bluuebunny/crossref_metadata_2025 huggingface dataset:
TU7.6 Comparing Cholecystectomy Day Case Rates during the pre-COVID and COVID Era at a Rural District General Hospital
Authors: Chituku Tsitsi , Lim Eammon , Nithiyabhaskaran Raekulan , Anderson Catherine , Ali Mahmoud , Rao Milind
Published: November 2022

Aims

67 000 cholecystectomies performed every year in the UK and 92% are laparoscopic. 75% of operations should be done as day cases. National rates vary between 6–50% with the most successful centres at 70%. Our aim was to audit the day case rate at our Trust pre-COVID and compare it to during COVID.

Methods

A retrospective audit of patients identified via clinical coding who had an elective cholecystectomy at one hospital in the Trust between 1 December 2018 to 31 November 2019. During COVID we did a prospective audit of patients identified via Theatreman who had an elective cholecystectomy at the Trust's designated “Green Hospital” between 21 September 2020 to 21 December 2020. Data for all patients was collected from electronic discharge summaries, clinic letters and patient notes.

Results

Pre-COVID our day case cholecystectomy rate was 73% compared to 54.7% during COVID. Pre-COVID conversion rate from planned day case to inpatient stay was 16.3% and during COVID the conversion rate increased to 44%. The waiting time for a cholecystectomy doubled during COVID to 26.3 weeks from 13.6 weeks pre-COVID. Average re-admission rate with symptomatic gallstones was 0.79 pre-COVID and 0.95 during COVID, with 64% of patients having at least one admission prior to surgery. The average length of stay pre-COVID was 0.75 days compared to 0.57 days during COVID.

COVID adversely affected our day case cholecystectomy rates with resultant increased waiting times for surgery and re-admissions with symptomatic gallstones however the average length of hospital stay was reduced.
TU7.7 Cheques and Balances: A Five Year Review of Surgical Settlements
Authors: Clements Caterina , Bezzaa Sabrina , Curwen Oliver , Vance-Daniel Joseph , Lewis Trystan , Nehra Dhiren
Published: November 2022

Aim

The litigious burden in the NHS has been increasing yearly, costing an estimated £2.5 billion per year in financial settlements. We investigated the causes of general surgical settlements and attributed costs at a district general hospital over a five-year period.

Method

A retrospective analysis of all general surgical claims between 2016–2021 using the NHS Resolutions Case Management System. Selected cases were those which resulted in out of court financial settlements; whilst these claims have been settled, the trust admitted no negligence in each case.

Results

A total of 12 settlements were made with a total cost of £249,918 (£8000-£60,000, mean £20,827). Eight of the claims (67%) related to elective cases with four (33%) emergency cases. Of the total cases, 41% and 33% related to management of gallstones and appendicitis respectively.

The majority of claims (58%) related to delays in treatment with a total cost of £103,500 (£8000-£35,000), accounting for 41% of total settlement costs. Five cases (42%) were due to harm with a combined total of £146,418 (£9000-£60,000), 59% of the total settlement. Of the claims due to harm, 80% suffered recognised complications of the procedure.

Conclusions

Increasing litigation in the NHS over the last decade now accounts for 2% of the total NHS budget. The majority of settlements reviewed here were for avoidable delays in elective treatment, with higher financial settlements for well documented surgical complications related to the consent process. Better access to investigations, earlier clinical review, and reductions in delays to elective surgeries may reduce the financial burden of litigation.
TU7.8 Pay Per View: Cost and Satisfaction of Virtual Video Clinics
Authors: Clements Caterina , Bezzaa Sabrina , Graham Gemma , Tharmarajah Emmanuel , Jamal Karim , Lewis Trystan
Published: November 2022

Aims

The Covid-19 pandemic necessitated use of video consultations to provide continued patient care. It is not clear if video clinics are well received by patients, or if they are cost efficient. We evaluate the benefits of video consultation and review the impact on waiting times and cost implications to a trust.

Methods

100 patients referred between January - December 2021 with gallstones were invited to complete a patient satisfaction questionnaire after initial clinic consultation. Patients were divided into three groups based on consultation type; face-to-face, telephone and video consultation (via the Attend Anywhere platform). Secondary outcome measures included time from referral to appointment, time to final outcome and cost implications.

Results

93 patients responded; 33 video, 30 face-to-face and 30 telephone consultations. Of these patients 62% were female and 38% male with an average age of 51 (25–84).

Average time from referral was 22 days in the video cohort, 22 in the telephone cohort and 32 for face-to-face appointments. Of the video cohort, 44% were booked for cholecystectomy from initial consultation and 56% sent for further investigation. The conversion rate from video to face-to-face consultation was zero.

50% of respondents stated face-to-face consultations as their preferred method of future consultation, 49% of patients opted for video and 1% preferred telephone consultation. 79% reported increased satisfaction due to convenience of consultation.

Conclusion

This study demonstrates video consultations decrease costs and waiting times. Patient satisfaction is comparable to in-person visit. Specific referral criteria and patient selection is essential to maximise the benefits of video consultations.
TU7.9 Validation and comparison of new scoring clinical systems to predict uncomplicated versus complicated appendicitis
Authors: McGuire Andrew , Clifford Siobhan , Dhannon Amenah , Hill Arnold
Published: November 2022

Aims

Methods

This was a retrospective review of a sample of patients whom underwent appendicectomy between 2018 and 2021 in a tertiary university teaching hospital. Inclusion criteria consisted of CT imaging prior to surgery to confirm diagnosis, along with clinical and laboratory data needed to analyse the two scoring systems. Final histological diagnosis of complicated versus uncomplicated appendicitis was employed as the gold standard. Positive predictive (PPV) and negative predictive values (NPV) were calculated for CT, Atema and APSI scoring systems.

Results

In total, 92 patients were included in the study, whereby 55 patients (59.8%) presented with uncomplicated and 37 patients (40.2%) with complicated appendicitis. With regards to predicting complicated appendicitis: Atema score had a PPV of 47.5% and a NPV of 73%. APSI had a PPV of 43.9% and a NPV of 62.7%. CT had a PPV of 50% and NPV of 65.5%.

Conclusion

The accurate diagnosis of uncomplicated versus complicated appendicitis may aid in selection of patients to conservative versus surgical management of acute appendicitis. Our study has shown that radiological findings alone have low positive and negative predictive values. The use of the new Atema scoring system was found to have a higher NPV when compared to radiology findings and the APSI scoring system. This may improve accuracy in discriminating uncomplicated versus complicated appendicitis when selecting treatment pathway.
TU7.10 Short and medium-term symptom response to fundoplication in reflux-associated chronic cough in a UK Centre
Authors: Dexter Eloise , Siracusa Francesca , Brown Ayla , Wilkins Alexander , Dolan Ciaran , Pellen Michael
Published: November 2022

Aim

To identify whether anti-reflux surgery is an effective treatment for reflux-associated cough in a single specialist unit.

Method

A retrospective analysis of patients referred for suspected reflux-associated cough undergoing anti-reflux surgery over a 12 month period in a single centre. Pre-operative oesophageal physiology and imaging, operative technique and follow up records were examined. Symptom resolution and relapse was assessed four years postoperatively.

Results

15 patients underwent anti-reflux surgery following referral with suspected reflux-associated respiratory symptoms. 6 patients had hiatus hernia (40%). There was no correlation between symptom improvement and presence of hiatus hernia, lower oesophageal sphincter (LOS) pressure or DeMeester score (DS).

13 of 15 patients attended initial follow-up. 12 (92.3%) reported complete or partial resolution of symptoms. Acid suppression medication was discontinued in 7 (53.8%) patients at follow up. 100% of patients with marked oesophageal dysmotility (OD) and elevated DS reported their symptoms either partially or fully resolved. One patient who reported no symptom improvement had normal LOS pressures and normal DS but marked OD.

At four-year follow up, 7/13 reported symptoms (53.8%). Of these 3 have been re-referred for recurrent cough (23.1%), 1 for dysphagia (7.7%) and 2 experienced symptomatic reflux (15%). The final patient (7.7%) underwent revision surgery (partial reversal of Nissen Fundoplication) and was satisfied postoperatively.

Conclusion

Patients referred by the respiratory service for reflux-associated cough show good symptom improvement which is largely maintained following anti-reflux surgery. Relative contraindications of dysmotility did not appear to be predictive of worse outcome in this group.
TU7.11 Skin Grafts Vs. Local Skin Flaps in Management of Contracted Scar Finger
Authors: Noureldin Khaled , Issa Mohamed , Maryosh Sally , Xerri Samuel
Published: November 2022

Introduction

In our study, we reviewed the outcome of using skin grafts and different regional flaps of the hand in order to correct flexion contractures of the Proximal Interphalangeal (PIP) joints of fingers. In both techniques, vigorous postoperative exercises were advised for an interval of time between 3–6 months.

Patients and Methods

16 patients were included. All the scar tissue was excised, and the resultant raw area was covered. In Group A consisting of 8 patients, skin grafts were used. Split thickness grafts were selected in 3 cases and full thickness grafts in 5 cases. While in group B, Z-plasty and Cross finger regional flaps were used in 4 cases per each flap. The cause of the contracture was thermal burn in 8 patients, mechanical trauma in 7 cases, and a case of contracture secondary to dupytrene's disease. The mean follow-up period was 6 months.

Results

The mean flexion contracture/further flexion in the joints were improved markedly at the last follow-up. More extension was gained by exercising after the operation. Near full ROM was achieved in 15 cases with strong hand grip and cosmetic satisfaction. There were no major complications.

Conclusion

Wise selection between different skin grafts and regional skin flaps is important, to achieve best outcome in managing finger contractures and gain satisfactory ROM. Choosing the best reconstruction method depend on the size, extent and depth of the raw area. Exposure of the deep structures is an indication to use skin flaps over grafts. Vigorous extension exerc
TU8.1 Evaluation of drain insertion after appendicectomy for complicated appendicitis: A systematic review and meta-analysis of 17 studies
Authors: Abbakar Malaz , Mohamedahmed Ali Yasen
Published: November 2022

Introduction

Surgical drains are used to reduce post-appendicectomy collections. However, they can cause considerable discomfort or increase the risk of surgical site infection (SSI), among other problems. Our aim is to review the literature systematically and conduct a meta-analysis to assess the advantages of using drains (DG) versus no drain (NDG) in complicated appendicitis.

Methods

This systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. All randomized control trials, comparative observational studies comparing outcomes of drain or no drain after appendicectomy for patients with complicated appendicitis were considered.

Results

Seventeen studies (n=4255 patients) who underwent appendicectomy for complicated appendicitis with drain (DG=1580) without a drain (NDG=2657) were included. There was no difference between the two groups regarding abdominal collection [Odd ratio (OR)=1.41, P=0.13] and mortality [ risk difference (RD)= 0.01, p= 0.18]. NDG was superior to the DG regarding SSI [OR=1.93, P= 0.0001], faecal fistula [OR=4.76, P= 0.03], Intestinal obstruction [OR=2.40, P= 0.04], and ileus [ OR=2.07, P=0.01]. The No-drain group showed statistically significant shorter LOS when compared to the drain group [MD 1.79, 95% CI (1.25, 2.34), P= 0.00001].

Conclusion

In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of post-operative complications such as fistula, surgical site of infection (SSI), bowel obstruction, ileus, and prolonged hospital length of stay.
TU8.2 Percutaneous cholecystostomy for acute calculous cholecystitis an observational study from a single institute
Authors: Abdelsaid Kirolos , Jeilani Milad , Hassan Mohamed , Jayasankar Balaji , Ali Haythem
Published: November 2022

Introduction

Although percutaneous cholecystostomy (PC) is generally accepted as a bridge to definitive therapy for acute cholecystitis (AC), which remains cholecystectomy, some patients did not undergo cholecystectomy mostly due to contraindications to surgery. Here, we aimed to audit our clinical practice from a single institute.

Methods

153 patients presented with AC and initially managed with PC were included. The proportion of patients who did not undergo subsequent LC and their characteristics were analysed.

Results

27% (41/153) of the study cohort underwent LC while the remaining patients (n=112) did not receive any surgical intervention.22/122(20%) were presented with AC and coexisting hepatobiliary malignancy. The mean age of the remaining patients (n=90) was 75±13 years and the median length of drain insertion of those patients 40 days.

The majority (57%) was presented with sever AC while 8% had AC with adjacent liver abscess. 55% of those patients did not develop any further attacks of AC after PC removal while 25% deemed unfit for surgery. The rest of the patients (20%) either refused the operation or died before LC. The American Society of Anaesthesiologists (ASA) score was 3 IV in 9% of patients (8/90).

15% (13/90) experienced post PC complications including either blocked stent, pain and cellulitis around tube. The 60-day mortality rate of patients who did not underwent LC was 11% (10/90).

Conclusion

The majority of AC patients treated initially with PC did not undergo subsequent LC. PC in high surgical risk patients with AC could be consider as definitive treatment.
TU8.3 The optimal timing of Laparoscopic cholecystectomy following percutaneous cholecystostomy in Acute cholecystitis
Authors: Abdelsaid Kirolos , Sultan Majid , Rae Thomas , Hassan Mohamed , Jayasanakar Balaji , AbdulAal Yasser
Published: November 2022

Introduction

Percutaneous cholecystostomy (PC) is an effective option for high risk and/or delayed presented Acute cholecystitis (AC). However, the optimal timing for subsequent laparoscopic cholecystectomy (LC) as a definitive treatment remains controversial.

Methods

This study includes 41 patients underwent LC following PC for severe AC. We compared the length of tube insertion, period from PC till LC and period from PC removal till LC against co-morbidities, another attack of AC, subsequent pancreatitis/jaundice and operative difficulties in terms of intraoperative adhesions, drain insertion, conversion to open, length of operation.

Results

The median time of length of tube insertion was 36 days (range 5–208) while the median time of PC insertion till LC was 144 days (range 31–744) and for period from PC removal till LC was 78 days (range 0–714). Patients with prolonged tube insertion (more than a month) showed higher risk of developing subsequent pancreatitis and or jaundice (P=0.04) while intraoperative adhesions was associated with prolonged time from tube insertion till operation (more than 4 months). There was no significant association between neither the length of tube insertion, period from PC insertion till LC nor period from PC removal till LC and other studied parameters.

Conclusion

Prolonged time of PC insertion and/or prolonged time form PC insertion till LC in patients with AC have higher risk of pancreatitis and surgical difficulties. Further studies including larger number of patients’ sample is warranted to confirm the outcomes and determine the optimal time of LC following PC in those patients.
TU8.4 Standard of Operation Notes in General Surgery
Authors: Agboro Stephen , Yomi-orungbe Esther
Published: November 2022

Aims

To assess the quality and precision of operation notes, as well as, ensure that they were written in accordance to requirements and standards set by the Royal College of Surgeons England as stated in “Good surgical practice”.

Method

It was a retrospective local audit and re-audit of patients admitted under the General Surgery department where 50 & 30 patients were selected randomly in May 2021 and October 2021 respectively. Data was extracted from applications on secure trust servers and analyzed on Microsoft Excel with patient information carefully anonymized.

To establish the standard of best practice for this audit, guidelines published in The Royal College's “Good Surgical Practice” were used to devise a comprehensive list of criteria that should be present on every operation note. These can be found at: http://www.rcseng.ac.uk/standardsandguidance.

Results

The results of the initial audit were compared with that of the re-audit. Significantly noted in the re-audit, was the 50% improvement in documentation of criteria such as the name of anesthetist, anticipated blood loss, operative diagnosis, and antibiotic prophylaxis. There was also more clarity in the documentation of post-op plans in the re-audit (e.g duration of post-op antibiotics/VTE prophylaxis and wound care) for each patient as recommended in the initial audit.

Conclusion

The improvement in clear and precise documentation of operation notes noted in this re-audit helped to improve the quality and safety of patient care delivered. Further audits and re-audits, as well as, quarterly re-education of surgeons have been recommended to attain and maintain targets.
TU8.5 Management of acute lower gastrointestinal bleeding (LGIB) remains largely conservative and the impact of BSG recommendations largely unseen: results of a 4 year audit
Authors: Ahmed Salma , Patten Alan , Guy Richard
Published: November 2022

Background

LGIB accounts for 3% of all emergency referrals in the UK. BSG Guidelines for management were recently published, largely based upon the findings of the 2015 UK Nationwide Audit. A retrospective 4-year audit was conducted to assess the impact of these guidelines.

Methods

All patients presenting to an EGS service with LGIB, 2 years before and after BSG guidelines, were identified. Data on demographics, mode of presentation, investigation,management and diagnoses were retrieved. A comparison was then made with The UK Audit and BSG Guidelines.

Results

Some 98 patients were identified. Re-admission rate was 19% and median length of stay 2.7 days compared with 3 days and 21.4%, respectively, in the UK audit. Diverticular disease accounted for the majority of known diagnoses but with a higher proportion of malignancies. The usage of Oakland score as a criterion for safe discharge was significantly evident following BSG guidelines, an increase from 7.1% to 14.6% was noted (P. value 0.005). 41.8% of the patients underwent CT scans compared with 25.9% in the UK audit. Similarly, higher percentages of colonoscopy/ flexible sigmoidoscopy were noted, 65.3% compared with 25.4%. Surprisingly, 0% of the patients underwent angioembolization, not very different from the national average of 0.8%.

Conclusion

This audit demonstrates a practice that is largely in line with national experience but with variations potentially related to social deprivation. Access to urgent inpatient colonoscopy remains a problem but CT rates are high and need for surgical intervention is low. A significant impact of the BSG guidelines is not demonstrable.
TU8.6 Pharmacological management of post-operative pain following appendicectomy: a meta-analysis
Authors: Alam Benyamin , Akbari Amir Reza , Awodiya Afolarin , Alali Bader , Ekhlacy Shaida
Published: November 2022

Introduction

Appendicectomy is an increasingly common procedure internationally, and is the most frequent emergency surgery performed in the UK. Post-operative pain is common after surgery, if poorly controlled it can cause many negative outcomes for patients. Despite the large number of patients that undergo appendicectomy and the potentially severe outcomes of post-operative pain, there is no clear guidance on how best to control pain following appendicectomy. The aim of this meta-analysis is to compare the efficacy of different modalities of analgesics following appendicectomy, to identify which is best at controlling post-operative pain

Methods

A literature search was conducted across online libraries for trials assessing pain scores after appendicectomy with different analgesics administered. These were grouped based off modality. Using the data in these trials a forest plot was created for each modality with an effect estimate and confidence intervals calculated for each trial

Results

6 studies investigated nerve-blocks; an estimated effect of -1.01 with CIs of -1.39 to -0.4 was calculated. 3 studies investigated NSAIDs; an estimated effect of -0.46 with CIs of -0.70 to -0.23 was calculated. 3 studies investigated local anaesthetics; an estimated effect of -0.83 with CIs of -1.91 to 0.26 was calculated. 1 study investigated opiates with an estimated effect of -0.82 with CIs of -1.47 to -0.17 was calculated

Conclusion

Nerve-blocks were the most effective modality of analgesic followed by NSAIDs. No clinically significant effect was proved for local anaesthetics as the CIs crossed the null hypothesis. Opiates were not compared due to insufficient data
TU8.7 An audit of the investigation and management of acute appendicitis at a tertiary referral centre in Ireland
Authors: Alanza Uchechukwu , Julius Barbara , Merrigan Anne , Baban Chanrow , Tormey Shona
Published: November 2022

Aim

Acute appendicitis (AA) is among the most common emergency surgical presentations to Irish hospitals. In 2020, the World Society of Emergency Surgery (WSES) updated its Jerusalem guidelines for the investigation, diagnosis, and management of AA. We aimed to evaluate our institutional compliance with these guidelines in the COVID era and outline potential areas for improvement.

Methods

We performed a retrospective chart review of all patients admitted to our institution with the diagnosis of AA in July 2021 and compared them against the standards outlined in the WSES Jerusalem guidelines.

Results

39 patients were identified. Average age was 25.4 years. 2.6% (n=1) had clinical scores documented. 33.3% (n=13) had computerised tomography scans performed, 33.3% (n=13) underwent ultrasound scans and 33.3% (n=13) had no diagnostic imaging. 100% proceeded with surgical management. Average time to theatre was 16.9 hours. 23.1% (n=9) were open appendectomies, 74.4% (n=29) were laparoscopic appendectomies and 2.6% (n=1) was a laparoscopic converted to open appendectomy. 100% had histopathological analyses. 69.2% (n=27) were true AAs, 15.4% (n=6) were negative appendectomies and 15.4% (n=6) were non-inflamed appendices with other pathology including lymphoid hyperplasia, fecolith or enterobius. Average length of stay (AvLOS) was 3.6 days.

Conclusions

As regards timely surgical intervention and routine histopathology, we are compliant with the guidelines. However increased utilisation of validated clinical scoring systems could potentially reduce negative appendectomy rates and AvLOS. We believe an educational intervention is required to improve our compliance with these standards.
TU8.8 Fundoplication or gastropexy in emergency giant hiatus hernia repair?
Authors: Alasmar Mohamed , Mckechnie Iona , Chaparala Ram
Published: November 2022

Aims

Operative management of emergency presentation with a hiatal hernia aims to reduce the herniated stomach, dissect the hernial sac and reapproximate the crura. This will often be followed by fundoplication or gastropexy to minimise the risk of recurrence. This study compares the recurrence rates between patients who underwent fundoplication and gastropexy.

Methods

From October 2012 to November 2020, 80 patients were admitted to a tertiary oesophagogastric centre requiring emergency surgery to repair a giant hiatal hernia. We conducted a retrospective review and analysis of their admission and follow-up. The primary outcome measure was acute and post-discharge symptomatic recurrence of hiatal hernia.

Results

Of the 80 patients requiring emergency hiatal hernia surgery, 38% had fundoplication procedures, 53% had gastropexy, and 3% had both (n 30, 42, 2 respectively). One patient had neither, and 6% (n 5) patients had a complete or partial stomach resection due to necrosis. Eight patients (10%) had a symptomatic recurrence of hiatal hernia requiring a repeat operation; three within the index admission, five postdischarge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n 4, 3, 1)(p-value 0.5). 19% (n 15) patients were readmitted. Post-operative mortality was 6% (n 5).

Conclusions

There is no conclusive evidence in the literature favouring fundoplication versus gastropexy. The surgeon's experience and patient factors influence choice of technique. This review, which includes the largest cohort of patients available in the literature, demonstrates that surgical technique does not influence the symptomatic recurrence rate in our patient group.
TU8.11 Improving the efficiency of the EGS service in a University Teaching Hospital. Smarter application of standards and use of resources
Authors: Bose Sayantan , Baltatzis Minas , Carlson Gordon
Published: November 2022

Aim

Effective utilization of resources for emergency general surgery (EGS) is essential for operational efficiency. Many patients have pathology with a time-dependent outcome and clinical standards have been established regarding timing of surgical intervention. The aim of this study was to investigate barriers to the delivery of timely EGS.

Methods

The delivery of EGS between 31/01/21 and 30/08/21 was studied. All cases were reviewed to determine clinical urgency, appropriateness of “urgency” within the clinical context (diagnosis, NEWS-2 score) and timing of EGS. Discrepancies between theatre booking and clinical need and delay in undertaking EGS compared with the relevant clinical standards were identified.

Results

EGS was undertaken in 520 patients (262M:258 F), mean age 49 (16–101) years. 34(6%) were booked as needing “immediate”, 130 (25%) “urgent 2–6hr”, 242 (47%) “urgent 6–18 hr” and 114 (22%) “expedited” EGS. In 373 (71.7%), EGS was undertaken in a time frame which met (or exceeded) relevant standards. In 235 (45%) cases, the urgency of booking exaggerated clinical need. EGS was “delayed” in 147 (28.3%) cases when compared with urgency as booked, but when actual clinical need was reviewed EGS was delayed in only 66 cases (12.7%). Delay was due to unavailability of facilities in 25 (38%) of cases, whereas in 24 (36%) treatment was delayed purely “overnight”.

Conclusion

Inappropriate allocation of clinical urgency resulted in the majority of “delayed” EGS. The routine application of RCS18 standards would prevent this. Avoiding delay overnight and an increase in theatre resource would improve efficiency.
TU8.12 Group and Screen for Laparoscopic Appendicectomies: Is It Necessary?
Authors: Bradley Rebecca , Linder Cortland , Marsden Max , Abraham Adjit
Published: November 2022

Background

Blood transfusion is rarely required in laparoscopic appendicectomies. The incidence of major vessel injury is 0.04%, yet many trusts require two valid G+S samples prior to the operation. A retrospective review was conducted to assess the incidence of peri-operative blood transfusion in laparoscopic appendicectomies in a large tertiary centre, to challenge the requirement for these G+S samples in the hope to reduce clinical and financial burden.

Methods

A retrospective case note review of patients undergoing emergency laparoscopic appendicectomies in the Royal London Hospital was conducted from 01/06/21 – 01/12/21. Patients under 18 years and those who received an appendicectomy as a concurrent procedure during other operations were excluded. The monetary value of each G+S sample was investigated through discussion with laboratory staff, and a total saving was calculated.

Results

95 patients were included. 93 patients had two valid G+S samples prior to their appendicectomy. No patients required perioperative blood transfusion (within two days pre and post op). One patient required a blood transfusion in the 5th postoperative day. An estimated total of £10,500 could be saved per year in this hospital alone, should G+S samples not be required for laparoscopic appendicectomies based on this data.

Conclusions

We concluded that two G+S samples are not necessary for every patient undergoing a laparoscopic appendicectomy. The incidence of transfusion is scarce throughout literature, and it appears that the financial and clinical burden of these blood samples far outweighs the population transfusion requirement in this particular surgery
TU8.13 How can we help things move along? – A review of the management of the acute bowel obstruction
Authors: Tijani Muzammil , Anjum Nabeel , Byrne Hannah , Musse Umeyma , Abdulkadir Munirashirwa , Ahmed Jamil
Published: November 2022

Background

Acute bowel obstruction (ABO) is a common surgical emergency and is associated with significant morbidity and mortality. Currently there is no national guidance for the management of ABO and an NCEPOD study highlighted the resulting variance in care nationwide. This study recommended several standards of care for the management of ABO and we aimed to review our practice against this guidance.

Method

A retrospective review identified all adult patients admitted with a radiologically confirmed diagnosis of ABO, over an 8 month period. 8 key performance indicators (KPIs) were adapted from the NCEPOD recommendations and data was collected from patient notes, drug charts and computer records. A total of 22 patients are included in this study to date.

Results

The median length of time from referral to surgical review and from surgical review to CT scan was 112 mins and 134 mins respectively. 31.8% of patients underwent emergency surgery. Pain documentation was the only KPI that met 100% target compliance. A MUST score was completed in 72.7% of cases, a treatment escalation plan in 36.4% of cases, hydration status was documented in 4.5% of cases and no patients had a frailty score documented.

Conclusion

Our results demonstrate that significant improvements can be made in the management of ABO and the recognition of aspects known to impact patient morbidity and mortality. In keeping with NCEPOD recommendations we suggest the implementation of an ABO pathway. We hope this will assist clinicians in caring for patients with ABO, promote MDT collaboration and highlight clinical concerns early.
WE1.1 Bilateral Gracilis Reconstruction following Extra-Levator Abdominoperineal Excision: an updated case-series
Authors: Jenkins Evan , Humphrey Hannah , Watts Andrew , Rogers Patrick , Rogers Patrick , Daniels Ian
Published: November 2022

Introduction

Circumfrential resection of low rectal or anal cancers poses a challenge to the reconstructive surgeon. Resective procedures including the extralevator abdomino-perineal excision or pelvic exenteration utilise a wide margin of excision, creating a significant tissue deficit. The aim of this case series is to demonstrate that use of bilateral pedicled gracilis muscle flaps (BPGMF) may offer several advantages to other methods of perineal reconstruction. This technique avoids any disruption to the abdominal wall; a benefit in laparoscopic surgery. Fashioning both muscles into a ‘weave’ creates a muscular sling across the perineum. This offers support to pelvic contents following the excision of the pelvic floor muscle groups.

Methods

This is a retrospective, single centre study, of patients undergoing reconstruction of perineal defects using BPGMF. All cases took place between January 2008 to July 2021.

Outcomes

There were 56 patients who underwent perineal reconstruction using BPGMF. The indications for surgery were cancer (52 patients) and perineal hernia repair (4 patients). There were 24 female patients and 27 male patients in the patient. The average age of patients was 60 years. The 30 day mortality was 2% (1 patient).

A healed perineal wound was seen at 30 days following surgery in 82% (46/56) of patients. The complication rate for the donor site and reconstructed site was 14% and 23% respectively. Complications included infection, hematoma, dehiscence and seroma formation.

Conclusion

BPGMF offers a reliable and technically simple muscle flap to reconstruct large perineal defects. It is associated with low morbidity and recreates support to the pelvic floor.
WE1.5 Management of Anorectal trauma - A UK trauma centre based experience
Authors: Keshishian Karekin , Bradley Rebecca , Forsyth Katrina , Knowles Charles , Hancorn Kate
Published: November 2022

Introduction and Aim

The evidence base supporting the management of traumatic anorectal injuries is poor. Previous case series provide some general observations on management decisions. The aim of the current study was to describe the largest UK experience of anorectal trauma management from a national major trauma centre.

Methods

Retrospective review of prospective data, collected systematically as part of routine trauma practice locally, was performed. Data were extracted on mechanism of trauma, immediate hospital care, diagnostics and operative management. Outcome data were extracted, where available, from follow up. Data are presented descriptively in a case series format.

Results

37 patients (35 male vs 2 female) presented with traumatic anorectal injury between March 2012 and December 2021. The median age was 34 (6–93), 20 (54%) were penetrating injuries (11 stabs, 5 GSW, 5 other) vs 17 (46%) blunt (13 RTA, 4 other). Median Injury severity score was 16. Of the 37 cases treated, there were 18 intra peritoneal (8 both intra and extra) vs 16 extra peritoneal injuries. 30 patients had defunctioning stoma (DS), 8 cases had primary repair (PR) (with or without DS). Mean length of stay was 27 days. 15 out of 37 have had GI continuity restored, out of which 13 had a water-soluble contrast study and 5 anorectal physiology preoperatively.

Conclusions

Traumatic anorectal injuries are uncommon within UK practice, affect predominantly young men and have high morbidity. In the majority of cases defunctioning stomas are still the mainstay of treatment. Primary repair of extraperitoneal injuries is a viable procedure.
WE1.6 Effects of prehabilitation programme on outcomes after colorectal cancer surgery
Authors: Kumaran N , Al-Eryani Y , Ihedioha U
Published: November 2022

Aims

Surgery for colorectal cancer is associated with risks of complications and death. These are associated with higher mortality and morbidity rates, lower quality of life and increased expenditure in healthcare. We aimed to determine the impact of prehabilitation on patient outcomes with regards to length of hospital stay and postoperative complications.

Methods

The prehabilitation programme was introduced to our unit in March 2021. We compared outcomes of all patients undergoing elective colorectal cancer surgery before and after introduction of the programme from a prospectively maintained database. Records of patients in the non prehabilitation group (NP) between January to June 2019 and those in the prehabiltation group (PhP) between April to October 2021 were analysed. Our primary aim was to compare the length of stay between the groups with a secondary aim to compare postoperative complications.

Results

A total of 151 elective colorectal cancer patients were included. There were 64 patients in the NP group and 87 patients in the PhP group. The median length of stay in the NP group was 7 days and in the PhP group was 5 days. 30% of patients in the NP group developed post-operative complications while only 19% of patients in the PhP group developed post-operative complications.

Conclusion

Prehabilitation is a vital component in a patient's treatment journey. Results from our study have shown an improvement in postoperative outcomes. It should therefore be an element of all enhanced recovery programmes. Further research in this domain could include individualised programs to obtain more benefits
WE1.7 Comparing the white cell count (WCC) and C-reactive protein (CRP) in robotic and laparoscopic colorectal resections within the immediate post-operative period
Authors: Liu Mamie , Gami Mayur , Hopson Bradley , Saju Christy
Published: November 2022

Aims

Determining factors affecting the WCC and CRP in laparoscopic and robotic colorectal cancer resections within the immediate 48-hour period.

Methods

Single centre data was collected retrospectively.100 robotic and 193 laparoscopic cases were included.

Cut offs for WCC and CRP were set at >11 and >50. Fisher's Exact test was used for analysis.

Results

Robotic group had 67% left sided operations vs 43% laparoscopically. Stoma formation was higher in the robotic group (61% Vs 15%). Other patient demographics including male to female ratio, BMI, ASA and tumour size were comparable.

Average length of stays (LOS) and operation times were longer for robotic than laparoscopic approaches of the same operation. Average lymph node yield was higher for robotic right hemicolectomy 26.6 (vs 23.5 laparoscopic) (P=0.05).

Median WCC within 48-hours was higher in the laparoscopic group 10.9 (vs 11.3 robotic). More laparoscopic cases 53% (vs 35% robotic) had WCC >11 (P=0.006). Median 48h CRP was higher in robotic 51.6 (vs 45.6 laparoscopic).

CRP was consistently higher in operations involving stoma formation (P= 0.008) and operative time >4 hours (P=0.001) both laparoscopically and robotically.

Conclusions

Absolute median immediate WCC and CRP were similar between laparoscopic and robotic colorectal resections although operative times were longer and stoma formation higher in the robotic group. Stoma formation and longer operations correlated with higher CRPs. No firm conclusions can be drawn about differences in the immediate serum WCC and CRP between laparoscopic and robotic cases in this study due to confounding factors.
WE1.10 Acute Diverticulitis: Are We Following National & International Guidance On Antimicrobial Strategy For Uncomplicated Cases?
Authors: Patel Nikheel , Oladeji Emmanuel , Bains Parisha , Day Nigel , Gupta Ashish
Published: November 2022

Aims

Uncomplicated acute diverticulitis is conventionally treated with antibiotics. Emerging evidence has suggested a non-antimicrobial approach in systemically well patients is a safe alternative strategy. Our aim was to assess adherence to national (NICE) & international (WJES) guidelines for uncomplicated cases.

Methodology

Data was gathered from PACS imaging & discharge summaries retrospectively (1st October 2020–1st March 2021).The inclusion criteria was: CT confirmed cases of modified Hinchey stage 0 or 1a. The cohort was stratified into systemically well or unwell based on: admission CRP <150, observation score <2 (NICE sepsis stratification), immunocompetance status & Charlson score <3, as evidenced in the literature.

Results

There were 48 patients included (female 29 vs male 19). The number of systemically well patients was 32 (67%) & unwell 16 (33%). Compliance to guidance 1 (NICE) - ‘systemically well & therefore no antibiotics’, was low with only 2/32 (6%) patients. Of the remaining, 14/30 (47%) were given intravenous antibiotics. Compliance to guidance 2 (NICE) - ‘systemically unwell & therefore oral antibiotics’, was 4/16 (25%) with the remaining majority of 12/16 (75%) treated with intravenous form. The median number of inpatient nights was 1.48 (well: 1.28 vs unwell: 1.88).

Conclusions

The majority of patients with uncomplicated diverticulitis were systemically well. Compliance with guidelines on antimicrobial strategy was low. The incorporation of a risk stratification tool as demonstrated, allows for identification of patients that be discharged (with ambulatory follow up) after assessment. CT scans should be reviewed by radiologists with a multidisciplinary discussion on the most appropriate antimicrobial strategy.
WE2.1 An Audit of MRCP usage in patients with suspected biliary disease in a major teaching hospital in Dublin
Authors: Aketch Martin Safari , Qaoud Yazan , Hill ADK
Published: November 2022

Aim

To assess MRCP usage in patients with suspected biliary disease in a major teaching hospital in Dublin

Background

Our surgical team in this hospital regularly admits patients with complications arising from gallstones e.g. acute pancreatitis. This audit is aimed at looking at the appropriateness of using MRCP in this cohort of patients.

Methods

We accessed Beaumont's electronic patient records and its radiology system to gather the data. Data was collected over 3-months between September and December 2021 which included 91 patients.

Results

There were 82 inpatient and 9 outpatient requests performed over the 3-month period. The average inpatient wait for MRCP was 3.2 days. The commonest clinical indication was CBD stones. There were 55 females and 36 males with suspected biliary disease with an average age of 58 years. Majority of our patient cohort had deranged LFTs and had symptoms suggestive of a biliary disease. Ultrasound abdomen was performed in 41 patients (45%) prior to MRCP. CBD stones were only found in 15 patients (16%). 20 patients (22%) had surgical decompression of their biliary system.

Conclusion

Our clinicians use BSG guidelines on gallstones as an adjunct whether a patient needs an urgent MRCP. We still place a strong emphasis on the patient's clinical presentation and background history prior to ordering this scan.

Recommendation

Work with our radiology and gastroenterology colleagues, come up with a tailored approach and hospital guideline, to diagnose and treat our cohort of patients with biliary disease.
WE2.2 Video Presentation of performing a Laparoscopic Cholecystectomy on a patient diagnosed with Situs Inversus Totalis
Authors: Asnani Kusum , Ikechi Chijioke , Shah Ankur , Fernandes Roland
Published: November 2022

Background

Situs inversus totalis (SIT) is a condition in which the arrangement of the internal organs is a mirror image of normal anatomy, occurring in 0.0001% of patients. A thorough understanding of the human anatomy and anatomical variances is crucial in everyday clinical practise and emergency surgical care. We present a video on a patient with SIT who underwent a Laparoscopic Cholecystectomy (LC).

Case

Our patient is a 40-year-old lady with a known diagnosis of SIT. She presented with jaundice and left upper quadrant pain (LUQ). An ultrasound and CT scan confirmed the diagnosis of gall stones, CBD stones and SIT. She underwent an ERCP to clear CBD stones.

LC is one of the commonest general surgical procedures, however, this case proved challenging due to reversed anatomy. Intraoperatively, operating positioning was reversed with mirror imaging of ports used normally. Standard 10mm ports were placed in the infraumbilical and epigastric regions and the remaining ports placed in the LUQ. Abdominal organs were inspected and SIT was confirmed. It was ensured that a slow, meticulous delineation of Calot's triangle and window of safety was performed. The cystic duct and artery were clipped. The rest of the procedure was uneventful.

Results

The patient was discharged on the same day as the procedure. There were no immediate or short-term complications. Gallbladder histology showed chronic cholecystitis, cholelithiasis and cholesterolosis.

Conclusion

This case demonstrates that with appropriate planning and an advanced skill set, a LC can be performed in a patient with SIT, with little or no complications.
WE2.3 Comparative study of early versus delayed laparoscopic cholecystectomy following endoscopic sphincterotomy for mild to moderate acute biliary pancreatitis
Authors: Devkaran Bhavesh , Sharma Shivam , Sodhi Surinder , Chauhan Arun
Published: November 2022

Background

Acute pancreatitis is an inflammatory disease of the pancreas with acute biliary pancreatitis (ABP) accounting for 75% of cases. Current recommendations favour early laparoscopic cholecystectomy (LC) for mild acute gall stone pancreatitis during the same index admission to prevent recurrent attacks reported to be as high as 18–61% in various studies. Endoscopic sphincterotomy in cases who are unfit for cholecystectomy during the index admission or there is delay in cholecystectomy due to logistics may benefit from ES while waiting for elective cholecystectomy, in terms of reducing the number of recurrent attacks and decreasing morbidity.

Methods

A total of fifty-seven (57) patients of mild to moderate ABP were included in this study and were divided into three groups undergoing LC within 5 days of admission, ES within 7 days of onset of pain abdomen and LC within 4 weeks of initial illness and LC after 8 weeks of attack in the three respective groups and evaluated for level of difficulty of cholecystectomy, recurrent attacks and associated morbidity.

Results

Difficult LC in terms of adhesions, calots anatomy was seen in 17(n=57) patients. 13(n=38) patients had recurrent attack of pancreatitis during the waiting period for cholecystectomy, 2(n=19) in the ER group and 11(n=19) in the conservative management group, with all patients in the conservative group having more than 2 recurrent attacks.

Conclusion

LC in early period is a safe, effective, in patients of gallstone induced pancreatitis. ES is well tolerated and viable alternative to cholecystectomy to prevent recurrent pancreatitis until definitive treatment.
WE2.5 Laparoscopic Common Bile Duct Exploration using disposable Bronchoscope and Cystoscope: Case Series in a District General Hospital
Authors: Hackney Lauren , Eta Asim , Eltayeb Omar
Published: November 2022

Aims

Case Series performing Laparoscopic Common Bile Duct Exploration (LCBDE) using single use bronchoscope and cystoscope in a district general hospital. Aim is to explore the safety and efficacy of using single use instruments.

Methods

Retrospective study of all LCBDE from a single consultant using single use scopes from May 2019 to January 2022. Data collected from Electronic Care Record, notes and theatre management system. Both choledochotomy and transcystic approaches were used. Operations were recorded and outcomes of patients explored.

Results

Fifteen laparoscopic CBD explorations were carried out during the identified period. Indications included young patients (<50yr) 33.3%, Failed ERCP 13.3%, Referral by gastroenterologist 13.3% and other reasons 40%.

The mean age (+/- SD) was 58 (+/-17) and 80% of patients were female. 66.6% of cases were emergencies, 40% had intraoperative cholangiograms, 100% underwent primary closure. The average length of stay (±SD) after the operation was 10 (±8). One patient developed a haemoserous collection that required a laparoscopic washout, one developed post-operative atrial fibrillation and one patient was readmitted with post-operative infection. There were no intraoperative complications or equipment failures.

Conclusions

The use of disposable bronchoscope and cystoscopes are safe and effective way of performing LCBDE. This approach is also cost effective compared to the more expensive reusable choledocoscope particularly when considering delays due to sterilisation as well as issues with availability in departments. Providing this service in district general hospitals will assist in extensive waiting lists and potentially avoid morbidity associated with ever lengthening waiting lists and reduce pressure on tertiary centres.