bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.TU.203COVID-19 related myocarditis following laparoscopic appendicectomy
Authors: O'Connor Adam , Loganathan Santosh , Aziz Rizwan
Published: October 2021

We report a 23 year-old male patient who presented to the emergency department with 2 days of central abdominal pain, with associated pyrexia, lethargy and nausea. Of note he had had COVID-19 in November 2020 which self-resolved. Examination revealed right sided abdominal and epigastric tenderness. His C-reactive protein was 302U/L but the remaining bloods unremarkable. The working diagnosis was unclear and a computed tomograph of the abdomen and pelvis arranged which revealed uncomplicated appendicitis with mesenteric lymphadenopathy. He underwent laparoscopic appendicectomy, revealing a macroscopically inflamed appendix without perforation or peritoneal contamination. Day 1 post-operatively, he deteriorated with acute hypoxia, tachypnoea and rigors. Additionally his inflammatory markers had increased. Respiratory physician advice was sought and an urgent computed tomograph pulmonary artertiogram performed, showing no pulmonary embolus but did show bilateral lower lobe consolidation and groundglass opacities in both lungs suspicious of COVID-19. Furthermore given his persistently low blood pressure, he underwent echocardiogram which revealed the presence of COVID-19 myocarditis and impaired left ventricular systolic dysfunction with an ejection fraction of 35%. He was admitted to the intensive care unit for blood pressure support and monitoring from a respiratory perspective. With such measures both his chest and cardiovascular function improved markedly and he was discharged on long-term cardioprotective medication. This highly rare long COVID-19 related complication following laparoscopic appendicectomy is highlighted for surgeons to be aware of and consider in cases of post-operative deterioration in patients with prior COVID-19 infection.
EP.TU.266Anatomy teaching to prepare medical students for placements during COVID-19 pandemic: a cross-sectional study on the use of online near-peer teaching
Authors: Thirupathirajan Vikram Ajit Rajan , Georgi Maria
Published: October 2021

Aims

Medical students have reduced small-group teaching due to the COVID-19 Pandemic. Anatomy is taught thoroughly in pre-clinical years but not specifically during clinical years. We introduced online small-group near-peer anatomy teaching for students in their first clinical year to help them before starting clinical placements. We investigated the usefulness of revisiting anatomy and the effectiveness of small-group teaching in an online setting.

Methods

Tutors were 5th or 6th Year medical students, each teaching a group of 5 to 8 tutees anatomy relevant to their clinical placements via Microsoft Teams. Tutees completed a post-tutorial feedback form. The primary outcome was confidence on subject content before and after the tutorial. Each outcome was measured by a Likert Scale, 1 (worst outcome) to 4 (best outcome).

Results

127 feedback responses were analysed, a response rate of 62.0%. Mean tutee confidence improved markedly, from 1.520(SD 0.6281) to 3.079(SD 0.5856, p < 0.0001). The mean score for effectiveness of delivery and the effect of technical issues was 3.811 (SD 0.4127) and 3.667 (SD 0.7114) respectively. Analysis of free-text comments showed that the tutorials had a “really great group size” and were “interactive and well-informed”.

Conclusions

Clinically relevant anatomy teaching in a small-group-setting is useful in improving students’ confidence about the content covered in the placements. The use of online platforms to deliver this in small groups was successful, underwent smoothly and is something that can potentially be implemented in the curriculum.
EP.TU.296A Significant Difference in Cancer Proportions Between Two Modelled Cohorts Investigated by 2-WeekWait (2WW) Colorectal referral pathway
Authors: Gendia A , Tam A , Faux W
Published: October 2021

Aim

To compare the proportions of malignancy between two modelled cohorts of referred and investigated by our colorectal 2 WW referrals pathway.

Methods

Two modelled cohorts were analysed from our prospectively maintained colorectal 2WW referrals database from August 2018 to July 2019. One cohort (group A) included patients without anemia, rectal mass or overt rectal bleeding. The other (group B) included the rest of referrals. Data collected and analysed in each group included total numbers of referrals, investigated referrals and malignancy proportion in each group. One tailed Z test was used to analysis statistical difference.

Results

4240 referrals were made to our colorectal 2 WW pathway during the given period. 1333 (31%) were group A and 2907 (69%) were group B. Total number of patients investigated in group A was 1227, of those only 34 (2.8%) were colorectal cancer and 18 (1.5%) were extracolonic cancer. One the other hand, 2705 patients were investigated in group B, colorectal malignancy were found in 142 (5.3%) patients and 33 (1.2%) were extracolonic. There was a significant difference (p < 0.05) in total number of malignancies between Group A (53/4.3%) and Group B (175/6.5%).

Conclusion

While the 2 Week-Wait referral pathway plays an important role in rapid testing and identifying colorectal cancer, there was a difference between malignancy distribution within the referrals. this difference doesn’t reflect a clinical significance but it can be a good stratification tool.
EP.TU.313Colorectal cancer follow up: Can CT Colonography replace Colonoscopy?
Authors: Jolliffe Samantha , McGivney Feidhilm , Chin Mei , Shalli Kawan
Published: October 2021

Aims

Current guidelines recommend surveillance colonoscopy at one year following Colorectal Cancer Resection (CCR), yearly CT chest, abdomen and pelvis, CEA, and colonoscopy in 3 years. Previous studies showed no significant difference between CTC and colonoscopy detection rates of colorectal cancer or polyps >6mm. A review of abnormalities detected on surveillance colonoscopies one year following CCR. If the incidence is low CT Colonography (CTC) would be an alternative to colonoscopy and, when performed simultaneously with surveillance CT chest would be cost-effective, and help in the selective use of colonoscopy.

Methods

A retrospective analysis of one-year surveillance colonoscopies following CCR in 2016 at a health board with three different sites. Normal colonoscopy criteria included: no polyps, no tumour, and no abnormality at the anastomosis. Subtotal colectomy, panproctocolectomies and incomplete colonoscopies were excluded.

Results

111 surveillance colonoscopies were performed one-year post CCR. Age range 30-87 years (39 patients were above 75). Ninety scopes were normal (81.1%). Eight identified only hyperplastic polyps (7.2%); indirectly making over 88% of surveillance colonoscopies unremarkable. Detected abnormalities: nine low-grade adenomas (8.1%), one anastomotic recurrence (0.9%), and only three new cancers (2.7%). There were no complications related to the procedure. Each colonoscopy costs £996 at this health board, CTC is significantly cheaper.

Conclusion

New cancer or recurrence post-CCR detected at one-year colonoscopy is very low; therefore, CTC would be ideal alternative surveillance. Adding it to CT Chest would significantly reduce the number of hospital attendances per patient, which is more cost-effective and reduces risk.
EP.TU.333FIT stratification in the COVID era - Is it safe for rectal bleeding?
Authors: Seehra Jaspreet , Bailey James , Chapman Caroline , Morling Joanne , Humes David , Banerjea Ayan
Published: October 2021

Aims

Faecal Immunochemical Tests (FIT) are increasingly used for stratification of colorectal cancer risk in symptomatic patients. FIT is not currently recommended for use in patients with rectal bleeding, but recent studies have reported its safe use. We report our experiences of FIT in patients presenting with rectal bleeding during the COVID-19 pandemic.

Methods

Patients referred to NUH NHS Trust with rectal bleeding from 15/04/20-15/08/20 were invited to complete a postal-based FIT (OC-Sensor). Demographics, symptoms, investigations and results were recorded. Outcomes were retrospectively reviewed using an electronic hospital system.

Result

344 patients were invited to participate, with 301 (87.5%) returning FITs in accordance with testing protocol. 36 patients declined to be seen, 4 were considered not fit for investigation, and 4 had incomplete records. 257 patients were included in the final analysis with 10 CRC detected (3.9%).

Rectal bleeding (257, 100%) was the most common presenting symptom followed by change in bowel habit (133, 51.8%). 10 CRC were diagnosed (3.9%). 2 CRC were detected with FIT <4 µg Hb / g faeces (2/137, 1.5%) and 8 were detected >100 µg Hb / g faeces (8/45, 17.8%). FIT result was significantly associated with CRC diagnosis (p < 0.0001). 4 with CRC had anaemia (4/53, 7.5%), 1 had thrombocytosis (1/12, 8.3%).

Conclusions

FIT missed 20% of CRC in this patient group with the application of a very low threshold (<4 µg Hb / g faeces). Both cancers missed by FIT were detectable on digital rectal examination, emphasising the importance of this examination in primary care.
EP.TU.370A 5-year re-audit of quality indicators for potentially curative rectal cancer resections by a single surgeon
Authors: Lockhart Jessica , McKay Damian
Published: October 2021

Aim

High quality operations with low rates of tumour perforation and circumferential resection margin (CRM) positivity are associated with improved long-term outcomes following surgery for rectal cancer. Previous audit has demonstrated lower rates of tumour perforation and CRM positivity by a single surgeon compared to the published standards. Our aim is to re-audit this surgeons’ outcomes for curative rectal resections.

Methods

Data was collected retrospectively for all potentially curative rectal resections over a 5-year period performed by a single surgeon using a local database and electronic care records. The CRM status and tumour perforation status were considered. Other end points included the rate of local recurrence, survival and length of stay.

Results

Fifty-one patients underwent rectal resections with curative intent, with a median age of 67. Complete resection (R0) was achieved in 94.1% of cases; 3.92% were found to have nodes less than 1mm from the margin and 1.96% were found to have tumour deposit less than 1mm from the margin – these cases were considered to be an R1 resection. Tumour perforation was present in 3.92% of cases, all of which had occurred pre-operatively. Local recurrence was found in 5.88% of cases and 90-day mortality was 1.96%. Median length of hospital stay was 7 days.

Conclusion

Our data demonstrates sustained high quality surgical outcomes with low tumour perforation rates and CRM positivity rates which compare favourably with the published standards to date. Local recurrence rates are comparable to published standards and 90-day mortality continues to be low.
EP.TU.482A closed loop audit on patient nutrition in a general surgical ward
Authors: Ramadan Wafaa , Iqbal Muhammad Rafaih , Walton Sarah-Jane
Published: October 2021

Aim

Nutrition is an important aspect in the patient’s road to recovery after any surgical procedure. Often there is a communication gap which is not beneficial for the patient. The aim of this audit was to evaluate the communication regarding patient nutrition requirements.

Method

All consecutive patients on a General surgical morning ward round were included. Four communication points were reviewed:

Data was collected prospectively on a predesigned proforma.

Results

First Cycle:

Second Cycle:

Conclusion

Nutrition in surgical patients is very important. It is proven that patients on ERAS programme have fewer complications, more rapid return to function and shorter hospital stay. Emphasis and education about the importance of nutrition is the way forward.
EP.TU.653Improving surgical admission clerking by introducing a standardized clerking proforma: a quality improvement project
Authors: Geropoulos Georgios , Kennedy Clio , Tang Stanley , Elhamshary Ahmed , Rakhshani-Moghadam Sara , Grant Calum
Published: October 2021

Aims

When clerking new admissions several critical actions must be performed in a timely and accurate way. These include reviewing referral letters, obtaining a detailed medical history and documenting the patient’s plan. This is of paramount importance, especially in high volume surgical hospitals. The aim of this quality improvement project is to evaluate a standardized electronic proforma for surgical patient clerking in an attempt to minimize missing information that can compromise peri-operative care.

Methods

A short questionnaire assessing the clerking process was handed out to doctors and allied health professionals. It was completed before and after the introduction of the clerking proforma. Proportion confidence intervals (95% CI) compared for each answer before and after the proforma releasing.

Results

Domains with a statistically significant improvement were the admission reason, management, treatment escalation and venous thromboprophylaxis plan in patients on long term anticoagulation. After introduction of the proforma, feedback still implied that the social history needed to be more extensive. Further edits to the proforma in a second cycle include prompts regarding baseline function and ADLs, as well as existing packages of care.

Conclusions

Overall, the introduction of the surgical patient clerking proforma lead to an improvement of the quality of the clerking as assessed by standardized questionnaires. It is noteworthy that a complete clerking is correlated with more effective handover between health care providers, less medical errors, less treatment delays and improved patient outcomes.
EP.TU.734Rectal mesh erosion post pelvic gynaecological surgery: A literature review
Authors: Morris Lucy , Patrick Robyn , Ali Bakar , Tarazi Munir
Published: October 2021

Introduction

Surgical mesh has long been used for the repair of pelvic organ prolapse. In recent years high rates of serious complications have been reported and the US has withdrawn it from use, while the UK advises extreme caution. Here, we present a review of the literature with a focus on causative factors.

Methods

Twenty-three articles were included in the review: 21 cases of rectal mesh erosion and three cases of sigmoid mesh erosion. Causative factors were subdivided into patient-related, mesh-related and procedure-related.

Results

Main patient related risk factors included pre-existing intestinal diseases (reported in 4 cases) and an older age (median 65.5). Risk factors that were mesh related included increased porosity. 11 cases were reported with a macroporous (>75µm) mesh, whereas only 1 case had used a microporous (<10µM) mesh. 9 cases with partial/ no details of the mesh. The main risk factor that was procedure related was concomitant hysterectomy with 7 cases of mesh erosion had concomitant hysterectomy, 11 cases without concomitant hysterectomy, with a further 5 being unclear.

Conclusion

Pre-existing bowel disease, mesh type and mechanical factors associated with surgical technique all influenced the risk of mesh erosion into the bowels. A lack of reported information regarding the original surgical mesh and operation hindered the ability to draw conclusions. A step into rectifying this in the future would be the provision of medical device cards directly to the patient detailing the mesh.
EP.TU.785Quality Improvement Project: Improving Oxygen therapy prescription in surgical inpatients
Authors: Hamid Mohammed , Al-Saket Laith , Rawashdeh Arab , Sudarsanam Raman
Published: October 2021

Aims

The 2015, British Thoracic Society (BTS) Oxygen audit demonstrated that 42% of hospital inpatients were using Oxygen without a prescription. National and local standards state that Oxygen, as a drug, should be routinely prescribed and checked along with regular medications and VTE risk assessment. Our baseline audit conducted over a two month period on the surgical wards of a large city hospital revealed that 78% of patients were not being prescribed oxygen. We set a SMART aim to increase the percentage of surgical inpatients being prescribed oxygen by 20% each month.

Methods

We used the trust e-prescription software to record our data, with three-stage verification and subsequent senior analysis of data. The three primary drivers identified were factors intrinsic to the department: lack of standard awareness, education and safety-net to ensure sustainability. To tackle these in-turns, we designed three PDSA cycles: Departmental poster, seminar with induction material, and system checklist notification.

Results

Following our first PDSA cycle, the mean percentage increased from 22% to 60%. Using projection analysis, we anticipate this to increase to > 75% after the second PDSA cycle, and >95% after PDSA3, with 100% sustainability one year later.

Conclusion

Our results to-date show that practice standards have improved following our first PDSA cycle, indicating that awareness played an important role. We predict that education will play an equal role; and given the research supporting the implications of checklists, we forecast that this later element will be the ultimatum leading to 100% sustainability of patients receiving oxygen prescription.
EP.TU.809Challenges in management of acute diverticulitis within a district general hospital
Authors: Butterworth James William , Lafaurie Guillaume , Fabowalwe-Makinde Blessing , Aikins Lois , Oke Tayo Olatokunbo
Published: October 2021

Aim

Incidence of perforated sigmoid diverticular disease is estimated at 3.4 to 4.5 per 100,000. Perforation may be the first manifestation of complicated diverticulitis with a range of 50% to 70%. We aim to review management of systemically unwell patients with acute diverticulitis in a district general hospital against the 2019 NICE guidelines.

Methods

29 patients presenting septic with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed over a 6-month period.

Results

Mean time to antibiotics was 3.96 hours (range 0-23.11). Of the 7 with perforated diverticulitis severity classification included: Hinchey I – n = 1, 3.4%; Hinchey IIa – 5 (17.2%), and; Hinchey IIb – 1 (3.4%). Time to CT abdomen pelvis was 3.38 hours (range 0-16.4 hours). Two pericolic abscesses met NICE drainage criteria at 3.7 cm and 3.9 cm respectively. The 3.7 cm abscess was drained radiologically at 7 days post-admission and was re-admitted 6 days later requiring further radiological drainage. The patient with a 3.9 cm abscess received a Hartmann’s procedure and had multiple re-admissions requiring a hospital stay of 34 days. There was 0% mortality at 30 days.

Conclusion

Management of acute diverticulitis continues to present a unique challenge. For systemically unwell patients, timely administration of antibiotics within an hour of sepsis recognition is encouraged to optimise outcomes. Timely cross-sectional imaging is pivotal in disease classification and decision-making regarding acute management. Interventional drainage and surgical resection remain important therapeutic strategies for unwell patients with Hinchey grade II diverticulitis.
EP.TU.854Happy Patients and Updated Open Wound Management Protocols
Authors: Peri Harish , Harvitkar Rafique Umer
Published: October 2021

Introduction

Open injuries have a potential for serious bacterial wound infections and may lead to long term disabilities, chronic wound or bone infection, and even death. This QI study was undertaken to ring in changes to the current management protocol and align them as per WHO guidelines.

Method

Implementing changes through a Plan-Do-Study-Act (PDSA) cycle post an initial clinical audit among 38 patients of the organization. Re-audits were done to measure the outcome against the standard and establish a new protocol.

Results

Initial audit showed only a dismal 37% (n = 14) of patients being managed as per WHO protocol. Patient satisfaction percentage (as measured by a questionnaire) was also low with only 54% of patients satisfied with the treatment. Significant variations were noted post implementation of changes after the first PDSA cycle where >90% (n = 35) of patients reported that they noticed better wound healing, transition to optimal performance and were satisfied with treatment outcomes.

Conclusions

Timely wound dressings, appropriate antibiotic prophylaxis and increased patient’s awareness on wound hygiene through means of regular educational sessions and updated management protocols have led to healthier patients, lesser long term disabilities and happy patients.
EP.TU.870Challenges of Surgical Site Infections (SSIs) and Stoma
Authors: Ma Jennifer , Whitehouse Pauline , McFall Malcolm
Published: October 2021

Aims

Surgical site infection (SSI) is a costly health burden and is frequently observed in patients who undergo large bowel surgeries with stoma formation. The use of PICO has been associated with reduced rate of SSI and its use is encouraged by NICE.

Method

We identified patients who underwent elective or emergency large bowel surgeries, between 2014-2018, using the local database collected for national SSI surveillance. PICO order forms were cross-referenced with SSI database. Analysed data is presented as percentages, and variable testing is performed using Chi Square test.

Results

The overall rate of SSIs was 12.7%. 6.8% of the cohort developed an incisional SSI, while 5.9% developed an organ/space SSI. The presence of stoma had a significant impact in the rate of incisional SSI (10.3% v 4.2%; p = 0.000179). Amongst all patients with PICO dressing applied, stoma formation was associated with a higher rate of incisional SSI (15.2% vs 6.9%, p = 0.042).

28.7% patients with stoma formation had PICO applied. The use of PICO in this group of patients was associated with statistically significant improvement in the rate of incisional SSI (4.4% v 8.4%; p = 0.026) but not in the rate of organ/ space SSI (2.1% v 4.5%; p = 0.18). Similar findings were not observed when considering elective and emergency cases separately.

Conclusion

The risk of incisional SSIs is high in patients with stoma formation, even in those who had PICO dressing fitted. Tricky fitting of PICO dressing in the presence of stoma could be one hurdle in reducing SSIs.
EP.TU.883Improving diagnosis in all male patients admitted with right iliac fossa pain
Authors: Ballance Laura , Withers Chloe , Nair Dheepa , Galloway Simon
Published: October 2021

Background

Right iliac fossa pain is a common presenting complaint in males. Ultrasound is a cheap non-invasive investigation, yet results can be non-diagnostic. CT is becoming more accessible and available for patient assessment.

Aim

Our primary aim is to estimate how many unnecessary US scans are gained prior to CT imaging, thereby delaying surgery, increasing cost and increasing length of stay (LOS).

Method

We conducted a retrospective analysis of all male patients over the age of 16 admitted to a single unit with RIF pain over 12 months. Outcome and length of stay was recorded.

Results

162 male patients were admitted to a single University teaching hospital between 2017 and 2018. 33% (n = 53) of patients having an US scan require further imaging, 40% ( n = 21 ) of these had a surgical pathology, 80% (n = 17) of these requiring appendicectomy. Patients (n = 39) who had an initial CT scan subsequently requiring surgery length of LOS 3.6 days compared with US imaging with additional imaging requiring surgery ( n = 17) LOS 5.8 days.

Conclusion

Evaluation of practice of males over the age of 16 shows that US is frequently non diagnostic, requiring further investigation with CT or MRI. Imaging initially with CT scan aid diagnosis and decrease length of stay. An education steering committee of surgical trainees, consultants and radiographers has been created to adapt practice in our centre through continued education and training.
EP.TU.920Modified Surgical Heads-Up Charades – using gamification of surgical topics to enhance learning and make revision enjoyable and useful
Authors: Ahmad Manal , Law Sarah , Everett Samuel , Benton Kirsty , Bamford Richard , Hunter Ian
Published: October 2021

Introduction

Gamification has been shown to be successful in surgical education. Charades is an adaptable game and can be utilised as a form of peer learning and adjusted to various levels of knowledge incorporating fun, competition and team working.

Method

The project was piloted with a group of Third year medical students. Each player on a team had a short time frame to guess the maximum number of correct answers on the basis of what their colleagues would tell them about the given surgical term to gain points and win. Knowledge based assessments (KBA)were used to determine baseline knowledge and assess learning. A 5 point Likert scale was used to gain feedback from participants.

Result

100% agreed that they found this motivating and engaging, enjoyed this form of revision and would like to participate in this in future and that this helped them to identify gaps in their knowledge. Average scores from KBA’s increased from 52.5% to 86% based on new questions from session whilst the score from repeating the initial assessment increased by 10%.

Conclusion

Charades is an effective tool for identifying knowledge gaps and developing knowledge base in surgical education and supports the use for gamification as a learning tool.
EP.FRI.4 Cholecystostomy presents as a viable option in acute biliary sepsis during the COVID-19 pandemic
Authors: Gunn Christopher , O'Connor Adam , Alam Imran
Published: October 2021

Aim

To audit and evaluate gallstone related admissions during the COVID-19 pandemic and assess cholecystostomy as an interim and potentially life-saving measure in acute biliary sepsis

Methods

Patients attending with gallstone disease related complaints from January to September 2020 were assessed, along with data collection on ‘hot’ gallbladder operations, elective cholecystectomies and cholecystostomies performed. Data was assessed on a month by month basis

Results

There were 306 gallstone related acute admissions in this audit time period. August had the highest number of admissions with 42 (14%) and March the lowest with 21 (7%). Despite 15 hot cholecystectomies (94%) being performed from January to March, only 1 was performed from April to September (6%). 116 elective cholecystectomies were performed during the time period, with 94 (81%) occurring from January to March. 15 cholecystostomies (9 radiologically, 6 surgically) were performed in the period, with 12 (80%) occurring from March onwards. All cholecystostomy patients have been subsequently listed for laparoscopic cholecystectomy.

Conclusions

This study demonstrates a drop in elective surgery from March 2020 onwards consistent with the COVID-19 pandemic peak. Furthermore, acute admissions related to gallstones decreased over a similar timeframe. Cholecystostomy proved itself to be a viable and potentially life-saving option in dealing with acute biliary sepsis during the COVID-19 pandemic
EP.FRI.82 Using NCEPOD guidelines to develop an evidence based pathway for acute bowel obstruction
Authors: Bierrum William , Bashkirova Varvara , Jones Thomas
Published: October 2021

Bowel obstruction is a common presentation and poses a significant challenge for clinicians. This condition is associated with a high level of mortality and morbidity. The aim of this project was to assess the clinical pathway for patients presenting with bowel obstruction and improve the overall care they received. This was achieved using guidance from the 2020 NCEPOD report looking at bowel obstruction management. Best practice guidelines from the NCEPOD report were used to assess aspects of patient care such as the time to senior review, assessment of nutrition/fluid status and risk of mortality/morbidity assessment. This identified areas where the standard of care was good, such as the majority of patients being assessed by a consultant within 14 hours. However, it also identified areas such as hydration and nutritional status assessment, documentation of ceilings of care/treatment escalation plans and calculation of risk of mortality and morbidity, which required improvement. An admission checklist and nutritional scoring sheet was created to help prompt clerking doctors when admitting patients with acute bowel obstruction. All cases of bowel obstruction were then prospectively audited over a 2 month period to assess the impact of these changes. The findings were presented at the departmental meetings to increase clinician awareness. Following the audit period, local guidelines were amended to incorporate the NCEPOD recommendations, specific pathways were also made for adhesive small bowel obstruction and malignant large bowel obstruction due to the specific requirements of these conditions.
EP.FRI.90 Should laparoscopy be performed before or after appendicectomy in females of reproductive age with a clinical diagnosis of appendicitis?
Authors: Scott Charles , Lambert Anthony
Published: October 2021

Introduction

Females of reproductive age with a clinical diagnosis of appendicitis may undergo laparoscopy prior to appendicectomy. This paper advocates laparoscopy after appendicectomy only if the appendix is macroscopically normal in this patient group. 

Method

A cohort of patients under the care of a single general surgeon is reported. If the appendix was macroscopically normal a laparoscopic port was inserted through the right iliac fossa incision. This single port was used for laparoscopic assessment of the pelvic organs.

Results

Fourteen females of reproductive age underwent laparoscopy following a macroscopically normal open appendicectomy. No additional laparoscopic ports were required. A benign dermoid ovarian cyst was identified in a 14 year-old which was electively excised following further investigation by a gynaecologist. Two ruptured simple ovarian cysts were also identified. There were no complications reported in this patient group.

Conclusions

Laparoscopy following a macroscopically normal open appendicectomy allows assessment of the pelvic organs in females of reproductive age and reduces the number of ports required during surgery.
EP.FRI.98 Perioperative blood glucose monitoring and handover in Post-Laparotomy Diabetic patients admitted to Intensive Care
Authors: Chang David , Tan Joni , Liu Keri , Mohsan Mallick
Published: October 2021

Aim

To identify the percentage of diabetic laparotomy patients admitted to ITU who had a pre-operative blood glucose check, and the frequency of post-operative blood glucose checks in the immediate 24 hours post-operatively, with any association with 30 day mortality

Method

We identified diabetic post-laparotomy patients admitted to a large tertiary hospital ICU, identifying handover between medical and critical care teams and perioperative blood glucose monitoring up to the first 24 hours of ICU admission post-operatively using both physical and electronic notes.

Results

We identified 79 diabetic laparotomy patients admitted to ICU of which 49.3% (39/79) did not have diabetes recorded as a comorbidity in nursing handover charts. We found that 27.8% of these patients did not have an intra-day pre-operative blood glucose recorded and that frequency of post-operative glucose monitoring in the first 24 hours ranged from 0.5 to 10 hourly. ITU monitoring charts could only be found for 69 of the 79 patients, out of which 40.7% of patients had at least one hyperglycaemic episode while 11.6% of patients had a hypoglycaemic episode. We found no correlation between incidences of hyperglycaemia and hypoglycemia or handover with 30 day mortality (13.9%). 

Conclusion

72.2 percent of post laparotomy diabetic patients admitted to ICU have a preoperative blood glucose recorded, with considerable variance in blood glucose monitoring frequency 24 hours post-laparotomy from half hourly to 10 hours between blood glucose monitoring but we found no association between hyperglycaemic and hypoglycaemic events in the first 24 hours post-laparotomy with 30 day mortality.
EP.FRI.154 Could Antiangiogenic Drugs be the Solution to Tendon Injury? A Literature Review on the use of Antiangiogenic Drugs for Tendon Regeneration
Authors: Kirchhoff Chris
Published: October 2021

Background

Tendinopathy accounts for more than half of reported musculoskeletal injuries worldwide. The subsequent healing process results in a disorganised tendon structure secondary to neovascularisation, forming a bulky tendon with overall reduced strength. Current treatment options remain controversial as re-rupture rates following surgical intervention are high. It has been proposed that the use of anti-vascular endothelial growth factors could improve tendon healing.

Methods

This literature review employed a systematic approach. The search strategy incorporated an adjusted PICO format and PRISMA flow diagram. Search findings were critically appraised using the CASP tool checklist. Identified studies investigated the effect of injectable anti-angiogenic drugs on tendon healing. 

Results

Three final studies were identified. Tempfer et al. showed a reduction in cross sectional tendon area in the intervention group (5.6mm²+1.8), comparatively to the control group (9.1mm² +2.0), and increased tendon strength in the intervention group (47.7N+6.41) comparatively to the control group(32.41N+9.23). Dallaudiere (2014) et al. showed reduced cross-sectional area in the intervention group (0.95mm²+0.01) compared with the control group (0.75mm²+0.01). Dallaudiere (2013) et al. also showed reduced cross sectional areas in the intervention group (1.10mm²+0.01) compared with the control group (1.11mm²+0.03). 

Conclusion

All studies supported the use of anti-angiogenic drugs to support tendon healing. The use of injectable anti-angiogenic drugs may potentially serve in conjunction with surgical intervention or as an alternative minimally invasive intervention to improve tendon rehabilitation. This review recommends that further randomised control studies will be needed to strengthen the current evidence.
EP.FRI.159 Crohn’s terminal ileal perforation peri partum; a case report and review of the literature
Authors: Tokidis Evripidis , Malcolm Francesca , White Timothy
Published: October 2021

Introduction

Surgical care of complicated Crohn’s disease (CD) during pregnancy is often a clinicodiagnostic conundrum. We present a case of a 26 year old with active CD and subsequent terminal ileal (TI) perforation diagnosed post-partum.

Case

A 26 year old with known CD presented with abdominal pain at 24 weeks pregnant to Obstetrics. Surgical opinion was sought due to increasing abdominal pain; MRI was performed and found active TI CD but no free gas. Within 24 hours the patient prematurely delivered. Immediately post-partum the patient reported worsening pain with notable peritonism on examination. Urgent CT abdomen was arranged demonstrating free aim secondary to TI perforation. The patient underwent laparotomy. Intraoperatively there was 4 quadrant peritonitis, confined TI loops behind the gravid uterus and TI perforations. Following drainage of the intrabdominal sepsis, a ileo-caecal resection was performed with end ileostomy and colonic mucous fistula formation. Post-operative recovery was uneventful and the patient was discharged 5 days later.

Discussion

There is a paucity of evidence describing manifestations of CD during pregnancy. Meta-analysis has shown a correlation of active CD and adverse perinatal outcome. The specific complication of TI perforation is a rare sequelae of CD; documented in less than 5% of cases. TI perforation during pregnancy has been described in only a handful of case reports.

Conclusion

This case report illustrates diagnostic challenges faced in the investigation and management of active CD in pregnant patients. It also highlights the importance of dynamic reassessment and the collaborative efforts of the multidisciplinary team.
EP.FRI.241 Negative appendicectomy rate and role of biomarkers in predicting the severity of acute appendicitis
Authors: So Cher Pin , Bradley Nicholas , Crumley Andrew B C , Wilson Michael Samuel James
Published: October 2021

Aim

Acute appendicitis is the most common general surgical emergency. A recent consensus study has proposed a 10% negative appendicectomy rate. We aimed to determine the negative appendicectomy rate in our centre whilst evaluating the role of biomarkers in predicting the severity of appendicitis.

Methods

A single-centre retrospective analysis of consecutive laparoscopic appendicectomies from 2019-2020 was performed. Patients were categorised by severity using AAST grading system. Kruskal-Wallis test was used to compare biomarkers levels (WCC, CRP, bilirubin, neutrophil:lymphocyte ratio (NLR) and platelet:lymphocyte ratio (PLR)). T-test, ROC curve and Fisher’s exact test were used to differentiate between perforated and non-perforated appendicitis and negative appendicectomy rate. WCC ≥11, CRP ≥50, bilirubin ≥21, NLR ≥6.4 and PLR ≥153 were the cut-off values. Negative appendicitis was defined as normal appendix at histopathological analysis.  

Results

224 patients were included; mean age 33.7 years, 57.1% were male. 17 patients (7.6%) had negative appendicectomy.  CRP, NLR, bilirubin and PLR increase with AAST score (P < 0.001).  WCC ≥11 (p < 0.001) and NLR ≥6.4 (p = 0.007) predicted acute appendicitis.

WCC (p = 0.018), CRP (p < 0.001), bilirubin (p < 0.001), NLR (p < 0.001), PLR (p = 0.002) were predictive for appendiceal perforation.

Conclusion

7.6% negative appendicectomy rate in our centre is below the recommended standard of 10% and lower than other centres. In our centre, raised WCC and NLR were predictive of acute appendicitis. WCC, CRP, bilirubin, NLR and PLR may be used to distinguish between perforated and non-perforated appendicitis. Our results add to the conflicting body of evidence relating to biomarkers and the severity of appendicitis.
EP.FRI.344 Training in remote and austere emergency surgery - Is it UK relevant or Medical tourism?
Authors: Murgitroyd Ellen
Published: October 2021

Aims

Military surgical trainees from ST4 were deployed to Afghanistan. They gained extensive experience of surgical trauma. The placement no longer exists, and the type of deployment has moved from fully equipped, multi-disciplinary team scenario to small team, remote and austere.

With increasing specialisation and advancing technology how do surgeons prepare for remote and austere surgery with resource-limited decision making? One consideration is an out-of-programme experience in a developing nation. This needs to be balanced with the impression of “medical tourism.

Methods

A charity-funded experienced UK general surgeon was needed in an Eastern Province hospital, Rwanda. This provided opportunity for a registrar to assist. “Give back” was by assisting in the training of Rwandan doctors and establishing a stand-alone surgical service. 

Results

The workload included resource-constrained operative and non-operative management of significant trauma (including head injuries and burns), general surgery, vascular, urology and gynaecology disease in all age groups. 114 operations in 29 working days, Non-operative management decisions were the most challenging, resulting in immersive trauma and emergency surgery experience.

The surgery involved unusual operations and creative clinical and technical thinking. There was a significant amount of trauma, most presenting very late, creating management complexities due to infection risk. 

Conclusions

The role of remote and austere surgery is applicable to UK trainees, in particular military trainees, those who wish to work in remote and austere environments and for real life critical thinking exposure that could apply to resource limitation or delay-to-surgery in mass casualty situations.
EP.FRI.398 Diverticular Disease Patient Presenting with Acute Abdominal Pain, Guidelines and Management
Authors: Elnaggar Mahmoud , Bukhary Syed Zain , Fafemi Oladapo , Saber Moustafa
Published: October 2021

Aim

Diverticular disease of the sigmoid colon is a common condition in Western society, 10-25% will develop an acute episode of diverticulitis, Since Hinchey’s traditional classification for perforated diverticulitis in 1978, several modifications and new grading systems have been presented to display a more contemporary overview of the disease

Methods

100 patients diagnosed with acute diverticulitis admitted to the surgical unit in NMUH starting from 1/1/2019 (the first 100 patients were chosen - they attended over a period of 6 months) Data were checked for all patients from the patients' notes and electronic hospital systems for as compared to the: “Acute Diverticulitis Management Algorithm”, provided on the NMUH intranet since April 2015.

Results

10% of patients Had pain and tenderness in an abdominal quadrant other than left iliac fossa. Standard investigations including WCC, CRP & erect chest radiograph were done to all patients.  84% of patients were diagnosed with CT scan while the rest were diagnosed clinically.  96% of patients had colonoscopy appointments while 4% had CT colonography appointments. There was no mention of Hinchey grade, despite cases were managed according to this classification.

Conclusions

There was a good degree of commitment to the management algorithm in some parts, like blood tests and antibiotic prescription, however other parts were not adhered to like the Hinchey's classification documentation for each case. There is a need for more clinical and management related classification system of acute diverticulitis, some classifications were proposed.
EP.FRI.450 Gastrograffin use in Non-Adhesional Small bowel Obstruction
Authors: Hughes Rebecca , Ali Oroog , O'Loughlin Paul
Published: October 2021

Aims

Use of Gastrograffin (GG) radio-opaque contrast has been documented in the management of adhesional small bowel obstruction. It is not widely used in other causes of small bowel obstruction. The aim of this study was to assess the effectiveness of GG use in non-adhesive small bowel obstructions. 

Methods

A retrospective review of patients who had GG administered following CT confirmed small bowel obstruction (SBO) over 2-year period was conducted. Demographics, cause of SBO and outcomes were recorded. The primary outcome was resolution of SBO with GG.  

Results

80 patients received GG for management of radiologically confirmed small bowel obstruction. The mean age was 62.7 years +/- 14.64 (SD) and M:F ratio was 1:1. The causes of small bowel obstruction included adhesions (n = 37, 46%), hernias (n = 17, 21%), progression of known cancer (n = 3, 4%). 18% (n = 15) had no clear cause of SBO on CT. In the adhesion group, GG resolved SBO in n = 27 (73%) of patients. In the hernia group 7 (41%) were incisional hernias and 7 (41%) were parastomal hernias. GG was given to both groups and the obstruction resolved in n = 6 (86%) and n = 4 (57%) of cases respectively. 

Conclusions

This study shows the effective use of GG in hernia related SBO where there is no absolute indication for surgery. GG might be suitable for incisional and parastomal hernias as a bridge to resolving acute SBO allowing a delayed repair with complex techniques.
EP.FRI.452 Complicated Littre Hernias
Authors: Matias Mariana , Kronberga Madara , Aghahoseini Assad
Published: October 2021

Background

Meckel’s diverticulum is the most prevalent congenital anomaly of the gastrointestinal tract with an estimated prevalence ranging from 2% to 4%. The diverticulum is a remnant of the vitelline duct, which leads to the formation of a true diverticulum containing all the layers of the small intestine. The condition is usually clinically silent; however, it can present with unusual symptoms and signs and therefore can result in a delayed diagnosis, particularly in adults. 

The aim of this study is to review the most recent literature reporting Littre hernias in adults, the diagnostic approach and its subsequent management. 

This is a literature review, complemented by unusual clinical case of an adult patient who presented with a Littre hernia containing a Meckel’s diverticulum in a strangulated umbilical hernia sac, which required emergency surgery.

Method

Literature review using Web of science, PubMed and other reliable sources using the possible combinations of the following key words: Meckel’s diverticulum, Littre hernia, umbilical hernia, adults, complications, surgical treatment.

Results

The herniation of a Meckel’s diverticulum through a potential opening in the abdominal wall is defined as a Littre hernia, representing a rare complication of the diverticula. Due to their rarity, they often remain underdiagnosed, potentially leading to sub-optimal treatment and significant morbidity.

Conclusion

A Meckel’s diverticulum, despite being a rare clinical entity in adults, can theoretically be found in any hernia, with patients experiencing a wide range of potential complications.
EP.FRI.461 Management of acutely ill surgical patients NICE guidance CG50: a complete audit cycle
Authors: Kalaskar Shrinivas , Bonomoully Mathew
Published: October 2021

Aim

NICE CG50 guidelines are a response to evidence suggesting patients who are, or become, acutely unwell may receive suboptimal care. The guidelines suggest:

After previously unsuccessful audits a fourth re-audit was designed to re-assess compliance with the CG 50 guidelines.

Method

After implementing previous recommendations like, keeping a poster of recommendations in the handover room and making these guidelines as part of surgical induction, a re-audit was planned. A prospective random sample of 40 patients admitted during the general surgery was taken. Using the audit tool the following parameters were recorded for each patient in the sample:

Results

The compliance was 100% for patients who have had their physiological observations recorded at the time of admission or initial assessment, the percentage of patients monitored using a physiological track and trigger system, and the percentage whose physiological observations were monitored at least every 12 hours. The compliance was 95% for the percentage of patients with a clear written monitoring plan.

Conclusions

Following the interventions detailed above, there is now 95 to 100% compliance with NICE guidelines in the documentation.
EP.FRI.468 A review of the management of malignant bowel obstruction at an NHS teaching hospital
Authors: Banks Jessica , Aiynattu Sony , Ishak Rafik
Published: October 2021

Patients presenting with malignant bowel obstruction (MBO) due to peritoneal metastasis present a clinical dilemma for surgeons: although palliative surgery is beneficial, post-operative complications and mortality are as high as 30%.  A personalised and multi-disciplinary approach is paramount when treating these patients.

Aims

This study aimed to review the management (surgical versus conservative) of patients presenting with MBO; ascertain if a multi-disciplinary approach was adopted; and compare clinical outcomes including length-of-stay, readmission rates and mortality. 

Methods

All patients admitted with MBO secondary to peritoneal metastasis between January 2019 – January 2021 were identified.

Results

29 patients; 14 females, were identified with a median age 72. The median length of stay was 16 days.

All patients had a CT scan and 76% were performed within 24 hours of admission. 25/29 patients were referred to palliative care.

Conclusions

Overall mortality and morbidity in our cohort, regardless of surgical or conservative management, is consistent with existing literature. Palliative care input was sought for the majority of patients.

Management decisions should be individualised and focus on ensuring the best quality of life for the patient. All decisions should be made with multi-disciplinary input.