bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.FRI.1036 Provision of 7 Day Radiology Service: Are we compliant against standards
Authors: Ikram Saad , Demetriou George , Shariff Umar , Helmy Salah
Published: October 2021

Aim

The audit aimed to retrospectively look into reporting times for investigations for acute surgical inpatients and determine if we were able to meet standards as set in NHS 7 day service provision standards which aims to provide 7day radiological service for hospital inpatients from commission to reporting.  

Method

A prospective audit is undertaken to collect waiting times for investigations for all acute admissions requiring radiological investigations over one month. Investigations were categorized into ‘critical’, ‘urgent’ and ‘non-urgent’ according to guidelines set by Royal College of Surgeons. The results were tabulated in Excel and analyzed to determine level of compliance.  

Results

Collected data shows that off the total 119 investigations performed, 34% were USG, 63% were CT scans and 2.5% were MRI. Standards were met for a total of 67% of the investigations. Only 20% of critical, 67% of urgent and 76% of non-urgent scans were done within the standard time while by modality, CT scans had the highest rate of compliance. 60% of investigations requested over weekends met standards with highest compliance for USG and for non-urgent scans. Average reporting time was approximately 50 minutes.  

Conclusion

The audit outcome highlighted that 1 out of 3 investigations did not meet standards. Within its limitations of no numerical parameters to guide urgency, the audit was able give an idea of the radiology service offered by the hospital and highlighted clear areas for improvements which can be suggested to improve compliance such as documenting ‘operative catergory’ of requested investigations on request forms.
EP.FRI.1040 Management of Acute Colonic Diverticulitis According to The WSES (World Society of Emergency Surgery) Classification in a Tertiary Centre
Authors: Hickey Lorraine , Goldsmith Paul
Published: October 2021

Aims

Debate remains regarding management of complicated diverticulitis. The WSES acute diverticulitis working group published in 2015 a CT-guided classification of left colon acute diverticulitis, divided into uncomplicated (Stage 0) and complicated (Stage 1a-4). Using this classification, we reviewed our management of CT-proven acute colonic diverticulitis.

Methods

A single-centre retrospective review of management of CT-proven acute colonic diverticulitis over 12 months based on the WSES classification.

Results

24 males and 31 females presented (median age=56, IQR 45-68). Median white cell count=12 (IQR 10-16) and median C-reactive protein=88 (IQR 41-157).

Based on CT, 25 (45.5%) patients =stage 0, 14 (25.5%) =stage 1a, 6 (11%) =stage 1b, 4 (7%) =stage 2a, 6 (11%) =stage 2b, and none staged 3/4.

15% (8/55) patients had an operation, remainder were conservatively managed. 2 patients had laparoscopic washout/drainage (stages 1b and 2b). 6 patients had Hartmanns (x1 stage 1a, x1 stage 1b, x4 stage 2b). 

Median length of stay=5 days (IQR 4-8). There was 1 related reattendance declining readmission (stage 1a managed conservatively) and 2 readmissions (1 stage 0 managed conservatively, other initially stage 1a managed conservatively but on readmission staged 2b proceeding to Hartmanns). 30-day mortality included 3 deaths (stages 1b/2a/2b all managed conservatively).

Conclusions

Hartmanns resection is advocated as treatment of choice for complicated acute diverticulitis, particularly for Stage 2b or above.
SP1.1.12Post laparotomy rectal sheath catheter analgesia, systematic review
Authors: Hatem Fady , Mostafa Samir
Published: October 2021

Midline laparotomy is still performed in high proportion of patients during elective and emergency procedures. Effective analgesia is essential for enhanced recovery programs especially with the focus of multi-modal opioid sparing analgesia with its benefits in reducing opiate related side effects. Many centres adopted the use of rectal sheath catheters (RSC) in all patients undergoing laparotomy, yet its use not been standardised as there is no hard evidence supporting its use.

We aim from this systematic review to explore the effectiveness of RSC in post laparotomy analgesia and to compare between different techniques of insertion.

We performed a systematic review in accordance with PRISMA standards. Search of electronic information data base (Medline, Embase, Cochrane, Library, Dynamed).

Results

(45) studies reviewed. (33) included with (1326) patients.

Conclusion

There is lack of high level evidence investigating RSC rule in post laparotomy analgesia, nonetheless which is the most effective technique (USS vs surgically inserted), in spite of large heterogeneity in methodology and scarcity of trials; the consensus of the reviewed studies concluded that it decreases opiates requirements by at least (70%) in patients receiving PCA and as good as ED but with less side effects.
SP1.1.14Future Insights on Virtual Reality Potential Uses as a Care Package for Colorectal Patients
Authors: Gendia A , Rottenburg H , Hutton M , Cota A , Clark J
Published: October 2021

Aim

To provide an insight on current applications of immersive virtual reality (VR) on patients undergoing surgery and to project the potential uses of these applications on colorectal population.

Methods

A non-systematic literature search of PubMed using key subject “Virtual Reality and Surgery” to identify relative articles. On reviewing applications of VR in surgery we identified four main areas of interest: preoperative education, perioperative support, postoperative pain management and rehabilitation.

Results

VR technology showed promising results in all three stages of patient’s journey ; In pre-surgery, VR was used as a powerful educational tool for vascular patients. Intraoperatively, it showed promising results as a distraction method to relief stress and discomfort in patients undergoing colonoscopy and gynaecology procedures. Postoperatively, VR was utilized in pain management in orthopaedics, cardiothoracic populations with acceptable results. Moreover, physical rehabilitation showed a strong outlet of the technology due to its engaging properties.

Conclusion

VR has been showing applicable benefits in different stages of patient’s care undergoing surgery. With proper future development of Its applications, VR potentials in colorectal population could be numerous; education on stoma and type of surgery with help of 3D environment, distraction tool for colonoscopy screening and postoperative pain. In addition, VR could help with enhanced recovery inform of physical and mental rehabilitation. Future uses of VR in colorectal population could be a key in improving outcomes and overall satisfactions. However, formulated studies and validated applications should be tackled to apply the technology safely in the standard care of colorectal patients.
SP1.1.15Long-term Outcomes of Open Verses Closed Rectal Defect After Transanal Endoscopic Microscopic Surgery
Authors: Altaf Kiran , Gahunia Sukhpreet , Slawik Simone , Andrews Timothy , Kehoe Ashley , Ahmed Shakil
Published: October 2021

Aims

Management of rectal defect after TEMS is a matter of debate. Data are lacking on the effect of these techniques on long term outcomes and continence of patients. We sought to analyse these in our patient cohort.

Methods

Patients who underwent TEMS between 2012 and 2019 were examined retrospectively from a prospectively maintained database. These were divided into two groups – open and closed rectal defect. Patient demographics were recorded and outcomes assessed including oncological staging, morbidity, mortality, length of stay and FISI scores.

Results

170 matched patients were included, with 70 patients in the open and 100 in the closed rectal defect group. Short-term complications were 18.8% with no significant difference between the two groups. Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Overall, there was a significant difference in pre and post TEMS FISI scores in all three groups (p < 0.00001, p < 0.00001, p = 0.02). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus or stricture but a significant difference in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02)

Conclusion

Both the approaches of rectal defect management are associated with pros and cons. Long term complications should be expected and actively followed up for. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEMS
SP1.1.17The relationship between colorectal neoplasia and body composition in a bowel screening population
Authors: Di Rollo Domenic , Morton Christopher , McMillan Donald , Horgan Paul , Mansouri David
Published: October 2021

Aims

Conflicting evidence exists as to the effect of elevated BMI in the development of colorectal neoplasia. Yet BMI is a crude measure of adiposity. The present study investigates the association between CT derived measures of body composition including sarcopenia, subcutaneous fat index (SFI) and visceral obesity and colorectal neoplasia.

Methods

358 consecutive patients undergoing CT virtual colonoscopy (CTC) as part of the Scottish Bowel Screening Programme were eligible for inclusion. Demographic data and the above measures body composition were calculated using previously published CT derived methods. Medical records were examined for colonoscopic findings and pathology reports.

Results

121/358 (34%) were males. Median age 65. 126/358 (35%) patients were found to have a colorectal neoplasia. 84/126 (67%) had advanced neoplasia. 26/358 (7%) had adenocarcinoma. On multivariable analysis, both male sex and visceral obesity was associated with the presence of colorectal neoplasia, OR 2.62, [95% CI 1.51-4.55, p = 0.001] and OR 2.83, {95% CI 1.25-6.41, p = 0.01] respectively. The relationship was dose dependent with an increased risk of colorectal neoplasia in the 3rd [OR 2.13 95% CI 1.09-4.14 p < 0.05] and 4th [OR 3.77 95% CI 1.96-7.26 p < 0.001] quartiles of visceral fat area. BMI, SFI and sarcopenia were not associated with colorectal neoplasia in the present study.

Conclusions

Male sex and in particular, visceral obesity is associated with increased risk of colorectal neoplasia. In addition to the known cardiovascular and metabolic dangers of visceral obesity, the present work suggests that visceral obesity may also play a role in colorectal neoplasia formation.
SP1.2.7Developing a fast- track pre-assessment pathway for laparoscopic cholecystectomy
Authors: Karar Shoura , Berry Stephanie , Dear Carin , Day Anne-Marie , Jones Natalie , Berry David
Published: October 2021

Aims

To develop a safe and reliable assessment process for patients undergoing laparoscopic cholecystectomy and negate the need for formal pre- assessment.

Methods

A system consisting of a health screening questionnaire completed by patients (previous general anaesthesia, cardiac and respiratory history, bleeding disorders and medications) along with a functional capacity assessment (Duke Activity Status Index), allied with screening blood tests was developed. Only patients who passed all 3 components were fast-tracked to surgery while the remainder proceeded to formal pre-assessment.

Results

Data was collected and analyzed on 90 consecutive patients.

An interim analysis identified the format of some questions needed to be altered to facilitate patient completion, resulting in 59% (rather than 36%) of patients successfully fulfilling the fast-track criteria and not excluded by incomplete entries.

Overall, 40 of the 90 patients (44%) successfully completed the fast-track assessment of whom 38 underwent surgery (2 waiting). Six patients incorrectly passed the assessments due to misinterpretation of the Duke Activity Status Index but proceeded to surgery. All 38 patients had an uneventful peri-operative course.

45 of the 50 patients who failed fast-track assessments subsequently passed formal nurse-led pre-assessment, as did 4 of the remaining 5 patients after anaesthetic review – all had an uneventful peri-operative course.

Conclusion

Pre-assessment driven by a health screening questionnaire, activity index and simple blood tests is safe, reduced formal pre-assessment by 44% and avoids delays. Such tools may have a significant resource impact in appropriate patient populations. The health screening questionnaire needs further revision.
SP1.2.9To Evaluate the Analgesic Efficacy of Intraperitoneal Tramadol Vs Placebo for Post Operative Pain Relief Following Laparoscopic Cholecystectomy, A Double Blind Randomized Control Trial
Authors: Handa Siddhartha , Sangolli MS , Panchal Sanjay
Published: October 2021

Aim

To study the effectiveness of intraperitoneal instillation of tramadol for postoperative laparoscopic cholecystectomy (LC) pain relief and improve incidence of adverse effect.

Methods

Double blinded randomized controlled trial over 1 year. The Ethical Clearance was obtained from Institutional Ethics Committee. 60 patients scheduled for LC were enrolled in the study. Patients were randomly assigned into 2 groups using computer generated random numbers. Group T: Received intraperitoneal tramadol 100 mg (diluted in 20 mls distilled water). Group S: Received 20 ml of intraperitoneal normal saline. Pain was assessed using VAS. The assessment was done at 0, 15, 30, 60 minutes, 4, 8, 12, 16 and 24 hours. Incidence of adverse effect were observed.

Results

In group T, the mean pain scores at all the intervals were significantly low (p < 0.050) except at 24 hours (p = 0.210). Analgesia requirement was significantly high in group S compared to group T immediate post op, 15, 60 minutes, 8 and 12 hours (p < 0.050). The mean requirement of analgesia immediate post op, 15 minutes, 4 and 8 hours was significantly low in group T compared to group S (p < 0.050). 30% patients in group T did not require analgesia at all compared to S (p < 0.001). Incidence of adverse effects at 4 hours was 43% in group S compared to 40% in group T (p > 0.050).

Conclusion

Intraperitoneal instillation of tramadol in LC has beneficial effect in terms of postoperative pain relief following LC and lower requirement of analgesia. However, the incidence of adverse effects was comparable in both the groups.
SP1.2.13Prediction of malignant progression of colorectal adenomatous polyps – A complete systematic review and meta-analysis
Authors: Altaf Kiran , Gahunia Sukhpreet , Zhao Sarah , Ahmed Shakil
Published: October 2021

Aims

Only 5% of colorectal adenomas (CA) progress to cancer. Identifying these is highly relevant for colorectal cancer screening risk. Currently, no biomarkers exist that predict this malignant progression. We looked at the effectiveness of common genetic aberrations as potential biomarkers through systematic review and meta-analyses.

Methods

MEDLINE, EMBASE and Cochrane Library were searched to identify all studies that assessed p53, APC, p21, BRAF, MLH1, MSH2, CIMP and Kras mutations as prognostic markers in CA. Main outcome measure was the development of colorectal cancer.

Results

109 clinical studies were included. P53 mutation [DOR 8.37 (5.21-13.42), sensitivity 55% (52-58%), specificity 85% (83-87%), PLR 4.23 (2.60-6.88), NLR 0.57 (0.57-0.64), AUC 0.7532] was found to be superior to all other mutations. Mutations of APC [DOR 0.57 (0.16-2.01), sensitivity 19% (4-25%), specificity 71% (66-76%), PLR 0.71 (0.33-1.54), NLR 1.19 (0.84-1.69)], BRAF [DOR 0.38 (0.22-0.67), sensitivity 12% (11-14%), specificity 60% (58-62%), PLR 0.57 (0.38-0.84), NLR 1.27 (1.12-1.44)], Kras [DOR 1.22 (0.72-2.0), sensitivity 33% (30-37%), specificity 74% (71-76%), PLR 1.17 (0.81-1.68), NLR 0.94 (0.83-1.07)], MLH1 [DOR 2.48 (1.05-5.84), sensitivity 26% (23-30%), specificity 82% (79-84%), PLR 1.74 (0.95-3.19)], MSH2 [DOR 1.06 (0.53-2.13), sensitivity 22% (17-27%), specificity 88% (84-90%), PLR 1.03 (0.62-1.70), NLR 0.99 (0.91-1.07)] and CIMP [DOR 1.88 (0.25-13.88), sensitivity 30% (23-36%), specificity 76% (72-80%), PLR 1.31 (0.29-5.99), NLR 0.76 (0.40-1.45)] failed to demonstrate any advantage over p53.

Conclusions

p53 mutations effectively predict malignant progression in CA. Panel of biomarkers would be more suited for surveillance programme. This needs confirmation in prospective clinical trials with cost-efficiency analyses.
SP2.1.2Online near-peer practical skills teaching for medical students: A cross-sectional study
Authors: Thirupathirajan Vikram Ajit Rajan , Georgi Maria , Hajra Ankita , Myint Fiona
Published: October 2021

Aims

Medical students have reduced small-group teaching due to the COVID-19 pandemic. Online teaching typically involves large-groups and covers theoretical topics rather than practical skills. We investigated the effectiveness of a six-part online small-group tutorial series, teaching key practical skills to medical students in their first clinical year.

Methods

Tutors taught using Microsoft Teams, with a tutor:student ratio being between 1:3 to 1:5. Tutorial themes were: examinations (Cardiovascular & Respiratory, Abdominal), A-E assessment and imaging (Thorax imaging & Histology, AXR & CT). Tutees completed a post-tutorial feedback form; the primary outcome was confidence improvement on the subject content. Likert Scales were used to measure the primary aim, with 1 corresponding to the worst outcome, and 4 corresponding to the best outcome.

Results

152 tutee feedback responses were analysed, a 60.0% response rate. Response numbers were lowest in the examinations tutorials. Mean tutee confidence improved markedly, from 1.954(SD 0.7918) to 3.414(SD 0.5572, p < 0.0001). This was highest in imaging tutorials (p < 0.05). Mean scores for effectiveness of delivery and effect of technical issues were 3.868(SD 0.3762) and 3.908(SD 0.3327) respectively. From tutors’ feedback, 100% preferred teaching small-group over large-group sessions. However, only 33.3% prefer to teach online over face-to-face. Mean student engagement was rated at 3.417(SD 0.5149).

Conclusions

Small-group teaching improves students’ confidence in practical skills. Conducting this online is more effective for skills with little physical examination components and is something that can be expanded to a bigger cohort to maximise use of the online platforms.
SP2.1.5Does the introduction of ward round stickers improve surgical ward rounds?
Authors: Sharma Vivek , Fitz-patrick Emma , Sharma Dhiraj
Published: October 2021

Aims

With surgical teams in the NHS pushed to their limit under unprecedented demands, simple and effective ways for maintaining standards of patient care are necessitated. This quality improvement project aims to implement user-friendly and coherent ward round stickers as an adjunct to surgical ward rounds to deliver standardised care.

Methods

Baseline performance was measured against The Royal College of Surgeons of Edinburgh Surgical Ward Round Toolkit. Five recorded items were studied including: bloods, venous thromboembolism (VTE) prophylaxis, regular medications, observations, and handover to nursing staff. The surgical team was informed of the audit but not over which dates it would be conducted. In the first cycle, data was collected over a 4 week period. Ward round stickers were then implemented and a second cycle was completed 2 months later over another 4 week period.

Results

Baseline performance recorded from 74 ward round entries showed checking of bloods, VTE, regular medications, observations and handover ranged from 0% to 65%. After the introduction of ward round stickers, a second cycle was performed from 81 ward round entities. There was significant improvement from baseline with compliance in recording all five items > 85%.

Conclusion

This quality improvement project showed that the use of stickers as an adjunct to surgical ward round is a simple and effective way of evidencing good practice against recommended standards.
SP2.1.7Navigating surgical training: a game of trust
Authors: Shah Adarsh P , Walker Kim , Hawick Lorraine , Walker Kenneth G , Cleland Jennifer
Published: October 2021

Introduction

One premise of the Improved Surgical Training (IST) pilot is delivery of better quality of early years surgical training. However, the quality of the trainee-trainer relationship can positively or negatively impact trainees’ experiences of the specialty. Trust is a key determinant of the relationship, which is influenced by trainers’ level of risk aversion and trainees’ motivation. Game theory provides a framework to understand cooperation amongst rational ‘players’. This study explores how trainee-trainer relationships impact trainees’ experiences through the IST curricular reform.

Methods

Using a qualitative case study approach, data were obtained from interviews with core surgical trainees across Scotland. Data coding and inductive thematic analysis were undertaken.

Results

Forty-six trainees participated. Trainees and trainers regularly interacting in clinical activities demonstrated growing levels of trust, aided by: specialty rotations of 6 months or more duration, working at junior registrar level with structured weekly clinical activities and direct consultant supervision, individual goal-setting and regular progress check, and meaningful and timely feedback. Cooperative relationships led to individual fulfilment, growth, and trainee autonomy. Factors hindering development of trust included: temporal and/or geographical distance between trainee-trainer, poor communication and understanding of expectations and training needs, and lack of interest and enthusiasm from either party.

Conclusion

Cohesive trainee-trainer relationships demonstrated cooperative equilibrium; both trainees and trainers met each other’s expectations and positively impacted on trainees’ experiences. On the contrary, ‘players’ in relationships deficient in trust achieved the minimum to ensure trainee progression. Addressing factors fostering a cooperative trainee-trainer relationship positively impacts trainees’ experiences.
SP2.1.8Novel ultra low-cost laparoscopic trainer design and development
Authors: Schaffer Sierra , O'Neill Parker
Published: October 2021

Aims

The high cost of laparoscopic training kits is a major barrier for trainees of any level to learn basic laparoscopic skills. Research shows that consistent practice is more effective than intensive training sessions, therefore having access to an at-home training kit provides surgical trainees optimised learning opportunities. During the current pandemic when access to hospital training centres is limited, at-home training kits have become an increasingly vital component of surgical education.

Methods

A scoping review of current laparoscopic training kits was conducted and based on the results, medical students designed and built ultra low-cost laparoscopic graspers and training kits.

Results

The laparoscopic training kits were reviewed and approved by a surgical consultant and senior surgical registrars and are currently being trialled in a virtual training course at a tertiary care centre. Each kit cost £10 and was created using commonly available materials.

Conclusions

The ultra low-cost laparoscopic training kits were successfully created and remain one of the most cost-effective to date. These training kits provide a cost-effective solution for providing trainees with the opportunity for extended practice of basic laparoscopic skills, further improving surgical education worldwide.
SP2.1.11Real-world use of workplace-based assessments in surgical training: a UK nationwide exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training
Authors: Beamish A.J. , Rabie M , Johnston M.J. , Nally D , Humm G , Mohan H
Published: October 2021

Background

The utility of Workplace-Based Assessments (WBAs) in surgical training depends on the way they are completed. This study aims to ascertain the real-world usage of WBAs, as perceived by UK surgical trainees.

Methods

An anonymous national online questionnaire was conducted via the Association of Surgeons in Training (ASiT). The evaluation employed mixed methods to interpret quantitative and qualitative data. Suggestions for improvement were identified from free-text comments and considered through a formal two-round modified Delphi consensus process by ASiT council members.

Results

Analysis included 906 complete responses from all surgical specialities across all training levels. WBA use was perceived to deviate markedly from the Joint Committee on Surgical Training standards with significantly identified misuse across all surgical specialities. Inaccurate completion was acknowledged by 89.6% of respondents, and some trainers appear complicit with 40.9% of respondents aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers.

Most trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Main reasons for misuse were time restraints, lack of engagement and the will to achieve career progression targets.

Conclusions

UK surgical trainees perceive a significant deviation from WBAs standards due to multiple factors. The frequency and nature of misuse are worrying and undermines the existing evidence for the WBAs role in training. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.
SP2.1.13Does Health Insurance Status Affect Patient Outcome After Emergency Surgery?
Authors: Quah Samantha , Cheah Hock Ping , Wong Kenneth
Published: October 2021

Aim

Under the Australian Medicare Scheme, Australian residents are covered for many hospital-related costs. Patients with private insurance presenting with appendicitis can elect to be admitted as a private patient. Despite the stereotypes, little is known on whether the patients’ health cover actually affect clinical outcomes. This study aims to compare the differences in patient outcomes between public and private patients after undergoing operative management for appendicitis.

Methods

A multi-centre prospectively collected health service database of all appendicectomies performed over a 16-month period was reviewed. In particular, patient demographics, type of operation, primary surgeon, complications and mortality rates were analysed.

Results

Of the total of 652 patients who underwent an appendicectomy, 203 patients were private, 444 patients were public, and 5 were overseas patients. During the post-operative period, public patients had higher rates of representation to the Emergency Department (ED) for post-operative symptoms (public 12.8% vs private 4.4%, p 0.0007, two-tailed chi square test). In comparison, the rate of post-operative complications with Clavien-Dindo (CD) score ≥ 2 is similar in both groups (p = 0.18, public 4.5% vs private 2%). There were no mortalities recorded for both groups.

Conclusion

Public patients have higher representation rates to the emergency department after an appendicectomy however post-operative outcomes are similar in both groups in our health system. The difference in complication rates were not significant with both groups recording low complication rates of under 5%.
SP2.1.15Consensus recommendations on balancing educational opportunities and service provision in surgical training: An Association of Surgeons in Training Delphi study
Authors: Pucher Phillip , Nally Deirdre , Peckham-Cooper Adam , Fleming Christina , Mohamed Walid , Mohan Helen
Published: October 2021

Background

Ensuring high quality surgical training remains a challenge as demands on the NHS rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity and recommend solutions.

Methods

Participants were drawn from the Association of Surgeons in Training national council. Nominal Group Technique (NGT) was employed by members of the ASIT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two round Delphi process was conducted via electronic survey to ASIT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement.

Results

47 statements, generated through NGT, were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as those which progressed a trainee’s skill set, could be tailored to a trainee’s own ability, or involved training more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers.

Conclusion

This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.
SP2.2.2Analgesia prescribing in acute surgical admissions - dual-centre cross-sectional study
Authors: Makhort Alexei , Gavrila Ana , Hill Frances
Published: October 2021

Aim

Pain is a common presenting complaint of acute surgical inpatients and has a great impact on their subjective wellbeing and the perception of care they receive if not addressed promptly and efficiently. It is also a common cause of patients’ complaints if not properly addressed. We set out to evaluate if analgesia is prescribed locally in accordance with WHO analgesia ladder and NICE CKS analgesia guidelines for mild-to-moderate pain.

Method

We performed cross-sectional studies of adults aged 16 and over, admitted under general or vascular surgery in two DGHs (2018-2020) with complaints of pain on admission. 30 patients were included in both studies with an average age 53/56 years. We undertook notes review, checked observation charts and drug charts for pain grading and analgesia prescribing following initial clinical assessment.

Results

In the first study, average pain score of 6 was obtained. Only 19/30 patients (63%) had regular analgesia prescribed. Only 2/30 (6%) were started on regular weak opioids, with further 8/30 (26%) on as required/PRN weak opioids. 17/30 (56%) patients had PRN Oramorph prescribed. Only 2/30 (6%) were started on PRN NSAIDs despite only 46% having cautions/contraindications. 5/30 patients with pain scores of 9-10 not had any regular analgesia prescribed.

Comparable results were achieved in the second hospital we audited.

Conclusions

This study shows significant under-prescribing of analgesia, especially regular analgesia for surgical patients with moderate-severe pain, and skipping of weaker opioids/NSAIDs in favour of Oramorph. There is significant scope for improvement following educational session implementation.
SP2.2.10Barriers to Compliance of the WHO Safe Surgical Checklist in an Ethiopian Tertiary Referral Centre
Authors: Hunter Ross
Published: October 2021

Aims

Ethiopia is the world’s 12th most populous country, with a health care system currently undergoing significant development. Current data shows perioperative mortality at 7%, compared to the 0.4– 0.8% reported in more economically developed countries. In 2008 the WHO created the Safe Surgical Checklist (SSC), globally shown to dramatically improve perioperative mortality and used throughout Ethiopia since 2010. The author aimed to review compliance to this checklist within emergency theatres in Ethiopia and assess potential barriers to its use.

Methods

A prospective observational study was undertaken at Felege Hiwot Referral Hospital, a tertiary referral hospital in Northwest Ethiopia, over a six-week period. 70 emergency operations were directly observed.

Results

The SSC was used in 0 out of 70 cases, no surgical pauses were observed and during each operation, a member of the anaesthetic team was observed to tick each box incorrectly as completed while finalising paperwork at the end of the case. Interviews with surgical and anaesthetic staff members revealed poor compliance to be secondary to a lack of knowledge of the benefits of the checklist and no training in its use.

Conclusions

After its introduction in 2008 compliance with SSC was poor globally, with the published data revealing this to be secondary to poor initial implementation from senior hospital staff and a lack of staff training. While compliance has improved in more economically developed countries, the same barriers are still faced in Ethiopia. These barriers must be targeted in order to improve perioperative outcomes.
SP2.2.11Improving the quality of the documented weekend surgical handover: Implementation of a handover sticker within an urban teaching hospital
Authors: Gall Lewis , Meney Laura , Macdonald Andrew
Published: October 2021

Aim

Effective, high-quality patient handovers between the surgical team are essential for safe transfer of responsibility for patient care whilst ensuring continued patient-safety and supporting good clinical governance. Weekend handovers provide a particular challenge, with error potential, when patients are cared for by multiple different healthcare professionals. This project aimed to improve the documentation of the weekend handover for the surgical inpatients of a busy UK teaching hospital.

Method

Quality Improvement project performed within a single General Surgical department between August and October 2020. An initial casenote audit on 3 consecutive Fridays compared available handover information against RCS guidance. A comprehensive surgical weekend handover sticker was designed and all members of the surgical team educated in its use. Following sticker introduction, handover quality was similarly re-audited. **=p<0.00001 using Chi-squared/Fisher exact.

Results

138 inpatient records were evaluated in cycle 1 and 135 in cycle 2, with the proportion containing a weekend handover increased post-intervention (96 vs. 82%,p=0.0004). Handover quality improved following sticker introduction with more frequent documentation of: diagnosis (96 vs. 21%**); need for imaging review (94 vs. 29%**); intravenous fluid plan (84 vs. 21%**); blood test requirements (94 vs. 24%**); mode of nutrition (90 vs. 24%**); antibiotics (90 vs. 30%**); drug monitoring (90 vs. 1%**); discharge planning (94 vs. 44%**) and escalation plan (87 vs. 0%**).

Conclusion

Introduction of a sticker has significantly improved the quality of documented handover available to the responsible on-call team. Future work will assess sticker impact on quality of care and clinical outcomes.
SP2.2.13Audit to evaluate the use of tumor marker CEA in a level 3 hospital
Authors: Murphy Gearoid , Fatima Iayla
Published: October 2021

Background

Tumor markers play an important role in cancer cases and their application in practice needs an understanding of its pathophysiology, testing techniques, range of values and their role in any given malignancy. The appropriate use of tumor marker testing is facilitated by national and international guidelines, inappropriate use increases both the laboratory workload and cost.

In this study, we evaluated the appropriateness of ordering the tumour marker Carcinoembryonic Antigen (CEA) in a Model 3 general hospital.

Methods

A single centre retrospective audit was conducted between 1st to 31st October 2020. Patients demographics and admitting consultants details were obtained through HSE online Lab Web Enquiry system. Files were reviewed for indications using the guidelines by the Association of Clinical Biochemists Ireland (ACBI).

Results

A total of 52 tests were ordered over the month, 38 (73.1%) of these tests were ordered correctly following ACBI guidelines. The remaining 14 (26.9%) tests were ordered inappropriately.

50% (26/52) of the total tests were ordered by oncology, 31% (16/52) by General Surgeon and the remaining 19% (10/52) by other specialities.

No inappropriate tests were ordered by Oncology, inappropriate tests ordered by General Surgery were 35.7% (5/14) and 64.3% (9/14) by other Specialities.

Conclusion

Nearly 26% of the tests were ordered inappropriately and did not comply with published ACBI guidelines and cost 294 Euros.

The tumour marker CEA is not useful as the initial work up of nonspecific complaints. Its main use is surveillance after curative resection and for monitoring treatment for patients with advanced colorectal cancer.
SP2.2.17The leaning tower of pasta: lessons in team performance and creativity from a core surgical training boot camp design challenge
Authors: Eley Catherine , Mellor Katie , Luton Oliver , James Osian , Robinson David , Lewis Wyn
Published: October 2021

Aims

Unity of effort is an important component of strategic leadership and management theory associated with Core Surgical Training (CST) outcome. The aim was to determine the impact of team diversity on task completion: a creative design challenge, during CST Boot camp.

Methods

Attendees (n = 44) at a single Statutory Education Body’s CST Boot camp were stratified into teams related to specialty theme, and set a design challenge as described by Peter Skillman, to build the tallest free-standing tower out of spaghetti (20 pieces), tape (1 m), and string (1 m), with a marshmallow on top in 18 minutes. Primary outcome measure was tower height.

Results

Five teams (50%) completed the task with the tallest tower measuring 70cm (median 51, range 0-70). Median satisfaction with the simulation exercise was 4 (2-5) on a scale of zero to five, with five corresponding with highest satisfaction. Successful task completion was associated with team surgical specialty (p = 0.032), ethnicity ratio (p = 0.010,), and gender ratio (p = 0.003), respectively. On multivariable analysis, only team gender ratio was independently associated with tower height (HR 0.515, 95% CI 0.350 - 0.759, p = 0.001).

Conclusion

Modern leadership theory emphasises the important dynamic relationship between individual team members, the team, and task completion. General surgery themed teams with a gender mix were most successful in completing the design challenge; whether relative simulation performance predicts strategic organisational skill and career progression will be the next question.
SP3.1.1Research Priorities in Emergency General Surgery
Authors: Vaughan Elizabeth , Pearson Robert , Wohlgemut Jared , Knight Stephen , Wilson Michael
Published: October 2021

Aims

Delphi methodology can be used to achieve consensus opinion amongst experts in a particular field. This study used a modified Delphi approach to identify research priorities in emergency general surgery (EGS). The aim was to establish a research agenda using a formal consensus-based approach in an effort to identify questions relevant to EGS that have been prioritised by relevant stakeholders with an equal voice.

Methods

Three rounds were conducted using an electronic questionnaire and involved health care professionals, research personnel, patients and their relatives. In the first round stakeholders were invited to submit clinical research questions that they felt were priorities for future research. In rounds two and three, participants were asked to score individual questions in order of priority using a 5-point Linkert scale. Between rounds an expert panel were asked to analyse results before forwarding questions to subsequent rounds.

Results

Ninety-two EGS research questions were proposed in Phase 1. Following the first round of prioritisation, 47 questions progressed to the final phase. A final list of 17 research questions were identified from the final round of prioritisation. These included questions on peri-operative strategies, EGS outcomes in elderly and frail patients as well as non-technical and technical influences on EGS outcomes.

Conclusion

Our study provides a consensus delivered framework that should determine the research agenda for future EGS projects. It may also assist setting priorities for research funding and multi-centre collaborative strategies within the surgical subspecialty of EGS.
SP3.1.2 The influence of frailty on outcomes for older adults admitted to hospital with benign biliary and pancreatic disease
Authors: Thomas Michael , Baltatzis Minas , Price Angeline , Pearce Lyndsay , Fox Jenny , Vilches-Moraga Arturo
Published: October 2021

Aims

To study the prevalence and complications of biliary disease with increasing age. We describe the prevalence of frailty in older patients hospitalised with benign biliary and pancreatic disease and establish its association with mortality and duration of hospital stay.

Methods

Prospective observational cohort study of patients aged 75 years and over admitted with acute biliary disease between 17/09/2014 and 20/03/2017. Clinical Frailty Scale (CFS) score was recorded on admission.

Results

200 patients with a median age of 82 (75-99), 60% females, 154 (77%) were independent for personal and 99 (49.5%) for instrumental activities of daily living. Acute cholecystitis was the most common diagnosis (43%), acute cholangitis (36%) and acute pancreatitis (21%). 99 patients were non-frail (NF = CFS 1-4) and 101 were frail (F= CFS ≥5).

104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%).

Frailty was associated with worse clinical outcomes. F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%).

Conclusions

: Higher frailty scoring is associated with increased mortality in acute biliary disease. Individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge.
SP3.1.6 Operative difficulty grading scale for laparoscopic appendicectomy: A novel tool
Authors: Smigielski Michelle , Mackenzie Scott , Dent Owen , Giles Anna
Published: October 2021

Aims

Acute appendicitis is a common emergency surgical presentation accounting for approximately 30,000 emergency operations annually in Australia. There is need for a clinical grading tool that can quickly and reliably assess the severity of appendicitis at the time of surgery and predict the difficulty of the operation.

Methods

Over 12 months, 111 questionnaires relating to the difficulty of laparoscopic appendicectomy operation, anatomical and pathological features, time taken, and need for senior assistance were completed by surgeons and trainees of varying seniority. Construction of a scale of the difficulty of operation was by the method of summated ratings. The final scale was generated utilising further item analysis, principal components analysis, internal consistency reliability analysis and concurrent validity analysis.

Results

A scale of 8 anatomical and pathological features that predict the difficulty of laparoscopic appendicectomy was formed. These include the presence of acute adhesions, gross pathology of the appendix, quality of the appendix, mesoappendix, appendix base and retroperitoneum, visibility of the appendix artery, and adherence of the appendix to adjacent structures. The scale has high internal consistency reliability, and both individual items and the scale has been validated by comparison with the surgeons’ perceived difficulty, the length of the operation and the need to call for senior assistance.

Conclusions

This appendicectomy grading scale based entirely on readily identifiable laparoscopic findings is able to predict the difficulty of the operation and can be used to facilitate operative planning as well as to improve criteria for assessing operative competency in trainee surgeons.
SP3.1.7 Performance of ultrasound in the diagnosis of cholecystitis and prediction of the “difficult cholecystectomy”
Authors: Room Hywel , Wood Anna , Ji Chen Chen , Dowell Hannah , Toh Simon
Published: October 2021

Aims

Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients.

Methods

All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics.

Results

In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days.

Conclusions

We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.
SP3.1.8 What happens to patients with acutely symptomatic hernia in the UK? Findings from the MASH study
Authors: Proctor Victoria , Group MASH Steering , Collaborators MASH
Published: October 2021

Aims

Acutely symptomatic abdominal wall and groin hernias (ASH) are a common reason for acute surgical admissions in the UK. There is limited data to guide the treatment of such presentations. This study aimed to assess outcomes of emergency hernia surgery, and identify common management strategies, to improve care for these high risk patients.

Methods

A 12 week, UK-based, multi-centre, collaborative, prospective cohort study (NCT04197271) recruited adults with ASH. Data on investigations, specific surgical intervention, in-hospital morbidity and mortality, and quality of life was measured. 30 and 90-day follow-up phone calls collected complications and quality of life. Descriptive analyses were performed to describe population and outcomes.

Results

Twenty-three acute Trusts recruited 264 patients. Inguinal (37.9%) and umbilical (37.1%) were the most common hernia locations. 17% were awaiting elective surgery and 17% had been previously declined intervention. CT was performed in 47%. 82% of patients had surgery within 48 hours, with 95% of procedures performed open and 93% under general anaesthesia. 3/11 laparoscopic procedures were converted to open. Mesh was used in 55%, this was typically synthetic non-absorbable (86%). Complications were infrequent; 2% developed pneumonia or delirium. Surgical site infection occurred in 3% and mortality was 1.2%. Quality of life improved between baseline and 30-days following repair.

Conclusions

There is variation in the management of ASH in the UK, particularly with repair techniques, use of mesh and laparoscopy. One in five patients was awaiting repair; this might indicate a need for expedited pathways and reprioritising of elective hernia repair.