bluuebunny/crossref_metadata_2025 huggingface dataset:
MS O05 - HPB The ORDEAL Study: A Multi-Centre Retrospective Cohort Study Assessing the Optimal Resection for Proximal and Distal Duodenal Adenocarcinoma
Authors: Horne Sophie , Kowsik Mukunth , Pandé Rupaly , Chatzizacharias Nikolaos
Published: November 2024

Background

Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of cases and outcome data, no UK guidelines for surgical management, and a lack of contemporaneous UK patient data. There is debate as to whether oncological and perioperative outcomes differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD (cPD or PPPD) and limited resection (LR) in distal DA (D3/D4). This study aimed to determine the optimal type of resection for proximal and distal DA through investigating differences in long-term survival and perioperative outcomes.

Method

A national retrospective audit of consecutive patients from 2008-2023 undergoing curative resection for DA was conducted, with data collected anonymously via REDCap. Baseline demographics, radiological, operative, pathological and short and long-term outcomes were collated. Analysis was performed using SPSS with standard descriptive statistical methods. Chi-Square, Mann-Whitney and ANOVA were used as appropriate to compare variables and outcomes between two groups, with statistical significance set at p<0.05. Survival analysis (overall survival (OS) and disease-free survival (DFS)) was performed using the Kaplan–Meier method and the log-rank test to compare differences between survival curves. Time-to-event analysis was calculated with Cox regression.

Results

The study cohort (median age 68 years, 54.4% males) had a mean follow-up of 35.6 months. For proximal DA, 56 underwent PPPD and 87 underwent cPD; for distal DA, 26 underwent PD and 37 underwent LR. For proximal DA, survival and lymph node clearance were similar, with severe complications and no adjuvant chemotherapy independently decreasing survival. For distal DA, survival was similar despite greater lymph node clearance with PD, with age and no adjuvant chemotherapy independently decreasing survival. Complications including pancreatic fistula, delayed gastric emptying, and post-pancreatectomy haemorrhage, were comparable for proximal DA but greater with PD in distal DA.

Conclusion

Preliminary findings suggest adequate lymphadenectomy and comparable long-term survival for cPD and PPPD in proximal DA. For distal DA, LR is associated with similar long-term survival but lower morbidity despite greater lymph node clearance with PD. Additional records will validate these findings further.
MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia
Authors: Howey Caitlin , Sinha Yashashwi , Akbari Khalid
Published: November 2024

Background

Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population.

The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia.

Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility.

Method

Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic.

She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome.

This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA.

Results

Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy.

Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying.

Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery.

Conclusion

Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures.

Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions.

Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.
VS 06 - HPB Laparoscopic Caudate lobectomy and resection of exophytic cyst
Authors: Kadamapuzha Jacob , Lambert Joel , Satyadas Thomas
Published: November 2024

Background

A 64 year old lady with no comorbidities presented with early satiety and upper abdominal discomfort. Imaging (CT abdomen and MR Liver) revealed multiple cystic lesions in liver including 9cm X 8cm X 6 cm cyst in segment 2 and 10cm X 8 cm X 8cm cyst in caudate lobe suspicious of Simple cyst/biliary cystadenoma.

Method

A laparoscopic caudate lobectomy and resection of exophytic cyst was done.

Results

Post operative period was uneventful and patient was discharged on post operative day 5. Patient is on follow up.

Conclusion

A video of a successful laparoscopic caudate lobectomy and resection of exophytic cyst is presented.
VS 07 - OGC Visualisation of variant thoracic duct anatomy using mesenteric injection of Indocyanine Green (ICG) and early ligation of the high thoracic duct can decrease the occurrence of chyle leaks after robotic oesophagectomies: Insights from a single-centre case series
Authors: Salem Riadh , Mastoridis Sotiris , Sgromo Bruno
Published: November 2024

Background

Chyle leak (CL) remains a relatively common complication following oesophagectomy, with reported incidence up to 9%, and is associated with significant clinical and financial consequences. We assess the feasibility and utility of fluorescence to visualise the thoracic duct (TD), using an easy-to perform intraoperative technique. This involves injecting ICG into the small bowel mesentery during robotic Ivor-Lewis oesophagectomy (RAMIO) and early ligation of the thoracic duct above azygos arch.

Method

Between 2022-2024, 36 patients undergoing RAMIO received ICG (2ml of 2.5mg/mL solution) injected in the root of jejunal mesentery by endoscopic needle injector via laparoscopic port during the abdominal phase. A minimum of 60min following injection, fluoroscopic visualisation of TD anatomy was performed with Firefly® system.

During the initial phase of the thoracic stage, the thoracic duct was located in the upper mediastinum, just above azygos arch, and was securely clipped using the Hem-o-Lok® system.

Results

Successful TD imaging using ICG-fluorescence was achieved in all 36 patients undergoing RAMIO. Variations from the standard single duct structure were observed in 4 (11%) of patients. Specifically, two cases exhibited duct bifurcation at the level of the azygos arch, one case had branching in the lower mediastinum, and another case demonstrated branching from the main duct over the thoracic aorta. All observed branches were individually clipped with Hem-o-Lok® system. Two individuals (5.5%) experienced low-volume chyle-leak post-operatively, which was successfully managed conservatively. No chyle leaks were detected at the end of the surgery in any of the cases.

Conclusion

In our single-centre experience, fluorescence visualisation of the thoracic duct during RAMIO by intraoperative mesenteric injection of ICG is an easily performed, reproducible technique which can assist in the visualisation of variant TD anatomy and reduce the incidence of CL. In addition to its impact on clinical outcomes and healthcare costs, the approach can also support a better appreciation of TD anatomy among surgeons.
VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy
Authors: Bakewell Zoe , Thiagarajah Viswan , Zino Samer , Gemenetzis Georgios
Published: November 2024

Background

Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy.

Method

Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum.

Results

The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life.

Conclusion

This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.
AHP SO06 - A case report of the nutritional and multi-disciplinary team (MDT) management of an emergency oesophageal perforation associated with Eosinophilic Oesophagitis (EOE)
Authors: Ribalta Rachel , Owen Kellie , Saunders John , Grimshaw Kate
Published: November 2024

Background

EOE once considered rare, is a chronic inflammatory condition of the oesophagus presenting as dysphagia and food impaction in children and adults. Awareness and management of EOE is variable despite an increasing prevalence and the condition deemed the most common cause of oesophageal perforation in adults and children by the British Society of Gastroenterology (BSG). This case review aims to increase the awareness of EOE, highlight the clinical presentation of EOE, discuss considerations for the nutritional management and the importance of an MDT approach to the care of this condition in relation to the BSG consensus guidelines.

Method

The patient was admitted to a specialist oesophago-gastric surgical centre in the Northwest of England. A retrospective review of the patient’s case notes was completed. This included exploration of all inpatient and outpatient contacts stored in the electronic patient records system.

Results

18-year-old underweight male with IgE-mediated nut allergy and odynophagia, developed complex multi-site oesophageal perforations following OGD. Management included 40-day endoluminal vacuum therapy and extensive nutritional support. Although initial biopsies lacked diagnostic quality and conclusive results, EOE was subsequently confirmed. Dietetic evaluation included nutritional status, atopic history, symptoms, and dietary intolerances. MDT discussions influenced care continuity and patient compliance. Feeding delays attributable to frequent theatre visits impacted continued weight loss; addressed with allergen-free enteral and parenteral feeding, and dietary reintroduction, following six-food elimination once perforations had healed. Healthy BMI was achieved through patient’s preferred long-term management of normal diet and Budesonide.

Conclusion

Increased awareness of EOE is paramount for patients presenting with unexplained oesophageal perforation. Obtaining biopsy samples as per BSG guidance supports earlier diagnosis and management plan. A thorough clinical history including childhood eating behaviours, atopic history, dietary intolerances and symptom presentation from the patient and relatives gathers collateral information to support diagnosis and treatment planning. Joint discussions regarding pharmaceutical management, dietary elimination and reintroduction are important to achieve remission. The case highlights the importance of collaborative MDT working with the surgical, medical and dietetics whilst empowering the patient to make informed decisions regarding the nutritional and medical management of condition.
EDI&S SO08 A novel approach to environmentally sustainable surgical theatre by rationalising surgical instrument set – a qualitative analysis
Authors: Warner Jennifer , Singh Gautam , Dronamraju Shridhar , Fawole Adeshina
Published: November 2024

Background

The surgical theatres are a major source of hospital waste generation. The NHS has set a net zero supply chain target by 2045. This aim is supported by the RCS intercollegiate green theatre checklist to reduce the environmental impact of operating theatres. One key area identified in this process, that will support the net-zero target is surgical instrument tray rationalisation. Laparoscopic cholecystectomy was identified as one of the most common surgical procedures performed in England. The purpose of this study was to demonstrate the impact of rationalising the number of surgical instruments, enabling surgeons to drive towards net zero surgery.

Method

Our Trust participated in this study, in collaboration with NHS England sustainable procurement team and the innovation agency.

Total 58 cholecystectomies performed across two sites, Pinderfields and Dewsbury were included in this prospective audit undertaken from January – March 2023. The surgical tray checklists were used to record the actual instrument usage and noted the redundant and supplementary instruments. This data presented to a surgical advisory group, who agreed on routine instruments and proposed removal of redundant.

A green pilot tray was approved and used for cholecystectomy. Qualitative questionnaire feedback was collected from surgeons and operation theatre staff from both sites.

Results

The instrument use matrix revealed almost 50% instruments from the previously used major tray were never used in any of the 58 cholecystectomy surgeries performed.

Subsequently, based on the use matrix data, we switched from using major tray containing 84 instruments, to a reduced size tray containing 46 instruments including re-usable metal ports.

Survey results revealed tray rationalisation led to easier and faster surgery preparation, improved efficiency and a reduction in waste, thereby reducing the cost to the Trust.

It was also noted that having a smaller tray means less time to count instruments during the surgical pause.

Conclusion

The results of tray rationalisation are very positive and have demonstrated cost savings, carbon reduction and time saved preparing for surgery and the post-operative instrument count.

This pilot study has shown that by making the surgical set smaller, savings have been achieved from a reduction of slots required per machine cycle for decontamination.

Tray rationalisation goes some way towards the net goal of zero carbon surgery and delivering a sustainable future.
BS SO06 - Bariatric Surgery is a Safe, Effective and Feasible Option in Super-Super Obese Patients
Authors: Haider Ijlal , Kaur Mandeep
Published: November 2024

Background

Bariatric surgery is proven to be feasible and safe in obese and super obese patients (BMI < 60). SSO patients pose greater challenges from technical and medical standpoints. This cohort study aims to assess the safety and feasibility of bariatric surgery in SSO individuals.

Method

A retrospective analysis of a prospective database was conducted, encompassing 4471 bariatric procedures performed over seven years (January 2016 to December 2023). Fifty patients were classified as SSO (BMI > 65). Key outcome variables examined included length of stay (LOS), intra-operative complications, and 30-day morbidity and mortality rates. We evaluated the Resolution of Obesity Related Morbidity (RORM).

Results

Sleeve gastrectomy most common procedure (24, 48%), followed by One Anastomosis Gastric Bypass (17, 34%). Six patients underwent Roux-en-Y Bypass (12%), and six others received SADIs (12%).

Among these, [24 (48%)] had obstructive sleep apnea (OSA), [14 (28%)] had diabetes mellitus (DM) and [9 (18%)] had hypertension.

Average LOS was 2.5 days. No mortality was reported within 30 days with no intra-operative complications. One patient required readmission to the hospital within 30 days after discharge due to vomiting.

The report at 6 months was positive. OSA, DM and Hypertension were resolved in [11 (46%), 13 (92%) and 7 (77%)]

Conclusion

Bariatric surgery should not be dismissed for SSO patients solely due to perceived increased risk based on BMI. Evidence suggests that it can be safely performed on SSO individuals, yielding significant benefits particularly for obesity-related morbidity.
BS SO10 - Predictive Factors in the Development of Dumping Syndrome After Bariatric Surgery
Authors: Tase Arkeliana , Niaz Osamah , Askar Lina , Askari Alan , Musendeki Debbie , Jambulingam Periyathambi , Rashid Farhan , Whitelaw Douglas , Jain Vigyan , Adil Tanveer , Al-Taan Omer , Munasinghe Aruna
Published: November 2024

Background

Dumping syndrome (DS) is a recognised complication of Roux En-Y Gastric Bypass (RYGB) and rarely Sleeve Gastrectomy (SG). The prevalence of DS is unclear, with current literature ranging from 10-50%. The condition is characterised by gastrointestinal and vasomotor symptoms resulting in a significant impact on quality of life. This study aimed to prospectively utilise Sigstad scoring to evaluate post-operative patients, investigating the timing of symptom onset and its correlation with pre-existing diabetes, revision surgery, and percentage of Total Body Weight Loss (TBWL).

Method

We used the Sigstad scoring questionnaire, administered by our bariatric Clinical Nurse Specialists (CNS) at outpatient clinics to assess patients for DS between January to May 2024. Data collected included patient demographics, surgery type and date, TBWL, Body Mass Index (BMI), and whether the patient had a diagnosis of Diabetes Mellitus type II (DMII). A diagnosis of DS was confirmed if a patients score ³7 points on the Sigstad questionnaire. We explored factors influencing the development of DS.

Results

In total, 64 patients were evaluated for DS of whom 86% were female and the median age was 44 years (IQR: 35-45). Most patients (67%) had undergone primary RYGB, 19% SG, 11% conversion from SG to RYGB and 70% were assessed within one year of surgery. DS symptoms emerged in 25% of patients, predominantly within the first-year post-operation (60%). The median TBWL was 12% (IQR: 9-22%), showing no correlation to DS onset. Patients with DMII exhibited a higher propensity for DS (66% vs 20%, p=0.029). Patients undergoing revisional surgery also had a higher incidence of DS (33% vs 6%, p=0.117).

Conclusion

A quarter of patients undergoing bariatric surgery will develop DS, most of whom within the first-year post-surgery. Revisional surgery and pre-existing DMII are the primary predictors in developing DS. There was no observed association between TBWL and DS onset. Further extensive studies are needed to confirm these observations.
BS SO11 - Impact of various biliopancreatic limb lengths on EBWL, Nutritional deficiencies and resolution of ORMs -MGB/OAGB
Authors: Kaur Mandeep , Haider Ijlal
Published: November 2024

Background

OAGB was first described by Robert Rutledge. There have been a few modifications of MGS since its first introduction. There have been modifications in the limb length, pouch side, type, and location of anastomosis.

Concerns have been raised about nutritional deficiencies by various authors about the longer limb length. Few other authors have published promising results from their studies regarding good outcomes on longer limb length.

Method

We follow BMI based guidelines at our center to decide on OAGB limb length.BMI < 50- BP limb length – 150 cmBMI >50 BP limb length- 200 cmBMI > 60 BP limb length- 250 cm.

We analysed our results from BP limb lengths >/=200 cm in terms of EBWL, ORM resolutions, Nutritional deficiencies and compared it to similar outcomes in BP limb lengths of 150 cm

Results

Our data is currently under review. Initial assessment suggests promising results of longer limb lengths with no major complications highlighted. All the longer limb length patients are under 3 monthly follow up with 2 years follow up data now being analysed.

Literature review suggests inadequate weight loss with shorter limb lengths. The longer limb lengths are associated with nutritional deficiencies. We are excited to take this opportunity to discuss our results

Conclusion

Limb length should be tailored as per patient factors and available support. One standard limb length doesn't apply to all the patients.
BS SO17 - Large Bowel Occlusion as a Manifestation of Gastric Adenocarcinoma in a Patient with Previous Gastric Bypass
Authors: Araújo Bruna , Damas Carlos , Dionísio Daniela , Sousa Rui , Marques Hugo Pinto
Published: November 2024

Background

Gastric bypass surgery has become one of the hallmarks of the treatment of obesity and metabolic syndrome. Over the last decade, an increasing number of gastric cancer cases have been reported following gastric bypass, particularly in the excluded stomach. The anatomical changes and the difficult access to the excluded stomach via endoscopy hinder the diagnosis and treatment of this cancer.

Method

Literature review and clinical case analysis through clinical records and exam results.

Results

A 59-year-old male with a history of gastric bypass 15 years prior was admitted to the emergency department with bowel occlusion. A CT scan revealed colonic obstruction due to invasion by a neoplastic/inflammatory process. Consequently, a right hemicolectomy was performed. Histopathological analysis revealed infiltration of the colonic wall by poorly cohesive gastric carcinoma cells. A follow-up CT scan confirmed a lesion in the excluded stomach. A LAMS (lumen-apposing metal stent) was placed to repermeabilize the excluded stomach, and biopsies confirmed gastric mixed adenocarcinoma. A gastroduodenal stent was placed for antropyloric stenosis. A multidisciplinary team opted for palliative chemotherapy.

Conclusion

The association between bariatric surgery and gastric cancer remains controversial. As described in previous studies, this clinical case demonstrates that gastric adenocarcinoma in patients who underwent gastric bypass often presents as an aggressive and advanced-stage disease. Given the mortality associated with gastric cancer and the increasing number of bariatric surgeries, this case report highlights the important need to develop patient selection protocols for gastric bypass and respective appropriate follow-up.
BS SO20 - The impact of Ethnicity and Social Deprivation on Weight Loss following Roux-En-Y Gastric Bypass Surgery
Authors: Karim Seiver , Askar Lina , Al-Fagih Othman , Niaz Osamah , Loh Alex , Razzaq Ahsen , Ahmar Moaz , Sesby-Banjoh Oluwatofunmi , Adil Md Tanveer , Munasinghe Aruna , Rashid Farhan , Jambulingam Periyathambi , Whitelaw Douglas , Jain Vigyan , Al-Taan Omer , Askari Alan
Published: November 2024

Background

Long-term weight loss and weight regain are markers of success following bariatric surgery. The aim of this study was to determine whether there are differences amongst various ethnic and social deprivation groups in terms of weight loss following Roux-En-Y Gastric Bypass (RYGB) at 24 months post-surgery.

Method

Data from a single high-volume UK Bariatric centre (Luton & Dunstable Hospital) were analysed. Relevant variables such as patient demographics, weight and Body Mass Index (BMI) at surgery, were included. Failure to lose sufficient weight was defined as failure to lose ³20% TBWL at 24 months post-surgery.

Results

A total of 1,427 patients underwent RYGB during this time, of whom 80.2% were female. The median age was 48 years old (IQR: 39-55) and the median BMI was 44.7Kg/m2 (IQR: 40.6-50.1). At 24 months post-surgery, 39.3% of patients had failed to lose 20% TBWL. Multivariable analyses demonstrated that the most socially deprived patients were less likely to achieve a TBWL of ³20% at 24 months post-surgery (OR: 0.71 95% CI: 0.56-0.89, p=0.023) as were those from Black (OR: 0.69, 95% CI: 0.50-0.83, p=0.019) and Asian backgrounds (OR: 0.73, 95% CI: 0.61-0.88, p=0.013) compared to patients from a White background.

Conclusion

Ethnicity and social deprivation serve as key indicators of predicting weight loss at 24 months following bariatric surgery. These findings suggest the possible need for tailored care and treatment strategies to optimise long-term outcomes for diverse populations. Understanding these differences is crucial for developing personalized treatment plans and improving the efficacy of bariatric surgery across various ethnic groups. Future research should focus on identifying the underlying causes of these disparities and evaluating interventions to mitigate them.
EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis
Authors: Ragunathan Ragshna , Raza Mehdi
Published: November 2024

Background

Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms.

Method

This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards.

Results

Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups.

Conclusion

This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.
EGS SO06 - Emergency provision for Oesophago-Gastric Surgery in the United Kingdom: A National Survey
Authors: Sivarajan Sri , Penney Nicholas , Sreedharan Loveena , Lewis Michael , Kumar Bhaskar
Published: November 2024

Background

Oesophagogastric (OG) emergency conditions may require specialised intervention in centralised OG cancer surgery units. Recently published AUGIS OG commissioning guidance recommends OG units provide 24/7 on-call cover for internal and external OG emergency referrals with a formalised rota. However, there may be widespread inconsistent provision of OG emergency services across United Kingdom (UK) regions with significant workforce, capacity, and funding challenges. This may lead to barriers to provision of on-call OG services. Currently there is no research that establishes current OG on-call coverage or explores OG surgeons’ perceptions and attitudes towards providing this service.

Method

An 11-item electronic questionnaire was developed at an OG cancer unit to identify OG consultant emergency on-call coverage at NHS OG cancer units in the UK. The questionnaire was initially piloted among OG surgeons for refinement and subsequently disseminated through professional networks (AUGIS), direct contact, and snowballing. It was active for three weeks in January 2024. Secondary outcomes included: identifying barriers to providing an emergency OG service; defining the scope of conditions acceptable for transfer; understanding current referral mechanisms and examining OG consultant attitudes and perceptions towards providing an on-call OG service.

Results

71 consultant OG surgeons from 26 UK OG cancer units responded (Figure 1). 61% (n=43) report participating in a 24/7 formalised emergency OG on-call rota, staffed by a median of 5 (range 3-8) surgeons. Among the nine respondents from three centres without a formal OG emergency service, all cited limited funding as the primary barrier. Only 31% (n=19) used auditable referral mechanisms like email or online systems. 97% percent (n=69) of respondents perceive an OG emergency service to be beneficial for patients, and 86% (n=61) agreed it should be nationally mandated for OG cancer units to provide a 24/7 service.

Conclusion

Consultant OG surgeons recognize the importance of delivering high-quality OG emergency services. However, the data indicates inconsistent delivery across the UK. Given the seriousness of OG emergencies, mandatory provision of this service with appropriate funding and remuneration is essential. Several workforce challenges, including potential impacts on OG cancer resection volume and provision of General Surgical on-call, need to be addressed. Ultimately, patients require timely and specialised intervention. As one respondent emphasized: "A situation where surgeons in non-OG centres can spend a whole night ringing around various OG centres looking for help with a Boerhaave perforation is unacceptable."
EGS SO10 - Restructuring of emergency surgical service in DGH leads to significant reduction in time to cholecystectomy for gallstone pancreatitis in line with international guidance
Authors: Ainley Paul , Kerr Barry , Davis Helen , Gallagher Charles , Byrnes Colman , McAree Barry
Published: November 2024

Background

The International Association of Pancreatology guidelines suggest that patients with mild biliary pancreatitis undergo cholecystectomy during their initial hospital admission. A single-center retrospective study was conducted to examine adherence to this guideline following a significant overhaul of emergency surgical services. Our team, with support from the surgical ambulatory emergency care network, revolutionized care through an Emergency Surgery Unit (EmSU) system. This included surgical assessments with ambulation, coordinated radiology appointments, semi-emergency theatre lists twice a week in addition to NCEPOD theatre sessions, and an emergency roster split by patient gender, ensuring a balanced caseload for the surgeons on duty each week.

Method

A retrospective study of patients with mild biliary pancreatitis for three years before (n = 107) and after (n=108) the EmSU system. Cholecystectomy on index admission was recorded, as was overall time to surgery (days). Data was analysed using GraphPad Prism Version 9.5.1. Data is expressed as Mean ± SEM. Percentages underwent Arcsine transformation prior to inferential analysis. Groups of data were analysed using Students T-Tests.

Results

The percentage of patients operated on index admission increased 13.1-fold (4.8% to 62.9%; P < 0.01).

Days to surgery saw a 10.1-fold reduction (332.5 ± 41.1 to 32.9 ± 6.3 days; P < 0.0001).

Conclusion

The adoption of our EmSU system has drastically improved care for patients with gallstone pancreatitis, bringing it much closer to best practice guidance. Further improvement is likely with increased buy-in from all members of staff.
EGS SO11 - A Retrospective Review of Perioperative Outcomes after Laparoscopic Cholecystectomy in Older Patients
Authors: Jemmett Hermione , Khoo Emily , Dean Christopher , Walker Carwyn , Kanesan Hariprasath
Published: November 2024

Background

Laparoscopic cholecystectomy is the definitive treatment for gallstone-related disease. With an increasingly aging population, a growing number of elderly patients are presenting acutely with gallstone pathology. However, rates of perioperative mortality and complications are significantly higher in elderly patients undergoing laparoscopic cholecystectomy (Kamarajah et al). We aim to evaluate peri-operative outcomes in elderly patients presenting with acute gallstone disease who have been clinically evaluated to be appropriate for emergency cholecystectomy, and explore the impact of frailty on these outcomes.

Method

A retrospective study was performed on patients over the age of 75 presenting acutely with gallstone disease over a 3-year period. Data on perioperative complications, mortality at 1 year, post-operative length of stay (LOS) and 90-day readmissions were collected and analysed. The patient’s pre-operative fitness was categorized using the ASA classification of physical status and the Clinical frailty score (CFS); a 9-point scale quantifying frailty based on function. Statistical significance was assessed to determine differences between the age or frailty score groups.

Results

592 patients attended hospital with gallstone-related pathology; 99 patients underwent emergency laparoscopic cholecystectomy, 486 patients were managed conservatively, and 25 patients had cholecystostomies. The post-operative mortality rate was 4%, post-operative complication 19.2% and readmission rate 11.1%. Post-operative LOS was significantly longer in frailer patients (p=0.02299). There were no statistically significant differences in mortality or post-operative complications between the CFS3 or less and CFS4 or more groups, although a general trend towards higher rates of complications and mortality was noted with increasing frailty.

Conclusion

Patients over 75 years of age should be carefully considered before proceeding with surgical management. Although older and frailer patients exhibited increased rates of complications and mortality post-operatively, these didn't reach statistical significance, reflecting the role of clinical decision-making regarding surgical fitness. Even for a pre-selected patient group, there is statistically significant prolonged post-operative LOS in frailer patients. This suggests a need for comprehensive preoperative assessment in this population, and a combination of CFS and ASA may be key determinants. Further studies assessing frailty and non-operative outcomes are required to substantiate these findings and guide clinical management in this population.
EGS SO12 - A District General Hospital experience for setting up a "Hot Gallbladder" pathwayBackground
Authors: Lau Kwan Yuen Joshua , Hao Tony , Tio Yong Hui , Dawson-Kavanagh Amelia , Zahari Amiza , Chui Samantha , Thaker Dev , Liew Xiang , Ravi Krish , Ardley Rohan
Published: November 2024

Background

This project details a quality improvement initiative at Chesterfield Royal Hospital (CRH) to establish a “Hot Gallbladder” pathway (HGP) amidst immense NHS pressures. Before this service, CRH performed emergency cholecystectomies solely in an NCEPOD emergency theatre shared with other specialities, resulting in low case volumes, unpredictability, long patient waiting times with extended inpatient stays. The new service now dedicates two half-day lists per week to suitable patients admitted acutely and managed by five dedicated surgeons.

Method

This quality improvement project involves two separate yearly retrospective audits analysing patients who underwent gallbladder removal through the HGP in 2022 and 2023 at CRH. The primary objective was to assess the HGP's efficacy in terms of the number of cases performed and list completion (2 cases per half-day list). The secondary objective evaluatedadherence to the HGP protocol, appropriate patient selection, indications, and completion of adequate pre-operative investigations. The final objective assessed the HGP's safety by comparing incidence of complications and length of stay with patients undergoing cholecystectomy on the emergency NCEPOD list.

Results

268 patients had gallbladder removal through the HGP and 84 cases in the emergencyNCEPOD theatre. The median age was 51, with a 3:1 female-to-male ratio. 75% of patients were managed through surgical ambulatory care. The HGP saw a 30% increase in cases and list completion rates rose from 41% to 61% in one year. NCEPOD emergency theatre usage reduced to 37%. All patients had appropriate indications and pre-operative investigations. 70% of cholecystitis patients were operated within 7 days. The HGP had a lower complication rate (6.2%) compared to emergencies (8%) and shorter post-operative stays (2 days vs 2.5 days).

Conclusion

This project demonstrates the benefits of establishing a HGP in a DGH. Inpatient stays were significantly reduced as 75% of patients were managed through the ambulatory carepathway. This led to financial benefits and greater patient satisfaction. Timely operations by dedicated surgeons resulted in a lower complication rate and shorter length of stay. The pathway increased the number of cases performed. The reduction in emergency theatre cases allowed better care for patients requiring emergency theatre access.
EGS SO15 - The “Not” Cholecystectomy: Barriers to Early Cholecystectomy in a District General Hospital
Authors: Zhao Sarah , Cheng Amanda , Shaikh Amarah , Kapsampelis Panagiotis , Kaur Vasha
Published: November 2024

Background

The benefit of early or “hot” cholecystectomy in acute cholecystitis and pancreatitis is now widely recognised and recommended by NICE guidelines. However, in reality, surgery within the index admission is not always universally practised. We aim to report our experience of barriers to performing emergency cholecystectomy in the context of a district general London hospital.

Method

Data from patients admitted within a 1 month period with acute calculous cholecystitis, gallstone pancreatitis or recurrent biliary colic were retrospectively collected. Data points included patient demographics, reasons for not having emergency surgery and time to subsequent elective surgery. Any patients who underwent early emergency cholecystectomy were excluded from analysis.

Results

Twenty six (76.5%) out of 34 admissions did not receive emergency cholecystectomy. Eight (30.8%) were male and mean age was 69. Most common presentation was acute calculous cholecystitis (13, 50%). Reasons for not having surgery included frailty (7, 26.9%), waitlisted for endoscopic investigation (5, 19.2%), lack of emergency theatre capacity (4, 15.4%), unknown (3, 11.5%), severe disease (2, 7.7%), patient refusal (3, 11.5%) and acute medical contraindication (2, 7.7%). Four (15.4%) patients had repeat acute admission. To date, 4 patients subsequently underwent elective cholecystectomy with one procedure within 3 months.

Conclusion

Early cholecystectomy rates in district general hospitals can be affected by availability of local resources. By identifying the key factors for not proceeding to surgery, we can increase efforts to improve access to emergency theatre space, high-risk anaesthetic input and acute endoscopy services.
EGS SO16 - Retrospective review of adherence of emergency theatres operation notes to Royal College of Surgeons in England Guidelines
Authors: Liyanage Dinithi
Published: November 2024

Background

Adherence to standardized operation note guidelines is crucial for ensuring patient safety and maintaining high standards of surgical practice. This study aims to evaluate the compliance of emergency theatre operation notes with the Royal College of Surgeons in England guidelines, identifying areas for improvement to enhance documentation practices.

Method

A retrospective review of 50 patients was conducted on operation notes from emergency theatres. The notes were assessed for adherence to the Royal College of Surgeons in England guidelines. Parameters evaluated included completeness of patient information, surgical procedure details, intraoperative findings, and postoperative instructions.

Results

There was good compliance in sections such as the name of the operative and assistance, operative findings, and closure. However, improvements are needed in sections such as problems encountered, anticipated blood loss, and the name of antibiotics used. Compliance can be improved by making the notes clearer and more comprehensive.

Conclusion

Our analysis suggests room for improvement in adherence to postoperative surgical note guidelines. We recommend adding further details such as the name of the scrub nurse, indication, to the operative notes. A postoperative checklist template has been devised to ensure adherence to guidelines and improve documentation practices.
EGS SO20 - Management & outcomes from oesophageal perforations at a tertiary centre
Authors: Chowdhury Atiqur , Alam Mushfique , Ahmed Sheheryaar , D’Souza Joel , Bird Nick , Rao Rohith , Gunasekera Rohan , Howes Nathan , Stephens Nathan
Published: November 2024

Background

Oesophageal perforations, whilst rare, are a challenging surgical emergency. Traditionally associated with high morbidity and mortality, outcomes have progressively improved over the past 25 years, likely due to advances in medical care and specialised management in high volume tertiary centres. This study examines the management strategies and outcomes from oesophageal perforations at our tertiary unit.

Method

A retrospective cohort analysis was conducted on consecutive emergency cases of thoracic and junctional oesophageal perforations from January 2019 to June 2024. Data on patient demographics, baseline characteristics, management strategies and clinical outcomes were extracted from the patient’s electronic records. Kaplan-Meier survival curves were generated using the management approach and the extent of perforation as the predictive variables.

Results

51 patients (mean age 47 years, 66% male) were treated for oesophageal perforations. The predominant aetiology was spontaneous (80%, n=41). Contained perforations were identified in 57% (n=29) of patients based on imaging, endoscopic, or operative findings. Conservative management was applied in 57% (n=29) of cases. Among those requiring intervention, 11 (58%) underwent surgery, while the remainder underwent endoscopical via vacuum therapy (32%, n=6) or stenting (11%, n=2). The mean in-hospital stay was 11 days (IQR 7-29). The 30-day mortality rate was 18% (n=9). Survival analysis revealed improved survival probabilities with contained perforations and non-surgical management strategies (p=0.023 and 0.001 respectively).

Conclusion

Our results demonstrate that the outcomes from oesophageal perforations continue to improve, reflecting ongoing advancements in therapeutic management. Furthermore, whilst surgery was once the mainstay, there appears to be a safe, increasing shift towards more conservative and endoscopic management.
EGS SO22 - When What Is Left Is Not Right
Authors: Menon Sreelakshmi , Nair Vishnu , Menon Jay
Published: November 2024

Background Aims

We present a case of small bowel obstruction in a massive inguinoscrotal hernia, with loss of abdominal domain, treated successfully by emergency surgery. The chronicity of the condition resulted in a large pendulous pelvic stomach, with the Duodeno jejunal flexure within the hernia and constricted by the hernial ring.

Method

The first contact with surgical team was as emergency, since initial referral to surgical outpatients was deferred by the patient, due to his embarrassment. After initial attempts to decompress the stomach through nasogastric tube and with nutritional support with parenteral nutrition, the patient was counselled for surgery. Informed consent was taken for right orchidectomy, possibility of open abdomen with delayed reconstruction, stoma, respiratory compromise, multiorgan failure and death.Prior to intervention, Intensive Therapy unit was consulted for admission following surgery, with plans to use Botox in the abdominal wall, to improve compliance, in case of abdominal compartment syndrome or respiratory failure.

Results

Through an inguinoscrotal incision, the inguinal canal was opened and the cord structures were transfixed and divided. The internal ring was divided laterally to allow gradual compression and replacement of the hernia intraabdominally. Over 8 litres of fluid was removed from Nasogastric aspirate. Lymphoedema in the scrotum made the laterality of the testis seen in the operative field ambiguous. The hernia was repaired with Bassini repair of the muscles, followed by polypropelene mesh. Following surgery, patient was discharged home with no immediate complications. Histology of the sac and Tunica Vaginalis revealed an atrophic right testis.

Conclusion

Distorted anatomy from chronicity of common surgical pathology may present challenge to even experienced surgeons. Unusual presentation of common pathology requires thinking outside the box.

Since the lymphoedema in the scrotal hernial sac made the laterality of the testis unclear, an informed decision was taken not to remove the single testis seen in the operative field. The histology confirmed that this was the right decision, since the atrophic right testis was included in the operative specimen.

Post operative imaging confirmed what was left, was the left testis.