bluuebunny/crossref_metadata_2025 huggingface dataset:
WTP4.7 Evidence-Based care for Acute Uncomplicated Colonic Diverticulitis. Effects on Bed Occupancy, Broad Spectrum Antibiotic Therapy and Cost savings
Authors: Bose Sayantan , McWhirter Derek , Carlson Gordon
Published: August 2023

Aims

To investigate the impact of failure to adhere to best-practice guidelines in the management of acute uncomplicated colonic diverticulitis on use of hospital resources.

Methods

Retrospective study from January 2019 till December 2021. The clinical pathway, including disposal (admission vs discharge), imaging, time course, illness severity, treatment and outcome of all adult patients (18 years and older) attending as an emergency with acute colonic diverticulitis were identified from ICD-10 coding data. All radiology reports were reviewed and a modified Hinchey classification of disease severity recorded.

Results

339 patients were identified during the study period. 79 were excluded because of incorrect coding. In 260 cases (222 patients) median (range) age 56 (23-92) years, the diagnosis was confirmed by CT scan in 247 (95%). Of these, 174 (67%) had uncomplicated (Hinchey 1a) acute colonic diverticulitis. 235 (90%) of all attendances resulted in an acute hospital admission. However, 149/174 (86%) of all patients with Hinchey 1a disease were admitted to hospital and 142 of these (95.3%) were treated with broad spectrum IV antibiotics, despite evidence-based guidance indicating that this treatment is unnecessary. 605/1268 (48%) of all bed days for the management of acute diverticulitis over the study period were used to treat patients with Hinchey 1a disease.

Conclusion

Almost half of all patients admitted with acute diverticulitis could have been managed on ambulatory pathways without antibiotics. Adherence to evidence-based guidance and development of appropriate patient pathways provide an opportunity for considerable improvements in efficient use of hospital resources and improved antibiotic stewardship.
WTP5.1 Perioperative hypothermia in elective surgical patients
Authors: Arifuzaman Mohammed , Shah Jigar , Bhattacharya Sayan
Published: August 2023

Introduction

Perioperative hypothermia is an under-reported, yet well recognized complication of surgery. Normal thermoregulatory mechanisms are disrupted in anesthetized patients. Up to 70% of surgical patients develop perioperative hypothermia, with serious consequences including coagulopathy, sepsis and cardiac events.

Methods

In this single centre study, we collected prospective data from 100 elective operations in urology, gynaecology, general and breast surgery. The pre-operative, pre-induction, intraoperative, post-procedure and in recovery temperatures (in Celsius) were recorded. Any temperature below the 36°C was regarded as hypothermia and the total incidence of hypothermia during all the 5 phases were calculated.

Results

Incidences of hypothermia in pre-operative, pre-induction, intraoperative, post-procedure and in-recovery were 4 %, 5%, 12 %, 11 %, 8 % and 6 % respectively. Multiple regression analysis of pre-operative, pre-induction and intra-operative temperatures resulted in a p value of 0.237 for pre-operative temperature and 0.000032577 for pre-induction temperatures respectively. This suggests that pre-induction temperature was the most statistically significant parameter for intra-operative hypothermia. Furthermore, regression analysis predicted the intra-operative temperature for a given pre-induction temperature. Regression analysis line fit plot between preinduction and intra-operative temperatures predicted that for intraoperative temperature to be 36.74 °C, mean preinduction temperature is to be raised to 37.2 °C.

Conclusion

This study highlights the incidence of intraoperative hypothermia and need for active interventions to prevent the same. It paves the way for a single blinded randomized controlled trial for comparing different modalities to pre-warm patients and prevent intraoperative hypothermia.
WTP6.4 Influence of Annual Record of Competence Progression panel profile on Differential Attainment
Authors: Barlow Emma , Luton Oliver , Eley Catherine , Hemington-Gorse Sarah , Egan Richard , Lewis Wyn
Published: August 2023

Introduction

Differential Attainment (DA) refers to divergent achievements when related to protected traits. Annual Review of Competency Progression (ARCP) panels play a key role which compositions should reflect, yet no guidance exists on panel profile related to protected traits. This study aimed to evaluate the influence of panel profile on DA.

Methods

Anonymised ARCPs numbering 1090 in a UK Statutory Education Body (SEB) were examined and primary effect measure was ARCP Outcome (ARCPO) with satisfactory ARCPO classified as 1, 2 or 6, and unsatisfactory as 3 or 4.

Results

Satisfactory ARCPOs numbered 1005 and unsatisfactory 85. Median panel number was 7 (range 1-15, p<0.001). Median female percentage consultant representation was 18.2% (0% (Urology, Plastic & Paediatric Surgery) to 40% (Core Surgery) and median ethnicity (BME) consultant representation 14.3% (0% (Vascular & Neurosurgery) to 80% (Cardiothoracic Surgery). Multivariable analysis revealed: Trainee seniority (OR 0.800, p<0.001), SAC Liaison Member gender (OR 0.720, p=0.013) and Panel gender balance (N ARCP panel females, OR 10.695, p=0.003) to be independently associated with adverse ARCPO.

Discussion

Important two to five-fold variance in ARCP panels were found related to gender and ethnicity profile respectively with apparent significant impact on DA.
WTP6.9 Post-operative Management Study Day: Improving knowledge and confidence of senior medical students when managing post-operative patients
Authors: Powell Harriet , Bridgeman Joseph
Published: August 2023

Aim

Focus groups run by teaching facilitators with medical students highlighted a lack of confidence around how best to assess and manage post-operative patients.

In response we aimed to provide a focussed study day covering key aspects of post-operative management, and complications for undergraduate medical students at St George's University.

Methods

A study day dedicated to the assessment and management of post-operative patients was created. The day incorporates different types of learning including case-based discussions, game-based learning and simulation. Topics covered are aligned with the curriculum for senior medical students at St George's University, including post-operative pain, bowel obstruction/ileus and haemorrhage. Information gathered from local clinical guidelines.

Results

Pre-course confidence scores on management of common post-operative complications were on average a 2 out of 5 (5 being very confident, and 1 being not confident at all). Post-course confidence scores increased to an average of 4 out of 5 for managing the majority of common post-operative complications. Feedback on the teaching and content of the course was good, with 95% of participants rating the session as 5 out of 5.

Results

Post-operative assessment and management is an area of teaching that students feel has been neglected within their prior years of study. This dedicated study day allows for in-depth discussion and practice at assessment of post-operative complications. Future development of the course may include opening the participants to foundation doctors, involvement of senior surgical staff in facilitation and assessment, and use in other local hospitals.
WTP7.6 Novel ambulatory surgical pathways can reduce operation waiting times whilst maintaining patient outcomes
Authors: Johnson Nathan , Nassr Noon , Freimane Katrina , Manford Evelyn , Peckham-Cooper Adam , Rajput Ibrahim
Published: August 2023

Introduction

A record number of patients are currently awaiting NHS treatment. A novel ambulatory surgical pathway (Rapid Access Theatre (RAT) lists) can reduce patient wait times for common operations such as cholecystectomies and ease the burden on the traditional elective operating list. However, it is important that this approach does not jeopardise patient safety.

Method

All non-inpatient cholecystectomies carried out in a large teaching hospital from 01/10/21 – 31/01/22 were analysed. Operations carried out on RAT lists were compared to those on elective lists for time to surgery from listing, post-op length of stay (LOS), number of patient returns within 30 days and rate of post-op complications.

Results

There were 85 cholecystectomies carried out on RAT lists and 86 carried out on elective lists. The average time to surgery from listing was 70.56 days for RAT lists and 152.19 for elective lists (p = 0.0005). The average post-op LOS was 0.73 for RAT lists and 1.00 for elective lists (p = 0.43). The number of patients who returned to hospital within 30 days of their operation was 8 (10.39%) for RAT lists and 11 (14.86%) for elective lists (p = 0.751). The number of post-op complications was 10 (13.33%) for RAT lists and 13 (17.81%) for elective lists (p = 0.52).

Conclusions

The introduction of a novel ambulatory surgical pathway (RAT lists) has reduced the waiting time for cholecystectomies whilst maintaining outcomes and patient safety. This pathway is therefore cost effective and an important tool for reducing length waiting lists.
WTP7.11 CEPOD Booking Audit in General Surgery
Authors: Kitsikosta Loukiani , Diaz Maria Hernandez , Galides Chloe , Morsi Mai , Morrison-Jones Victoria , Berry David
Published: August 2023

Introduction and Objectives

Repeated internal audits suggested 20% of patients booked into the emergency general surgery theatre list failed to achieve their allotted time to theatre. We wished to investigate this further, identify potential reasons and whether any delay resulted in patient harm.

Materials and Methods

We retrospectively reviewed 748 consecutive adult patients over a 12 month period booked for appendicectomy, hernia repair, laparoscopic cholecystectomy or abscess I+D. We excluded laparotomies and patients under 18yoa.

We recorded pre-operative CEPOD classification, adherence to the timeframe and reasons for delays. Outcome measures included post-op length of stay (POLOS), prolonged hospital stay, and unexpected intraoperative findings.

Results

Of 748 emergency procedures, 632 (85%) achieved the desired time frame and 116 (15%) were delayed. Of the 116 delayed cases, 94 (81%) were appropriately booked (clinical review). Most delays were caused by a higher priority emergency but in one third of delays no reason was recorded.

There was no difference in mean POLOS or unexpected findings between the two groups of those achieving expected time to theatre and those delayed.

Conclusions

Despite our initial concerns regarding delays to theatre this only occurred in 15% of the study group with no discernible difference in outcomes as measured.

The repeated clinical review of potentially delayed emergency patients accessing the operating theatre appears to be safe.

Improved documentation for delays and accurate pre-operative bookings across all surgical teams will aid running and assessing the emergency provision.
WTP7.12 Investigating the duration of empirical antibiotic treatment and subsequent reduction in hospital readmission rates for perforated appendicitis in the paediatric patient population
Authors: La Costa Francesca , Haq Iqraa , Hammer Clare , Lahiri Rajiv
Published: August 2023

Background and Aim

Acute appendicitis is the most common surgical emergency in the paediatrics. Complicated appendicitis often involves perforation, requiring a longer course of antibiotics post-appendicectomy [1]. There is considerable variability on post-operative antibiotic regimes and duration within hospital trusts with no national guidelines. Local Trust-based consensus [2] recommends a 5-day course IV co-amoxiclav with American Paediatric Surgical Association guidelines suggesting oral conversion if IV antibiotic duration is less than 5 days [3, 4]. Therefore, we measured compliance with local and international guidelines.

Methods

Paediatric patients aged 5-17 years were selected for the study using ICD-10 codes for ‘Perforated Appendicitis’ (K35.2 and K35.3). Patients were included if they had operative management for perforated appendicitis between 1 April 2021 and 31 March 2022. Key parameters collated included; re-admission, duration of re-admission, complication, post-operative antibiotic use (selection, intravenous/oral dose and duration of use).

Results

Twenty-six paediatric appendicectomies for perforated appendicitis occurred within the time frame. Nine had IV antibiotics for >5 days, of this cohort, 7 had oral conversion and completed 2-5 days of oral antibiotics with re-admission rate 33%. Eleven had IV antibiotics for < 5 days with oral conversion for 4-7 days, readmission rate was 18.2% on days 4 & 5 respectively. Six had IV antibiotics for <5 days with no oral conversion and no patients were re-admitted.

Conclusions

A longer duration of antibiotics with an earlier conversion from IV to oral, reduced readmission rates. However, greater research with more participants and standardised antibiotics can explore other influencing factors.
WTP7.14 The ‘Right’ Strategy? Can we change the risk profile of emergency presentations of right sided colorectal cancers?
Authors: Banks Jessica , Lee Mathew , Wilson Tim
Published: August 2023

Background

Up to 30% of patients with colorectal cancer present acutely and have worse outcomes than elective patients. We sought to compare cancer care quality and clinical outcomes between emergency and elective presentations of right-sided colon cancer.

Methods

This single-centre, retrospective study included all patients who underwent operative management (emergency and elective) for a right-sided colon cancer, from 1st April 2017 to 31st March 2022. Data were collected from electronic patient records and analysed to compare host and tumour factors as well as outcomes between emergency and elective cohorts.

Results

Overall 303 patients (median age 72) were included. 65 patients (22%) presented as an emergency: 36 presented in obstruction and 11 with tumour perforation, compared to 1 patient with tumour perforation in the elective group (p=<0.0001). Emergency presentation was associated with more advanced tumour stage (p=0.001).

The emergency group had lower rates of laparoscopic surgery (32% vs 86% p=<0.0001); higher rates of post-operative complications (47% vs 27% p=0.05); increased 90-day mortality (20% vs 3% p=0.001); and a longer hospital stay (9 vs 4 days p=0.048). 50% of emergency patients received adjuvant chemotherapy compared to 56% of elective patients (p=0.71). No differences were found between the two groups regarding demographics, comorbidities, or time to MDT discussion.

Discussion

Outcomes of acute right-hemicolectomy are poor, with inadequate access to subsequent chemotherapy. Strategies addressing acute presentations of left-sided tumours have moved towards temporisation and elective surgery; this strategy is rarely adopted for acute presentations of right-sided tumours. Delaying major resectional surgery for optimisation may improve short-term outcomes, and access to adjuvant therapies.
WTP8.3 Failing to record consent discussions on clinical records leaves us vulnerable
Authors: Mantova Maria , Mahalingam Praveena , Gambhir Raghvinder Pal Singh
Published: August 2023

Aims

Documenting informed consent discussions in patient clinical records is a mandatory requirement by the General Medical Council (GMC). This study aimed to evaluate the adherence to that mandate.

Methods

We looked at GMC and Royal College of Surgeon’s guidance on consent and its documentation in patients’ records. The recommendations are:

We retrospectively looked at the Electronic Patient Record (EPR) of patients admitted for surgery under the Vascular department at a tertiary centre over 3 months.

We excluded patients who passed away prior to surgery or needed Consent form 4.

Results

136 out of 150 patients admitted for surgery during the study period met the inclusion criteria. Of these, 90 were admitted electively and 46 as emergencies.

We found evidence of consent discussion for only 60% (n-54) of the elective admissions and for 59% (n-27) of emergency admissions, through clinic letters or ward entries. For the remaining, there was no recorded EPR documentation of the consenting discussion though all had a consent form signed.

Conclusions

Although GMC and Royal College of surgeons have clear guidance regarding documentation of consent in patients’ notes, this is often not followed in clinical practice. This leaves the trusts open to future litigation.
WTP8.9 3D volume assessment as an objective tool in breast asymmetry management
Authors: Makram Mahmoud , Noaman Ayman , AboZeid Mohammed , Noureldin Khaled
Published: August 2023

Background

The normal symmetrical appearance of the breast is a vital. It can be psychologically distressing to patients and affects their body perception when these differences are obvious. The goal of breast surgeons is minimising these differences to make them more acceptable to patients.

Methods

This study was done on 20 females seeking breast asymmetry correction. Age ranged from 18 to 45 years (mean age: 30.4). All patients had volumetric breast assessment using a (3D) imaging system (3D LifeViz®, Quantificare system). The first 10 patients were chosen randomly for breast (MRI) volumetry to confirm the results of the 3D system. The patients were managed with different single-stage surgical procedures depending upon the objective assessment of the volume difference between their breasts.

Results

Breast volume assessment using the 3D camera was done in all 20 patients pre-operatively 30 and postoperatively. The preoperative mean volume difference was 159.45 cm3, and the postoperative mean difference was 16.75 cm3, with an overall reduction in mean volume difference of 89.5%. Breast MRI volumetry was done for 10 randomly chosen patients to confirm the results and ranged between 3 and 12 cm3 (average 7.1 cm3) on the right and 0 and 15 cm3 (average 6.3 cm3) on the left. Comparing the 3D camera and MRI in assessing breast volume difference showed that the difference ranged between 1 and 5 cm3 with an average of 2.4 cm3, which was not statistically significant.

Conclusion

The 3D technology is useful objective tool to augment the surgeons’ experience. It helped to achieve an 84.57% reduction in volume difference in managing asymmetry with single-stage procedure.
WTP8.11 Late Implant Loss Following Implant-based Immediate Reconstruction of the Breast
Authors: Anena Brenda , Ravichandran Duraisamy
Published: August 2023

Aims

Implant-based reconstruction is the most popular reconstruction in patients undergoing mastectomy for carcinoma or risk reduction. Postoperative complications such as infection are well known to result in implant loss, but the incidence and causes of late implant loss are not well studied.

Methods

We reviewed patients who underwent an implant-based reconstruction over a 5 year period (2018-2022) and identified those who had an unplanned implant removal 3 months after reconstruction. We looked at the comorbidities, method of reconstruction, exposure to radiotherapy and reasons for removal.

Results

Amongst 196 reconstructions there were 17 (8.7%) unplanned late removals, average time to removal 11.4 months. The reasons are infection or wound healing issues (8), rupture (3), cancer recurrence (3), deflation during port removal (2) and migration (1). Radiotherapy exposure was 41% vs. 18% in non-removal group.

Conclusions

A significant number of implants continued to be lost after the immediate postoperative period. Patients should be aware of that possibility. Radiotherapy appears to increase this risk.
ThTP1.5 Evaluating the Impact of Electronic Documentation on the Consent Process for Whipples Procedures within a HPB Department
Authors: Fadipe Toks , Iqbal Affan , Jamdar Saurabh , Patel Agastya
Published: August 2023

Background

The Whipples is an operation associated with major morbidity. Common risks include infection, wound problems and delayed gastric emptying. Less common but significant complications include fistula, anastomotic leak and cardiorespiratory dysfunction. This often requires intensive care or further procedures. Overall, mortality is 3%. This wide array of possible post-operative outcomes must be documented accurately on a consent form. However, what is stated often varies significantly depending on the consenting clinician. We assess the effect of a transition to an entirely electronic patient record (EPR) system on the consent process and the subsequent impact of standardised electronic consent forms.

Methods

Comparison of documented risks and additional procedures against ideal consent adapted from a patient information leaflet for Whipples. Cases performed by a tertiary centre hepatobiliary surgery department. Paper consent forms from July to September 2022 compared to electronically signed consent forms obtained from the EPR system from September to November 2022. Intervention in December 2022 (automated consent form). Re-audit from December 2022 to January 2023. Descriptive statistical analysis.

Results

25 consent forms assessed. Majority of forms completed by middle grades (92%). Eighteen documented risks and four additional procedures in ideal consent. Complications such as bleeding, infection and cardiorespiratory complications consistently feature in consent forms. Transition to electronic system meant most additional procedures documented less frequently, as are other complications such as visceral injury. Broad improvements in consenting documentation following intervention.

Conclusions

Introduction of pre-filled consent forms produced swift and significant improvements in consistency of consent forms. Further assessment of other index procedures of hepatobiliary, general and vascular surgery to follow.
ThTP1.10 Whipple's for ampullary adenocarcinoma: can we predict who will develop local only recurrence and tailor treatment to individuals?
Authors: Russell Thomas , Labib Peter ,   RAW Study Collaborators, Aroori Somaiah
Published: August 2023

Aims

Following pancreatoduodenectomy (PD) for ampullary adenocarcinoma (AA), cancer recurrence rates are high. There are currently no models available which can estimate which patients are likely to develop local only recurrence. Using a multicentre cohort, this study aimed to compare patients who developed local only recurrence to those who developed distant (+/- local) recurrence.

Methods

A retrospective review of patients who underwent PD for AA was carried out (2012-2015). The group that developed local only recurrence was compared to the group that developed distant (+/- local) recurrence (within five years of PD). The following were compared: demographics, preoperative comorbidities/functional status, preoperative imaging and blood tests, postoperative complications and histological details, and adjuvant treatment. Means were compared using Student’s t-test, medians were compared using the Mann Whitney U test and percentages were compared using Fisher’s exact test.

Results

Of the 394 included patients, 45% developed recurrent AA. Of these, local only recurrence, distant only recurrence, and local and distant recurrence affected 34 (20%), 94 (55%) and 41 (23%) patients, respectively (unknown site of recurrence: 7). When the group that developed local only recurrence (n=34) was compared to the group that developed distant (+/- local) recurrence (n=135), no statistically significant differences were observed.

Conclusions

In our multicentre study of patients who underwent PD for AA, 9% developed local only recurrence and 34% developed distant (+/-local) recurrence. No significant differences were observed between the two groups. This highlights the difficulties clinicians face when attempting to tailor treatment to individuals.
ThTP1.11 Closed Loop Audit on The Timing of Hot Gallbladder Surgery
Authors: Shabana Amanda , Patel Mahul , Samra Benjamin , Pustula Mary , Zhuang Qi
Published: August 2023

Introduction

Almost 70,000 cholecystectomies are performed each year in the United Kingdom (UK). The Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) 2016 and The National Institute for Health and Care Excellence (NICE) 2021 Guidelines on “Gallstone disease” recommend performing a Laparoscopic Cholecystectomy (LC) within 7 days of admission for hot gallbladder. We aimed to establish if guidelines were being met at a tertiary hepatobiliary unit in Oxford.

Method

Two cycles of the audit were completed using a retrospective cohort design. The first cycle of the audit was completed between January 2019 – August 2020 (n=466) to include patients that had a LC for a hot gallbladder. An intervention included an educational teaching session within the department and posters distributed of the guidelines. The second cycle of the audit was completed during November 2022 (n=50).

Results

In the second cycle, more patients had a LC within 3 days of admission (36% vs 24.7%), with the average waiting time from admission to a LC being 6.4 days. However, less patients had their LC within 7 days of admission in the second cycle (68% vs 75.3). The most common cause for delayed LC was waiting times for ERCP/MRCP and theatre availability.

Conclusion

An improvement was found in the number of LC's performed within 3 days of admission in the second audit cycle. We are, however, still not meeting the AUGIS and NICE guidelines on performing a LC within 7 days of admission. Future work will look at Intra-operative laser breakdown of gallstones to reduce waiting times.
ThTP2.12 The impact of acute systemic inflammation and the metabolic response to surgery on computed tomography body composition analyses
Authors: Brown Leo R , Ramage Michael I. , Bruce Nikki , Dick Lachlan , Sami Sharukh , Skipworth Richard J.E.
Published: August 2023

Aim

Body composition has been used extensively for prognostication across malignant and benign diseases. Systemic inflammation is both a key driver of cancer cachexia and a common finding in patients presenting with acute pathology. However, its influence on body composition is poorly understood. This study aimed to longitudinally assess computed tomography (CT) body composition, in patients who experienced an anastomotic leak post-oesophagectomy, as a model of acute, severe systemic inflammation.

Methods

Consecutive patients who suffered an anastomotic leak, following oesophagectomy, between 01/01/2012 and 01/01/2022 were identified from a prospectively maintained database. Changes in body composition were assessed across staging, pre-operative, post-complication and follow-up scans at the L3 vertebral level.

Results

Twenty patients (median 65 years, 90% male) were included. Of these, fifteen underwent neoadjuvant chemo(radio)therapy. Body composition was not altered by neoadjuvant treatment. Following surgery and anastomotic leak, a decrease in skeletal muscle volume (mean difference: -68.06cm3, p=0.028) was noted. Estimates of intramuscular and subcutaneous adipose tissue conversely increased (p=0.038 and p=0.039 respectively). Skeletal muscle density fell while adipose densities were higher following anastomotic leak. Although tissue radiodensity and subcutaneous fat volumes normalised on follow-up CT scans, skeletal muscle volume remained below pre-treatment levels.

Conclusion

Acute systemic inflammation has a marked effect on body composition analyses. Decreased muscle volume and increased volumes of adipose tissue were evident following the inflammatory insult. Radiodensity across muscle and adipose tissues trended towards that of water, likely secondary to oedema. Research utilising body composition variables should be interpreted with consideration of the potential of influence of underlying inflammatory status.
ThTP2.14 Robot-assisted repair of paraoesophageal hernia: a systematic review
Authors: Brooker-Thompson Chad , William Butterworth James , Doran Sophie , Qureshi Yassar , Dawas Khaled , Mohammadi Borzoueh
Published: August 2023

Aim

Laparoscopic repair is quoted as the standard of care for paraoesophageal herniae but limitations include the 2D image, requirement of a trained camera assistant and surgeon fatigue. Robotic-assisted (RA) repair promises improved 3D visualization and ergonomics. However, there is limited data on short and long-term outcomes from RA repair. We aimed to systematically review literature on RA repair of paraoesophageal herniae and post-operative outcomes.

Methods

A systematic on-line literature search of Embase and Medline identified 200 articles of which 13 relevant studies were selected, including 7 retrospective and 6 prospective studies. Selected articles were assessed by two reviewers to extract relevant demographic and outcome data.

Results

1601 patients received RA repair of paraoesophageal herniae with a median age of 62 years and 72% were female. The majority had Hill type 3 paraoesophageal herniae (80.5%). Predominately elective operations (86.4%) they had a mean operative time of 169.7 minutes, used mesh in 44.0% and included a fundoplication in 78.2%. Only one required open conversion. Median length of stay was 2.45 days (1.3-4.5 days). 15.4% had reported complications (dysphagia (9.7%), pneumothorax (0.4%), pneumonia (0.3%) post-operative haemorrhage (0.3%) and thrombosis (0.4%)). There were no post-operative mortalities. Few symptomatic recurrences were reported and there was a 1.8% re-operation rate within this cohort.

Conclusion

RA paraoesophageal hernia repair offers similar outcomes to those published in recent literature for laparoscopic repair, with potential for improved surgeon ergonomics and visualisation. Carefully designed, prospective trials comparing laparoscopic and robotic repair are required to further delineate the optimal surgical approach.
ThTP3.5 Electronic consent improves patient safety
Authors: Fraser-Govil Shubhangi , Cowley Sarah , Elmowafy Ahmed , Pardoe Helen
Published: August 2023

Background

Consent is a core pillar of patient care, especially for surgical procedures under anaesthesia. Some patients lack capacity to consent, and in these cases documentation of capacity assessment and a best interests decision is essential. Error rates on hand-written consent forms can be high and this can be reduced by using electronic consent forms. In a UK DGH, electronic consent was implemented in October 2022, and we look at the impact this has had on the process of consent in patients who lack capacity.

Methods

We examined the process required for documentation of consent in patients who lack capacity to be sent to the safeguarding team and how many they had received in the 3 years prior to electronic consent implementation. We then compared the process for the safeguarding team to be sent electronic documentation and how many they had received from October-January.

Results

For paper documentation to be received by the safeguarding team, a clinician would have to scan the MCA and email it to the safeguarding team. In the 3 years prior to October 2022, they had received 1 form. Currently, the safeguarding team request a weekly report from the electronic consent supplier and receive electronic copies directly. They have received 45 to date.

Conclusions

The implementation of electronic consent has resulted in the safeguarding team having greater insight into the number of patients who are having procedures that lack capacity. This enables them to follow up the patients and ensures better, more holistic, patient care.
ThTP3.8 Promoting Awareness and optimizing perioperative management for Jehovah's Witnesses (JW) patients: A Quality Improvement Project (QIP)
Authors: Jatania Jignesh , Locurcio Lino , Kavourides Michalis , Nishith Shikha , Singh Daya
Published: August 2023

Aims

The restriction in using blood products poses a unique challenge to healthcare providers during treatment of JW patients. Current trust guidelines cover the peri-operative aspects of the management. We carried out a QIP to review the awareness amongst clinicians of appropriate guidelines and protocols in managing this cohort of patients.

Methods

An online survey was sent out to clinicians of all grades within the Trust, asking specific questions related to the use of blood products and alternative options; awareness of protocols including who to contact for advice.

Results

Our results of 102 responses revealed, 76% clinicians were not familiar with the trust guidelines.

There was a wide variation in the knowledge about blood products which could be used and 42% were not aware of acceptable alternative options.

68% were not sure whom to contact for advice in and out of hours.

20% knew how to update an alert on the online medical records to identify patents’ wish of refusal for use of blood products.

94% were unaware of any preoperative and consent checklist for blood products.

50% were aware of checking Advance Directive for Refusal of Treatment (ADRT).

Conclusion

This QIP highlighted the lacunae in the awareness of trust protocols amongst clinicians of all grades. We aim to provide support and alerts on our Trust Intranet for managing this cohort of patients. Our ultimate goal is to produce a uniform national protocol available to all hospitals in the UK.
ThTP4.1 Evaluation of Post-operative Outcomes in Laparoscopic & Open Anterior Resections (AR) for Rectal Cancer: A 15 year cohort study
Authors: Gok M A , Mughal H N , Bughio M , Khan U A
Published: August 2023

Aims

AR offers sphincter preserving surgery for rectal cancers, & has functionally comparable results to APER's or Hartmann’s resection. Use of mechanical stapling devices has allowed laparoscopic AR to become widely available. Aim of study is to evaluate post-operative outcomes in laparoscopic AR’s.

Methods

A cohort study collated post-operative outcomes in laparoscopic AR’s performed at a single-centre from January 2008 to February 2023. Open AR’s were recruited as controls.

Results

Conclusion

Laparoscopic AR accounted for prolonged operative times & shorter hospital stay. There were no differences in early post operative mortality & complications. Laparoscopic AR had better long term survival, This could be explained by better case selection for laparoscopic AR (since laparoscopic resection were adopted as routine practise, as opposed to open AR became less employed in recent years).
ThTP4.10 Evaluating the Outcomes of Anal Squamous Cell Carcinoma with Curative Intent- a 10-Year Experience
Authors: Noureldin Khaled , Ayantunda Abraham , Issa Mohamed , Shalaby Ahmed
Published: August 2023

Background

Our 10-year experience in treating anal squamous cell carcinoma (ASCC) with curative intent.

Patients and Method

Clinical and pathological data were analysed between January 2011 and December 2019. All patients underwent the standard workup and treated accordingly. Patients were followed up according to the network protocol. The outcome measures were clinicopathological characteristics, treatment modalities, response, recurrence, disease-free and overall survival.

Results

117 patients followed up over the 10-year. 26 patients treated palliatively, 11 patients with adenocarcinoma, 1 melanoma, 1 Paget disease and 1 carcinoid tumour were excluded. Median age was 65 (38-90) years with male to female ratio of 1:1.9. 3 patients were HIV+ve and 52% of the patients had AIN of varying degree of dysplasia. AJCC stages were I (16), II (18), IIIA (19), IIIB (9) and IV (15). 88.3%% of the patients had radical chemoradiotherapy while 9 patients with tumour ≤2cm underwent wide local excision. 81.8% of the patients treated with radical chemoradiotherapy had complete response while (5/77) had partial response.4 patients with incomplete response underwent salvage APER. Recurrence rate was 13%.

The overall mean survival time was 99.82 (95% CI 88.87-110.77) months with 5-year survival rate 78.0%. Overall recurrence rate was 13.0%. Mean disease-free survival time in 77 patients was 111.82 (95% CI 102.38-121;26) months. 75.3% of the patients were alive at the end of the study with an overall mortality rate was 24.7% and disease-specific mortality was 15.6%.

Conclusion

Recurrent anal SCC occurred in 1 in 10 after radical chemo-radiotherapy with disease-specific mortality of 26%.
ThTP5.8 Single centre, single surgeons’ experience of laparoscopic emergency surgery from a tertiary care NHS hospital: delay in surgery is associated with higher mortality and morbidity
Authors: Subramanian Atreya , Swaminathan Christie , Siby Jayas , Singh Anurag , Sajid Muahmmad
Published: August 2023

Aims

The objective of this article is to present a single centre experience of laparoscopic emergency surgery reporting outcomes influenced by delay in surgery.

Methods

A retrospective review of case notes to evaluate postoperative outcomes in patients undergoing laparoscopic emergency gastrointestinal surgery.

Results

There were 172 major laparoscopic emergency procedures over a span of 5 years. Forty-one colorectal resections were performed within 48 hours of admission (group A) compared to 50 resections (group B) after 48 hours. Mean hospital stay was shorter in group A (10.57 versus 19.97) days. No mortality reported in the group A whereas 4 patients died (8%) in group B. Lower morbidity percentage was also observed in group A (14.6 % versus 22 %). Twenty small bowel resections were performed within 48 hours of admission (group C) compared to 6 resections (group D) after 48 hours. Mean hospital stay was shorter in group C (8.6 versus 29.5) days. 3 patients died (15%) in group C whereas no mortality reported in the group D. Lower morbidity was also observed in group C (14.6 % versus 22 %). Laparoscopic adhesiolysis was performed in 28 patients and significant reduced hospitalization (3.6 versus 12.5 days) and reduced morbidity (0 versus 0) was noted in patients undergoing surgery within 48 hours of the admission. Laparoscopic hernia repair was performed in 20 patients and significant reduced hospitalization (4.5 versus 8.2 days) and reduced morbidity (13.7% versus 20%) was noted among patients who underwent surgery within 48 hours of admission.

Conclusion

Early laparoscopic surgery in acutely ill surgical patients is associated with better surgical outcomes
ThTP6.9 Assessing the Quality & Completeness of Discharge Summaries
Authors: Thorold Colette , Cooper Danni , Badrinath Krishnamurthy , Hope Carla
Published: August 2023

Objective

A review of the timeliness, accuracy, and completeness of surgical discharge summaries.

Aims

To assess whether discharge summaries are sent within 24hours of discharge and if they contain accurate information for the patient and the GP in terms of case summary, follow up plans and post-operative instructions.

Methods

Patients admitted under General Surgery/Urology at a DGH during February and May 2022 were identified. 162 patients were identified, and a random sample of 45 patients was analysed.

The discharge summary was compared to inpatient notes and rated against a pre-determined standard including accuracy of operative details, use of patient friendly language and safety netting advice. Data was collected by two independent doctors.

Results

43/45 (96%) of discharge summaries were completed on the day of discharge. 44/45 completed operative details which was accurate in 40/44. 83% specified a follow up plan. 50% described a follow up investigation, but these were only requested in 33% of cases. When relevant, instructions regarding stitches were given in 38% of cases, wound care instructions in 0% and in 50% instructions were given regarding indwelling drains. Overall, 51% of summaries were rated as using patient friendly language. 22% had inadequate safety netting advice.

Conclusions

Overall, discharge summaries were completed within 24hours. The use of patient friendly language, safety netting advice and post-operative instructions needs improvement. It is important that ongoing investigations are requested at the time of discharge to avoid delays or omissions in patient care. We recommend additional training for rotating doctors at induction and propose a discharge template for common surgical conditions.
ThTP6.10 A multi-specialty clinical audit to assess true surgical site infection incidence at a district general hospital in Kent
Authors: Gardner Alvin , Tamrakar Abhishek , Wates Emma , Atherley Isabella , Nebo Vivien , Fernandes Roland
Published: August 2023

A surgical site infection (SSI) is a healthcare-associated infection which occurs within 30 days of surgery, or within 90 days of surgical implantation. SSIs cause significant morbidity and mortality. 3 types of SSI are recognised: superficial incisional, deep incisional and organ/space.

Our audit aim was to assess our hospital performance against established national targets: SSI rates <1% following clean procedures and <10% following clean-contaminated surgery.

Retrospective data collection was carried out. Patients who underwent surgery in theatres throughout 12/7/22 - 31/8/22 were included. Clinical records were reviewed, and follow-up telephone calls were made to capture any additional SSIs.

955 patients were included in the 1st cycle. Overall SSI rate was 14.5% (n = 138). This varied across specialties, being 18.1% for general surgery (n = 45/249) to 4.3% for paediatric surgery (n = 2/47). Incidence of SSIs in the elective and emergency settings for general surgery were 12.84% (n = 14/109) and 22.14% (n = 31/140) respectively. SSI rates also varied within each specialty according to procedure type. Within orthopaedics, Spearman’s correlation coefficient for procedure type and association with SSI showed statistical significance, Rs 0.961, P < 0.001. 38 SSIs were identified from follow-up telephone calls.

This audit has demonstrated that the true incidence of SSIs is likely to be significantly higher than anticipated if hospital admission is the only criteria to capture data. Our results show there is scope for improvement to reduce SSIs. We have since implemented Oxford’s 8-point SSI reduction bundle. A re-audit is scheduled for 2023.
ThTP7.1 An audit of outcome of rectal cancer patients who were offered primary surgery. Are we following NICE guidelines for management of rectal cancer? –A retrospective cross sectional study at a District General Hospital
Authors: Wani Ishfaq , Husain Najam , Alam Abu , Narayanasamy Sangara , Thomas Pradeep
Published: August 2023

Aims

The aim of this audit was to analyse whether we are following NICE guidelines regarding management of the rectal cancer. We also analysed the outcome of rectal cancer patients who were offered primary surgery.

Methods

It was a retrospective study in design. We evaluated 47 patients out of 266 patients who were registered as rectal cancer between 2017 to 2022. Only patients who were offered primary surgery were included. Patients with metastatic cancer, those unfit for chemoradiotherapy and those who were offered neoadjuvant therapy were excluded.

Results

We identified 47 patients with rectal cancer for evaluation. The mean age at presentation was 72 years. 65.95% (n=31/47) were men, 34.05 % (n=16/47) were women. After a median follow of 34 months, local recurrence rate was noted in 24% and distant metastasis in 32%. We also noted that 52% of the patients were disease free and total mortality of 12%.

Conclusion

Preoperative chemoradiotherapy comprises a vital part of the management part for rectal cancer patients. Evidence has showed that it decreases the local recurrence rate and increases the overall disease free survival. In our study, we found that compliance to the NICE guidelines was not satisfactory and outcome results were not at par with National Cancer Excellence centre's of the United Kingdom. The recommendation was to follow the updated NICE guidelines in order to standardize the treatment throughout the United Kingdom and for better outcome results.
ThTP7.2 For T4 rectal cancers (low) undergoing abdominoperineal resection (APER), should surgery be based on baseline MRI or Preoperative scans?
Authors: Saklani Avanish , Desouza Ashwin , Kazi Mufaddal , Raj Prudvi , Sharma Vivekanand , Janesh M
Published: August 2023

Background

Neoadjuvant therapy is standard of care for locally advanced rectal cancer. For low Rectal cancer which are T4 and require surgery after neoadjuvant treatment, there is a dilemma whether plane of surgery should be based on primary MRI or restaging MRI. At our institute surgery is based on Preoperative MRI scans.

Methods

To test this hypothesis, we compared outcomes of low Rectal cancers which were T3MRF (mesorectal fascia) positive (high risk) i.e group A to T4 rectal cancers, i.e group B who underwent APER after neoadjuvant therapy. Patients who underwent pelvic exenteration for persistent disease, or those who went on wait and watch programme were excluded.

Results

Between June 2010- July 2022, 953 APER were performed for low rectal cancers (adenocarcinoma) at our institute. Keeping follow-up in mind, we included 311, T3 MRF-positive patients and 101 T4 patients operated between 2010-2018.

Group B patients included a higher number of females, lower BMI, and had a higher incidence of consolidation chemotherapy and short-course radiation. They were more likely to undergo extended TME compared to Group A (33.33%) vs (50.16%). This group also had higher blood loss and morbidity.

In terms of oncological outcomes, circumferential margin involvement and local recurrence (isolated + systemic) in 2 groups were similar, Group A(37.12%) and (9.35%) compared to group B (11.11%) and (6.93%).

There was no difference in 5 year disease free or overall survival.

Conclusion

T4 low rectal cancers, APER after neoadjuvant therapy can be based on preoperative MRI scans with no detrimental outcomes.
ThTP7.3 Do patients receive written information? An overview of the management of acute uncomplicated diverticulitis
Authors: Robertson-Jones Beatrice , Rahman Atiqur , Elzaafarany Ahmed , Chu Ee Earn , Thomas Kerushan , Mostafa Mohamed
Published: August 2023

Background

The management of acute uncomplicated diverticulitis was audited in compliance with NICE, the World of Society of Emergency Surgery and the Association of Coloproctology of Great Britain and Ireland guidelines. Included was the advice for appropriate written information. The initial cycle found no consistency in written advice if given at all.

This audit analysed the compliance of providing written information to patients with acute diverticulitis. Following the initial cycle identifying significant discrepancies between patients, a secondary aim was formed to publish a standardised patient information leaflet.

Method

50 consecutive patients presenting to A&E with CT-proven uncomplicated acute diverticulitis were included. If any, advice on discharge was assessed for topics and consistency. Other factors were considered including if discharged directly from A&E or antibiotic administration.

Results

The mean age of patients was 58.4 years. 30 patients were admitted, 20 were discharged from A&E. 41 patients received antibiotics. All patients were Modified Hinchey Classification 1a or 1b.

21 patients had no documented written advice on discharge. Most commonly, the advice given was to seek medical attention or return to hospital if increasingly unwell (eight) or dietary advice while in acute infection (12).

Conclusion

Almost half of patients had no written advice and there was no consistency in the other half. A standardised approach was required hence the need for the patient information leaflet to be created. This includes all topics recommended by guidelines and ensures no information is missed for patients. The leaflet is now published.