficacy of a single agent, single dose protocol in cases of endonasal anterior skull base surgery. Database of all endonasal anterior skull-base procedures performed in ENT Department at Leeds General Infirmary between 2008 and February 2022 was prospectively recorded. The primary outcome measure was development of meningitis within 30-days of surgery. Our protocol uses single dose of IV co-amoxiclav 1.2g (or teicoplanin if allergy precludes co-amoxiclav). The data was further divided according to primary or revision surgery, the presence or absence of intra-operative CSF leak, and the development or not of a post-operative CSF leak. Over the 14-year period, 574 endoscopic endonasal operations that fulfilled inclusion criteria were performed. The overall rate of post-operative meningitis across the entire cohort was 2.6%(n = 15). Among the 15 cases:80% (12/15) had intra-operative CSF leak47% (7/15) were revision cases73% (11/15) had extended endoscopic approach as pathology that required an intentional opening of the arachnoid80% (12/15) had post-operative CSF LeakThere were no cases of meningitis following repair of long-standing CSF fistula or encephalocele and surgery for sinonasal tumours with skull-base involvement.

In conclusion, a single dose of 1.2g intravenous co-amoxiclav (or teicoplanin) is safe in the context of sellar-centred pathologies, repair of pre-existing spontaneous CSF leaks, and surgery on sinonasal tumours with skull base involvement.
413 Percutaneous Bone Anchored Hearing Rehabilitation in Adults - the Nottingham Experience Over a 5 Year Period
Authors: Hao T , Cho W S , Kasbekar A
Published: August 2023

Aim

Percutaneous bone anchored hearing aid (BAHA) is an effective hearing rehabilitation option. However, complications including granulation, skin overgrowth and infections may lead to revision surgeries. This study aim was to assess the complication rate and potential contributing factors leading to revision surgeries.

Method

Adult patients who underwent BAHA connect (Cochlear Corp) operations between 2016 to 2021 were included. Patient notes were retrospectively reviewed.

Results

166 patients received a BAHA connect. Twenty-nine (17.5%) patients required revision surgery; 2 for granulation, 10 for skin overgrowth, 9 for infection, 7 for traumatic extrusion and 1 for failure of osteointegration. Excluding traumatic extrusion patients, 22 (13.3%) required revision surgery. 56% of patients were performed under local anaesthetic, with no difference in complication rate compared to general anaesthetic. 70% patients with Holger’s grade 4 changes and 40% patients with grade 3 findings required revision. 31% cases required revision when primary surgeon was trainee, compared with consultant (17%). There was no difference in post-operative skin problems between skin incisions made in-line vs separate from abutment. Cases with intra-operative complications, including re-siting of initial hole due to bleeding or loose fixture, had higher rate of revision. Of revision surgery patients, 14% were active smokers and 21% ex-smokers. 31% required multiple revision operations.

Conclusions

Percutaneous BAHA insertion can be performed under local and general anaesthetic. Grade of primary surgeon and intra-operative problems appear to be risk factors for requiring revision surgery. Smoking and site of incision does not appear to be risk factors for postoperative skin problems.
1208 Post-Tonsillectomy Re-Admissions – a Real Pain in the Mouth for Our Patients
Authors: Al-Hity S , Rajdev K , Giblett N
Published: August 2023

Aim

Uncontrolled post-tonsillectomy pain is detrimental to patient safety and recovery, increasing the risk of morbidity from complications such as infection and secondary haemorrhage. A closed-loop audit of the adult and paediatric population evaluated operative and post-operative factors, and readmission and return to theatre rates against the National Prospective Tonsillectomy Audit (NPTA) and ENT UK Tonsillectomy Commissioning standards.

Method

Data from seventy-one and forty-three patients were collated over two treatment quarters in 2019/2020, including operative indication, surgical grade, dissection technique, estimated blood loss and local anaesthetic infiltration, in addition to post-operative analgesia instruction, length-of-stay, and discharge medications. Incidences of re-presentation within thirty days were reviewed, assessing the nature of complaint and indication for readmission. Inter-cycle intervention involved departmental education and dissemination of post-operative verbal/written patient education.

Results

Overall readmissions (15.5%), pain readmissions (1.4%/n = 1) and return to theatre cases (2.8%) exceeded national standards in cycle one (<15%, <1%, <1%), improving to standard in all domains bar pain readmission in cycle 2 (9.3%, 2.3%/n = 1, 0%). Length-of-stay was compliant throughout (0.2, 0.1 days). Documentation of post-operative analgesia instruction and simple and opiate discharge medication prescription in both adult and paediatric populations improved post-intervention (83% to 98%).

Conclusions

Scheduled, multimodal analgesia and discharge education that sets realistic expectations post-operatively are key in optimising the post-operative safety of our patients. In addition to verbal and written education, collaborative work with pharmacist colleagues to create and standardise a post-operative pain protocol and discharge analgesia pack will support and empower patients to enhance post-operative recovery and minimise avoidable hospital admission.
70 Decision to Incision Time: Can the Principle Be Applied to Emergency General Surgery in Order to Tackle Delays in Patient Care?
Authors: Smith C , Aly E
Published: August 2023

Aim

General surgical patients who require emergency surgery should have timely access to operating theatre to ensure optimal outcomes. It is important to evaluate delays in order to identify contributing elements and help to improve standards of surgical care. The decision to incision time interval is a benchmark used in obstetric practice. This study aimed to assess the use of this time interval in the emergency general surgical setting to consider whether the principle may be translatable.

Method

Prospective data were collected on patients undergoing emergency general surgery in a tertiary care centre over four weeks. Data were extracted from patient notes and anonymised for statistical analysis.

Results

No statistically significant associations were found with the studied variables and decision to incision time. However, this study identified clear delays, with 66% of emergency operations taking place after target time assigned by NCEPOD classification. It identified trends in varying decision to incision time in patient and procedure type. It also identified issues with documentation and an association between longer decision to incision time and post-operative length of stay.

Conclusions

This study highlights important delays in emergency general surgery. Decision to incision time reveals important trends and, with larger sample sizes, may identify areas which hinder time-sensitive procedures. This study recommends that decision time could be more formally incorporated into surgical documentation to better monitor delays. The findings of this study could inform future research, which is required to determine the true potential of using decision to incision time interval in emergency general surgery.