bluuebunny/crossref_metadata_2025 huggingface dataset:
TH5.9 Role of Ultrasound in Management of Acute Appendicitis
Authors: Morsy Hesham , Elkorety Mohamed , Massias Samuel , Salsabil Sharaf , Owera Anas
Published: November 2022

Aim

Assess the outcomes of suspected appendicitis patients who had an abdo-pelvic ultrasound, and whether the scan made a difference to their management.

Method

Cycle 1: we collected data retrospectively for confirmed appendicitis patients admitted for the period betweeen 03/06/2021–01/09/2021. Clinical coding department supplied a database of EAU admissions diagnised with appendicitis based on histology. Cycle 2: we collected data retrospectively for all surgical patients with acute abdominal pain during the period between 1/11/2021–30/11/2021. Ultrasounds requested were provided by the Radiology department. Admission summaries were used to assess patients' management.

Intervention

Presentation of Audit results in departmental teaching, Teaching to junior doctors on the NICE guidelines for management of Appendicitis.

Results

Cycle 1: Out of 60 patients, only 10 were included as most patients had CT scan. 25% of which suggested appendicitis and 25% suggested different pathology. The appendix couldn't be visualised in 75%. Cycle 2: Out of 83 patients, 23 patients were included as suspected appendicitis. Confirmed cases were 4.34%, not visualized were 86.96% and NAD 8.70% (their final diagnosis on discharge: Appendicitis). Other suspected pathologies of biliary, gynaecological and post-op collections were mostly correctly confirmed/denied.

Conclusions

Ultrasound was very informative in Biliary pathology, Gynae Pathology, Other pathology like Hematoma, post-op collection. However, in terms of suspected appendicitis, it was only informative in a rare occurrence. Of the patients who were diagnosed as Appendicitis in the final diagnosis, only an eighth were confirmed by US. Ultrasound didn't change the management plan in majority of patients with suspected appendicitis.
TH5.10 Results of a pilot programme of Care of the Elderly inreach in Emergency General Surgery patients
Authors: Nair Nandu , Kalatzis Vasileios , Gaunt Anne , Dawson Julian , Rao Vittal , Browne Marilyn
Published: November 2022

Introduction

Due to adverse outcomes in patients age >65years who undergo emergency laparotomy NELA suggests surgical units engage with care of the elderly inreach services. This twelve week pilot programme ran during the summer of 2021.

Aim

To assess the feasibility and benefits of elderly care review of acute general surgical patients aged >65 years.

Methods

Surgical team identified elderly patients requiring medical input which were reviewed by the elderly care team. Outputs of consultations were recorded and standard proforma developed.

Results

129 reviews (male- 63, female- 66) of 121 patients, aged 65–94, were seen between 1st June and 31st August 2021. There were 13 patients more than 90 years old. 54 patients had undergone an emergency operation and 36 had bilio-pancreatic disease. 23 patients needed modification of medications for management of heart failure, fluid balance and Parkinson's disease. Further medical investigations for pre-existing medical conditions were arranged and acted upon. There was significant help in managing patients with delirium and in organizing follow up in memory clinic. SNPs were trained in comprehensive review of elderly patients including clinical frailty score and delirium wheel app to aid in assessment.

Conclusion

There was evidence that review by the elderly care team helped in preventing call out to the on call medical team and in optimisation of medical comorbidities in complex older patients. Referral criteria to elderly care around medical optimisation and polypharmacy for complex pre-existing disease, management of delirium, discharge planning and end of life care have been developed.
TH6.1 Fasting times and medication administration in ‘nil by mouth’ emergency surgery patients
Authors: Oxley Catherine , Lingam Gita , Metcalfe Matthew
Published: November 2022

Aims

1) To determine whether ‘nil by mouth’ (NBM) emergency surgery patients are fasted for longer than the recommended 6 hours for food and 2 hours for clear fluids. 2) To establish whether oral medications are being correctly administered/omitted in these patients.

Methods

Fasting and medication administration data were collected prospectively on patients who received emergency surgery over a 2- week period. Drug administration decisions were categorised as ‘correct’ or ‘incorrect’ by comparison with local guidelines.

Results

A total of 65 patients were identified with the average preoperative fasting times being 24 hours for food and 14 hours for clear fluids. However, the range of fasting times exceeded 110 hours. Notably, only 16 (25%) patients had a drink while they were NBM and 29 (45%) patients were incorrectly administered medications, including several instances of omission of critical drugs.

Conclusions

Further work is needed to establish the cause of prolonged fasting periods. However, likely factors include; operation scheduling difficulties, lack of understanding of NBM guidelines, inadequate communication with patients, and patient choice. This is resulting in poor preoperative optimisation of patients (e.g. dehydration of patients), as well as a significant risk to patient safety with critical medications being omitted.

In order to rectify the severe lack of adherence to the guidelines, we are introducing further NBM training for medical professionals in our trust, in addition to updating the current trust guideline to reflect a wider range of medications and keep up to date with current national guidance.
TH6.2 Day Case Laparoscopic Appendicectomy for Acute Appendicitis In Adults: A Retrospective Case Series Study
Authors: Peristeri Dimitra , Jaunoo Shameen
Published: November 2022

Aims

Laparoscopic appendectomy (LA) is nowadays considered the standard of care as it is associated with shorter hospital stay and fewer complications. The purpose of this study was to assess the safety of same-day discharge after laparoscopic appendectomy for acute appendicitis at a tertiary Care Center.

Methods

A retrospective chart review was performed for patients >18 years old who underwent LA for acute appendicitis in 2021. Patients were categorized into 2 groups: discharge in <24h or admission for >24-h. Demographic data, postoperative length of stay, histology report, complications and readmission rates were abstracted from patient medical records.

Results

A total of 303 laparoscopic appendicectomies were included. Of these, 71 patients had Length Of Stay (LOS) less than 24 hours. Pathology, comorbidities, and readmission were recorded. Average LOS for all patients was 7 hours with a minimum stay of 4 hours and a maximum stay of 23 hours. For patients discharged in less than 24 hours, there was no readmission and 58 (19.1%) of these patients had simple appendicitis on pathology. A total of 26 patients (8.58%) were discharged in less than 7 hours (from the recovery room). There was no significant difference in complications or readmission between patients discharged in less than 24 hours and those who stayed longer.

Conclusion

Day case LA is a safe and effective practice for treating selected patients with non-perforated appendicitis, as it decreases the length of stay and hospital charges.
TH6.3 Establishing a sexually transmitted infection (STI) testing programme in an ambulatory surgical clinic for female patients aged 18–44 years presenting with abdominal pain
Authors: Please Helen , Mahon Ciara , Hughes Michael , Ewans Michael , Hartley Anna , Peckham-Cooper Adam
Published: November 2022

Introduction

Young females presenting to hospital with acute abdominal pain (AP) are often discharged without clear diagnoses. Gynaecological causes including chlamydia and gonorrhoea (C&G) are increasing, however STI testing remains underutilised. This study aims to:

1. Establish robust STI testing in an ambulatory surgical clinic (ASC), utilising collaborative pathways between GUM and EGS services.

2. Identify barriers.

Methods

This pilot ran from October to December 2021. GUM-led training for all ASC staff was delivered. All females (18–44yrs) presenting to ASC with AP were offered vulvo-vaginal self-swabs (VVS) and a patient information leaflet. Positive results were referred to GUM for treatment and contact tracing. Following the pilot, a focus group was facilitated to identify barriers and potential improvements.

Results

Twelve eligible patients (mean 28yrs) consented to testing. All results were negative for C&G. Fifteen patients declined (mean 33yrs). The remaining eligible population were not approached. Barriers identified included: nursing staff concerns that offering VVS could make patients feel judged regarding sexual promiscuity; male staff being uncomfortable discussing VVS; concerns regarding other patients overhearing; and a single toilet being inadequate for testing.

Conclusions

The pilot confirmed a robust STI testing programme can be delivered within ASC, which we believe is the first in the country. Strong collaborative working between EGS & GUM teams delivered clear mutually beneficial pathways. However, low numbers of patients undertook testing, accounting for the lack of positive results. Clear barriers were identified which are being addressed prior to delivery of a second pilot period and pathway rollout.
TH6.4 Clinical Audit on the Assessment and Management of Lower Gastrointestinal Bleeding: A Single Centre Experience
Authors: Ling Quake Sharmaine Yen , Johnson Charles , Coulson Alastair , Courtney Michael
Published: November 2022

Aim

To audit our local practice in the management of patients with lower gastrointestinal bleeding (LGIB) against the 2018 British Society of Gastroenterology (BSG) acute LGIB guideline

Method

Patients aged ≥18 years presenting with LGIB at our local trust between January 2020 – May 2020 were included. Data were collected via electronic documentation to identify the following: shock index (SI), whether patients with high-risk Oakland score (>8) were admitted and inpatient investigations received including CT angiogram (CTA), OGD and colonoscopy. Data were analysed according to two patient groups: unstable bleed (SI <1) and stable major bleed (SI>1 with Oakland score >8).

Results

Conclusion

There are potential barriers to implementation of the BSG LGIB guideline, such as reduced awareness of the BSG recommendations, resource availability and economic implications.
TH6.6 Characteristics of Cervical Lymph Node Involvement in Papillary Thyroid Carcinoma
Authors: Rezkallah Emad , Elsaify Wael
Published: November 2022

Background

Papillary thyroid carcinoma (PTC) accounts for 80–85% of all thyroid carcinoma. The SR reaches over 90% over a 10-year of follow-up. The frequency of cervical lymph node metastasis ranges from 40–90%.

We analyzed the data of 37 PTC patients who underwent thyroidectomy and neck dissection to illustrate the pattern of cervical lymph node metastasis in PTC.

Methods

Retrospective review of 37 patients who underwent thyroidectomy with neck dissection for PTC. Preoperative assessment included FNAC, US +/- CT/MRI scans.

Results

The patients’ average age was 44± 19.5 years. Female to male ratio was 1.5:1. The incidences of lymph node metastasis according to the neck level were; 40.5% (15) at level II, 67.6% (25) at level III, 45.9% () at level IV, 16.2% (6) at level V, 54% (20) at level VI, while no metastasis was found at level I. 29 cases (78.4%) had multiple levels involvement, while 6 patients had single level metastasis; 5 at level VI and one at level II. Two patients had no metastatic lymph nodes.

Conclusion

Selective neck dissection has proven to reduce the potential morbidity associated with more extensive neck dissection without affecting the oncological outcomes. Levels III and IV are commonly involved, and usually dissected in continuity. Level II dissection is recommended whenever there is extensive involvement of levels III/IV. Level VI is usually dissected, even as a prophylactic procedure due to the high frequency of microscopic metastases. Level V dissection is usually not recommended unless involved. Involvement of Level I is rare.
TH6.7 Direct Streaming of Acute Surgical Patients to an Advanced Nurse Practitioner-led Service: A Prospective Audit of a Pilot Service to Improve Patient Flow
Authors: Riley Anna , Aherne Aileen , Box Joe , Grady Natalie , Maria Jashmin , Chan Anthony
Published: November 2022

Aims

The ongoing uncertainty of the COVID-19 pandemic and recovery to re-establish elective services presents a major challenge to the NHS. Patient flow and bed capacity is now a priority for acute hospitals. We have implemented a new service model aimed at improving patient flow from A&E, where acute surgical patients are triaged and referred directly to the Advanced Nurse Practitioner (ANP) team for assessment and management. A criterion based on the presenting complaint and clinical observations was developed to identify suitable patients. The utilisation of this service was audited for its safety and impact on the Emergency General Surgical provision.

Methods

The setting is a busy University Teaching Hospital with a diverse catchment population of 75,000. A prospective audit identified the number of patients utilising the new care pathway and details of any adverse events or delays in treatment identified. All patients presenting with a General Surgical condition were included.

Results

Between August and December 2021, 361 patients were referred directly from A&E (81% within first 2 hours of presentation) to the surgical ANP team for assessment. Of these, 85 (24%) were admitted for emergency treatment and 276 (76%) were discharged the same day for either ambulatory or outpatient follow-up, or back to Primary Care. There were no adverse events identified during the audit period.

Conclusion

Direct streaming of acute surgical patients within a defined criteria to an ANP-led service is safe and effective in helping to improve patient flow and experience within an acute care model.
TH6.8 The Utility and Impact of Advanced Nurse Practitioners in Unplanned Surgical Admissions: A Review of the Literature
Authors: Riley Anna , Tod Angela , King Rachel , Chan Anthony , Robertson Steve
Published: November 2022

Aims

Advanced Nurse Practitioners (ANP) are well established within acute medical and Critical Care environments. The evolution of surgical ANPs have tended towards preoperative roles, such as anaesthesia or scrub, with few clinical roles involving the assessment of acute patients or inpatient care. The Royal College of Surgeons of England have recently recognised, by professional membership, the roles of non-medical members of the surgical team, such as ANPs and physician associates. This review explores the areas of impact of ANPs on the emergency General Surgery service provision to help develop the role of the modern surgical ANP.

Methods

A scoping literature review was performed to identify themes of ANP function and outcome. Search terms such as “Advanced Nurse Practitioners”, “Surgical Assessment Units” and “outcomes” were combined with Boolean operators to query PubMed, BNI, CINAHL, Google Scholar and HMIC databases. Studies in the last decade were included.

Results

We identified and screened 54 unique articles. 40 articles were reviewed for eligibility and 21 were included in this review. A thematic analysis identified the impact of ANPs on the process of care (such as assessment and treatment waiting times and patient satisfaction) and outcomes of care (readmission rates, length of stay and cost-effectiveness).

Conclusion

Research into the impact of ANPs are largely focused on objective outcome measures and within non-surgical specialties. Whilst this review demonstrates the positive aspects of ANP care on emergency care, we identify a paucity of evidence on patient-focused outcomes and the impact of ANPs on the patient journey within surgery.
TH6.9 Does the management of right iliac fossa pain vary between men and women?
Authors: Smellie Eloise , Doughty Alice , Cheetham Stephanie , Kenber Melisa , Saha Arin
Published: November 2022

Aims

Recent studies have suggested that women are more likely to suffer a bad outcome after surgery compared to men with similar findings in healthcare areas including pain management and diagnosis. This study aimed to assess the management of female patients with right iliac fossa (RIF) pain.

Methods

Patients who presented to a DGH general surgical unit with RIF pain from March to October 2020 were identified from a prospectively maintained database of admissions. Clinical parameters, management and final diagnosis were recorded. Minimum follow-up was 12 months (October 2021) to identify re-admissions and morbidity.

Results

There were 417 patients; 274 (66%) were women. Women were more likely to have an ultrasound (39% vs. 4%, P<0.001) and less likely to have a CT (60% vs. 67%, P=0.250), though they had the same proportion of normal CT imaging (33% vs. 34%). Men were more likely to undergo surgery (49% vs. 29%, P<0.001) but, despite this, women were more likely to have a diagnostic laparoscopy alone or a normal appendix after appendicectomy (15% vs. 4%). The proportion of women without a definitive diagnosis was greater (39% vs. 32%, P=0.024) and only 4 women were referred on for further investigations leading to a greater proportion of re-admissions with ongoing pain amongst women.

Conclusions

More women than men with RIF pain did not have a diagnosis and women were more likely to have ‘unnecessary’ surgery. Closer attention to gynaecological past medical history or symptoms may improve diagnostic yield and management of women with RIF pain.
TH6.11 Successful Relaunching of NELA at an inner City District General Hospital: Need for Multidisciplinary Approach
Authors: Sarodaya Varun , Gohil Bhavesh , White Alastair , Garg Arti
Published: November 2022

Introduction

The national case ascertainment rate for National Emergency Laparotomy Audit (NELA) over 179 hospitals is 84.5%. Our hospital is one of the few hospitals despite being eligible, had not submitted any data to the NELA for the past three years.

Methods

We retrospectively collected data for all the patients that underwent laparotomy for a period of 2 years. The mean age of patients was 58 years. We found 83 patients who fit the NELA inclusion criteria from January 2020 to November 2021.

Results

The 83 patients were divided into low risk (<5%) and high risk (>5%) and further analysed. The results of the high risk group are illustrated in Table 1.

Discussion

There were various factors which resulted in a low compliance rate. These included a lack of surgical / anaesthetic trainees, a poor understanding of NELA and an overall reluctance to engage in data collection. By re-engaging with NELA data collection, we have facilitated discussion and education regarding laparotomy care at NUH on a multidisciplinary level. We hope to demonstrate improvements in care with subsequent re-audit.

Conclusion

NELA is a useful audit for the comparison of national care. It allows for reflective practice at local level with aim to deliver a uniform standard of care.
TH6.12 Predicting Mortality and Morbidity in Oesophageal perforation: A Review of Current Tools
Authors: Alasmar Mohamed , Shehata Zak , Altarawni Mohammad , Casey Patrick , Melhado Rachel , Sultan Javed
Published: November 2022

Aim

Oesophageal perforation is a challenging condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on.

The aim of this study is to identify the optimal morbidity and mortality risk prediction tool for patients with oesophageal perforation.

Methods

We compared and validated commonly used risk prediction models, including the Pittsburgh Severity Score (PSS), the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The ability to predict morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated for both operative and non-operative cohorts.

Results

Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p<0.001).

Conclusion

Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.
TH6.13 Post-Operative Pain Management Following Emergency Laparotomy
Authors: Shepherd Thomas , Butterworth James , Islam Rafiza , Asante Kirsty , Oke Olatokunbo
Published: November 2022

Aims

Post-operative pain is a common yet challenging presentation. Although an expected part of the acute recovery phase, uncontrolled pain is associated with poorer patient experience, delayed functional recovery and increased morbidity. Up to 40% of patients report severe pain that negatively impacts on their post-operative recovery. We aimed to determine whether post-operative complications and length of hospital admission were associated with choice of analgesic agents.

Methods

We conducted a retrospective observational study of 42 patients who underwent a laparotomy between March – May 2021. Data was extracted from patients electronic medical records and summarised in Microsoft Excel. Statistical analysis was performed using the Chi-Squared and Mann-Whitney U tests.

Results

22 patients (52.4%) experienced post-operative complications whilst 20 (47.6%) did not. In those without post-operative complications, a greater proportion received Patient Controlled Analgesia (PCA) compared to those with post-operative complications (17, 85% vs 11, 50%, p = 0.02). We also observed a trend towards greater use of Oxycodone (11, 55% vs 6, 27%) and Meptazinol (11, 55% vs 7, 32%) in those without post-operative complications (p= 0.07 and p = 0.13 respectively). The length of hospital admission was significantly shorter for patients who received PCA (median = 11 days) compared to those who did not (median = 15 days) (U = 111.5, p = 0.04).

Conclusions

This study emphasises the importance of effective post-operative analgesia in reducing post-operative complications and improving speed of recovery. We suggest that the use of PCA should be encouraged for post-operative analgesia following emergency laparotomies.
TH7.1 Patient Reported Outcomes and Experiences Following Emergency Laparotomy: A Mixed-Methods Patient Survey
Authors: Silva Louise , Abbas Sarah Mohammed , Watts Tessa , Torkington Jared , Cornish Julie
Published: November 2022

Aims

Emergency laparotomy (EmLap) is a “life-saving” procedure, but little is known about how “life-changing” it can be.

This study aims to establish the impact of EmLap using PROMs and PREMs.

Methods

All surviving patients who had an EmLap from 2016–2019 were included. Eligible patients were invited to complete a postal questionnaire. Responses underwent qualitative and logistical regression analysis.

Results

Response rate was 42.6% (n=310). 11.3% reported that they had not resumed intimacy post-op. Patients were less likely to resume intimacy if they were >80 years (OR 10.500, p0.003), had a return to theatre (OR 5.111, p0.017), IBD diagnosis (OR 5.00, p0.009) or stoma (OR 4.906, p0.003). Patients were more likely to change employment if female (OR 2.858, p0.009), more comorbid (ASA3 OR 5.000, p0.024), had a stoma (OR 4.006, p<0.001), or incisional hernia (OR 4.228, p<0.001).

Qualitative analysis revealed deconditioning, lack of employer support, and delays to reconstructive surgery were the main reasons for not returning to work.

Qualitative analysis of experience exposed a number of unmet needs: surgical “debrief” and “what to expect” (33.6%), surgical aftercare (25.2%), mental-health support (22.6%), and timely restorative surgery (11.7%). 88.1% felt a specialist nurse would have improved their experience. Patients were more likely to have reported a negative experience if they had benign disease (p0.010).

Conclusion

This is the first study to describe PROMS and PREMS following EmLap, and also to identify patients at risk of poor outcome. It advocates the need for an EmLap specialist nurse to facilitate holistic aftercare.
TH7.2 The EXTEND trial: EXTENDed antibiotics to improve outcomes in patients with complicated Intra-Abdominal Infection (cIAI)
Authors: O'Connor Olivia , Ahmed Shadia , Burke Dermot , Kirby Andrew , Pinkney Thomas , Szakmany Tamas
Published: November 2022

Introduction

Complicated intra-abdominal infections (cIAI) pose a major challenge in surgical patients. Despite the heterogenous aetiology they have a common disease process, which is bacterial infection of the peritoneal space. Hence, all cIAIs are managed with source control, plus antibiotic therapy. However, there is uncertainty regarding the optimal antibiotic treatment strategy in order to prevent relapse or extra-abdominal spread of infection. Presently, there is no UK guidance on the management of cIAIs. For other serious infections outside the abdomen microbiologists often advise at least 28-days of antibiotics. Currently the effectiveness of extended duration antibiotics in patients with cIAI is unknown. This trial aims to compare the clinical and cost effectiveness of 28-day duration antibiotics with standard care with respect to rate of treatment failure in patients with cIAIs. Secondary outcomes include complications and quality of life.

Method

A multicentre, open label, two-arm, parallel group, pragmatic, randomised controlled trial with internal pilot. A total of 1166 consenting adult patients with cIAI will be recruited over 3 years and randomised on a 1:1 basis between 28-days antibiotics and standard care antibiotics. Patients will be recruited from ICUs and hospital in-patient wards across 30 sites.

Trial management and funding

EXTEND is sponsored by University of Leeds and hosted by York Trials Unit. It is funded by the NIHR. The Trial Management Group will oversee design and running of the trial. Each site will have a Principal Investigator (PI) with local responsibility. The NIHR Associate PI scheme will be adopted to enable trainees to participate in the trial.
TH7.4 Improving quality of message taking for on-call surgeons unable to answer calls during emergent operating
Authors: Walters Anna , Sanders Katie , Marsh Robyn , Malik Mariam , Stonelake Stephen
Published: November 2022

Aims

Responding appropriately to messages taken by theatre staff whilst the on-call surgeon is performing emergency operations is an important aspect of emergency care. As part of a quality improvement project we produced a standardised proforma aiming to ensure messages had sufficient information to enable the on-call surgeon to prioritise referrals according to clinical urgency

Methods

Written messages from emergency theatre were collected from February to December 2021. A new proforma for message taking was introduced in May 2021. This consisted of a pre-printed A5 sheet with space for eight specified informatics to be recorded alongside the free-text message; namely, patient name, DOB, PID, location, name and role of caller and time of message. Additionally, the urgency and early warning score could be recorded. The presence or absence of the above 8 key pieces of information was examined and the score was recorded pre and post intervention.

Results

There was 60% (32/53) uptake of the new proforma following its introduction. The mean quality of information score for 60 messages pre-intervention was 2.6/8 (range 1–6) compared with 3.9/8 (range 1–8) in 53 messages collected post-intervention (P = < 0.01). One out of 60 (2%) versus 11/53 (21%) had the level of urgency stated in the pre-intervention and post-intervention group respectively. Three of the 11 urgent messages additionally included patient's observations and early warning score.

Conclusions

This simple and reproducible proforma produced a quantifiable improvement in the quality of messages received, enabling the on-call surgeon to better prioritise care for emergency surgery patients.
TH7.5 De Garengeot hernia: a combination of niche presentation, diagnostic, and anatomical factors
Authors: Sylvester Rochelle , Singh Gautam , Haque Ali
Published: November 2022

Background

De Garengeot hernias occur in almost 1% of femoral hernias and are diagnosed when the appendix is also present within. They are more commonly observed in post-menopausal women, but their pathogenesis remains controversial. Theories involve abnormalities in bowel rotation during embryological growth, caecum mobility or size, and increased abdominal pressure. Most are diagnosed intra-operatively and are otherwise incidentally discovered on imaging. An advised surgical technique has not been determined due to its rarity; however, most literature suggests laparoscopic hernioplasty and appendicectomy in absence of infection.

Case report

A 77-year-old female presented with a three-day history of a painless, right groin mass. Blood results were within normal range, and sonography identified a De Garengeot hernia suggesting appendiceal inflammation. She underwent emergency laparoscopic surgery that discovered a strangulated appendiceal tip within an incarcerated femoral hernia, which then unexpectedly divided during manipulation. Additional findings included a broad mesoappendix and lack of appendicitis. The team proceeded with a hernioplasty and appendicectomy, and the patient was discharged two days later without complications.

Conclusion

This case report highlights a few niche aspects of De Garengeot hernias. Firstly, it is unusual our patient's diagnosis occurred preoperatively via ultrasound; secondly, the ischaemic tip of the appendix unexpectedly self-detached upon mobilisation; and thirdly, the widened mesoappendix likely contributed towards her predisposition to De Garengeot hernias. Overall, our case represents laparoscopic surgery being optimal in treating De Garengeot hernias that are diagnosed preoperatively, and that they should remain a differential diagnosis for non-specific groin lumps, regardless of pain.
TH7.8 Delayed Diagnosis of Duodenal Injury in Blunt Abdominal Trauma following a normal initial Computed Tomography scan: A Systematic Review
Authors: Westerman Robyn , Stathakis Panos , Goldsmith Paul , Smith Stella , Macutkiewicz Christian , Chan Anthony
Published: November 2022

Aims

Isolated duodenal injury and perforation can result from blunt abdominal trauma (BAT) in approximately 5% of patients with intrabdominal injuries. Modern major trauma pathways mandate computed tomography (CT) as part of the primary assessment. The evolution of a duodenal injury to a perforation can be delayed. The aim of this review is to ascertain the proportion of false negative CTs for duodenal perforation in BAT.

Methods

A systematic review of the literature was conducted using PubMed, Embase and OvidSP databases to include search terms “blunt abdo*”, “duoden*”, “trauma”, and “computed tomography” combined with Boolean operators. Data were extracted from studies that report data on patients following BAT with a normal initial CT who subsequently develop a perforation. Studies were limited to the last 10 years.

Results

There were 315 articles identified, which after excluding duplicates and screening, 18 articles were reviewed in detail and 6 articles (3 case studies and 3 retrospective cohort studies) included in the final review. Across the 6 studies, a total of 159 patients suffered BAT with 29 patients (18%) having a normal CT on admission. The majority of patients underwent a repeat CT within 24 hours which then subsequently revealed radiological signs of a duodenal injury/perforation.

Conclusion

Patients who present with following BAT should be closely observed for delayed clinical signs of visceral perforation. CT (preferably with oral contrast) should be performed if there is any clinical suspicion of perforation, even if the timeframe is within 24 hours of the initial CT scan.
TH7.10 Extraction site hernias following Laparoscopic Right Hemicolectomy: Does location matter?
Authors: Smith Laurie , Filby Joseph , Coxon Harriet , Cornish Julie , Torkington Jared
Published: November 2022

Introduction

Laparoscopic colorectal surgery is the gold standard treatment for patients requiring colorectal resection, however the need to exteriorise the specimen and perform extracorporeal anastomosis leads to a risk of incisional hernia. Robotic surgery may facilitate intracorporeal anastomosis which could potentially negate the need for an umbilical extraction site. This study compares current practice of transverse versus midline extraction sites for laparoscopic right hemicolectomy and the incidence of incisional hernia.

Methods

A retrospective collection of all patients undergoing laparoscopic right hemicolectomy between 2018 and 2020 was performed using OPCS theatre codes. Only those undergoing laparoscopic right hemicolectomy, who had cross-sectional imaging post-operatively were included. Operation notes were scrutinised to identify extraction site and closure method. Post-operative CT scans were reviewed by a radiologist to identify presence of incisional hernia.

Results

Of 103 patients, 50 met the inclusion criteria. 25 were male. The mean age was 67 (Range = 21–85). 31 patients had midline extraction sites, with 19 having transverse. The average time from operation to CT was 662 days (314–1094) and 34% (n=17) had incisional hernia identified on a CT scan post-operatively. Midline extraction sites were associated with a significantly higher rate of incisional hernia when compared to transverse sites (n=16/31, 1/19; p<0.01).

Conclusion

Transverse extraction sites are associated with a lower risk of incisional hernia after laparoscopic right hemicolectomy and should be preferred to midline incisions where possible. As intracorporeal anastomosis becomes a more established technique, further work is needed to determine optimum extraction site to further reduce the risk of incisional hernias.
TH7.12 Improving electronic prescribing of mechanical VTE prophylaxis in general surgery patients
Authors: Gunn Christopher , Alam Imran
Published: November 2022

Aims

Mechanical VTE prophylaxis forms part of NICE guidance in general surgical patients. Locally, thromboembolic deterrent (TED) stockings are used but not available as a prescription item on the electronic system. They are often prescribed verbally or via noted plans but do not appear on the medication administration record. Importantly, multiple incidents of patient harm through pressure damage have been seen due to poorly checked TEDs. Our aim was to audit and improve safe mechanical VTE prophylaxis prescribing.

Methods

At each cycle, we retrospectively collected data from two weeks of admissions. Data relating to VTE assessment completion, VTE score, TEDs in use, TEDs prescription and LMWH prescription was collected. Our initial intervention consisted of departmental education regarding a work around enabling TEDs to be prescribed as a freehand extra-formulary item. This was reaudited at 12 months.

Results

All patients in both cycles had VTE assessments completed. TED stocking use increased significantly from 5.1% to 26.4% and prescription of TEDs, when used, increased from 0% to 61.1%. However, documentation regarding daily checks was non-existent.

Conclusions

Our QIP showed a significant improvement in TEDs use and prescription. However, the intervention is difficult and time consuming. Subsequently from this project, a TEDs stocking item is in the final approval phase for integration into the online prescribing system and will come with associated safety checks built into the nursing medication administration system. Once this is live, we will complete a third cycle to assess uptake and again at 6 months to assess for lasting change.
TH8.1 Radiological incidence of donor-site incisional hernia and parastomal hernia after Vertical Rectus Abdominus Myocutaneous Flap-based reconstruction following colorectal surgery
Authors: Tang Alethea , Spencer Naomi , Parkins Kristie , Bevan Victoria , Drew Peter , Harries Rhiannon
Published: November 2022

Aims

The vertical rectus abdominis myocutaneous (VRAM) flap is commonly used to reconstruct perineal defects for low rectal and anal cancer. The incidence of midline incisional hernias after VRAM reconstruction varies from 3.6% when detected clinically to up to 50% when detected radiologically. The aims of this study is to accurately determine the radiological incidence of donor-site incisional and parastomal hernia following VRAM reconstruction.

Methods

Retrospective cohort study of patients undergoing colorectal surgery requiring VRAM reconstruction over 10 years. Data were collected on patient demographics, indication for surgery and surgical procedure including details of any hernia repair. Images from surveillance CTs were reviewed for presence and size of midline incisional and/or parastomal hernias. Parastomal hernias were classified based on the European Hernia Society (EHS) classification.

Results

173 patients were included in the analysis. The median age was 67 years (range 29 – 88 years) and median length of follow up was 49 months (IQR 24.3 – 71.0 months). The overall radiological incidence of incisional hernia was 27.6%. The radiological incidence of donor-site incisional hernia after VRAM at 1, 2 and 5 years was 16.8%, 25.2% and 18.5%. The parastomal hernia incidence at 1, 2 and 5 years was 37.9%, 44.1% and 29.8% (48.6% overall).

Conclusions

The majority of patients who develop donor-site incisional hernia and parastomal herniation following VRAM tend to do so within the first two years. Although the use of CT imaging improves the diagnosis of donor-site incisional and parastomal hernias, the clinical significance of this is unknown.
TH8.2 Trans-umbilical versus peri-umbilical incision for general laparoscopic surgery
Authors: Jones Stacey , Sheredi Mohamed
Published: November 2022

Aims

The aim of this study was to determine whether a trans-umbilical or peri-umbilical incision is a better route for the initial umbilical trocar in general laparoscopic surgery in terms of post-operative pain, risk of surgical site infection (SSI), post-operative complications and scar cosmesis.

Methods

This was a prospective study of 128 patients who underwent a trans-umbilical incision and 97 patients who had a peri-umbilical incision during general laparoscopic surgery between January 2020 and July 2021. Demographic data and type of surgery were obtained from the operation note. Following the procedure each patient was contacted via telephone and asked questions regarding, post-operative pain, SSI, post-operative complications and cosmetic satisfaction.

Results

Of the 128 patients within the trans-umbilical group, 57.8% were female with a mean age of 44.4 years and a BMI of 26.6 kg/m2. Whereas, in the peri-umbilical group 62.9% were female with a mean age of 50 years and a BMI of 29.8 Kg/m2. The most common operation performed was laparoscopic cholecystectomy in both groups. The trans-umbilical group experienced less post-operative pain than expected p=0.03, less post-operative complications p=0.009 and better scar cosmesis satisfaction p=0.001. There was no statistically significant difference in the rate of SSI p=0.73.

Conclusion

The trans-umbilical incision for initial peritoneal access in general laparoscopic surgery is recommended due to the lower than expected post-operative pain, reduced post-operative complication rates and increased patient satisfaction with regards to scar cosmesis.
TH8.5 VTE Pharmacological Prophylaxis in Oesophagogastric Cancer Resection Patients: A Triple Cycle Closed Loop Audit Against NICE Guidance NG89
Authors: Baxter Jessica , Room Hywel , Parsley Conor , Smith Benjamin , Sechante Chalint
Published: November 2022

Aims

NICE NG89 Guidance introduced in 2018 recommends 28 days extended VTE pharmacological prophylaxis in patients who have major abdominal surgery for cancer. In 2018, our oesophagogastric unit protocols prescribed only inpatient VTE prophylaxis. Through the interventions of clinician education and modified unit protocols we improved our unit's compliance with NICE NG89.

Methods

We conducted a three cycle hybrid audit. 50 patients who underwent either oesophagectomy or gastrectomy were randomly chosen from 2017–19 (Cycle 1), 2019–21 (Cycle 2) and 2021–22 (Cycle 3). The first cycle intervention was the requirement for 14 days postoperative VTE pharmacological prophylaxis. The second cycle intervention increased this requirement to 28 days. All cycles additionally had interventions of clinician education.

Results

Against the NICE NG89 recommendation for 28 days postoperative pharmacological prophylaxis, our audit showed 14% compliance in Cycle 1, 26% in Cycle 2 and 91% in Cycle 3. The median duration of VTE prophylaxis prescription (combined inpatient and outpatient) was 7 days in Cycle 1, 23 days in Cycle 2 and 28 days in Cycle 3. The correct dose by weight for VTE prophylaxis was prescribed in 89% of cases in Cycle 1 and 100% of cases in Cycle 2 and 3. Whilst small numbers preclude statistical analysis, there were 2 bleeding events and 1 VTE event in both Cycles 1 and 2 but none in Cycle 3.

Conclusions

Our unit made a stepwise improvement against the NICE NG89 recommendation for extended VTE prophylaxis in cancer resections. Furthermore, clinician education improved correct weight based dosage.
TH8.8 Retrospective study on the safety of thyroid surgery with confirmed benign histology in a UK district general hospital
Authors: Adedeji Ayodeji , Omakobia Eugene , Agada Frank , Gordon Conor
Published: November 2022

Aim

With increasingly aging population, more thyroidectomies are being performed in the elderly. These surgeries may be suspected to be unsafe as majority of the geriatric population suffer from comorbidities. Our local study explored the safety of thyroid surgery with confirmed benign histology in the elderly, with the post-operative complication rates being the primary outcome measures.

Methods

The study group included patients over 75 years who had thyroid surgeries with confirmed benign histology in a UK district general hospital from January 2010 to January 2022. We then analysed the rates of complications including temporary hypocalcemia, permanent hypocalcemia, vocal cord palsy and haematoma.

Results

41 elderly patients underwent thyroid surgery with confirmed benign histology in our facility within the period. 78% of them had thyroid lobectomy and the commonest indication for surgery was benign multinodular goitre. There were no haematomas, no permanent vocal cord palsies and no cases of permanent hypocalcemia. Only 3(7.3%) patients had transient hypocalcemia, and 2(4.9%) had vocal cord palsy which all resolved before 6 months.

Conclusions

Our study has demonstrated that it is generally safe to perform thyroidectomy in the elderly population with low hypocalcemia and vocal cord palsy rates as compared to the British Association of Endocrine and Thyroid Surgeons’ report of 10.2% and 7.8% for hypocalcemia and early cord palsy rates respectively in all age-groups. Nevertheless, we would advocate appropriate patient selection in terms of ASA classification. For example, 50% of those who had post-operative vocal cord palsy in our study had an ASA of 3.
TH8.9 Impact of laparoscopic sleeve gastrectomy on fibrosis stage in patientswith child–A NASH–related cirrhosis
Authors: Salman Mohamed , Noureldin Khaled , Issa Mohamed , Tourky Mohamed , Badawi Marwa , Abdelaziz Ayyat
Published: November 2022

Introduction

Bariatric surgery can improve non-alcoholic fatty liver disease (NAFLD). This work endeavored to evaluate laparoscopic sleeve gastrectomy (LSG) in cases with compensated non-alcoholic steatohepatitis (NASH)-related cirrhosis and its impact on fibrosis stage.

Methods

A prospective work involved 132 cases with Child-A NASH-related cirrhosis suffering from morbid obesity scheduled for LSG. They had preoperative assessment, wedge biopsy, and ultrasound-guided true-cut liver biopsy after 30 months. Patients with F4 fibrosis were included. Liver condition was assessed based on NALFD Activity Score (NAS).primary outcome measure was the impact of LSG on fibrosis stage and its relation to weight loss.

Results

Analysis included only 71 patients who completed the 30-month follow-up period. By the end of follow-up interval, there was a substantial weight loss with a reasonable resolution of comorbidities. median NAS decreased from 6 (1–8) to 3 (0–6) after surgery. Fibrosis score regressed to F2 in 19 patients (26.8%) and F3 in 29 (40.8%). Patients with improved scores had a significantly higher amount of weight loss (p < 0.001). Improvement was more frequent in males (p = 0.007). By 30 months after treatment, 53.8% of cases with borderline NASH and 36.8% of those with probable NASH showed complete resolution, and 44.7% of patients with NASH showed improvement. Steatosis improved in 74.6% of patients.

Conclusion

Patients with NASH-related liver cirrhosis of Child class A, LSG may be a secure approach for the management of morbid obesity. It has a long-term benefit for both obesity and liver condition with significant improvement of steatosis, steatohepatitis, and fibrosis.
324 Total Knee Arthroplasty in Haemophilia Patients: A Systematic Review and Meta-Analysis of Long-Term Survivorship, Functional Outcomes and Complications
Authors: Fu H , Peacock C , Wang C , Kader D , Asopa V , Sochart D
Published: November 2022

Aim

End-stage arthropathy is a well-known complication of haemophilia, with recurrent haemarthroses leading to joint destruction, deformity, pain, and stiffness. In the knee, this is often treated with total knee arthroplasty (TKA), which can be more challenging in patients with haemophilia (PwH) and associated with poorer outcomes. We conducted a systematic literature review and meta-analysis to determine implant survivorship, functional outcomes, and complication rates.

Method

A systematic review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting TKA outcomes with Kaplan-Meier survivorship in PwH (PROSPERO registered). Meta-analysis was performed for survivorship and outcomes, and the results were compared to outcomes from the National Joint Registry (NJR).

Results

19 studies, totalling 1187 TKAs (average age 39 years) were reviewed. In PwH, implant survivorship at 5, 10, and 15 years was 94%, 86%, and 76% respectively, whereas NJR reported survivorship for males <55 years was 94%, 90%, and 86%. Survivorship generally improved over the time period studied (1973–2017) but was inversely correlated with HIV infection (common in PwH). Range of motion improved by 10–20° post-operatively, and there were large improvements in Patient Reported Outcome Measures (PROMS). The prosthetic joint infection rate (PJI) was 6% compared to 0.5–1% in non-PwH, but the reporting of other complications, especially haematological, was inconsistent.

Conclusions

TKA in PwH has similar 5-year survivorship to non-PwH, but a six-fold higher infection rate. There were marked improvements in range of motion and PROMS, but complications were poorly reported. There remains a need for larger, long-term studies with standardised reporting.