bluuebunny/crossref_metadata_2025 huggingface dataset:
EGS P03 Outcomes from 450 Endoluminal Vacuum Therapy (EVT) Procedures in the Management of Upper Gastrointestinal Leaks and Perforations
Authors: Alkhaffaf Bilal , Powell Arfon , Ibrahim Ahmed , Farooq Naheed
Published: November 2023

Background

Anastomotic leaks and perforations of the upper gastrointestinal (UGI) tract are life-threatening conditions which result in significant rates of morbidity. There is no consensus with respect to how these challenging cases should be optimally managed.

Endoluminal vacuum therapy (EVT) is a novel approach for the management of leaks and perforations in the UGI tract. Proponents highlight the benefits of its use particularly in cases where major invasive surgery or re-operation would otherwise usually be required. We present the outcomes from nearly 450 EVT related procedures during the last 5 years.

Methods

A retrospective analysis of all UGI leaks and perforations managed with EVT between September 2018 and June 2023 was undertaken. This included patients who had undergone cancer resections (oesophagectomy and gastrectomy), bariatric surgery (both within and out with our centre) and those presenting with benign disease (e.g. oesophageal perforation and iatrogenic injury). The setting was a regional tertiary oesophago-gastric and bariatric centre in the North-West of England serving a population of over 3.5 million people. Demographic data, patient and disease factors, nutrition-related data, and outcomes related to EVT were collected. Descriptive and statistical analysis was undertaken.

Results

59 patients (43 males; median age 61) underwent 446 EVT related procedures during the study period, of which 52 (88%) were alive at discharge. Median LOS was 43 days. 66% (39/59) cases related to post-operative leak (resection 28, bariatric surgery 11) vs 11/59 spontaneous and 8/59 iatrogenic perforations. Median number of procedures was 6 (IQR 3-11) over a median of 21 days (IQR 11-41). Successful healing was achieved in 86% (51/59) cases. There was no difference in success rate between pathologies (p=0.88), however, iatrogenic perforations required fewer EVT procedures before healing (p=0.00). No adverse events were directly attributable to EVT.

Conclusions

UGI leaks and perforations represent a heterogeneous group which pose a significant management challenge. Our study suggests that EVT is a safe and effective approach in managing a broad range of different UGI leaks and perforations. EVT opens the possibility of active treatment for patients unsuitable for more invasive surgical intervention. Further study is required to standardise nomenclature, indications and follow-up. Comparisons to other management approaches are required to further explore the benefits for patients, taking into consideration clinical efficacy, impacts on quality of life and cost-effectiveness.
EGS P08 The effect of socioeconomic status on traumatic liver injuries: A prospective multicentre study
Authors: Koh Amanda , Lewis-Lloyd Christopher , Blackburn Lauren , Adiamah Alfred , Brooks Adam ,   LIPTA Collaborators
Published: November 2023

Background

Abdominal traumas only represent 10% of all trauma-related injuries but is associated with significant morbidity and mortality. This is especially true for liver and pancreatic injuries. There is a growing interest in understanding the complex relationships between socioeconomic deprivation and trauma in recent years. Evidence from the US demonstrates that social deprivation is strongly associated with violent traumas and more severe injuries. There is, however, a lack of research examining the relationship between socioeconomic deprivation and severe abdominal traumas. This prospective multicentre audit investigates the association between socioeconomic status and the mechanisms and outcomes of liver and pancreatic traumas.

Methods

This prospective, multicentre audit was conducted through the National Trauma Research and Innovation Collaborative at18 participating major trauma centres and units in the United Kingdom between 01/01/2021 and 01/10/2021. The differences in patient demographics, mechanism of injury, injury severity score, operative management, length of hospital stay, and mortality were compared between patients from the five socioeconomic groups. The socioeconomic status for each patient was determined using the Index of Multiple Deprivation (IMD) tool, which is a recognised and validated tool published by the UK government. Chi-squared, Fisher’s Exact, and Kruskal-Wallis tests were used to compare categorical variables as appropriate.

Results

Of the 232 patients included, 75% were male. There is an increasing trend of deprivation in males, with 82.9% of the most deprived patients being male compared to the 66.7% in the least deprived quintile. The most deprived group had a lower comorbidity burden and were younger with a median age of 26 (IQR 19-39) compared to the least deprived group (median age 42, IQR 28-61,p<0.01). Penetrating injuries occurred more frequently in the 3 most deprived groups, although this was not significant (p=0.09). There were no differences in the management, length of stay, and mortality between the 5 socioeconomic groups.

Conclusions

The findings of this prospective study adds to the growing body of evidence associating socioeconomic deprivation and major trauma in the UK. Despite the differences in patient demographics across the socioeconomic groups, the definitive management and mortality did not differ. The planning and provision of preventative public health intervention should target areas of higher socioeconomic deprivation.
EGS P09 Audit of Management of Acute Upper Gastrointestinal Bleeding against National Standard
Authors: Ng Shou Kee , Namade Mitesh , Adeoti Olayiwola Moses , Khan Khurram Shahzad
Published: November 2023

Background

Acute upper gastrointestinal bleeding (AUGIB) remains a common gastrointestinal emergency with varying standards of care, management practices, patient outcomes and high mortality rates in the United Kingdom. National strategic initiatives have been implemented in response to this, the most recent and definitive one being the AUGIB care bundle released by the British Society of Gastroenterology (BSG) led multisociety consensus in 2019. We audited our performance against BSG AUGIB care bundle.

Methods

This was a retrospective cohort study conducted in a single surgical unit on all consecutive adult inpatients who received emergency oesophago-gastro-duodenoscopy (OGD) from September 2021 to September 2022. Patients who were scoped for indications other than AUGIB were excluded. Patient demographics, inpatient hospital notes, laboratory multisociety consensus results, NCEPOD data and endoscopy reports were studied and analysed. These findings were then compared against recommendations as described by the BSG multiconsensus care bundle. The compliance target for each step was 100%. This study was registered with Clinical Quality Project (LanQIP 14739).

Results

150 OGDs were included; 79 (58.7%) were male and median age was 63 years (IQR 52.5-75.5). Median length of stay was 3.7 days (IQR 1.9-7.8). Melaena was the commonest presenting symptom (n=95, 63.3%). 54 (36%) presented with NEWS >2 and 12 (8.0%) in shock. Offending medications was the primary risk factor in 66 patients (44%).

All OGDs had consultant supervision. 85 (56.7%) were performed in-hours. 55 (36.7%) had gastritis and 20 (13.3%) had oesophageal varices. 10 (6.7%) were re-admitted within 3 months. 30-day mortality was 8.0%. Our audit outcomes were as follow (Table 1):

Conclusions

Whilst senior clinician involvement was strong in our unit, there was a significant gap in concordance with BSG measures in applying the care bundle, GBS risk scoring and the resuscitation and medical management of acute bleeders. Formally implementing the AUGIB bundle from the emergency department into the admission unit will provide a framework for junior doctors to safely and systematically assess and resuscitate of patients with AUGIB, and guide timely planning for endoscopic intervention and follow-up by the senior clinical decision-maker. This should be continually re-audited to ensure improvement in performance together with outcome measures to ensure real change.
EGS P12 To Perform Magnetic Resonance Cholangiopancreatography or Not in Gallstone Pancreatitis? – A Single Centre Retrospective Cohort Study
Authors: Ng Shou Kee , Stevenson Carla , Ansari Fraz , Khan Khurram Shahzad
Published: November 2023

Background

The management of gallstone pancreatitis (GSP) is well-described in guidelines from the Association of Upper Gastrointestinal Surgeons (AUGIS) and British Society of Gastroenterologists (BSG). Guidelines recommend laparoscopic cholecystectomy (LC) for mild GSP within 2 weeks of the admission, with endoscopic retrograde cholangiopancreatography (ERCP) as second-line for unfit patients. Magnetic resonance cholangiopancreatography (MRCP) plays a pivotal role in excluding choledocholithiasis. Our aim was to determine if MRCP is required to rule out choledocholithiasis in patients with GSP.

Methods

A retrospective cohort study of all consecutive adult patients who had MRCP for GSP in a single centre from September 2020 to September 2022 was conducted. Patient demographics, pre-MRCP peak liver function test (LFT) values and MRCP findings were analysed. Patients were risk-stratified based on modified AUGIS guidelines using the presence of hyperbilirubinaemia and the presence of biliary duct dilation on other imaging modalities. Patients with MRCP-proven choledocholithiasis were compared to those without. P-values were calculated using Fisher’s exact test. This study was registered with Clinical Quality Project (LanQIP 14738).

Results

138 patients were identified; median age was 61 years (IQR 45-73) and 95 (68.8%) were female. 20 (14.5%) patients were post-cholecystectomy. 115 (83.3%) had inpatient scans and 66 (47.8%) were urgent. Median waiting time for inpatient MRCPs was 1.1 days (IQR 0.8-1.9) and 22.9 days (IQR 13.4-28.0) for outpatient scans.

25 (78.1%) patients had raised alkaline phosphatase levels and 23 (71.9%) had hyperbilirubinaenia. 61.1% of abdominal ultrasounds and 38.5% of CT scans reported dilated bile ducts.

MRCP yielded 32 patients (23.2%) with choledocholithiasis, 3 of whom were post-cholecystectomy. Choledocholithiasis on MRCP was strongly correlated to higher risk stratification.

Conclusions

MRCP is useful imaging modality determining the presence of choledocholithiasis in high and moderate risk patients with GSP. We recommend that intraoperative cholangiography should still be performed during laparoscopic cholecystectomy where expertise is available.
EGS P19 Do Waiting Times for Inpatient Magnetic Resonance Cholangiopancreatography Affect Total Length of Stay? – A Single Centre Experience
Authors: Ng Shou Kee , Stevenson Carla , Ansari Fraz , Khan Khurram Shahzad
Published: November 2023

Background

Magnetic resonance cholangiopancreatography (MRCP) is an important imaging modality in ruling out choledocholithiasis and thus guide management of patients. However, access to MRI remains limited, which may lead to delays in discharge. Our aim was to analyse the waiting time for inpatient MRCP and its impact on total length-of-stay (LOS).

Methods

A retrospective cohort study of all consecutive adult inpatients who underwent MRCP in a single surgical unit was conducted from September 2020 to September 2022. Patients being investigated for non-biliary indications including hepato-pancreato-biliary malignancies were excluded.

Patient demographics, laboratory results, MRCP indications, results and timestamps from the hospital’s radiology information system were analysed. Peak liver function test (LFT) values before MRCP were used. P-values were calculated using Student T-test. This study was registered with Clinical Quality Project (LanQIP 14736).

Results

677 patient has inpatient MRCPs; 22 were excluded. Median age was 66 years (IQR 51-76) and 401 (59.2%) were female. 281 (41.5%) MRCPs were urgent requests. 128 (18.9%) patients were clinically jaundiced and 115 (17.0%) had gallstone pancreatitis. 228 (33.7%) patients had choledocholithiasis on MRCP, of which 192 (84.2%) were known to have gallstones pre-MRCP.

Median waiting time for urgent MRCPs from time of order was 1.0 days versus 1.3 for routine requests (p<0.001). Overall, median LOS was 6.7 days (IQR 4.1-10.9). This was 6.1 days (IQR 3.7-10.1) for urgent scans and 7.0 (IQR 4.5-11.5) for routine scans (p=0.106).

Conclusions

Inpatient MRCP does not significantly delay discharge in our centre. Patients screened for high-risk features of choledocholithiasis should have MRCPs marked as urgent to expedite clinical decision-making and mitigate complications from biliary obstruction. Therefore, it remains useful in determining the need for endoscopic retrograde cholangiopancreatography and/or intra-operative cholangiogram in patients with gallstone disease.
EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum
Authors: Iosif Evangelia , Beynon Victoria , Monkhouse Simon
Published: November 2023

Background

Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications.

Methods

This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management.

Results

To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well.

Conclusions

Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.
EGS P24 Management of oesophageal denture impaction and complications - a case series
Authors: Doran Sophie L F , Mohammadi Borzoueh , Tamhankar Anand P
Published: November 2023

Background

Dentures are sometimes inadvertently ingested and can impact in the oesophagus. This can lead to complications such as mediastinitis, perforation and major vascular fistulae. In 1914, Chiari coined ‘aorto-oesophageal syndrome’ following foreign body ingestion. Usually diagnosed post-mortem, he described a triad of chest pain, haematemesis and cardiac arrest resulting from perforation and aortic fistula. Modern dentures are radiolucent, have complex configurations and commonly impact in the oesophagus at the level of the aortic arch. Early specialist intervention by experienced oesophago-gastric (OG) surgeons is crucial to the prognosis. We present our personal experience of managing oesophageal denture impaction and complications.

Methods

A retrospective review of electronic health records of the authors’ case series of patients with a diagnosis of oesophageal denture impaction over a 13-year period from 01/01/2010 to 31/12/2022 was performed. The inclusion criteria was adult patients with a clinical diagnosis of oesophageal denture/dental bridge impaction. Pathology and complications from impaction and mode of intervention was reviewed. Other outcome measures evaluated were treatment complications, length of stay and 90-day mortality.

Results

Seven patients (6 males) with median age 54 were reviewed. Dentures were impacted at or above the aortic arch in 6 patients. Attempted retrieval with ENT rigid scope in 3 caused migration of denture causing perforation. Attempted retrieval with flexible gastroscope was successful in 3 but led to opening up of a fistula in one. Five patients underwent surgical intervention (results summarised in tables 1 and 2). 90-day mortality was 0%. The median length of stay in the surgical intervention group was 30 days. Two patients who had aorto-oesophageal fistulae required additional input by cardiac surgery and vascular radiology teams.  

Conclusions

This is a report of the authors’ experience of managing oesophageal denture impaction and it’s sequelae. A favourable 0% 90-day mortality rate despite complex presentations including aorto-oesophageal fistulae has been described. For patients presenting with haematemesis or prolonged history of denture impaction a triple phase CT scan should be performed prior to intervention. The variable complex configuration of dentures complicates their impaction or attempts at extraction. Attempts at extraction with a rigid endoscope can lead to oesophageal perforation. Successful management of these complex cases requires an effective multidisciplinary approach in a specialist OG surgery centre.
EGS P25 Patient outcomes after percutaneous cholecystostomy at Dorset County Hospital
Authors: English Camilla , Gavrila Ana , Rao Sudhindra , Chen Mengting , Abel Abel , Saberi Seena
Published: November 2023

Background

No guideline for percutaneous cholecystostomy exists at Dorset County Hospital, nor has an audit looking into patient outcomes after percutaneous cholecystostomy previously been carried out. This audit aims to identify the indications for cholecystostomy insertion, timing of insertion, complications thereafter, timing of any tubograms, and follow-up of patients after cholecystostomy. No universal management guidelines for percutaneous cholecystostomy currently exist, though studies have proposed treatment algorithms.

Methods

Retrospective cohort audit of all patients who underwent cholecystostomy insertion at Dorset County Hospital over 6 years from January 2017 – December 2022. Data was provided by the local radiology department of all abdominal drains inserted in this period, with further information collected from discharge summaries, clinic letters and tubogram data on local clinical systems. Data was inputted to and analysed on Microsoft excel.

Results

Between 2017 – 2022, 38 cholecystostomy drains were inserted. More men than women received drains, with a mean age of 71.8 at insertion. Inpatient stay varied from 2-71 days, with mean of 3 days between admission and drain insertion. 30 patients avoided cholecystectomy, whilst 34% of patients were re-admitted with drain-related or underlying pathology-associated complications.

Conclusions

Indications for drain insertion are in keeping with medical literature as a means of biliary sepsis control. Cholecystostomy was the definitive gallstone disease procedure for most patients. Most also had tubograms, yet tubogram timings varied significantly likely reflecting the lack of universally accepted management guidelines. This audit identified patients who have benefited from cholecystostomy insertion, allowing creation of a local management guideline for patients with biliary sepsis who undergo percutaneous cholecystostomy.
EGS P26 Facilitating the Emergency Surgical Ward Round: The Route to WardNav
Authors: Ireland Philip , Slim Naim , Thornton James , Arvind Nitin
Published: November 2023

Background

The ward round is a corner stone of surgical practice, this is no different when dealing with the acute surgical take. Constant bed pressures result in frequently needing to visit multiple wards, requiring time and effort on staff to ensure patients are reviewed. With frequent rotation of junior doctors, often the responsibility of planning the ward round falls to the ward round leader, who is also making the clinical decisions. We hypothesise a ward round planning tool available to the surgical team would result in more efficient ward rounds, freeing the team to focus on clinical decisions.

Methods

A survey of junior doctors (foundation doctors and core trainees) was distributed assessing their level of engagement with ward round planning while on surgical rotations at Southmead Hospital, Bristol. An initial planning tool was created in Microsoft Excel utilising a node edge graph and an algorithm based on the Hamiltonian cycle. After further survey feedback, the tool was developed into a web-based app using a version of Djikstra’s algorithm.

Results

25 junior doctors responded to the initial survey over two rotations. 100% had to go to multiple wards on a round, 64% actively think about the route required although only 28% would be confident in planning the route. 96% would find a planning tool helpful. Feedback on the Excel based tool from the first cohort revealed appetite for a mobile app-based version. The resultant application was created in R. The final version allows the user to start the round on any ward and creates the optimal route through the building, visually represented on a graph with accompanying text output.

Conclusions

Junior surgical doctors are not confident with planning ward rounds in a large teaching hospital. An app-based ward navigation tool has the potential to remove ward round planning from daily decision making and engage the junior surgical staff.
EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report
Authors: Elnogoomi Ahmed , Loganathan Santhosh
Published: November 2023

Background

Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure.

While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed.

Methods

Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified.

Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation.  

The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder.  

Results

The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed.

Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time.      

An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient.

Conclusions

Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023.

While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.
EGS P33 Audit of Serial Lactate Measurement in Septic Patients Admitted in Acute General Surgery Department
Authors: Hobeita Wesam , Ali Kiren , Khan Khurram Shahzad
Published: November 2023

Background

Timely and effective resuscitation is crucial for the stabilisation of sepsis-induced tissue hypo-perfusion. Elevated serum lactate is associated with increase mortality and longer hospital stays. A reduction in lactate levels towards normal during acute resuscitation is therefore associated with improved clinical outcomes. Surviving sepsis campaign 2021 therefore recommends using lactate as quantitative measure of resuscitation in patient with sepsis and has advised serum lactate levels to be measured within three hours of admission and repeated within 4-6 hours if ≥2mmol. This audit aims to evaluate efficiency of our surgical department in serial lactate measurement in septic patients.

Methods

This was a single centre retrospective audit of patients admitted to general surgical ward between October 2022 to January 2023 with sepsis and Lactate ≥2mmol. Patients were identified electronic handover database. Data was collected for demographics, initial time and value of lactate, NEWS score and time and value of subsequent lactate measurements. All patients with initial Lactate ≥ 2mmol were included in the study, although our laboratory upper limit of normal Lactate is 2.4mmol. This audit was registered with Clinical Quality Project ID: 14730.

Results

Sixty-nine patients were included; median age was 70 years (IQR 58-82) and 35 (50.7%) were female. Median Charlson Comorbidity Index was 4 (IQR 2-6). 56 (81.2%) patients were admitted to acute surgical ward and 13 (18.8%) to the ICU/HDU. 51 (73.9%) patients had first lactate level was between 2-4mmol and 18 (26.1%) had ≥4. 16 (28.6%) patients admitted to surgical ward with high lactate was repeated and 9 (56%) of these were ≥ 8 hours. In HDU/ICU 12 (92%) patients had their lactate repeated in targeted time.

Conclusions

This audit highlights the standards not being achieved. This is likely due to unawareness of the recommendations as well as time pressure. Awareness of the latest guidelines is paramount in improving the adherence to the guidelines.
EGS P37 Colonoscopy Induced Gallbladder Perforation
Authors: Yogarajah Tharsiga , Stevens Jennifer , Majumdar Debabrata
Published: November 2023

Background

Gallbladder perforations are rare and usually affiliated with as an advanced complication of acute cholecystitis. Isolated and unique causes of gallbladder perforations have been reported however the mechanisms of these are often poorly understood. To the best of our knowledge, this is the first report of a colonoscopy related gallbladder perforation in the literature.

Methods

Data was retrospectively collected from the patient’s clinical notes. A literature review of gallbladder perforations and colonoscopy complications was conducted using PubMed and EMBASE.

Results

A 74-year-old gentleman presented with gallbladder perforation post-colonoscopy. The patient had a polyp removal at the proximal ascending colon with cold snare. The following day the patient presented to the Accident and Emergency (A&E) department with abdominal pains. After two repeat presentations to A&E, gallbladder perforation secondary to acute cholecystitis was noted on computed tomography (CT) scan. The patient was treated conservatively with intravenous fluids, antibiotics and a common bile duct stent was inserted to aid with bile flow.

Conclusions

This case highlights a potentially new complication of colonoscopy. Clinicians should be aware of this as rare but potential complication and take caution with the endoscope at the ascending colon. Patients presenting post-colonoscopy with abdominal pain should be investigated for acute cholecystitis and gallbladder perforation and an abdominal symptom screen prior to endoscopy may be of benefit.
EGS P38 Audit of operative notes/ Clinical documentation of emergency laparotomy & laparoscopic bowel resection procedures
Authors: Shalaby Amr Ibrahim , Adenipekun Ayokunle , Zaima Omar , Mohamed Mohamed Saleem Noor , Elhawary Abdelrahman , Bedford Matthew
Published: November 2023

Background

Laparotomies and laparoscopic bowel resections are common emergency procedures carried out in General Surgery emergency theatres. Get It Right First Time (GIRFT), Royal College of Surgeons (RCS) and The Association of Surgeons of Great Britain and Ireland (ASGBI) have made best practice recommendations for documenting operative notes, to ensure effective communication with colleagues and for medicolegal purposes. Ensuing medicolegal issues and patient complaints have cost departments in recent times, due to poor documentation. This audit within a busy General surgery unit, assesses the quality of operative documentations against the standards set by GIRFT, RCS and ASGBI.

Methods

A retrospective audit of operative notes and relevant clinical documentation of 100 emergency laparotomies and laparoscopic bowel resections between August 2022 and March 2023 at a local General surgery unit. Patient Identification Numbers were extracted from the National Emergency Laparotomy Audit (NELA) database. Operative records and clinical documentations were obtained from electronic clinical records. The recommendations from the “GIRFT RCS and ASGBI Best Practice for Laparotomy and Laparoscopic Bowel Resection Surgery Documentation” guidance was used as the Standard. Up to 60 variables were assessed across different stages of the patient journey, from preoperative to intraoperative and postoperative stages.

Results

In the period reviewed, there was varying performance. Good performance in documentations of Indications, Operator names, patient position, incision, and findings, seen in 99, 100, 100, 100 and 100 percent of cases respectively. Anaesthetist name was documented in 48% of cases, whilst WHO checklist was documented in only 20% of cases. 64 of these cases had bowel resections. In this cohort, methods and location of resection was described in 95% of cases. Only 43% had the state of bowel prefusion at transection site documented. VTE prophylaxis, Antibiotics, sutures/clip plan, were documented in 87, 65 and 13 % of cases respectively.

Conclusions

The audit highlights deficits in important areas of documentation, despite the set guideline. Important medicolegal issues can arise when documentations are not clear, and steps considered routine as not written in the operative notes or patient’s records. The findings will be disseminated, and recommendations will be suggested across all grades of surgeons, with the aim to re-audit and improve quality of documentation and ultimately improve delivery of surgical care. A plan to have electronic documentation template or checklist for these procedures has been carried out for trial with the aim of developing standardised documentation process.
EGS P39 The first cycle of an audit assessing the quality of documentation of emergency laparoscopic appendicectomies at Birmingham Heartlands Hospital, a District General Hospital
Authors: Mohamed Yethrib , Mohamed Mohamed Saleem Noor , Rafique Ahmed , Shalaby Amr Ibrahim , Wiggins Tom
Published: November 2023

Background

Laparoscopic appendicectomy is a common general surgical procedure. Poor documentation can a) result in misunderstandings between healthcare workers looking after patients and b) limit fair investigation of incidents. The Get It Right First Time (GIRFT) guidance was produced to advise on the information that should be available in patient records to reduce risk of both of the above.

Aims and objectives

To assess how well laparoscopic appendicectomies are documented in accordance with the GIRFT criteria. To then develop interventions to improve documentation and ultimately improve communication with other healthcare workers and allow defence of good medical practice.

Methods

Three people collected data on 100 laparoscopic appendicectomies that took place in 2022-2023 at Heartlands Hospital. Data was collected based on the 34 GIRFT recommendations and the sources were: electronic patient notes (adults); scanned patient notes (children); electronic operation notes (all); and theatre logbooks. It was then analysed and grouped into factors that were documented well (>75% of the cases), moderately well (>50% but £75%), poorly (>25% but £50%) or very poorly (£25%).

Results

Factors that that were documented well (23%) included use of a sterile bag for appendix removal (83%), details of closure (96%), and instructions for post-operative antibiotics (88%) and recovery (97%).

Those documented moderately well (19%) included port location and size (70%) and achievement of haemostasis (62%).

Those documented poorly (23%) included whether ports were inserted under direct vision (38%) and whether any residual appendix was left behind (39%).

Those documented very poorly (36%) included sending a sample to histology and grade of doctors. Several of these were documented primarily in paper records that are not scanned - hence not readily accessible).

Conclusions

While there are several aspects of documentation which we are currently doing well, there is still much scope to improve documentation as a whole. The current format of the operation note itself limits the information which can be communicated. This in combination with the documentation of some important information on paper – which is largely inaccessible outside of theatre or once a patient has been discharged – produces unnecessary ambiguity. Discussion is ongoing with electronic records teams to alter the operation note format to improve documentation quality. These findings will be discussed at a departmental audit meeting to specify changes before re-auditing.
BS P01 Case Report: Emergency Laparotomy for Retrograde Intussusception after Roux-en-Y Gastric Bypass
Authors: De Pablo Ana Springall , Hutton Michael , Clarke Michael
Published: November 2023

Background

Roux-en-Y gastric bypass (RYGB) is a common operation performed to treat obesity and associated co-morbidities. When done with weight management programs, it is associated with 60% excess weight loss. A rare complication is retrograde intussusception (RI), which can require emergency surgery due to risk of bowel ischaemia and necrosis.

We report a case of a 66-year-old female who developed intermittent then acute RI, requiring urgent laparotomy for reduction of the intussusception and small bowel resection of the perforated invaginated segment. Her case is compared to the literature available, and a pathophysiological mechanism aiming to explain post-RYGB RI is proposed.

Methods

We compare the case of a patient with RI post-RYGB, to the available literature. The literature search was done on PubMed: “retrograde intussusception AND Roux-en-Y”. Results were limited to English language and human species. Paediatric and Maternity journals were excluded.

The patient is a 66-year-old female who had a laparoscopic RYGB for obesity in 2018; and lost 106% excess weight. In 2022, she presented with laparoscopic evidence of a resolved intussusception. In 2023, she was re-admitted with CT and laparotomy-confirmed RI and small bowel obstruction at the jejuno-jejunal anastomosis. She was managed with small bowel resection and anastomosis.

Results

The non-specific clinical presentation of RI makes prompt diagnosis challenging. Usually, patients have abdominal pain and lack peritonism. Severe cases may present with bowel ischaemia, as the intussuscepted segment can have compromised vascularity. Hence, prompt diagnosis and timely management is essential to reduce morbidity and mortality.

CT-AP is the diagnostic imaging test of choice, but delay in diagnosis of >48h may increase mortality to 50% due to delayed intervention. The surgical management is emergency surgery with gentle reduction of the intussusception. Resection of the invaginated small bowel segment with anastomosis may be indicated if there is bowel ischaemia.

Conclusions

We report the case of a patient with RI post-RYGB, with evidence of gut dysmotility prior to intussusception. The literature suggests that dysmotility disorders could underpin RI, as 80% of cases are anti-peristaltic. Obesity has a strong association with slow gastric and intestinal motility, likely due to impaired gut-brain biochemical messaging and altered gut microbiota. RYGB will disrupt these pathways, and we hypothesize that this may lead to further motility dysregulation. However, further research is necessary to provide supporting evidence. Nevertheless, this report provides a helpful reminder to prompt urgent investigation in patients who present with non-specific abdominal pain post-RYGB.
BS P02 Equitable access to bariatric surgery: an exploration of trends in health inequalities and patient profiles over the last 15-years
Authors: Aizan Luqman Naim Bin , Ahmed Babur , Syed Akheel , Alkhaffaf Bilal
Published: November 2023

Background

Bariatric surgery is a safe and effective treatment for obesity and associated co-morbidities. Equality of access to bariatric surgery in the NHS has long posed a serious challenge with significant variation in eligibility criteria between different regions. Obesity disproportionately affects more deprived groups and some ethnic minorities, who have also been shown to experience a worse quality of healthcare and poorer health outcomes. This study aimed to understand the profile of patients accessing bariatric surgery and explore changes in trends over a 15-year period to identify important areas of development for obesity-related healthcare services in our region.

Methods

This was a retrospective study of all patients undergoing primary and revisional bariatric surgery (gastric band, sleeve gastrectomy, RNY and single anastomosis bypass) for weight loss at our regional bariatric surgical centre since its inception in 2008 until the end of 2022.

Data was extracted from a combination of electronic records and a surgical database. Variables included gender demographic and procedure related data, baseline characteristics including height, weight, deprivation scores, co-morbidities, bloods, and micronutrient levels. Changes in patient profiles were mapped over the 15-year period and compared to population-level data derived from the national census and other publicly available sources.

Results

2062 (mean age 47) patients were included. 11 (0.5%) patients were aged over 70 and 155 (7.5%) were less than 30 years of age. 75% patients were women; 42% of patients in 2013 were men which steadily decreased to 17% in 2022 (p < 0.05). The mean BMI of patients undergoing surgery was 54 in 2010 and gradually decreased to 48 in 2022 (p<0.05). White British patients represented 93% of all patients. This decreased from 96.5% in 2009 to 86% in 2022. White British ethnicity was estimated to make up 81% of patients with obesity in the NW of England.

Conclusions

Several major groups who are likely to significantly benefit from bariatric surgery are disproportionately under-represented by patients accessing treatments for obesity. This includes those at the extremes of ages, men, lower BMI patients and ethnic minority groups. Trends over the last 15 years have either worsened or have insufficiently improved to bridge the gap in health inequalities. The findings from our study underscore the urgent need for wider-scale targeted approaches which aim to address obesity and increase more equitable access to these life-changing treatments.
BS P04 The Legacy of the Adjustable Gastric Band; 5-year study of the presentation and management of gastric band-related complications
Authors: Abunimeh Bara , Alwani Omneya , Alabdellat Osama , Alkhaffaf Bilal
Published: November 2023

Background

Laparoscopic adjustable gastric banding (LAGB), once one of the most popular surgical treatments for obesity, now represents less than 10% of procedures undertaken nationally. No accurate figures exist regarding how many UK patients have undergone LAGB; approximately 5000 procedures were submitted to NBSR between 2013-2015. Alongside procedures undertaken abroad and privately, the total number is likely to be several multiples of this figure over the last 20 years. Currently there is a perception that LAGB-related complications account for a disproportionate volume of non-elective episodes compared to other procedures. This study describes the presentation and management of gastric band dysfunction.

Methods

This was a retrospective review of all referrals, attendances and admissions to a regional bariatric service with a dedicated bariatric on-call, serving the North West of England between. The study period was January 2018 and April 2023. All elective outpatient (OPC) and non-elective (NE) LAGB-related episodes were included. Patient demographics, band-related data, presentation, investigations, interventions, and related complications were collected and described.

Results

375 episodes (212 OPC; 163 NE) accounted for 58% of all OPC and 44% of NE activity. Most patients had LAGB in the independent sector (OPC presentation 73% UK, 18% abroad; NE presentation 80% UK, 20% abroad). Median time from index surgery was 8 years (IQR 5-11, range 0-30 years). Erosions and infections accounted for 4% (14/375) and 5% (20/375) of cases, respectively. LAGB removal was required in 59% of OPC and 60% of NE presentations. LOS for NE presentations was 3 days (IQR 2-6, range 0-41 days). 5 patients required ITU admission (median LOS 2 days).

Conclusions

Whilst representing only a small proportion of current elective practice, LAGB-related complications represent the majority urgent and non-elective activity in the outpatient and emergency settings. Given that LAGB related complications often present many years after the index procedure, it is likely that this phenomenon will continue to be a challenge for UK surgeons and services for years to come. This has training implications for the future generation of bariatric surgeons and general surgical trainees, many of whom will likely never have seen a gastric band placed, and yet will have to manage complications, a significant proportion of which are complex.
BS P05 The Return to Bariatric Surgery Following the COVID Pandemic 2020- A Single Center Prospective Study
Authors: Ibrar Hussain Muhammad , Ghoneima Ahmed , Khawgali Mohamed , Farooq Rahy , Bonner Clare , Hammett Felix , Saha Arin , Peter Mark , Dobbins Brian , Adair Robert , Ainslie William , Salih Tamir
Published: November 2023

Background

Elective surgical practice was paused in March 2020 to cope with the Covid pandemic. Bariatric surgery was amongst the first specialities to be stopped as resource allocation prioritised lifesaving service for Covid positive patients over what is considered quality of life improving procedures. It was also one of the last to be restarted due to fears of Covid infection in obese patients undergoing surgery both of which are known risk factors of mortality in Covid cases. This study describes outcomes after bariatric surgery since the weight-loss program restarted and the measures to ensure service provision and maintenance of patient safety.

Methods

Elective bariatric surgery restarted in June 2021; patients were managed within a ‘green’ elective pathway in a new ring-fenced elective surgical hub. All patients who had surgery from June 2021 to January 2023 in a single centre were identified from a prospectively-maintained database of operations. The outcomes were patient safety measured by Covid infection and complication rates post operatively, impacts on hospital resources measured by length of stay in hospital and HDU/ITU bed occupation, impacts on the Bariatric Surgery service measured by waiting time for surgery and cancellations, and benefits to patients measured by remission of diabetes and hypertension.

Results

124 patients were included; 42 (34%) had sleeve gastrectomy and 82 (64%) had gastric bypass.

There were no Covid infections/complications in this series.

Median length of stay after surgery was two days with no admissions to HDU/ICU.

Waiting time for surgery was >52 weeks at the start of the study period which has fallen to 15 weeks after listing and no operations were cancelled due to lack of beds.

Post-operative outcomes were favorable and in line with national data; 87% of patients had remission of diabetes and 60% of patients were off anti-hypertensive medications one year after surgery.

Conclusions

The creation of dedicated ring-fenced elective surgical hub allowed the rapid restart of bariatric surgery despite the effects of the Covid-19 pandemic. This model separated elective and acute patients reducing exposure of high-risk patients. This allowed the resumption of weight-loss surgery safely as evident by the zero Covid-related complications, no additional pressure to hospital resources such as beds and intensive care unit capacity, a high-quality service with short waiting times and favorable long term outcomes. This are all signs of good practice in a resilient service and can very easily be replicated in the future whenever required.
OGBN P09 Management of acute gastric volvulus: a systematic review and practical guide to management
Authors: Butterworth James , Dawas Khaled , Ramdin Ashling
Published: November 2023

Background

Gastric volvulus can result in a life-threatening clinical course resulting in gastric ischemia. The optimal treatment strategy for gastric volvulus has not been established, hence we performed a systematic review and developed a practical guide to management.

Methods

A systematic on-line literature search of Embase and Medline identified 1435 articles of which 49 relevant studies were selected, including 32 retrospective studies, 17 case series. Selected articles were assessed by two reviewers to extract data.

Results

731 patients with gastric volvulus (76.8% organoaxial, 22.2% mesentericoaxial)were identified with a median age of 40 years, 50% were female. 233 (32%) of patients underwent a laparotomy, 255 (35%) a laparoscopy and 148 (20%) were managed conservatively. Endoscopic decompression was trialled initially in 81 patients and successful in 20 (26.3%) patients. A higher proportion of complications (22.4% versus 4.7%) and recurrence (33% versus 0%) was seen in those who had laparoscopic rather than open repair. A lower 30-day mortality (0% versus 4.7%) and length of stay (3.3 versus 12 days) was noted in the laparoscopic cohort.

Conclusions

A multimodal approach using endoscopic decompression and placement of an NG tube is vital followed by a prompt decision on definitive surgical intervention. Laparoscopic and open procedures are both possible however lower morbidity and recurrence rates are evident following an open-approach but with a higher associated mortality risk.