bluuebunny/crossref_metadata_2025 huggingface dataset:
Case Report. Cryoglobulin Hyaline-thrombi Associated Acute Jejunitis in A Patient with Type 2 Cryoglobulinemic Glomerulonephritis
Authors: Al-Othman Y , Qu Z , Zhang P
Published: October 2021

Introduction/Objective

Only one prior case report indicates that mixed positive cryoglobulin in serum can be associated with intestinal vasculitis (Annals of Internal Medicine, 1974).

Methods/Case Report

We report a 63-year old man with history of positive serum cryoglobulin and hepatitis-C 4 years ago and membranoproliferative pattern of glomerulonephritis with possible cryoglobulin type of deposits by electron microscopy on renal biopsy. After treatment, his hepatitis C became negative. But he was recently found to have monoclonal IgM-kappa and positive cryoglobulin in his serum, and the concurrent renal biopsy showed membranoproliferative pattern of glomerulopathy with many hyaline-thrombi (eosinophilic vascular occlusions with no lamination, inflammatory cells or nuclear debris) in the glomerular capillary loops (Figure, left panel). Both immunofluorescent and electron microscopy confirmed a mixed IgG polyclonal and IgM monoclonal type 2 cryglobulinemic glomerulonephritis. The patient also developed abdominal pain and underwent intestinal endoscopy with biopsy. His jejunal biopsy revealed neutrophil infiltration into glands and surface epithelium, with superficial sloughed epithelial cells, consistent with acute jejunitis with features of ischemic etiology. In addition, hyaline-thrombi were identified in the submucosal vessels with surrounding vasculitis (Figure, right panel); the central part of thrombi was morphologically similar to that found in glomerular capillary loops. Therefore, we conclude that cryoglobulin associated hyaline-thrombi were the most likely etiology to cause the acute ischemic jejunitis in this patient.

Results (if a Case Study enter NA)

NA

Conclusion

NA
Recurrent Focal Segmental Glomeruloscleosis Progressing to Collapsing Glomerulopathy in Renal Graft of an Autopsy study
Authors: Thorburn C , Jabbar K J , Li W , Kanaan H , Zhang P
Published: October 2021

Introduction/Objective

Collapsing glomerulopathy (CGN) mainly occurs in patients of African descent because a majority of these patients have APOL-1 gene mutations that results in damage of terminally differentiated podocytes, diffuse fusion of foot processes, and podocyte hyperplasia. Idiopathic FSGS is associated with high rates of recurrent FSGS in renal transplants and can be seen in patients with APOL-1 gene mutations as well, but recurrent FSGS progressing to CGN is not reported. Here we report an autopsy case with renal transplant showing recurrent FSGS progressing to CGN.

Methods/Case Report

Our patient was a 32 year old African American man who had a native renal biopsy which showed primary FSGS (with no infectious history) 8 years ago. Last year he received a renal transplantation (complex donor kidney from a deceased 25 year old man with pre-mortem serum creatinine (sCr) at 0.7 mg/dl). His initial post- transplant sCr level was as low as 1.17 mg/dl. However, in 4 months his sCr went up and he began to have higher levels of proteinuria. Sequential biopsies indicated that the patient developed a recurrent FSGS that progressed to show features of CGN. In his autopsy kidney graft, approximately 50% of glomeruli show collapsed loops with various degrees of hyperplasic podocytes, confirmed by positive CD133 staining (a progenitor cell marker). In addition, the hyperplastic podocytes lost WT-1 expression and were positive for Ki-67 staining. Distal tubules showed obvious cystic dilation. Overall findings were consistent with a severe form of CGN.

Results (if a Case Study enter NA)

NA

Conclusion

The clinical presentation of recurrent FSGS progressing to collapsing FSGS in our patient suggests that CGN and idiopathic FSGS may share a common pathophysiologic mechanism of disease.
Papillary Renal Cell Carcinoma with Extensive Spindle Cell Foci: Mimicker of Mucinous Tubular and Spindle Cell Carcinoma
Authors: Rajack F , Naab T J
Published: October 2021

Introduction/Objective

Papillary Renal Cell Carcinoma (PRCC), the 2nd most common RCC, accounts for 10-15% of cases and is usually composed of tubules and papillae with foamy histiocytes in papillary cores. Mucinous tubular and spindle cell carcinoma (MTSC) is composed of tightly packed, elongated, curvilinear tubules with smooth luminal surfaces, separated by mucinous stroma. MTSC is associated with a more favorable prognosis than PRCC. PRCC and MTSC have significant histologic and histochemical overlap including elongated tubules and stromal Alcian blue positive mucin deposits.

Methods/Case Report

We report a case of a 75 year old female who underwent a robotic assisted partial nephrectomy for resection of a 5.7 x 5.2 x 5.0 cm left upper pole solid renal mass. Spindle cell change with elongated tubules reminiscent of MTSC was present in several blocks; however, the luminal surface was shaggy favoring PRCC. Patchy prominent extracellular Alcian blue positive mucin deposits were also present. PRCC and MTSC both express CK7, AMACR, and EMA. However, absent expression of E-cadherin and strong CD10 expression favored PRCC. Multiple foci of solid spindle cells in a whorled pattern with clear cell change, necrosis, and high grade nuclei bordering on sarcomatoid RCC were present in other blocks. Multiple papillations and psammoma bodies also supported PRCC. A spectrum of spindle cell change was present, ranging from elongated tubules reminiscent of MTSC to whorled foci with high grade nuclei approaching sarcomatoid RCC.

Results (if a Case Study enter NA)

NA

Conclusion

Submission of multiple sections and awareness of the protean morphologic features of PRCC are essential in making the correct diagnosis.
Single institution retrospective review of CD34+ apheresis collection based on mobilization regimen and primary diagnosis
Authors: Puzo C , Li P , Siddon A , Tormey C
Published: October 2021

Introduction/Objective

Plerixafor has been increasingly used in conjunction with G-CSF to increase mobilization of CD34+ stem cells in patients undergoing leukapheresis collection for autologous stem cell transplantation. While G- CSF and plerixafor have been shown to increase CD34+ counts, studies examining patients’ ability to meet collection goals for patients with multiple myeloma (MM), diffuse large B-cell lymphoma (DLBCL), Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL) have not been well documented.

Methods/Case Report

All autologous stem cell collection patients between 2017-2021 were retrospectively reviewed and categorized by primary diagnosis. Patients received a mobilization regimen of G-CSF alone, G-CSF and plerixafor, G-CSF and chemotherapy, or G-CSF, plerixafor, and chemotherapy. CD34+ stem cell collection results were recorded. All units of CD34+ stem cells were processed according to protocol and viability was assessed by Trypan blue method on a thawed aliquot 2 weeks after processing.

Results (if a Case Study enter NA)

385 patients (271 MM, 41 DLBCL, 30 HL, and 43 NHL patients; male: 242; female: 143; age range: 16-78) were identified. Binomial logistic regression demonstrated that use of plerixafor with G- CSF was negatively associated with meeting CD34+ goal collection (OR= -1.57, p= 0.003) compared to G-CSF alone. This result was particularly true for MM patients (OR= -1.62, p= 0.014). A pairwise t-test indicated that patients receiving G-CSF and plerixafor had lower CD34+ cell viabilities (t= 2.21, p = 0.028); after Bonferroni correction for multiple comparisons, MM samples also had significantly lower percentage viability than DLBCL (p= 0.003) or HL (p= 0.022) samples.

Conclusion

A higher percentage of patients mobilized on G-CSF alone were able to meet collection goal versus patients who were mobilized on G-CSF and plerixafor. Patients who received G-CSF and plerixafor had significantly lower viability than those who received G-CSF alone. We hypothesize these findings to be due to lower baseline mobilization for patients on G-CSF and plerixafor.
Two Individuals with Rare Blocked Antigen Phenomenon and Coinciding Warm Autoantibody Mimicking Alloanti-Jk3 Resolved with JK Analysis
Authors: Zinni J G , Mullins D , DeChristopher P J , Ramsey G , Vission B , Stef M
Published: October 2021

Introduction/Objective

Kidd antigens can bind complement (C3) as well as Kidd specific warm autoantibodies (WAAb). An 838G>A single nucleotide variant (SNV) defines JK*01 and JK*02 which codes the antithetical Jka and Jk b, respectively. Both alleles translate the high prevalence (>99%) Jk3 (JK3). The 130G>A is associated with weak Jka and weak Jkb expression. In vivo binding of non-agglutinating globulins can cause false-negative phenotypes by means of the blocked antigen phenomenon (BAP).

Methods/Case Report

Transfusions were requested for a 74-year-old Caucasian (CA) female with Evan’s Syndrome, and an 85-year-old African American (AA) female with metastatic uterine cancer. Both had a history of nonspecific WAAb. Direct antiglobulin testing (DAT) detected moderate in vivo sensitization of IgG and C3. They phenotyped Jk(a- b-) with untreated and EDTA glycine-acid (EGA) treated IgG DAT-negative cells. Their serum contained anti-Jk3 reactivity, while a panreactive WAAb in the eluate reacted with Jk3- donor and EGA treated DAT-negative autologous cells. Weak anti-Jka and anti-Jkb reactivity remained in the alloadsorbed serum of the antithetical adsorbing cells.

Genetic testing of the CA revealed JK*01W.01(130A)/02 alleles, while cDNA confirmed the alleles would be transcribed into mRNA. Sequencing of the AA detected 130G/A, and 838G/A as well as other silent mutations predicting either a Jk(a+wb+) or Jk(a+b+w) phenotype. The CA received one compatible JK:-3 transfusion, and both individuals benefited from multiple least incompatible transfusions of Jk a+ and/or Jk b+ donors with expected hemoglobin increases (1 g/dL per transfusion). The CA serologically phenotyped Jk(a-b+) 132 days later following prolonged immunosuppressive therapy while a normocytic normochromic anemia and the WAAb persisted. No follow up evaluations of the AA are available.

Results (if a Case Study enter NA)

NA

Conclusion

Unexpected BAP can confound immunohematology testing and lead WAAbs mimicking alloanti-Jk3 to be mischaracterized as allogeneic. By predicting phenotypes, genetic analysis can aid serological techniques in antibody characterization and help circumvent complications searching for rare JK:-3 donors.
Allo-Anti-D vs. Auto-Anti-D in Females of Child Bearing Years: The Critical Role of Rh Genotyping
Authors: Keith J T , Hastings H
Published: October 2021

Introduction/Objective

In females of child-bearing years, establishing accurate D-antigen identification is critical; this can be further complicated when a D+ patient seemingly develops an allo-anti-D. We present a unique case series highlighting the critical role of genotyping in distinguishing allo-anti-D vs. auto-anti-D.

Methods/Case Report

Case 1: An African American, 21-year-old, nulliparous female with a history of sickle cell disease presented for transfusion. The patient’s blood type was O, Rh Positive on multiple testing platforms (ORTHO VISION® Analyzer, 1001 US Highway 202, Raritan, NJ 08869, and Immucor, Inc., 3130 Gateway Drive, Norcross, GA 30071). On type and screen performed by manual tube testing, anti-D was identified. DAT IgG was weakly positive. The patient’s phenotype had been performed previously, and she was negative for both the C and E antigens. Genotyping results: RhD homozygote. RHD*DAU0 and RHD*DIVa type 3.

The patient was determined to have auto-anti-D formation.

Case 2

A 42-year-old female presented for routine prenatal care. At a previous facility, the patient tested as D+ and typed as O, Rh Positive (ORTHO VISION® Analyzer). An anti-D pattern was identified. Due to the patient’s Rh+ history and early pregnancy status, no Rh immune globulin was administered. A sample was sent to the reference laboratory which confirmed D+ status and a pattern of anti-D. The current titer was 8.

Genotyping results

RhD hemizyote. Positive for hybrid Rhesus box associated with deletion of RhD and RHD*DIVa, Go(a+).

The patient was determined to have an allo-anti-D.

Results (if a Case Study enter NA)

NA

Conclusion

These two cases highlight the importance of RhD genotyping for resolutions of anti-D. In case 1, the patient had two altered alleles. While DIVa, type 3, is associated with anti-D formation, she also expressed RhD*DAU0 which is not considered to lack D proteins. We report the rare association between DAU0 expression and auto-anti-D formation.
Within-Visit Blood Pressure Variability in an Unselected Adult Population
Authors: Chen Xin , Xu Shao-kun , Li Yan , Hu Zhe , Wang Hong-yu , Yu Wei , Wang Sheng-huang , Chen Xiao-ping , Chu Shao-li , Wang Ji-guang
Published: October 2021

Background

To investigate blood pressure variability among 3 successive blood pressure measurements in an unselected nationwide population in China.

Methods

A total of 77,549 participants were included from measurements in May 2017 in China. Blood pressure was measured 3 times consecutively with a half minute interval. Blood pressure variability was estimated with the standard deviation and coefficient of variation of the systolic and diastolic blood pressure.

Results

Not all participants showed a decreasing trend with increasing number of measurements. In fact, 14% of the participants showed at least 5 mm Hg increase in systolic blood pressure. The coefficient of variation of systolic and diastolic blood pressure in women was higher than in men [(4.2 ± 3.3)% vs. (4.1 ± 3.3)%, (4.7 ± 4.0)% vs. (4.6 ± 4.1)%; P < 0.05]. The differences were significant (P < 0.01) among different groups of age and blood pressure levels. Multiple linear regression analysis showed that the systolic blood pressure variability indexes were inversely associated with age but positively associated with the level of the first systolic blood pressure reading (P < 0.01). The systolic blood pressure standard deviation and coefficient of variation in females were higher than in males (P < 0.01).

Conclusions

Not all subjects demonstrate a decreasing trend with increasing number of blood pressure measurements. Within-visit blood pressure variability varies with age, gender, and blood pressure.
Conditions, Fictions and the Basic Norm
Authors: Albrecht Kristin Y
Published: November 2021

This paper reflects on Christoph Kletzer’s absolute positivism and puts a focus on a view of the basic norm that grounds the validity of law in the law itself. I will try to explain the significance of this idea against the backdrop of Hans Kelsen’s transformation of the basic norm from a “hypothesis” to a “fiction.” I shall argue that the goal of an ultimate foundation of the objective validity of a legal order can only be accomplished by a fictional basic norm. In my eyes, contrary to what Kelsen claimed in his later work, such a norm cannot amount to a genuine epistemological fiction (echte Fiktion) in the sense of Hans Vaihinger’s “The Philosophy of ‘As If,’” but has to be regarded, rather, as a practical legal fiction.
EP.WE.48Emergency appendicectomy during COVID-19 pandemic – A single UK centre experience
Authors: Aladeojebi Adebimpe , Lo Ning , GD Sam , Salgaonkar Hrishikesh , Tsiamis Achilleas , Cheruvu Chandra
Published: October 2021

Background

In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic.

Methods

Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed.

Results

Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (<30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort.

Conclusion

In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies.
EP.WE.120Improving consenting for Emergency General Surgery during the COVID-19 pandemic
Authors: Elzaafarany Ahmed , Oyewole Bankole , Tawfik Ahmed , Ma Jennifer , Sandhya Anu
Published: October 2021

Aims

Patients undergoing surgery during the Covid pandemic are exposed to increased risks of pulmonary complications and mortality. These novel risks need to be documented on the consent form. We carried out various interventions to ensure appropriate consenting and documentation following an initial audit that revealed poor compliance with published guidelines.

Methods

The initial audit reviewed consent forms of patients undergoing emergency surgery over two-weeks in May 2020 while the re-audit was over a two-week period in June 2020 following implementation of interventions.

Inclusion Criteria: Age >18-years, urgent or emergency laparoscopic surgery

Exclusion criteria: Age <18-years, Open surgery, ‘Covid-light’ areas, NELA.

Results

57 consent forms were assessed during the audit loop; 22 laparoscopic appendicectomies and diagnostic laparoscopies, 14 incision and drainage, 8 laparoscopic cholecystectomies, 4 hernia repairs, and 9 other procedures.

Consenting for covid pneumonia increased from 70% to 89%, potential ITU admission 56% from 25% and the risk of death 63% from 21%

Conclusions

The covid pandemic changed our surgical practice. There are many unknowns regarding the risks to surgical patients, however, evidence shows increased risks of covid pneumonia, ITU admission and death in the perioperative period. Our consenting and the documentation of such conversations with patients must reflect our new reality.
EP.WE.135Analysis of National Bariatric Surgery Related Clinical Incidents
Authors: Omar Islam , Madhok Brijesh , Parmar Chetan , Khan Omar , Wilson Michael , Mahawar Kamal
Published: October 2021

Background

Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in the United Kingdom (UK) every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents.

Methods

We analysed bariatric surgery-related clinical incidents reported to the UK NRLS database between 01 April 2005 and 31st October 2020.

Results

We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative incidents represented 30.31% (N = 164), intraoperative 38.09% (N = 206), and postoperative accounted for 31.61% (N = 171). In terms of severity of incidents, (150;27.7%) were of high severity, whereas medium and low severity incidents were (244;45.1%) and (147;27.2%) respectively. The most common high severity theme was failure of thromboprophylaxis (50;9.2%). Intraoperative high severity incidents included 17 incidents of stapling of orogastric/nasogastric tubes or temperature probes, 8 missed needles, 8 broken graspers, and 6 incidents of band parts left behind. Postoperatively, the most common high severity theme was improper management of diabetes mellitus (DM) (35;6.5%). Medications errors represented a significant proportion of the medium severity incidents and included (26;4.8%) incidents of improper or missed prescription of routine medications and anticoagulants preoperatively and (45;8.3%) wrong prescriptions, dosage or prescribing of contraindicated medications postoperatively. Among the low severity themes identified there were (23;4.3%) incidents of postoperative diet problems, and (19;3.5%) patients listed for wrong procedures.

Conclusion

We identified 58 specific themes of bariatric surgery-related clinical incidents. Awareness of these themes should help to improve the safety of bariatric surgery worldwide.
EP.WE.173A Ticking Time Bomb – incidental finding of a giant thoracoabdominal aneurysm
Authors: Kam Cheuk Tung , Rait Jaideep
Published: October 2021

Background

Giant aortic aneurysm is a rare clinical entity. They may present with typical features of chest pain, or most feared complications with dissection and rupture. However, an asymptomatic and unruptured giant thoracic aneurysm is extremely rare with only two case reports in the literature.

Case presentation

An 80-year-old lady admitted to a local district general hospital with a 5-day history of productive cough with shivers. She tested positive for COVID-19 on admission.

Diagnostic workup demonstrated an incidental finding of a giant TAAA. Her case was referred to a tertiary hospital for vascular Multidisciplinary Team (MDT) discussion and planning.

It was decided that for her to have pre-operative assessment and MDT discussion after her recovery from infection to have definitive management of the TAAA. The patient is currently being managed supportively in hospital.

Discussion

According to National Institute for Health and Care Excellence (NICE), asymptomatic and 5.5 cm or larger aneurysm should be considered for repair. The case should be discussed in terms of the overall balance of benefits and risks with repair and conservative management, based on the current status of health and the expected future health. In this case, it was deemed that the risk of proceeding with repair at present outweighed the benefits.

Conclusion

This case describes a rare incidental finding of a giant TAAA. It emphasises the importance of MDT approach to direct and achieve appropriate management for a complex TAAA. Care treatment prioritisation, surgical planning and full complement expertise are required in complex cases such as this.
EP.WE.202Atypical presentation of Acute Aortic Dissection Standford type A dissection
Authors: Lim Su Kwan , Ekpete Neville
Published: October 2021

Introduction

Acute aortic dissection type A (AADA), a tear in the intima lining of the aorta, is a surgical emergency and contributes to high mortality rate if not managed promptly with surgical intervention.

Case presentation

We describe a case of a 63-year-old female with a history of hypertension presented with presumed seizure and hypotension to the emergency department. She did not have Computed Tomography (CT) chest despite having hemopericardium on her CT abdomen and pelvis. Her condition deteriorated to pericardial effusion, cardiac tamponade, multi-organ failure and shock. A diagnosis of AADA was only found on the stage of post-mortem.

Conclusion

AADA may not present with classical symptoms of tearing chest pain. The combination of hypotension and neurological deficit should trigger hospital team to consider aortic dissection higher up in the differential diagnosis for shock. If there is unclear diagnosis for an acutely unwell patient, hospital team should review the case and radiological imaging again. Hemopericardium on CT abdomen, pelvis should trigger hospital team to request for a CT chest to look out for the cause of hemopericardium. AADA is fatal without prompt surgical intervention. Immediate diagnosis can significantly reduce the mortality rate.
EP.WE.205Impact of the Covid-19 Pandemic on Loop Ileostomy Formation
Authors: Farrow E Z , Cook T A
Published: October 2021

Aim

Uncertainty during the early phases of the Covid-19 pandemic regarding availability of critical care beds and peri-operative impact of SARS-CoV-2 led to changing intercollegiate guidance in favour of increased stoma formation. This study assessed the impact the Covid-19 pandemic had on loop ileostomy formation.

Methods

Data were reviewed from a prospectively collected database on the number of loop ileostomies formed over a 10-month period from 1st March to 31st December 2020. Comparison was made with the same period in 2019. Details were confirmed using clinical letters.

Results

114 loop ileostomies were formed in the 20-month period. There was a 10.0% reduction in loop ileostomy formation in 2020 compared with 2019. The median number of loop ileostomies formed per month over the two 10-month periods was 6. This peaked at 11 in April 2020 coinciding with the first wave of Covid-19, falling in subsequent months. All 11 of these loop ileostomies were formed in colorectal cancer patients undergoing anterior resection, after appropriate counselling.

Conclusions

There was a reduction in the number of ileostomies formed in 2020 compared with 2019 reflecting the impact of the Covid-19 pandemic on both elective and emergency case load and presentations. These results show reactive change in surgical practice corresponding to guidance at a time of maximum uncertainty. Primary anastomosis still occurred but with an increased likelihood of a defunctioning stoma to minimise the consequences of an anastomotic leak. A subsequent reduction in stoma formation in the following months indicates that practice rapidly returned to normal.
EP.WE.308COVID-19 and the impact on oncological surgery at a district general hospital
Authors: Brown Jasmine , Dick Lachlan , Berlansky Martin
Published: October 2021

Introduction

Covid-19 has had a significant impact on all aspects of healthcare. Efforts to maintain oncological surgery have continued throughout the pandemic despite facing significant challenges. We aimed to characterise our experience of oncological surgery during the first 2-months of the pandemic in Scotland and compare that with the same period in 2019.

Methods

A prospective cohort study was performed from 23/03/20 to 07/05/20. All elective oncological operations at a single district general hospital, predominantly managing breast and colorectal malignancies, were included. Data on patient demographics, waiting time to surgery, inpatient characteristics and oncological outcomes were recorded. Statistical analysis was used to compare these with retrospective data from 2019.

Results

A total of 37 patients were included, 18 in 2019 and 19 in 2020. There were no differences in patient age (63 vs 66.2 years, p = 0.486), length of stay (5.3 vs 4.3 days, p = 0.697) time spent on waiting list (25.4 vs 20.9 days, p = 0.303) or surgical approach (p = 0.300). Oncological outcomes were comparable with no statistical difference in clear resection margin status (88.9 vs 84.2%, p = 0.189) or positive nodal status (5.6 vs 26.3%, p = 0.086). No patient in either cohort had a post-operative complication.

Conclusion

Oncological surgery during Covid-19 can be performed safely and with favourable oncological outcomes. The longer-term effects from delayed diagnoses remain to be evaluated.
EP.WE.339The Role of a “Clean Ward” Model in Minimizing COVID-19 Exposure for Elective General Surgical Patients
Authors: Deeny Dearbhla , Kerr Rebecca , Davidson Sophie , McKay Damian
Published: October 2021

Aims

To assess if a “clean ward” model is effective in preventing peri-operative COVID-19 infection in elective general surgical patients.

Methods

Elective general surgical cases were audited prospectively in three thirty-day cycles - May–July 2020, September–October 2020 and December 2020–January 2021. Patients isolated for 10 days and required a negative COVID swab prior to admission. Nursing and surgical staff underwent weekly swabbing, operations were carried out in a dedicated “clean theatre” and a no-visiting policy was enforced. Inpatient COVID cases and COVID-19 status at 14 days post discharge were recorded and compared to the community COVID-19 Reproduction (R) number.

Results

Cycle 1, (May-Jul 20, R number=0.3-1.5) 44 elective patients. One patient was diagnosed with clinical COVID post-operatively and recovered well.

Cycle 2, (Sept-Oct 20, R number=0.8-1.8) 57 patients identified. No positive COVID-19 cases during inpatient admission or at 14 days post discharge.

Cycle 3, (Dec 20-Jan 21, R number=1.0-1.9) 38 elective patients. One patient tested positive for COVID-19 following transfer to the emergency surgical ward due to COVID-19 related bed pressures. No other positive cases were identified during follow up.

Conclusions

Despite an ongoing rise in community COVID-19 cases, the “clean ward” model appears to be effective in reducing COVID-19 transmission for elective general surgical patients. When the R number was at its highest, the only COVID positive case developed symptoms after moving from the “clean ward” system. Extrapolation of this model could be considered in re-establishing elective operating lists across the region.
EP.WE.381Daycase Parathyroidectomy for Primary Hyperparathyroidism: Our Experience
Authors: Jayawardena P A , Turner P D , Shetty V D
Published: October 2021

Aims

Concerns due to postoperative complications following parathyroid surgery have precluded its consideration as a Daycase procedure. However recent BAETS guidelines have supported Daycase parathyroid surgery. To assess the outcomes of Daycase parathyroidectomy pathway we established in our Hospital since April,2018.

Methods

Retrospective review of all patients who underwent parathyroidectomy for Primary Hyperparathyroidism between April,2018 and October,2020. Patients with ASA 3 and above and patients undergoing total-parathyroidectomies were excluded. Outcome measures include length of stay, prerequisite for overnight stay, complications, and readmission rates. All patients were assessed and counselled for suitability for Daycase in surgical clinic and given detailed information leaflets.

Results

In this period, 40patients underwent surgery for primary hyperparathyroidism. Of these, 30 patients (75%), 8 males and 22 females with a median age of 59years fulfilled the criteria for Daycase surgery. 19 patients (63.3%) were successfully discharged on the day of surgery. 11 patients (36.7%) were discharged the following morning. The reasons for overnight stay are - 5patien ts(16.7%) developed post-anaesthetic nausea and drowsiness; in 5patients(16.7%) surgery started after 2pm and delayed postoperative return to ward lead to inadequate time for safe discharge; 1patient(3.3%) needed hospital transport. The readmission and postoperative complication rates were nil.

Conclusions

Daycase parathyroidectomy is safe in carefully selected patients. Adequate preoperative counselling, robust perioperative management to minimize postop morbidity and clear patient support package upon discharge are vital for wider acceptance. All Daycase patients should be operated first on the list and prior to 2pm to ensure safe discharge allowing adequate time for postoperative recovery.
EP.WE.446Adequacy of Endoscopic Photo-documentation in OGD, a retrospective audit
Authors: Fatima Iayla , Elnabil-Mortada Ahmed
Published: October 2021

Background

The technical competence of oesophagogastroduodenoscopy (OGD) is rapidly acquired but to support the practice of complete examination, the British Society of Gastroenterology (BSG) and Association of Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) strongly recommend photo-documentation of 8 standardized set stations in an OGD. Photo-documentation ensures complete examination, opportunity to inspect area of interest and serves as a legal record of adequate procedure.

Methods

Retrospective single center study involving review of randomly selected 100 OGD reports from 1/1/2018 till 31/3/2020 from the Endorad system. The reports on online Endorad system were reviewed for photo-documentation of 8 set stations and was also used to collect data on age, sex and the endoscopist. Microsoft Excel was used for data entry and analysis.

Results

Out of the 100 OGDs reviewed, 58% were males and 42% females. The mean age being 62.7 +/- 13.5. 60% of OGDs were done by surgeons, 25% by gastroenterologist and 15% by Advanced Nurse Practioner. No report had photo-documentation of all 8 stations. Most (40%) had photos of 5 stations, most common was photo evidence at retroflexion (95%) followed by photographic evidence of intubation to D2 (84%).

Conclusions

OGD is the gold standard test for the investigation of upper gastrointestinal symptoms, the importance lies in the early detection of cancers which maybe amenable to endoscopic treatment. For this reason its important to adhere to guidelines to improve quality in OGD
EP.WE.453Impact of COVID 19 pandemic on colorectal rapid access investigations
Authors: Maye J , Sen R , Sebastian B , Ward N , Athisayaraj T
Published: October 2021

Aim

The impact of the COVID-19 pandemic on delays in diagnosis of cancer has been highlighted at a national level. Such a delay represents an ongoing source of mortality and morbidity missing from the COVID-19 statistics. This study examines the delay in investigation of patients referred to the urgent colorectal cancer referral service at a single centre.

Method

Retrospective data was collated from prospective database for all 1,894 referrals to the urgent colorectal cancer referral service for the period 21 January to 24 December 2020. The time to appointment (TTA) was compared by date of referral and outcome type (endoscopy, CT abdomen pelvis (CT-AP), CT colonography (CT-C), clinic appointment).

Results

Across 2020, fewer than 25% of patients met the NICE recommendation of appointment within 14 days (median TTA 30 days, first quartile 19). TTA increased dramatically in the first months of the pandemic (February median: 19; March: 80.5). TTA remained high, not falling below a median wait of 28 days until November. CT-C tests were particularly delayed (median TTA: 86) due to concerns regarding aerosol generation and COVID-19 transmission. Patients were offered CT-AP tests while awaiting their delayed CT-C, as CT-AP had a significantly better wait of 15 days.

Conclusion

COVID-19 was a major disruptor of colorectal cancer diagnosis in 2020, with patients waiting more than twice as long as NICE recommends. This will likely continue into 2021, with further research required to assess the impact of this disruption on mortality and morbidity.
EP.WE.484Conservative management of post-operative chyle leak after surgery for a large adrenal cavernous haemangioma
Authors: Quake Sharmaine Yen Ling , Chua Yunli , Elsaify Wael
Published: October 2021

Post-operative chyle leak is a rare but recognised complication after abdominal surgeries particularly those involving dissection adjacent to the retroperitoneal lymph nodes and/or lymphatic systems. There are limited cases of post-operative chyle leak associated with adrenal surgery reported in the literature with no consensus on its management. Lymphatics of the adrenal gland drain into the thoracic duct via regional lymph nodes or directly into the cisterna chyli, posterior to the aorta. If not adequately managed, chyle leak can be associated with hypovolemia, electrolyte imbalances, malnutrition and immunosuppression. These consequences can be attributed to the loss of fluid, electrolytes, lipids, proteins, and immunoglobulins. We hereby report a case of post-operative chyle leak in a 79-year-old male who underwent an open left adrenalectomy, left nephrectomy, splenectomy and distal pancreatectomy for a large, 20.8cm left adrenal cavernous haemangioma. Chyle leak was confirmed on post-operative day 7 based on high levels of triglycerides in the abdominal drain output. Intra-operatively there was no evidence of lymphatic damage. However, the major abdominal surgery involving retroperitoneal viscera close to the lymphatic trunk predisposed the patient to this complication. The patient was managed conservatively with the aim of decreasing chyle production by dietary manipulation and use of somatostatin. Enteral nutrition was continued with a strict low-fat diet and regular dietician input. These strategies contributed to the gradual resolution of chyle leak and the patient’s recovery.
EP.WE.485An Audit to Investigate the Incidence of Face-to-Face Patient Review by GPs Prior to Referral to Surgical Assessment Unit
Authors: Murray Hannah
Published: October 2021

Aims

Since COVID-19, GP’s have been encouraged to do fewer face-to-face consultations to prevent unnecessary patient contact1. Anecdotally, this initially resulted in many patients being referred to SAU who had not been seen by a GP, and then being discharged back to the community the same day, causing potentially increased risk of contracting COVID-19 through hospital attendance.

The aim of this audit was to investigate the incidence of patients referred to SAU not seen by a GP and discharged the same day.

Methods

GP referrals were identified over a 7 day period through the surgical take electronic system Aramis©. The case notes and GP documentation were reviewed to identify whether a face-to-face GP consultation occurred, and then whether the patient was admitted to SAU or discharged the same day.

Results

During a 7 day period, there were 24 (n = 24) GP referrals of which only 3 (12.5%) were not seen by the GP, all of whom were admitted for at least one night. However, of the patients referred and seen by GP, 7 (29%) were discharged the same day.

Conclusions

This demonstrates that during this 7-day period, there was no incidence of inappropriate GP referral to SAU of patients not seen by a GP, and the majority of GP referrals warranted admission. This suggests that in most cases, GPs are avoiding unnecessary emergency surgical referrals and attempt to review patients face-to-face prior to referral, thus reducing patient risk of contact with COVID-19 in the hospital setting.
EP.WE.490Influence of age on post-operative outcomes from adrenalectomy for phaeochromocytoma
Authors: Mir S A , Lansdown M J , Collins Emma , Fraser Sheila
Published: October 2021

Methods

A retrospective search of institutional databases for histologically and biochemically confirmed cases of phaeochromocytoma, at a single tertiary care institution, from 2012 to 2020.

Clinical parameters, adrenal function, intra and postoperative data were obtained. Patients > 60 years were classified as elderly and outcome data within 30 days of operation compared to < 60 years.

Results

Patients > 60 years constituted 31% (n = 17) of the cohort, mean age 70 ± 6 versus 43 ± 13 years for < 60 years (n = 38).

There was no difference in tumour size, 4 ± 2.5 cm and 4.6 ± 2.6, p = 0.3. Frequency of laparoscopic resection was similar at 65% in both groups.

Intra-operatively 5% of < 60 years required blood transfusion compared to none in > 60 years group with 12% in older group undergoing en-bloc resection and nephrectomy and 6% experiencing cardiac dysrhythmias.

Postoperatively all patients were managed in level two care except 7% of < 60 years requiring level 3 care reflecting extent and complexity of resection. There was no difference in requirement and duration of vasoactive medication or length of stay in level 2, 1.6 ±1.2, 1.6 ±1.0 days.

Proportion of patients graded ASA 3 in > 60 years was 53% compared with 41% in < 60 years.

Postoperative complications in > 60 were 29% vs 13%, p = 0.003, with HAP being commonest. Length of hospital stay was also significantly longer at 5.8 ± 2.4 versus 4.5 ± 2.2, p = 0.02. There was no mortality.

Conclusions

Age of the patient alone does not influence post-operative outcomes from adrenalectomy in phaeochromocytoma.
EP.WE.555Impact of COVID 19 on Renal access surgery
Authors: Abdelwahed Abdallah , Gambhir Raghvinder , Mistry Hiren , de'figededu Fatima , Valenti Domenico , Rankin Alex
Published: October 2021

Aims

To assess the impact of COVID -19 on renal access surgery.

Methods

Electronic patient records and renal ware were accessed to obtain data of all renal access activity during the COVID period.

Results

There as a shutdown of all elective activity which affected the renal access surgery as well. No new Arterio venous fistulas (AVFs) were created in the time period 14 March to 05th May 2020. No pre-fistula mapping scans were performed. All new starters started with a tunneled dialysis line. In the recovery phase special theatre sessions were asked for and procedures carried out in Day surgery and in independent sector (n-18). A total of 203 new AVF’s were created compared to 272 the year before a fall of 25%. There were 48 patients admitted with blocked access, 70% of whom underwent radiological intervention compared to 52% in 2019. Surgical intervention was offered to just 4% compared to 25% in 2019. The number of access abandoned was 27% in 2020 vs 19% in 2019.

Conclusion

COVID-19 adversely affected the renal access population and none of the British Renal access surgery targets were met for 2020.
EP.WE.568Compliance with the Royal College of Surgeons of England Guidelines on the Surgical Consenting Process in the Era of the COVID-19 Pandemic
Authors: Ayantunde Boluwatife , Clyde Danielle , Ekatah Gregory
Published: October 2021

Aims

Due to the current COVID-19 pandemic, The Royal College of Surgeons of England released guidelines advising on additional considerations which should be discussed with patients as part of the informed consent process prior to surgery.

We conducted a prospective audit on whether COVID-19 infection was mentioned as a possible complication during the consenting process for patients undergoing emergency and elective general surgical procedures at a District General Hospital.

Methodology

We prospectively collected data on the patients admitted for surgical procedures over a 2-week period. Consent forms were reviewed noting whether COVID-19 infection was listed as a possible complication.

Results

35 patients were audited with a median age of 54 (12-94) years including 17 males and 18 females. Patients presented with varying surgical diagnoses, with 16 and 19 undergoing emergency and elective operations, respectively. 77.1% (27) of patients had COVID-19 infection mentioned as a possible complication on their consent forms. Five out of six consent forms completed by Clinical Fellows or CT trainees, 10 out of 13 by Registrars, 12 out of 16 by Consultants mentioned COVID-19 infection. We found no significant correlation between the grade of the consent taker and COVID-19 infection being mentioned as a possible complication.

Conclusion

Most of the consent takers were aware of the guidelines and mentioned COVID-19 infection as a possible complication during consenting. However, this awareness could be expanded. The results will be presented to the department before a plan to re-audit and close the loop in a few weeks.
EP.WE.726A snapshot audit of cholecystectomy for gallstone pancreatitis during the first wave of COVID-19
Authors: David Bryony , Aiynattu Sony , Jones Katie , Gallucci Antonio
Published: October 2021

Aims

COVID-19 has caused difficulties in providing efficient surgical care. We aimed to audit cholecystectomy provision for gallstone pancreatitis from January 2019 to June 2020. We audited time from admission with gallstone pancreatitis to cholecystectomy in pre-COVID and COVID cohorts in order to assess the effect of the first wave of the pandemic on service provision.

Methods

Patients with confirmed gallstone pancreatitis plus their age and gender were included using information software Cerner. We analysed length of stay, time to surgery and number of patients planned for surgery. We also looked at readmissions whilst awaiting surgery. Patients with previous cholecystectomies or deemed not fit for surgery were excluded.

Results

68 patients were included; 42 admitted from Jan 2019 to Feb 2020 (non-COVID group) and 26 from March 2020 to June 2020 (COVID 19 group). Average length of stay was 11.8 days for non-COVID group and 8.8 days for COVID group. Average time to surgery for non-COVID group was 47.4 days. 25 patients underwent surgery. Average time to surgery was 56.7 days and 9 patients received surgery, in the COVID group. In this group, 3 patients had index admission surgery compared to 15 in the non-COVID group.

Conclusions

Albeit small, our data set shows a longer wait to surgery in the COVID group with fewer operations performed at index admission, compared to the non-COVID group. Future surgical services will require careful planning to ensure that urgent cholecystectomies continue to be performed in acute gallstone pancreatitis.
EP.WE.739Antibiotics Prescriptions in Elective Laparoscopic Cholecystectomy
Authors: Abouelazayem Mohamed , Coles Sophie , Tsironis Dimitrios
Published: October 2021

Aim

To assess our compliance to the trust and national guidelines for antibiotic usage and prescription in elective laparoscopic cholecystectomy and to assess whether prophylactic antibiotics are prescribed appropriately and identify areas of improvement.

Method

Medical records for patients who underwent laparoscopic cholecystectomy over 3 months were collected (May – July 2019). Urgent laparoscopic cholecystectomies were excluded, and medical records were reviewed retrospectively for operative note details, patient risk factors, antibiotic prescribed, concomitant procedure, and complications.

Results

Appropriate antibiotic prescription represented 50% (Patient had at least one risk factor and prescribed antibiotic or no risk factors and wasn't prescribed antibiotics) and inappropriate prescription 50% (Patient had no risk factors and prescribed antibiotic or had risk factors and wasn't prescribed antibiotics). In the group with risk factors and wasn't prescribed antibiotics, Age was a risk factor in 17 patients, BMI in 25, Bile spillage in 10, and Diabetes in 3.

Conclusion

We are not compliant with the current guidelines for antibiotic prophylaxis in elective laparoscopic cholecystectomy, some patient with no risk factors received antibiotics while other with risk factors did not. We plan to disseminate this information in the governance meeting and print guidelines posters in theatres and then re-audit in 3 months’ time to assess progress.
EP.WE.832A silver lining in the dark COVID cloud: Total neoadjuvant chemotherapy results in complete pathological response in locally advanced distal gastric adenocarcinoma
Authors: Clements Hollie Alice , Patil Pradeep , Ramkumar Prasad Guntur , Walsh Shaun , Petty Russell
Published: October 2021

Aims

Perioperative oncological therapies resulting in complete pathological response in diffuse type distal gastric adenocarcinoma are extremely rare. We report the first case of complete pathological regression in a patient with locally advanced diffuse type distal gastric adenocarcinoma (CT3N2M0) who received “total neoadjuvant” chemotherapy with FLOT due to the COVID pandemic.

Methods & Results

A 73-year-old male patient was diagnosed with cT3N2M0 diffuse type distal gastric adenocarcinoma. He received 4 cycles of neoadjuvant FLOT as planned with immune checkpoint inhibitor Durvlumab and interval PET-CT showed massive reduction in 18F-FDG avidity. However, his surgery was postponed due to the COVID-19 pandemic and given his excellent response to chemotherapy his 4 adjuvant cycles of FLOT were advanced into the preoperative setting. Subsequent PET-CT showed close to zero 18F-FDG uptake and he proceeded to laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy. Histopathology of the resected specimen demonstrated no evidence of residual malignancy, a complete pathological response (TRG1a, ypT0N0 R0).

Conclusions

Amidst the dark cloud of COVID-19 there was a silver lining for one patient, who due to delayed surgery received total neoadjuvant FLOT (8 cycles). This should generate randomised controlled trials comparing the current standard of care with total neoadjuvant regimens and investigating the utilisation of interval investigations such as CT-PET in monitoring response to preoperative therapy, guiding optimal timing of surgical resection.