bluuebunny/crossref_metadata_2025 huggingface dataset:
BS O07 Secondary Hyperparathyroidism Before and After Bariatric Surgery: a Prospective Study with 2-Year Follow-Up
Authors: Salman Mohamed , Tourkey Mohamed , Noureldin Khaled , Khalid Sadaf , Issa Mohamed , Elewa Ahmed , Shaaban Hossam , Salman Ahmed , Elsherbiney Mohammed , Elhaj Mujahid , lee Shiela , Gebril Mahmoud
Published: December 2022

Background

Secondary hyperparathyroidism (SHPT) is linked to obesity. Bariatric surgery may be associated with calcium and vitamin D deficiencies leading to SHPT. This study aimed to detect the prevalence of SHPT before and after bariatric surgery

Methods

This prospective study assessed the prevalence of SHPT after sleeve gastrectomy (SG, n = 38) compared to one anastomosis gastric bypass (OAGB, n = 86). All patients were followed up for two years. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry.

Results

Of the 124 patients, 71 (57.3%) were females, and 53 (42.7%) were males, with a mean age of 37.5 ± 8.8 years. Before surgery, 23 patients (18.5%) suffered from SHPT, and 40 (32.3%) had vitamin D deficiency. The prevalence of SHPT increased to 29.8% after 1 year and 36.3% after 2 years. SHPT was associated with lower levels of vitamin D and calcium and higher reduction of BMD in the hip but not in the spine. After 2 years, SHPT was associated with a significantly lower T-score in the hip. SHPT and vitamin D deficiency were significantly more common in patients subjected to OAGB compared to SG (p = 0.003 and p < 0.001, respectively). There is a strong negative correlation between vitamin D levels and parathormone levels before and after surgery.

Conclusions

The prevalence of SHPT is high in obese patients seeking bariatric surgery, especially with lower vitamin D levels. Bariatric surgery increases the prevalence of SHPT up to 2 years. Gastric bypass is associated with a higher risk of developing SHPT compared to SG.
HPB O04 Venous thromboembolism after hepatectomy: comparison between open and minimally invasive liver resection. Results of a systematic review with meta-analysis
Authors: Lancellotti Francesco , Coletta Diego , de’Liguori Carino Nicola , Jegatheeswaran Santhalingam , Maruccio Martina , Siriwardena Ajith , Jamdar Saurabh
Published: December 2022

Background

Even though the risk of postoperative venous thromboembolism (VTE) after liver resection is well recognized, the association between surgical approach and VTE risk is unknown. This study aims to compare VTE rates following open liver resection (OLR) and minimally invasive liver resection (MILR).

Methods

MEDLINE, Web Of Sciences and EMBASE databases were analyzed to identify eligible studies. The studies that we included in the meta-analysis were published between February 2016 and May 2021. The last database search was performed on May 22nd, 2022. Studies were considered suitable if they reported a comparison between OLR and MILR (including laparoscopic liver resection [LLR] or robotic liver resection, [RLR]), or if postoperative VTE was the main focus of the study. Extracted data were pooled and subsequently used in a meta-analysis.

Results

14 studies including 11356 patients met inclusion criteria and were considered for meta-analysis, with a total of 5622 patients who underwent OLR and 5734 patients who underwent MILR. Overall, our findings showed that VTE rate was higher among patients who underwent OLR compared to MILR (2.8% vs 1.4%, p=<00001). Similarly, the subgroup analysis showed a higher rate of deep venous thrombosis (DVT) (1.4% vs 0.7%, p=0.02) and pulmonary embolism (PE) (1.3% vs 0.7%, p=0.002) in patients who underwent OLR compared to MILR.

Conclusions

Patients who undergo OLR have a higher incidence of postoperative VTE when compared to MILR. This finding is consistent for both DVT and PE.
OGBN O05 Safety and efficacy of endoscopic self-expanding stent insertion for benign oesophageal strictures – retrospective review of a single-centre case series
Authors: Huppler Lucy , chung Tham Ji , Lin Benjamin , Shaw Alice , Byrne Benjamin E
Published: December 2022

Background

Benign oesophageal strictures (BOS) are common and are most often managed with endoscopic balloon or bougie dilation. While self-expanding stents (SES) are a key tool for managing malignant strictures, their role in management of BOS is less well defined, usually being reserved for refractory strictures. Potential benefits include reduced frequency of intervention to stabilise nutritional status, and risks include migration, perforation or erosion. We conducted a single-centre retrospective review of our experience using SES for BOS to evaluate their safety and efficacy.

Methods

All patients undergoing SES insertion at a tertiary oesophago-gastric surgery unit between November 2015 and November 2020 were retrospectively identified using cross-referencing across 3 internal software systems. Patients undergoing primary SES insertion for BOS were identified, records were retrieved and reviewed. Data was collected on pre-insertion stricture management, post-procedure complications and outcomes including further interventions within the next year.

Results

During the study period, 425 oesophageal SES were inserted. From these cases, 18 patients underwent primary SES insertion for BOS. 14/18 (78%) of patients were male with a mean age of 68 years. Causes of BOS were reflux (7, 39%), 360 degree radiofrequency ablation of dysplastic Barrett's oesophagus (7, 39%), radiotherapy for squamous cell carcinoma (2, 11%), post-achalasia treatment stricture (1, 6%) and anastomotic stricture (1, 6%). In the 12 months prior to SES insertion, patients underwent a median of 3 (IQR 2–4) balloon dilations. During the immediate preceding month, patients underwent a median of 1 (IQR 0–1) dilations.

There were no cases of perforation, bleeding or erosion associated with SES insertion. 5 of 18 (28%) stents migrated. Median interval to the next endoscopy was just over 5 weeks (36 days (IQR 27.25–48). During the following 12 months after stent insertion, patients underwent a median of 5 (IQR 3–9.5) further endoscopies after primary stent insertion.

Conclusions

Stent insertion for BOS is safe and can provide a period of several weeks before further intervention is required. This may facilitate a period during which oral nutrition can be improved. However, SES for BOS is associated with a significant rate of migration, and patients continue to require frequent interventions after stent insertion. We suggest that SES insertion in this setting should be reserved for selected cases where intensive early dilation has failed to achieve progression in diameter with improvement in symptoms and nutrition as part of a standardised approach to improve management of BOS.
OGC O04 A Preoperative Scoring Model to Estimate the Risk of Conduit Necrosis in Oesophagectomy Patients - Results From the Oesophago-Gastric Anastomosis Audit
Authors: Halle-Smith James , Kamarajah Sivesh , Evans Richard , Griffiths Ewen
Published: December 2022

Background

Both conduit necrosis (CN) and anastomotic leak (AL) after oesophagectomy is associated with high morbidity and mortality and therefore identification of preoperative, modifiable risk factors are desirable. Once identified, risk factors can be used to create a risk scoring model which can be used to aid preoperative counselling and guide postoperative management. The aim of this study was to use the prospectively collected, multicentre data from the Oesophago-Gastric Anastomosis Audit (OGAA) to generate a risk scoring model for conduit necrosis and anastomotic leak after oesophagectomy.

Methods

This prospective multicentre cohort study included patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018 (with 90 days of follow-up). Definitions for AL and CN were those set out by the Esophageal Complications Consensus Group. Univariate and multivariate analyses were performed to identify risk factors for both AL and CN. The cohort was then randomly split into a derivation an validation set. A risk score was then produced for both AL and CN using the derivation set, then internally validated using the validation set.

Results

This study included 2247 oesophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% (n = 319) and CN rate was 2.7% (n = 60). Preoperative factors that were independent predictors of CN were: body mass index (BMI), Eastern Cooperative Oncology Group (ECOG) performance status, previous myocardial infarction (MI) and smoking history. These were converted into a risk-scoring model and internally validated using the validation set with an area under the receiver operating characteristic curve (AUROC) of 0.775. Preoperative factors that were independent predictors of AL were cardiovascular comorbidity (previous MI, peripheral vascular disease, previous stroke) and chronic obstructive pulmonary disease (COPD). This was converted to a risk scoring model but when internally validated the AUROC showed insufficient predictive ability (0.618).

Conclusions

The present risk scoring model provides an internally validated tool to estimate a patient's risk of CN preoperatively. This could be used to inform preoperative counselling and guide postoperative management. External validation is required to further assess the predictive ability of this score. Despite a large dataset, AL proves difficult to predict using preoperative factors.
OGC O08 Endoscopic surveillance alone is feasible and safe in type I gastric neuroendocrine neoplasms less than 10mm in diameter
Authors: Exarchou Klaire , Hu Haiyi , Stephens Nathan A , Moore Andrew R , Kelly Mark , Lamarca Angela , Mansoor Wasat , Hubner Richard , McNamara Mairead G , Smart Howard , Howes Nathan R , Valle Juan W , Pritchard D Mark
Published: December 2022

Background

Type I gastric neuroendocrine neoplasms (g-NENs) have a low risk of metastasis and a generally favourable prognosis. Patients with small type I g-NENs (≤10mm) frequently require no treatment, whereas those with larger polyps usually undergo resection. We evaluated the safety and outcomes of endoscopic surveillance after no initial treatment in selected patients with type I g-NENs.

Methods

Retrospective analysis of type I g-NEN patients across two European Neuroendocrine Tumour Society Centers of Excellence 2003–2019.

Results

Following initial assessment, 87 of 115 patients with type I g-NEN (75 with polyps ≤10mm) received no initial treatment and underwent endoscopic surveillance. 79/87 (91%) demonstrated no clinically meaningful change in tumour size or grade over a median 62 month follow up. Only two patients developed NEN progression that required a change in management and two other patients developed gastric adenocarcinoma/high grade dysplasia; all four initially had ≥11mm g-NENs.

Conclusions

Patients with ≤10mm type I g-NENs were unlikely to develop clinically significant tumour progression and in most cases, resection was not needed. The endoscopic surveillance interval could therefore potentially be safely increased to every 2–3 years in such patients. However, lifelong surveillance is still advocated due to the additional risk of developing gastric adenocarcinoma.
BS P01 Obesity – the last bastion of prejudice and stigma in the NHS?
Authors: Sokhal Balamrit , Menon S P K , Oputa S , Nanthakumar Nakulan , Ridwan Rahman Mohammed , Fabgemi Ona-Omovefe , Rao Vittal
Published: December 2022

Background

There is anecdotal evidence to suggest that patients with obesity face stigma in the NHS

Methods

A multiple-choice survey was sent out to consultants in a university teaching hospital with an established bariatric surgery unit. Respondents provided information on demographics and perceptions of obesity and bariatric surgery. Results were presented as frequencies and this was analysed.

Results

There were 167 consultant respondents with M:F = 114:53. 58% belonged to medical speciality and the rest belonged to the surgical speciality. 90% had over 10 years of NHS experience. 46.7% were in the normal BMI range and 3.5% had BMI 35 and above. 1.8% were not aware that obesity is classified as a disease. 42.5% felt that obesity is a self-inflicted disease. 73.4% agreed that bariatric surgery should be funded by the NHS, but 12% disagreed. 4.2% were of the opinion that bariatric surgery is a waste of money. 97% agreed that bariatric surgery resulted in weight loss and resolution of comorbidities.

Conclusions

There is a significant negative perception that obesity is a self inflicted life style disease even amongst the consultant work force reinforcing the premise that perhaps obesity is the last bastion of prejudice in the NHS.
BS P03 Safety of Laparoscopic Cholecystectomy in patients with BMI > 35 kg/m2 without preoperative screening for Obstructive Sleep Apnoea
Authors: Lee Shiela , Salman Mohamed , Chong Eric , Mahawar Kamal
Published: December 2022

Background

Preoperative Obstructive Sleep Apnoea (OSA) screening, followed by sleep studies as indicated, is commonly performed for patients undergoing bariatric surgery in our hospital but not for patients with similar weight undergoing other surgeries such as laparoscopic cholecystectomy. The purpose of this audit was to understand if laparoscopic cholecystectomy can be performed safely in patients with a Body Mass Index (BMI) ≥35 kg/m2 without such screening.

Methods

Patients with a BMI ≥ 35 kg/m2 undergoing elective laparoscopic cholecystectomy between 2nd May 2014 and 4th April 2022 were included. Patients with known OSA were excluded and no patients were referred for sleep studies. Data on patient demographics, co-morbidities, and any intraoperative or postoperative surgical complications were extracted and analysed. Univariate associations between different preoperative and operative variables and 30-day morbidity were studied using the Fisher's exact test.

Results

A total of 434 patients were included in the audit (64 male, 370 female). The mean age was 49 +/- 15 years. The mean weight and BMI were 110 +/- 20 kg (range 70–79kg) and 37 +/- 6 kg/m2 respectively. The mean operating time was 70 +/- 31 minutes (median=62). Approximately, 92% (398/434) had a day case procedure. The readmission rate at 30-day was 1% (5/434). There were no intraoperative complications. 17 patients had post-operative complications including deep vein thrombosis (n=2), leak in transverse colon secondary to cholecysto-colic fistula (n=1), wound infection (n=9), bile leak and post-op ERCP (n=3), common bile duct stone requiring ERCP (n=1) and pneumonia (n=1). No patients required ITU or HDU admission for further organ support.

The 30-day mortality rate was 0% (0/434) while the 30-day morbidity rate was 3.9% (17/434). ASA grade, previous abdominal surgery, hypertension, diabetes, dyslipidemia, smoking history, chronic obstructive pulmonary disease, ischemic heart disease, fatty liver disease, preoperative liver reducing diet, number of ports, and conversion to laparotomy were not associated with increased 30-day morbidity rate (p<0.05) on univariate analysis. Higher BMI values (≥40 and ≥50 kg/m2) were also not associated with increased 30-day morbidity rate (p<0.05).

Conclusions

This audit demonstrated that laparoscopic cholecystectomy can be performed safely without the need for preoperative sleep studies in patients with BMI ≥35 kg/m2.
BS P05 Laparoscopic repair of internal hernia post Roux-en-Y Gastric Bypass: Our tricks and technique
Authors: Elshaer Ahmed , Gouda Mohammed
Published: December 2022

Background

The incidence of internal herniation (IH) post Roux-en-Y gastric bypass (RYGB) is variable across literature (0.5–11%). This may be partially related to the difference in the operative techniques of RYGB. Routine closure of mesenteric and Petersen's defects has shown noticeable decline in the incidence of IH over last few years. Nevertheless, it didn't prevent the development of IH at long-term follow up.

Methods

We describe a video of a case with a large non-obstructing mesenteric internal hernia post RYGB. A 33 years old female patient presented to our bariatric clinic with recurrent attacks of post-prandial abdominal pain over 6 months. She had RYGB 2.5 years before this presentation, with EWL of 65%. Of note, the mesenteric and Petersen's defects were closed in the original RYGB operation. CT scan showed suspicious findings of internal herniation without obstructing signs. Patient had a laparoscopic exploration which showed a large internal herniation through mesenteric defect containing more than two thirds of bowel length. Closure of the defect was done by a purse string technique using non-absorbable prolene 2/0 stitch after reduction of the bowel. Patient had an uneventful postoperative recovery. She denied any further attacks of abdominal pain at her follow up till 6 months postoperatively.

Conclusions

Diagnosis of non-obstructing internal herniation post RYGB is very challenging. Low threshold for laparoscopic exploration in suspicious cases of remittent abdominal pain is highly recommended. CT scan can't rule out IH completely due to its intermittent nature. Laparoscopic repair remains the optimal approach, even in the large IH, with favourable outcomes. Appropriate identification of the bowel configuration is the key step in such procedure.
OGBN P03 Per oral endoscopic myotomy (POEM) for primary achalasia: single-centre, retrospective analysis of 128 patients
Authors: Theophilidou Elena , Catton James
Published: December 2022

Background

Achalasia is a neurodegenerative motility disorder of the oesophagus, presenting with the main symptoms of dysphagia, weight loss, chest pain, and regurgitation. Surgical myotomy is considered the gold standard treatment. However, peroral endoscopic myotomy (POEM) seems to be a safe and effective alternative option which was introduced in 2008. POEM is a procedure performed endoscopically, which allows transection of the muscular fibres of the distal oesophagus and of the lower oesophageal sphincter. In our centre POEM has become a more frequent management option to treat primary achalasia when compared to surgical myotomy. The aim of the study is to analyse the outcomes from a single centre experience.

Methods

From June 2015 to May 2022, 128 patients underwent a POEM procedure to treat primary achalasia. We performed a retrospective analysis focusing on short term outcomes.

Results

All 128 patients underwent gastroscopy and manometry as part of the pre-operative workup to diagnose achalasia. Out of the 128 patients, 66 (52%) were women with age ranging from 17 to 79. BMI values ranged from 17 to 42. At 3/128 occasions the procedure was abandoned due to technical difficulty with all 3 patients at the early days of performing POEM highlighting the learning curve of the procedure. 6/128 patients had ongoing symptoms of achalasia post POEM and went on to have a laparoscopic Heller's myotomy. Median length of stay is 2 days (1–11). 6/128 had Clavien Dindo complications class 2 and 2/128 patients required aspiration of peumoperitoneum intra-op and one patient requiring chest drain insertion for surgical emphysema. 15/128 patients had a post-operative water soluble contrast swallow study to exclude leak following challenging cases or concerns for perforation. The median Eckardt score at last follow-up decreased from 7 to 1.

Conclusions

Our results show that POEM is a safe procedure to treat primary achalasia with minimal complications and preferable outcomes for patients in terms of symptom control. It can performed safely by experienced oesophageal surgeons and there are very good short-term outcomes. In our unit POEM is the primary treatment modality for achalasia.
OGBN P14 The development, introduction and outcomes of an electronic, patient record-based, Morbidity and Mortality (M&M) reporting system
Authors: Couper Graeme
Published: December 2022

Background

Recording of patient complications and outcomes has suffered from the lack of a standardised reporting system. The aim of this project was to develop and introduce within our health board a generic M&M reporting tool for all surgical and medical specialities which would allow agreed outcomes and actions, following open discussion at M&M meetings, to be documented in the electronic patient record (EPR).

Methods

TrakCare® (Intersystems) is the electronic patient management system used within our region to record and store information for patient consultations, investigations and treatments. The criteria felt essential were for a reporting system that was suited to all disciplines, accessible to all levels of staff, interlinked between specialities and allowed analysis and reporting of outcomes. Access to all aspects of the EPR including results and imaging should be available during the M&M meeting to facilitate informed discussion. Agreement was reached on the required drop down menus which included patient details, background/event timeline, death certification, end-of-life care, clinical governance, lessons learned and actions and outcomes. ICD-10 codes were used for diagnosis and OPCS-4 coding for procedures. A complication list was developed with word recognition of either the organ system or the complication. Complications were graded according to the Clavien-Dindo classification. All entered data was analysed using Business Intelligence.

Results

The development process lasted 9 months with the input of the author and programmers from the TrakCare® team. The system was first introduced in September 2017 within the general surgical unit. 1855 patients have been discussed at the general surgical M&M meetings using the system. Since introduction, an additional 37 specialities have adopted the electronic M&M reporting tool. To date 4859 patients in total have been discussed. The introduction of the system has resulted in additional improvements to the M&M process including the requirement for a designated chairperson, a meeting attendance record and documentation of actions and outcomes from meetings. Automatically generated reports show all outstanding actions and recommendations identified at M&M meetings to ensure that the full process is completed.

Conclusions

The widespread adoption of a standardised M&M reporting tool clearly shows the willingness of care providers to engage in open discussion and learning from M&M meetings. The introduction of a standardised electronic reporting tool has led to additional improvements in the M&M process.
OGBN P15 Covid-19's impact on delays to elective Cholecystectomy
Authors: Picton Charles , Galloway Simon
Published: December 2022

Background

Patients waiting for elective cholecystectomy for symptomatic gallstone disease may need admission with biliary symptoms or complications whilst on the waiting list. The longer the length from listing to procedure the higher the risk of symptoms and possible admission with complications. Many elective operations were cancelled or delayed during the pandemic leading to increased waiting times. The trust noticed a significant number of patients presenting to hospital who were already listed for surgery. This study looks at emergency admission data of 100 patients awaiting elective cholecystectomy.

Methods

Hospital admission data on 100 successive patients from the cholecystectomy waiting list were analysed from Dec 2021-January 2022. Data was collected on when were they added to the list and whether they had presented to hospital in the waiting period before cholecystectomy. Of those that were admitted, reasons for admission, demographics of people who needed admission and length of stay in hospital were recorded.

Results

Of the 100 patients many had been waiting more than a year with Covid 19 a predominant delaying factor (cholecystectomy is a P3 or P4 procedure and many elective procedures were cancelled or delayed during the pandemic). This cohort of patients had 32 separate presentations to hospital while on the waiting list (some patients presenting multiple times). 9 patients required emergency hospital admission for clinical reasons such as pancreatitis and cholecystitis. This totaled 67 bed days for the admitting hospital, some data was unavailable due to admissions to other hospitals.

Conclusions

NICE guidelines recommend laparoscopic cholecystectomy within 1 week for patients presenting with acute gallstone disease. Early elective cholecystectomy is recommended for patients with symptomatic gallstones. Delays in elective cholecystectomy operations during Covid 19 have caused delays to definitive treatment and led to excess bed usage during the treatment pathway with the associated financial costs and patient morbidity.
EGS P10 The Effect of COVID-19 on the Management of Upper Gastro-intestinal Cancers at a London NHS Trust
Authors: Osilli Dixon , Horsley Varnika , Mukherjee Samrat , Amalesh Thangadorai , Mukherjee Dipankar
Published: December 2022

Background

The advent of the COVID-19 pandemic in 2020 led to staff redeployment and prioritization of urgent care services. Cancer services were impacted by staff and resource diversion. Cancer diagnoses fell by 33% due to reduction in surveillance, diagnosis, and screening. Upper gastro-intestinal cancers (UGI) include cancers of the esophagus, stomach, small intestine, pancreas, liver, and gall bladder. These cancers progress insidiously, present at late stages and are challenging to treat. Delayed diagnosis significantly reduces the scope of treatment options available and therefore impacts the prognosis of the patient. A Public Health England Report in 2021 showed a reduction in tumor resection surgeries in UGI cancers between March to May 2020 and December to February 2021. The backlog of surgical cancer management is ongoing as the pandemic evolves and NHS service provisions adapt. It is important to understand the effects of COVID-19 on diagnosis, staging and treatment of UGI cancers in order to improve service provision in the ensuing years.

Methods

This was a cross-sectional study conducted at Barking, Havering and Redbridge NHS Trust from January to June 2019, 2020 and 2021. Data for 316 study participants was sourced from the Somerset Cancer Database and supplemented with data from electronic patient care records. Six months of data was compared in 2019 (pre-pandemic), 2020 (mid-pandemic including the first lockdown) and 2021. The data was analysed as raw proportions and percentages.

Results

The number of UGI cancers diagnosed was lowest in 2020 during the height of the pandemic compared to 2019 and 2021. The most common cancer in all three years was pancreatic. Pancreatic cancer was also the most common emergency cancer presentation. The highest proportion of stage IV cancers presented in 2021 (67%). The proportion of cases that resulted in palliative care management increased from 2019 to 2021 (67% and 70% respectively). 53% of all patients came from neighbourhoods that fell within 50% of the most deprived areas nationally.

Conclusions

The COVID-19 pandemic has had variable impacts on the presentation and management of UGI cancers at the BHRUT NHS Trust. This study exhibits local trends and percentages following suit from Public Health England's National Cancer Registration and Analysis Service data for trend-based discussion. Further research within London NHS Trusts is encouraged to understand the full impact of COVID-19 on surgical cancer services in the NHS.
EGS P15 Role of electronic consent in emergency surgery – A QIP in a high volume surgical emergency unit at a tertiary hospital
Authors: Sharmin Afroza , Loyala Vishani , Shams Ola , Bond-Smith Giles
Published: December 2022

Background

The Royal College of Surgeons of England discusses the significance of maintaining a written record of consent in addition to completing the consent form under section 4.10 of the supported decision-making guide to good practice - “any written information given to the patient should also be recorded and copies should be included in the patient's notes”. Studies show high error rates (27–50%) with handwritten consent forms due to poor legibility, incomplete/ inaccurate information, increased variability, and risk of misplacement. The consequences of these errors can lead to poor patient experience as well as unfavourable outcomes at the operational and institutional levels. Missing or incomplete consent is also the most common reason for first case delay (average 1–75mins). This prompted the QIP and generation of a standard template for the common emergency general surgery procedures in a high-volume Surgical Emergency Unit (SEU) at the John Radcliffe Hospital.

Methods

Procedure-specific Electronic Surgical Consent (eSConsent) template for common emergency general surgery operations was added to the online database to easily be added to the electronic patient record. The format, as outlined below, was designed to allow even junior surgical trainees to adapt and perform the consent process early on in their placement-

Results

The consent for all the emergency general surgery cases in a given week was reviewed and the compliance to maintaining eSConsent was audited. The first cycle between 20th-26th September 2021 showed compliance of only 18% (9 out of 49 operations). After discussing the audit findings with the members of the surgical team involved in the consenting process in the local meeting and implementing eSConsent, the compliance increased to 83.7% (36 of 43 cases) in the following week, 78% (33 of 43 cases) between 12th-18th November 2021 and 73% (28/38 operations) in the beginning of March 2022.

Conclusions

A consent form is a medicolegal document. Health care systems have taken advantage of technology to facilitate accuracy and robust monitoring. The emergency surgical consent process can benefit from this to avoid delays, errors and litigation. This transition is justifiable from our results and easily translated to practice particularly by using simple technology demonstrated in our QIP. Challenges including trainee changeover and new recruitments will expectedly affect the compliance of eSConsent but a proper induction to ensure adequate staff education will help overcome this. Weekly data capture has been adopted in our department as a surveillance protocol to ensure adherence and to standardize our practice.
EGS P19 A new normal or the calm before the storm?
Authors: Olivier James , Walsh Adam , Old Oliver
Published: December 2022

Background

One of the highest risk factors for morbidity and mortality for general surgery patients is having their surgery in the emergent rather than elective setting. Patients are presenting older, with often complex pathology on a background of multiple medical comorbidities and sometimes extensive surgical history.

NELA (national emergency laparotomy audit) and similar projects have looked at assessing and improving upon the management of such cases. These have produced valuable data and improvement in outcomes but there remains a lack of information around the acuity of surgery and the provision of services in response to demand. This study sought to assess the number of NELA cases in hospitals around the UK and compare this to historical data pre-pandemic.

Methods

Acute trusts admitting adults under general surgery in England were identified from the online NHS Service Directory. This list was cross referenced with the National Emergency Laparotomy Audit (NELA) list of participating hospitals to check for completeness. This generated 123 acute trusts in England. Contact details for each trust's Freedom of Information (FOI) department was identified from publicly available data on each trust's website. Questions were submitted to the FOI via email for 112 trusts, and online form submission for 11 trusts. Responses were collected for 8 weeks from the date of submission and analysed in Microsoft Excel. Trusts were asked to provide the number of general surgery admissions, inpatient bed numbers and NELA numbers. These were cross-referenced with publicly available data from NHS and NELA websites. Comparisons were made to similar data from 2014.

Results

101 out of 124 trusts responded within the 8-week timeframe. 14,497 NELA cases were recorded from the national total of 21,846 stated in the NELA Year 7 report (66.36%). The mean number of beds reported per NELA case was 5.76 (+/- 1.46 CI 95%), with histogram peaking between 3 and 5 beds with a right skew distribution. The mean number of admissions per NELA case was 30.81 (+/- 3.29 CI 95%), with histogram data peaking between 21 and 26 admissions with right skew distribution.

A comparison with data from 2014 can be seen below (table 1).

Conclusions

The Covid-19 pandemic had significant and widespread effects on the provision of services but also to demand. We now know that presentations to hospital reduced as did subsequent inpatient admissions. Our study shows that the number of NELA cases decreased across England and this was independent of hospital size. The largest decrease was seen in quartile 2 followed by quartile 3 representing mid-sized hospitals. Whilst not certain it is likely that this decrease was secondary to the pandemic rather than any change in practices. The results from this study can be used to help hospitals and departments plan their provision of services and training.
EGS P22 Management of acute cholecystitis during the Covid-19 pandemic - A complete cycle
Authors: Islam Muhammad , Tan Jay Roe , Oldfield Frances , English Louise , Tandon Ashutosh , Al-Rashedy Mohammed
Published: December 2022

Background

Acute cholecystitis is a common surgical emergency. NICE guidelines recommend early laparoscopic cholecystectomy should be performed within 1 week of diagnosis. Emergency and elective surgical provision was affected during the first wave of the covid pandemic due to high postoperative mortality and pulmonary complications. The objectives of this audit were to assess and improve the local management of acute cholecystitis during the Covid-19 pandemic.

Methods

A retrospective review of all patients who presented with acute cholecystitis over 2 months was performed in April 2020. Several interventions were introduced following the first cycle to improve our adherence with NICE guidelines, including ‘green elective surgical pathway’, clinical priority coding for elective surgeries, a hot gallbladder pathway, and a dedicated weekend and evening list. A re-audit was performed over 2 months in July 2020. These findings were presented at the departmental meeting.

Results

34 patients were reviewed in the first audit and 37 in the re-audit. A higher number of patients with acute cholecystitis in cycle 2 had admission covid swabs (97.3% vs 64.7%) and interval covid swabs (54.1% vs 0%) compared to cycle 1. One patient was tested positive for Covid-19 in cycle 2 and was listed for elective operation. Cycle 2 revealed a higher rate of hot gallbladder (from 8.8% to 10.8%) and a shorter median length from admission to operation (from 4 to 1.5 days). A higher rate of patients was readmitted due to complications of cholecystitis in cycle 2 (29.7% vs 20.6%) compared to cycle 1.

Conclusions

The overall performance is still behind the NICE guideline recommendation. We have identified factors such as pressure on theatre facilities and resources and cancer fast-track priority surgeries during the Covid-19 pandemic. Ongoing audit and optimisation of the hot gallbladder pathway, elective surgical pathway, extra lists, and clinical priority of operations are important to improve the quality of care for patients with acute cholecystitis.
EGS P23 Boerhaave syndrome: provision of emergency services during the COVID era
Authors: Hawkins Rosalyn , Phillips Benedict , Amalesh Thangadorai , Mukherjee Dipankar , Mukherjee Samrat
Published: December 2022

Background

The provision of emergency surgery was significantly impacted during the COVID-19 pandemic. This was due to limited intensive care beds and the risk of catching COVID-19 in the post-operative period. The aim of this study was to determine whether outcomes for patients with Boerhaave syndrome were negatively affected by service constraints during the COVID-19 pandemic.

Methods

Single centre case control study of patients with Boerhaave syndrome before and during the COVID pandemic. Univariate and multivariate analyses was employed to determine whether patient outcomes following Boerhaave syndrome were influenced by the COVID pandemic (defined here as 2020–2022) compared to a pre-pandemic period (2013–2019).

Results

During the COVID pandemic, 7 patients presented with Boerhaave syndrome, although none of these patients tested positively for COVID-19. Patient characteristics and outcome data of these patients were compared to a group of 14 patients with Boerhaave syndrome during a pre-pandemic period. The median age of patients presenting with Boerhaave syndrome was statistically significantly lower during the pandemic compared to those presenting before the pandemic (28 years versus 60 years, p=0.04). There was no significant difference in the treatment approach between the two groups, with non-operative and operative measures being employed in both groups equally (p=0.66), suggesting that the pandemic did not influence treatment decision. There was no difference in the use of endoscopic stenting between the groups (p=0.25). 30-day mortality was equal between patients admitted during the pandemic and those admitted before the pandemic (p=0.13).

Conclusions

This study demonstrated that the median age of patients presenting with Boerhaave syndrome during the pandemic was significantly lower than it was historically. This may have reflected shifts in behaviour and lifestyle during the pandemic. Never-the-less, the impact on services during the pandemic did not appear to influence treatment choice, and 30-day mortality remained the same for both patient groups. This may have reflected provision of COVID-secure pathways and locations.
EGS P27 Evaluating the use of gastrografin for the management of small bowel obstruction at Harrogate District Foundation Trust
Authors: Tahir Wasif , Al-Ramadhani Hasan , Ding Wayne , McNaught Clare
Published: December 2022

Background

Small bowel obstruction (SBO) is associated with significant morbidity and mortality (90 day mortality: 13%). Common causes include: adhesions, hernias or tumours. Conservative management includes nil per oral, intravenous hydration and naso-gastric decompression. If conservative management fails (>72 hours) patients usually require surgery.

Recent national and international guidelines (ASGBI, Bologna, etc.) however advocate early use of gastrografin for the management of SBO.

The aim of the audit is therefore to review current HDFT practice of gastrografin use for the management of small bowel obstruction.

Methods

Retrospective data collection between April 2020- January 2022. All patients who underwent surgery for SBO were included. Exclusion: ischaemic or strangulated bowel, large bowel obstruction.

Results

A total of 50 patients were included in the analysis (25 male: 25 female) with a mean age of 73 years. 46% of the patients had undergone previous abdominal surgery. Cardiovascular conditions were the commonest pre-operative co-morbidity (32% had cardiac co-morbidities on presentation).

Adhesions were the commonest cause of SBO (64%). Gastrografin was only administered in 12% of patients prior to surgery. Majority of the patients underwent laparotomy (92%) with 58% requiring bowel resection during surgery (27% of these required a stoma).

52% of the patients undergoing surgery were admitted to ICU post-operatively with a mean stay of 4 days. The mean length of hospital stay was 19 days. The 30 and 90 day post-operative complication rate was 52% and 6%, respectively. Commonest post-operative complication was related to surgery (44% either developed wound infection, ileus, collections, leak, obstruction, etc.).

Conclusions

Emergency laparotomy for SBO is associated with significant morbidity and hospital stay. Use of Gastrografin for diagnostic/ therapeutic effect is suboptimal in HDFT and requires further work.
HPB P01 Volatile Organic Compounds for the Detection of Hepatocellular Carcinoma – a Scoping Review
Authors: Psica Alicja , Metwaly Sayed , Sogaolu Opeyemi , Ahmed Irfan , Delibegović Mirela , Bekheit Mohamed
Published: December 2022

Background

Hepatocellular carcinoma (HCC) is an increasingly common disease and is classified as one of the most common cancers leading to mortality worldwide. Only a small percentage of patients with this disease are eligible to curative treatment. Quite often the main reason is the late diagnosis of the disease. In the last decade, a Nobel prize awarded discovery of the volatile organic compounds in the breath opened the frontiers for new diagnostic tools and methods for several diseases. Cancer is one of the target diseases that appears to have unique biomarkers in the breath of the affected individuals. This have been found true in colorectal, breast, lung cancers. This systematic review aims to answer the question if markers specific to hepatocellular carcinoma exist in exhaled breath and what is the current knowledge regarding its detection.

Methods

A systematic search was conducted by two reviewers and the Royal College of Surgeons of Edinburgh librarian using the Embase, Medline, PubMed and Web od Science databases. Search strategy included all studied published until the 24th of March 2021 containing combination of keywords (Hepatocellular carcinoma, hepatocellular neoplasm, hepatocellular cancer, hepatocellular tumor, hepatocellular tumour, HCC, liver cancer, liver carcinoma, liver neoplasm, liver tumor, liver tumour AND volatile organic compound, VOC, volatilome, volatilomics, metabolome, metabolomics, breath analysis).

Results

The search yielded 6 publications using PRISMA pathway. Two of the studies described in vitro experiments and four were conducted on a small number of groups of patients. Overall, in the in vitro studies 42 headspace gases were analysed. Clinical studies included 164 patients with HCC and as control groups - 110 patients with cirrhosis and 130 healthy individuals.

Multiple VOCs were found in the studies. Following their identification in PubChem library, a pathway analysis was performed using the Kyoto Encyclopaedia of Genes and Genomes (KEGG). Only three VOCs were annotated in the KEGG maps and out of those, two could be traced back to their biological pathways. These are acetaldehyde and ethanol which participate in glycolysis and gluconeogenesis (Figure 1).

Conclusions

At present time there are no specific volatile biomarker in exhaled breath characterising hepatocellular carcinoma. Data on extracted studies emphasised lack of unified methodology. This review, however, highlighted metabolic pathway which might be the source of VOCs produced by cancerous hepatocytes. Large population studies are required to verify this finding.
HPB P11 Ex vivo human pancreatic cancer avatars; establishing a platform to evaluate chemotherapeutic sensitivity
Authors: Hughes Daniel , Willenbrock Frances , Reddy Srikanth , Udupa Venkatesha , Silva Michael , Soonawalla Zahir , Mukerjee Somnath , O'Neill Eric
Published: December 2022

Background

A significant variation is observed in the response rate to chemotherapy amongst patients with pancreatic cancer. Current guidelines advocate treatment regimes based purely on the patient's level of fitness. Such an approach fails to acknowledge the individual's tumour biology. Our aim was to assess whether patient derived cancer avatars could be used to deliver personalised therapy.

Methods

Individual avatars were created from resected tumours and were cultured ex vivo either under novel perfusion culture conditions or conventional static culture. Serial assessment of avatar proliferation capacity and metabolic function was performed to determine viability over time. Avatars were treated with chemotherapy and treatment sensitivity was determined. Avatar response to chemotherapy was subsequently compared to the patient's response in order to determine whether the patient's avatar could predict a clinically meaningful response to therapy.

Results

Patient derived cancer avatars (n=13) were successfully cultured for 12 days ex vivo. Perfusion culture of avatars was associated with a preservation of proliferative capacity (p < 0.01), metabolic function (p < 0.01) and a reduction in apoptosis rates (p < 0.05) when compared to conventional static culture. Avatars were treated with Gemcitabine and different response rates were observed varying from treatment sensitivity to resistance. A positive correlation was noted between the avatar's response and the patient's clinical response whilst on adjuvant Gemcitabine therapy.

Conclusions

Patient derived cancer avatars provide a window of insight into the tumour's response to chemotherapy and may allow for a paradigm shift in the long-term survival rates for this disease.
HPB P14 Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma
Authors: Pande Rupaly , Chughtai Shafiq , Ahuja Manish , Brown Rachel , Dasari Bobby , Marudanayagam Ravi , Mirza Darius , Roberts Keith , Sutcliffe Robert , Isaac John , Chatzizacharias Nikolaos
Published: December 2022

Background

Para-aortic lymph node (PALN) involvement is staged as metastatic disease but the literature is conflicting with no consensus on management. Aim: To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC.

Methods

A retrospective cohort study of prospectively maintained data of pancreatectomies for PDAC between 2011–2020. Statistical comparison between PALN+ and PALN- subgroups, using Kaplan-Meier and Cox regression analysis.

Results

81 cases had PALN sampling, 17 (21%) were positive. OS and DFS were comparable between PALN+ and PALN- patients (OS: 13.2 vs 18.8 months, p=0.161; DFS: 13 vs 16.4, p=0.179). No difference in OS or DFS was identified between PALN+ and PALN- patients when they received chemotherapy (neoadjuvant or adjuvant). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 vs 14.2 months; p=0.015) and DFS (4.4 vs 9.8 months; p<0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence.

Conclusions

PALN involvement does not affect OS when patients complete the multimodal treatment pathway and should not be considered as a contraindication to resection.
HPB P16 Impact of Frailty on Short-term Outcomes after Laparoscopic and Open Hepatectomy
Authors: Hall Lewis , Osei-Bordom Daniel , Hodson James , Joshi Kunal , Austen Luke , Bartlett David , Isaac John , Mirza Darius , Marudanayagam Ravi , Roberts Keith , Dasari Bobby , Chatzizacharias Nikolaos , Sutcliffe Robert
Published: December 2022

Background

Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on postoperative outcomes after LH and OH.

Methods

Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail.

Results

Of 1826 patients, 34.7% (N=634) were frail and 18.6% (N=340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p<0.001) and postoperative complications (36.3% vs. 26.1%, p<0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients.

Conclusions

Frailty is independently associated with inferior postoperative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.