bluuebunny/crossref_metadata_2025 huggingface dataset:
591 Abdominal Apoplexy – a Case of Spontaneous Haemoperitoneum from Pancreaticoduodenal Artery Bleed
Authors: Rizvi K , Beatson K , Lordan J , Moosvi R
Published: November 2022

Background

Inferior pancreaticoduodenal artery (IPDA) haemorrhages are extremely rare and often occur secondary to IPDA aneurysms. They can result in a spontaneous life-threatening bleed which requires urgent treatment via transcatheter arterial embolisation (TAE).

Case Summary

We report the case of an IPDA haemorrhage in a 52-year-old male who presented with a one-day history of severe worsening generalised abdominal pain. Although his initial blood pressure, heart rate and haemoglobin were within the normal range, he had a persistent metabolic acidosis with raised lactate. This prompted an urgent out-of-hours Computed Tomography (CT) scan. On return to the ward, he had a syncopal episode and was found to be in shock. An urgent venous blood gas revealed a substantial haemoglobin drop (133g/L to 88g/L) and review of his imaging identified intra-abdominal haemorrhage, confirmed by radiology to be an IPDA haemorrhage. The patient was managed according to the trust's major haemorrhage protocol and blue light transfer to a tertiary centre for embolisation by interventional radiology was arranged. He was transferred with ongoing resuscitation, and successfully underwent TAE of the IPDA. No aneurysm or other pathology was noted on angiography.

Conclusion

IPDA haemorrhages are uncommon. Physiological compensation may normalise initial observations and initial haemoglobin level may also be falsely reassuring. Therefore, it is important to monitor physiological indicators, such as pH and lactate, as real-time severity indicators to identify emergency pathology early.
630 Hailey-Hailey Disease: A Rare Presentation in the Hypopharnyx
Authors: Tan CH , Wright B , Black M , Devlin B
Published: November 2022

Background

Hailey-Hailey disease or familial benign pemphigus is a rare genetic blistering skin disease due to mutation of the ATP2C1 gene inherited in autosomal dominant fashion. Prevalence is around 1 in 50,000 and positive family history is observed in 75% of cases. Patients typically present with well-demarcated painful erosive and yellow-crusted rash in the skin folds, following a relapsing-remitting pattern. There are very limited known cases of extra-dermatological presentation of this disease.

Case

64-year-old gentleman presented with dysphagia, hoarseness, sore throat, dry cough, and intermittent haemoptysis. Initial flexible nasendoscopy showed mild erythema of epiglottis and false cords, post-cricoid oedema and very mild Reinke's oedema. He was treated as acid reflux with omeprazole but to little effect. Endoscopy 4 months later showed similar findings hence biopsy of the hypopharynx was taken. The sample demonstrated intraepithelial clefting, suspicious of intraepithelial vesiculobullous disorder particularly pemphigus vulgaris.

Looking into this gentleman's medical history, it was found that he is under the care of dermatology for Hailey-Hailey disease, which he was diagnosed 30 years ago. He also has a strong family history of this condition. Based on the biopsy findings and patient profile, it was concluded that this gentleman has a hypopharyngeal manifestation of Hailey-Hailey disease.

Discussion

Hailey-Hailey disease is traditionally described as a dermatological condition. This gentleman is one of the rare few cases of non-dermatological manifestation of this disease.
809 An Unusual Presentation of Left Sided Orbital Pathology- Intraconal Abscess
Authors: Mehtani N , Acharya V , Rennie C
Published: November 2022

Introduction

Orbital cellulitis is a severe, life-threatening infection of the orbit and its contents posterior to the septum.

Case Report

A 41-year-old admitted to hospital under ENT with complete proptosis on left eye and raising intra ocular pressure (IOP) - 26mmHg. He initially presented to Ophthalmology with worsening left eyelid swelling, pain, reduced visual acuity (VA) from 6/18 to 6/12 for the past 4 weeks. This was associated with restricted EOM, proptosis of left eye but intact colour vision and left sided headaches refractory to topical management. His ENT exam including a flexible nasoendoscopy was normal.

The CT Sinuses showed poorly enhancing retro orbital poorly enhancing mass. The differential diagnosis is wide and further assessment with MRI and tissue biopsy highly advised. He subsequently underwent MRI Head and Orbit with contrast: Appearances are suggestive of left periorbital cellulitis with an intraconal abscess.

He was started on intravenous (IV) antibiotics. His IOP had now increase to 35mmHg for which he underwent emergency lateral canthotomy and cantholysis (LCC) in clinic. This successfully reduced the IOP to 21mmHg and he subsequently had formal drainage of the abscess.

He made significant recovery and was discharged home a week after the operation. He went on to have repeat MRI- which showed almost complete resolution of the disease process. He was reviewed 4weeks postoperatively, his VA returned to 6/7.5 unaided 4 weeks but continued to have proptosis in that eye for which he is being followed up.
988 A Case of Cocaine Associated Pneumomediastinum: An Unusual Diagnosis
Authors: Jaly Y , Al-Masri K , Elamin A
Published: November 2022

Cocaine inhalation is an extremely rare but previously described association of spontaneous pneumomediastinum. We describe an unusual case of a previously well 20-year-old female who presented with a five-day history of central, pleuritic chest pain beginning one week after last cocaine inhalation. Blood tests were within the normal limits except for a positive d-dimer. Clinical examination was unremarkable, and a chest X-ray appeared grossly normal. A CT pulmonary angiogram revealed an extensive pneumomediastinum extending into the soft tissues of the neck and down to the peri-oesophageal region at the hiatus, without evidence of pneumothorax. The lungs and oesophagus appeared intact. The patient was admitted for observation and discharged within 48 hours. There is limited literature on this phenomenon, but almost all previous case reports suggest a benign, self-limiting course and resolution of radiological findings within 30 days. Invasive procedures are only considered if there is suspicion of oesophageal rupture or bronchial tree laceration. Spontaneous pneumomediastinum associated with cocaine inhalation is a relatively benign but uncommon condition with a predictable clinical course.
30 An Update on the Impact of Appendicectomy and Deprivation on Disease Course in Ulcerative Colitis
Authors: Sayers A , Brownson E , Nicholson G , Seenan JP
Published: November 2022

Aim

The impact of appendicectomy on the natural history of ulcerative colitis (UC) is unclear. We aimed to assess our cohort of patients with UC to examine the incidence of appendicectomy and association with disease severity. We also examined association of social deprivation with disease severity.

Method

Patients with UC in the health board region were identified by the Gastroenterology consultants. These were divided into moderate-severe (defined as current biologic therapy) and mild-moderate disease (no or 5-ASA therapy only). Two cohorts were sex-matched on a 1:1 basis.

Demographic data was identified by review of the patients’ Electronic Patient Record (EPR) and the Scottish Index of Multiple Deprivation 2020. The EPR was reviewed for evidence of previous appendicectomy.

Results

A total of 664 patients were identified: 328 mild-moderate and 336 moderate-severe. 145 patients (44%) in the mild-moderate group and 145 patients (43%) in the moderate-severe group were female. The majority of patients had left-sided disease. There were no significant differences in smoking status. Rates of appendicectomy in the moderate to severe group were double that of the mild to moderate group (8 v 4; p= .25). Mild-moderate disease was associated with increased social deprivation (X2 (2, N = 664) = 10.60, p = .03) (Fig. 3).

Conclusions

There were double the number of appendicectomies in the mild-moderate cohort, however the relationship between severity and previous appendicectomy was not significant. Disease severity appears to be negatively associated with social deprivation. Further collaborative work across Scotland is planned.
423 Endoscopic Balloon Dilatation for Paediatric Subglottic Stenosis: Systematic Review and Meta-Analysis
Authors: Ravikumar N
Published: November 2022

Aim

Subglottic stenosis (SGS) is a rare life-threatening condition that involves a narrowing of the airway. It may be congenital or acquired affecting children predominantly. Traditionally, it has been treated by surgical interventions, but in recent times a shift towards minimally invasive Endoscopic Balloon Dilatation (EBD) has been observed. This review aims to identify whether EBD is a safe approach in the treatment of SGS in the paediatric population.

Method

A systematic review was performed on EBD for paediatric SGS in compliance with the PRISMA guidelines. Studies published from 2000 onwards, with sample size greater than 5 and described EBD without adjuvant procedures were included. A meta-analysis of proportions was performed using the R software.

Results

25 studies were included, with a total of 1109 patients, of which 920 underwent EBD. The mean sample size of the studies is 43.48 (range 5–166), and the grand mean age is 3.77 years (range 0.7–17 years). Primary outcome assessed was technical success. A high overall technical success rate (successful decannulation and avoidance of tracheostomy/laryngotracheal reconstruction) was observed (83.95%, 95% CI [75.08% - 89.58%]). Similarly, low levels of mortality (3.29%, 95% CI [1.14% - 9.14%]), and high rates of symptom improvement (73.65%, 95% CI [57.81% - 85.09%]) were also observed.

Conclusion

EBD is a successful procedure in majority patients, with low levels of adverse events and marked symptom improvement. It is therefore a safe alternative to current procedures in the management of paediatric SGS.
672 Endoscopic Laser Pharyngeal Pouch Surgery: Is It Safe?
Authors: Dhar P , Maweni R , Kucheria A , Nair D , Nagala S , Corbridge R
Published: November 2022

Aim

Zenker diverticulum can cause significant dysphagia and surgery is the definitive management. NICE guidelines describe inadequate evidence on laser cricopharyngeal myotomy (CPM). This study aimed to assess the safety and efficacy of carbon dioxide laser and stapling CPM to treat Zenker diverticulum.

Method

Retrospective data was collected from patients who underwent endoscopic CPM at the Royal Berkshire Hospital between 2011 and 2021. Two cohorts were assigned: endoscopic laser (EL) or endoscopic stapling (ES). Primary outcomes evaluated safety. These were surgical complication rates, duration of inpatient stay, readmissions, barium swallow leak and considered case complexity (revision cases). The secondary outcomes, persistence or recurrence of symptoms evaluated efficacy.

Results

One-hundred and eight patients (mean [range] age 75 [38 – 95] yr, 71 (66%) men, 23 (21%) revision surgeries) underwent CPM. The EL (n = 76) cohort had two (2.63%) surgical complications (mucosal tear requiring no repair, mediastinitis from an oesophageal leak). The ES (n = 32) cohort had one (3.13%) surgical complication (mucosal tear requiring suture repair). The average duration of inpatient stay was 3.61 and 1.53 days for the EL and ES cohorts respectively. 65 patients (60%) underwent a post-operative barium swallow of which 2 (0.03%) patients, both from the EL cohort, had a leak. There were no readmissions. A chi-square test of independence showed no significant association between type of surgery and persistence [X2 (1) = 0.169, p = .681] or recurrence of symptoms [X2 (1) = 0.443, p = .506]

Conclusions

Treatment of pharyngeal pouches with endoscopic laser CPM is safe and efficacious.
1012 A Close Loop Audit of Acute Food Bolus Obstruction at a District General Hospital
Authors: Thakkar R , Lowe E , Dennis S , Islam M
Published: November 2022

Aim

The British Society of Gastroenterology (BSG) recommends biopsies from two different regions in the oesophagus. A close loop audit was undertaken to assess performance at a district general hospital, against these guidelines and following newly agreed trust guidelines after the first audit cycle of a follow up OGD within 6 weeks of the presentation.

Method

Data was collected of patients admitted with a food bolus over the first cycle (March2019 to February 2021) and the second cycle (1/10/21 to 14/10/21). Exclusion criteria were age of less than 18 and sharp food bolus.

Results

69 patients were identified. Average age was 60 years. There were 67% male patients and 33% female. 20% of patients underwent a follow up OGD in the first cycle and 45%underwent a follow up OGD within six weeks. 7% had two regions biopsy in the first cycle and21% in the second cycle. Average OGD follow up time was 92 days in the first cycle and 59days in the second cycle. Commonest findings on histology results were eosinophilic oesophagitis and Barrett's oesophagus (22% each), GORD (15%) and carcinoma (7%).

Discussion

Food bolus obstruction indicates the presence of pathology of the oesophagus and should be investigated as so, even despite spontaneous recovery from the acute event. Number of patients undergoing OGD within six weeks and a two regions biopsy improved through this audit by implementing the new trust guidelines.
58 The Unfolding Situation of Caecal Volvulus: A Review of 36 Cases
Authors: Mahendran V , Jaradat I , Reddy B
Published: November 2022

Aim

Caecal Volvulus is a rare cause of bowel obstruction. However, there has been a steady rise in the number of cases over the decades. The demographic profile of patients developing Caecal Volvulus has changed to a much older population. We conducted a retrospective review to find the incidence, demographic profile, management, and outcomes of Caecal Volvulus patients in our institution during the last nine years.

Method

A total of 38 patients were diagnosed with Caecal Volvulus at Worcestershire Acute Hospitals NHS Trust between 01.01.2011 to 31.03.2020.

Results

Most of our patients were females (78%) with a median age was 76 years. The majority (86%) had at least one medical comorbidity, and 36% had a previous abdominal operation. Abdominal pain was the main complaint in 94% of patients. All patients had a CT scan to confirm their diagnosis. Most of our patients (84%) underwent surgery. Open right hemicolectomy was the most commonly performed operation (87%). Out of the six patients who did not undergo surgery, three responded to bowel rest and nasogastric tube decompression; one patient underwent successful colonoscopic decompression. In contrast, two patients, unfortunately, passed away. The median length of hospital stay was 9 days, with a 30-day mortality of 3%.

Conclusion

Caecal Volvulus remains a rare cause of bowel obstruction. Most of our patients were old, frail and had medical comorbidities. More than a third of them had undergone previous abdominal surgery. Early CT scan followed by surgery was associated with low mortality.
341 Is CT Imaging Mandated for Confirming the Diagnosis of Acute Appendicitis in Patients Over the Age of 40?
Authors: Shepherd T , Farah M , Aljarad F , Bista G , El-Gaddal A , Ng P
Published: November 2022

Aim

Acute appendicitis remains a largely clinical diagnosis, with clinical scoring systems such as the Alvarado score calculated to give a quantitative assessment of the diagnostic probability. It remains common practice amongst surgeons to rely on CT scanning to confirm the diagnosis however, especially in older patients. Our aim was to assess the diagnostic performance of CT scanning compared with that of the Alvarado score in patients aged over 40 years old.

Method

We conducted a retrospective observational study of 149 patients greater than 40 years old who had a diagnosis of acute appendicitis and had undergone an appendicectomy with subsequent histological analysis. Data was extracted from patients’ electronic medical records. This was recorded in Microsoft Excel and analysed using NCSS.

Results

When using an Alvarado score cut-off point of ≥7, the sensitivity and specificity were 44.1% and 60.0% respectively. The sensitivity of the test improved to 80.3% when using a cut-off point of ≥ 5, however the specificity decreased to 50%. The accuracy improved to 78.1% from 45.3%, when using ≥ 5 as a cut-off point. On the other hand, the sensitivity of the CT scan was 84.9% and the specificity was 45.5%. The accuracy of CT scanning was 81.8%.

Conclusions

When comparing performance, pre-operative CT scanning did not show a statistically significant improvement in the diagnosis of acute appendicitis relative to Alvarado score. We recommend using an Alvarado score cut-off point of ≥ 5 to aid in diagnosing appendicitis in patients older than 40, as it accounts for a higher sensitivity.
574 The Successful Resurrection of NELA in a District General Hospital
Authors: Gohil B , Sarodaya V , White A , Garg A
Published: November 2022

Aim

The NELA requirements of data collection is known to be mandatory. Our DGH had three years of noncompliance. We present an executed plan in the collection of retrospective and prospective process to achieve national standard.

Method

A new structural setup with anaesthetic and surgical teams was formalised. A recruitment of 13 foundation doctors was made and each were induced to NELA with a teaching session. Allocation of 15–20 hospital numbers with a primary deadline of seven days to achieve full entry was expected. A formal NELA certificate and recognition for taking part from the divisional director was issued. A prospective strategy was initiated with patient ownership from the joint anaesthetic and surgical team involved. A NELA login with local access was setup, plus paper format readily available for rare access situations. A two-email reminder system with further escalation process was introduced if entry was incomplete. The escalation being contact from the clinical lead / divisional director. This information was highlighted at a local meeting plus a familiarity of the NELA database was ensured.

Results

A large proportion of the retrospective data has been collected over a short time period due to a clear incentivised scheme. Prospectively there has not been any escalation emails needed since the new setup.

Conclusion

Areas of problems were identified with a wide range of solutions being put forward. A multi collaborative approach was needed plus positive cooperation from the clinical lead, clinical director, and the divisional director to ensure the successful new era.
770 Determining the Diagnostic Value of an Abdominal Ultrasound in Women Presenting with Right Iliac Fossa Pain in an Acute Surgical Unit
Authors: Armstrong L , Sharif A , Thompson R
Published: November 2022

Aim

Right iliac fossa (RIF) pain is a common acute surgical presentation, with appendicitis being the main differential diagnosis. In women of childbearing age, abdominal and pelvic ultrasounds (USS) are often the imaging modality of choice and can be particularly useful when the diagnosis is unclear. We aimed to determine the diagnostic value of USS in patients of childbearing age, presenting with RIF pain.

Method

A single centre retrospective review, of women aged 14 to 45 years old, presenting with RIF pain and undergoing a subsequent USS, over a 6-month period. Investigation results, length of stay, white cell count (WCC) and C-reactive protein on admission, and treatment outcomes were all recorded.

Results

45 consecutive patients were reviewed, with a median age of 28 years (14–45). 37 USS were reported as normal and 8 illustrated gynaecological pathology. None could confirm appendicitis. 24 patients had a normal WCC and a CRP of <5 on admission, none of which had radiological findings requiring surgical intervention. 3 did progress to laparoscopic appendicectomy, 66.6% of which returned with negative pathology. Conservatively managed patients, with a normal USS and normal inflammatory markers, accrued a combined hospital stay of 53 days.

Conclusion

Our results illustrate that in patients with RIF pain and normal inflammatory markers, an USS is unlikely to demonstrate pathology requiring surgical intervention and therefore is of limited positive diagnostic value. However, a negative USS may aid patient reassurance and facilitate earlier discharge in this cohort.
950 Successful Relaunching of NELA at an Inner-City District General Hospital: Need for Multidisciplinary Approach
Authors: Sarodaya V , Gohil B , White A , Garg A
Published: November 2022

Introduction

The national case ascertainment rate for National Emergency Laparotomy Audit (NELA) over 179 hospitals is 84.5%. Our hospital is one of the few hospitals despite being eligible, had not submitted any data to the NELA for the past three years.

Method

We retrospectively collected data for all the patients that underwent laparotomy for a period of 2 years. The mean age of patients was 58 years. We found 83 patients who fit NELA inclusion criteria from January 2020 to November 2021.

Results

The 83 patients were divided into low risk (<5%) and high risk (>5%) and further analysed. The overall mortality was higher than the national (24% v/s 9.3%). Areas of excellent performance against NELA standards (i.e., > 80% compliance) included Consultant's involvement in theatres, Surgeons in 96.9% cases and Anaesthetist in 88.9% cases compared to National average of 96.9% and 93.9% respectively. Areas with poor compliance were Geriatrics involvement pre-operatively (14.7%) when compared to national average (24.7%). Pre-op assessment was done in 48% cases approximately half of national average of 84%. Post operatively 81.4% of the high-risk patients were directly admitted to ITU which was the same as the national average of 85%.

Conclusion

There were various factors which resulted in a low compliance rate. NELA is a useful audit for the comparison of national care. It allows for reflective practice at local level with aim to deliver a uniform standard of care.
147 Synchronous Parathyroidectomy and Extended Thymectomy in Multiple Endocrine Neoplasia Type 1- a Case Report
Authors: Robinson D , Smith A , Bille A , Simo R
Published: November 2022

In recent decades there has been a significant advancement in the management of neuroendocrine tumours (NETs) associated with multiple endocrine neoplasia type 1 (MEN-1). Hormone excess accounted for 75% of all MEN-1 deaths, however since the introduction of hormone blocking medication, deaths in patients with MEN-1 are now predominantly due to the malignant effects of the tumours. Half of all MEN-1 related deaths are due to tumours that are difficult to diagnose, including thymic NETs. Complete surgical resection is the mainstay of treatment for MEN-1 associated thymic NETs.

The case patient was a 49-year-old male who was being investigated for a 3-month history of symptoms consistent with hypercalcaemia. Initially a chest X-ray demonstrated a large anterior mediastinal mass. Further imaging revealed parathyroid lesions and a calcified lesion in the uncinate process of the pancreas. This combination of symptoms and radiological evidence raised the possibility of MEN-1 as the diagnosis. The lesions were biopsy-proven atypical carcinoid NETs and the patient later underwent simultaneous neck dissection for bilateral subtotal parathyroidectomy and a midline sternotomy for total thymectomy of the large mediastinal mass. Further testing revealed the pancreatic mass was another primary tumour and the patient is scheduled for excision of this. In addition, the patient is also being treated with Lanreotide alongside chemotherapy. Mutation of the MEN-1 gene was later confirmed on genetic testing.

Due to the increase in mortality from neuroendocrine malignancy, it is becoming ever more important to understand how to manage multiple NETs from a surgical perspective.
29 The Surgical Trainee Personality: Selected or Shaped?
Authors: Sayers A , Byrne M , Norman I , Jones J , Vig S
Published: November 2022

Aim

This study aims to describe the personality differences between trainees at different stages prior to and during surgical training.

Method

The Mental Muscle Diagram Indicator was distributed electronically to doctors in training in South West London. A total of 553 trainees completed the personality questionnaire. Specifically, there were general surgery specialty (n = 53), core surgical (n = 254), and foundation trainees (n = 246). 52% of trainees were female.

Results

Women scored significantly higher in the Extraversion, Sensing and Judging personality domains (p < 0.0001), there were no significant differences between genders for ‘Thinking’. One-way ANOVA only showed a significant difference in the ‘Judging’ domain between grades. Tukey's test was performed showing the difference arose from FT to CST (p = 0.008). Two-way ANOVA showed an interaction between gender and grade for ‘Judging’ and as such simple main effects were performed, with alpha = 0.017 to control for type 1 errors. Significant differences were found in the Judging domain between genders during in FT (p=0.002) and CST (p=0.002), and there was no significant difference for SpRs (p=0.15).

Conclusions

This study demonstrated differences in personality types between trainee stages and gender. These differences appear to decrease as trainees progress through their training, although the cause of this is unclear.
262 Abdominal Hernia Mesh Repair in Patients with Inflammatory Bowel Disease: A Systematic Review
Authors: El Boghdady M , Ewalds-Kvist B , Laliotis A
Published: November 2022

Aim

Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons’ decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications.

Method

A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE's recommendations. The research protocol was registered with PROSPERO (CRD42021247185).

Results

The present systematic search resulted in 11243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate qualities. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn's disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition, midline incision site of hernia, biological mesh, and digestive concomitant procedure.

Conclusions

Patients with IBD were subject, more so than controls, to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.
953 Amyand's Hernia: The Fortuitous Intraoperative Diagnosis – a Case Report
Authors: Adepoju O , Rahman A , Aladesawe O , Elemile P , Adepoju J
Published: November 2022

Introduction

Amyand's hernia is a very rare form of inguinal hernia, in which the vermiform appendix is in the inguinal canal/hernia sac. Its incidence is less than 1% of groin hernias and is complicated by appendicitis in about 0.1% of cases. It is commoner in males, on the right side and has a bimodal age distribution – neonates and the elderly.

We present the case of an elderly gentleman with amyand's hernia diagnosed intraoperatively.

Case Presentation

A 78-year-old male with a background of systemic hypertension presented to the clinic with an 18-month history of painless right groin swelling. Physical examination revealed a full, non-tender abdomen. He had a 4cm soft, reducible right groin swelling, with visible and palpable cough impulse. A diagnosis of right inguinal hernia was made. Baseline blood workup and ECG were unremarkable. He was listed for a day case open hernia repair.

Intra-operatively, the right indirect hernia sac contained a grossly uninflamed appendix lying freely within it. Figure 1.

Appendicectomy was performed and a tension-free repair was done.

The post-operative period was uneventful. Histology of the excised appendix revealed reactive lymphoid hyperplasia and submucosal fibrosis.

Conclusion

As only about 1 in 60 cases of Amyand's hernia are diagnosed pre-operatively, usually as an incidental finding on imaging; the overwhelming majority are intra-operative findings.

Although rare, the vermiform appendix remains a possible content of the inguinal hernia sac, and it is important to be aware of likely complications and options of repair.
207 Accuracy of Reviewing NELA Operation Data Entry in Emergency Laparotomy
Authors: Cirocchi N , Lee KM , Ahmed S , Brown K
Published: November 2022

Aim

The National Emergency Laparotomy Audit (NELA) is part of the National Clinical Audit and data can often be submitted by a non-surgical clinician who do not perform the procedure, whereas operating notes are written mostly by the primary surgeon. A concern for possible discrepancies prompted a comparison between the operation notes and the NELA audit data, to assess for accuracy and understanding of the NELA inclusion/exclusion criteria.

Method

Operation data was collected retrospectively from the NELA database from January to December 2020. The surgeon's operation notes were reviewed and compared. Main parameters compared included ‘indication of surgery’, ‘main operation procedure’, ‘operative findings', ‘peritoneal contamination’ and ‘level of contamination’. The inclusion and exclusion criteria for NELA audit was also assessed and compared. A further questionnaire survey was performed to review the understanding of the procedure

Results

Total of 171 data was retrieved from the NELA database from the selected time-period.

Out of these, 4.6% fulfilled the exclusion criteria. ‘Indication of operation’ were not consistent in 14 entries while in Operation procedure 4.9%. ‘Main operative findings’ were inconsistent in 11% cases. The Survey showed surgical difference in reviewing the operation notes.

Conclusions

There were significant portion of discrepancies between the surgical operating notes and NELA data entry when compared, due to retrospective entry and two different clinicians. There is a lack of clear understanding for the inclusion/exclusion criteria. We would like to recommend that the primary surgeon who performs the procedure records both the operating notes and the NELA data entry.
929 The Incidence and Outcomes of Delayed Laparoscopic Cholecystectomy and Bile Duct Exploration on a Unit Adopting Index Admission Surgery for All Comers. a Review of 5750 Patients
Authors: Welsh S , Sallam M , Nassar A
Published: November 2022

Aim

The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management.

Method

Analysis of prospectively maintained data in a unit adopting “intention to treat” during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications, and postoperative outcomes with index admission LC.

Results

Of 5750 LC performed 20.8% had previous biliary admissions; one in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p<0.001), longer operating times (86.9 v 68.1 minutes, p<0.001), more post-operative complications (7.5% v 5.2%, p=0.002) and longer hospital stay (8.1 v 5.5 days, p<0.001). However, conversion and mortality rates showed no significant differences.

Conclusion

Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and post-operative outcomes of biliary emergencies.
508 Are Omega 3 Nutraceuticals Effective in Temporomandibular Joint Disorder
Authors: Yaqoob O , Perretti M
Published: November 2022

Aim

Temporomandibular Joint (TMJ) osteoarthritis (OA) is a common type of arthritis that affects all ages. Currently conservative treatment is 1st line for osteoarthritis in the TMJ and surgical treatment should only be considered as a last resort. This study aims to assess whether nutraceuticals can provide any symptomatic relief to TMJ OA.

Method

A total of 10 studies were identified using electronic databases, no exclusion criteria were applied. Inclusion criteria consisted of studies investigating the effects of Omega 3 nutraceuticals and their benefit in their role regulating the inflammatory pathways in TMJ osteoarthritis. We considered randomised controlled trials, systematic reviews, and meta-analyses.

Results

Polysaturated fatty acids have a role in inflammation due to their unique pro-resolving properties. The studies are clear in highlighting that omega 3 supplementation in patients suffering from TMJ OA will have symptomatic benefit. EPA seems to be the most powerful modality in achieving this and there was an inverse dose response relationship when investigating pain scores and eicosapentaenoic acid (EPA) concentration.

Conclusions

Omega-3 is an inexpensive conservative treatment option to have and should be offered to the majority of patients suffering from symptomatic OA. It can be used in conjunction with analgesics and possibly help reduce the dose of these. Based on the available literature and extrapolating data and results from similar inflammatory disorders and studies, it would be reasonable to suggest that a daily dose of 3g omega 3 for 12 weeks would be effective in TMJ arthritis.
780 Are E-Scooters Safe for Widespread Public Use? A Case Series Examining Severe Facial Injuries Secondary to E-Scooter Accidents
Authors: Noton T , Armes H , Mistry R , Tam A , Collier J , Greaney L
Published: November 2022

E-scooter use is becoming commonplace across the UK as an increasing number of towns and cities launch trials with pay-as-you-go e-scooter companies. In addition, e-scooters are cheap method of transport, easily available for an individual to purchase online, without restriction. We present two cases of patients having suffered complex facial injuries secondary to e-scooter accidents.

The first is a 38-year-old male, who was thrown from an e-scooter and had associated loss of consciousness. CT facial bones demonstrated extensive fractures to the bilateral maxillary and frontal sinuses, nasal bones, bilateral orbital floors, and mandible. The Le Fort II and mandibular fractures were fixed in two procedures. The patient has ongoing neuropathic pain around the right mandibular condyle and is receiving input from orthognathic specialists.

The second patient is a 60-year-old male, who collided with the rear of a car and was thrown forward, hitting his face on the tarmac. CT facial bones showed a Le Fort II fracture pattern and a fractured left inferior orbital rim, with extensive surgical emphysema of the face. He underwent plating of the bilateral Le Fort II fractures and application of intermaxillary fixation wires.

With little to no enforcement of personal protective equipment use and safety advice whilst utilising e-scooter services, the number of people suffering serious injuries from using such equipment is set to skyrocket. Increased awareness and education around the danger of e-scooters needs to be addressed and should be prioritised by local authorities and public health services.
73 The Digital Cullen Chart: An App to Assess the Visual Field in the Context of Sellar/parasellar Tumours
Authors: Keenlyside A , Hughes M , Ho JW , Sieradzki J
Published: November 2022

Aim

30 years ago, Cullen1 (a neuro-ophthalmologist) developed and validated a simple paper chart for evaluation of the central 25 degrees of the visual field. We re-developed this concept in digital form (as a smartphone application) and sought to assess its sensitivity and specificity in detecting field loss, through comparison with formal machine-based perimetry.

Method

A case series pilot study was performed to test the app-based Cullen chart for concordance with formal machine-based perimetry (Humphrey and Octopus). 18 patients with a range of sellar/parasellar tumours (pituitary adenoma, craniopharyngioma, and meningioma) being managed in a single neurosurgical centre were involved in this study. Patients underwent formal visual field perimetry as part of standard care. They also underwent assessment using the smartphone-based Cullen chart as part of routine outpatient assessment. 37 eye episodes were assessed, incorporating pre- and post- treatment assessment for a range of potentially compressive pathologies.

Results

The digital Cullen chart had a sensitivity of 75% and specificity of 98% compared with machine-based perimeters. The positive predictive value was 93% and negative predictive value was 92%.

Conclusions

In the context of visual field assessment for patients with sellar/parasellar tumours, this smartphone-based chart shows strong concordance with machine-based perimeters. It is therefore an accessible visual field screening and monitoring tool for clinicians. With further study, there is also potential for approval as a remote patient-led visual field monitoring method.
228 Idiopathic Intracranial Hypertension and Pregnancy: A Comprehensive Review of Management
Authors: Scott C , Kaliaperumal C
Published: November 2022

Aim

To investigate idiopathic intracranial hypertension (IIH) and its management during pregnancy.

Method

PubMed and Embase databases were searched for studies on pregnancy and IIH, with the most recent search in July 2021. Mesh terms used were “idiopathic intracranial hypertension” or “pseudotumor cerebri” AND “pregnancy”. Papers were limited to studies with human subjects and written in the English language. There were no restrictions in study design or date of publication. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant publications.

Results

Management of IIH during pregnancy is similar to those who are non-pregnant. It is recommended that pregnant women with IIH are treated in health care settings that have access to multi-specialty input. Management depends on disease severity and includes conservative management, the use of medication such as steroids and diuretics, lumbar punctures, and surgical management.

An indication for surgical management includes worsening visual deterioration despite initial management with medication or serial lumbar punctures. Surgical management includes cerebral spinal fluid diversion procedures and optic nerve sheath fenestration. These operations can be performed in all three trimesters of pregnancy.

IIH in pregnancy does not increase morbidity or mortality in the newborn and method of delivery should be based on obstetrical indication.

Conclusion

This review highlights the role of multi-disciplinary approach in the management of IIH during pregnancy.
414 Are Lumbar Drains Necessary in Endoscopic Transellar Surgery with an Intraoperative High Flow Leak? a Systematic Review
Authors: Pak HYV , Hayhurst C , Taylor P
Published: November 2022

Aim

Perioperative lumbar drains have been used to facilitate healing of the dura and prevent postoperative cerebrospinal fluid (CSF) leaks. However, the use of perioperative lumbar drains is controversial and has primarily been left to the surgeon's preferences. Through the use of meta-analysis, we aim to find out whether lumbar drains effectively reduce the risk of postoperative CSF leak in the context of a high flow intraoperative leak.

Method

A systematic review was conducted using PRISMA guidelines. Databases used in literature searching include PubMed, Ovid (including Embase and Medline), Scopus and Cochrane Library. Articles published in 2006 or later were searched. The random-effects model was used in statistical analysis.

Results

A total of 2623 articles were identified. After screening and full-text reviews, 21 studies were included. From the quantitative data analysis, lumbar drains did not significantly lower the rates of postoperative CSF leaks. In addition, lumbar drains were associated with complications as well as a lengthier hospital stay.

Conclusions

Modern and rigorous repair techniques after endoscopic transsellar surgery are sufficient, and the use of lumbar drains is not necessary.
867 Transcranial Doppler Ultrasound for the Diagnosis of Cerebral Vasospasm After Aneurysmal Subarachnoid Haemorrhage
Authors: Masala I
Published: November 2022

Aim

This study aims to review the literature regarding the utility and accuracy of transcranial toppler (TCD) ultrasound in the diagnosis of cerebral vasospasm (CV) following aneurysmal subarachnoid haemorrhage (aSAH).

Method

A systematic review of the literature was conducted following the PRISMA guidelines. Pubmed and Google Scholar online databases were searched using the following designated MeSH search terms: “subarachnoid haemorrhage” AND “aneurysm” AND “aneurysmal” AND “cerebral vasospasm” AND “vasospasm” AND “transcranial Doppler” AND “TCD”. Results were limited to publications not older than 10 years prior this research (May-June 2020) and restricted to English language. All the articles found through the search were screened through their titles, then through the abstract and finally from reading in full. The remaining articles were then screened by the previously set inclusion and exclusion criteria. Finally, a further cross-reference search was completed in order to include articles missed in the database research.

Results

The database research yielded 1378 results. Of these, following the screening process, 6 papers were included in the study. A total of 403 patients was extracted from the data. Of these, the total number of reported diagnoses of CV was 172. The percentage of patients with CV was calculated for each study and overall, for an average of 42.68% of patients diagnosed with CV. TCD showed to have an average sensitivity and specificity of 68% and 74%, respectively and 71% accuracy.

Conclusion

TCD is a useful diagnostic tool that could help predicting and early diagnosing the occurrence of CV, with good sensitivity, specificity, and accuracy.
1041 Impact of Spectral Contamination and Anatomical Location on Diagnostic Accuracy of Single-Voxel Spectroscopy in Pre-Operative Glioma Characterisation
Authors: Crispi V , Sanders K , Kenning L , Spink G
Published: November 2022

Aim

Single-voxel spectroscopy (SVS) discriminates amongst brain tumours by measuring metabolite variations reflective of malignant transformation. However, spectral contamination may affect diagnostic accuracy, impacting radiological opinion of regions of interest (ROI) required to determine extent of surgical resection.

Method

A single-centre, retrospective, observational study, including 93 SVS meaningfully interpretable examinations between 2012 and 2018. Accuracy of lesion classification was assessed by comparison of histological diagnosis as reference standards against discrimination between entities and tumour grades by SVS, with consideration for voxel location, volume, and proximity to the calvaria or ventricular system. Quantification of metabolites was recorded as ratios, and visual inspection, qualitative and descriptive analysis were undertaken.

Results

SVS demonstrated high entity accuracy (100%) but lower grade accuracy (87%), ranging from periventricular (73%) vs non-periventricular (90%), and subcalvarial (86%) vs subcortical (88%) voxels. CSF contamination caused metabolite dilution and/or enhanced lactate signals from sub-arachnoid or ventricular CSF, especially in areas of increased brain-skull distance; lipid contamination from peri-calvarial fat and subcutaneous tissue resulted in enhanced lipid signals neighbouring areas of increased brain-scalp distance. Misclassified lesions were located regions of increased cranial concavity, reduced cerebral cortical thickness and inappropriate outer volume suppression (OVS). Voxel volume variation had no impact across cerebral coordinates (p=0.605), calvaria proximity (p=0.127) or ventricular proximity (p=0.367).

Conclusion

Spectral contamination significantly impacted grade accuracy, with metabolite dilution and enhance lactate and lipids signals leading to radiological under- and overestimation of glioma grade, respectively, thus indicating that avoidance of contaminating tissues and OVS are pivotal to adequate spectral quality for diagnostic accuracy.
82 Acute Acalculous Cholecystitis Caused by Epstein–Barr Virus Infection: Cohort Study of Literature
Authors: Latif S , Hajibandeh S
Published: November 2022

Aim

To perform a cohort study of literature to provide the best available evidence on clinical features and management of acute acalculous cholecystitis (AAC) caused by acute Epstein-Barr virus (EBV) infection

Method

A comprehensive search of electronic information sources was performed to identify all reported cases in the literature comprising patients of any age or gender who were found to have AAC due to acute EBV infection. Simple descriptive statistics were applied to present outcome data.

Results

Overall, 42 eligible patients were identified. The mean age of the included population was 17; 83% were female and 17% were male. Overall, 62% were from Europe; 21% from North America, 17% from Asia. Abdominal pain was present in all patients; sore throat in 62%; pharyngitis or tonsillitis in 50%; cervical lymphadenopathy in 62%; jaundice in 36%, hepatosplenomegaly in 60%; positive Murphy's sign in 69%. All patients had gallbladder wall thickening on imaging. Overall, 98% of patients were treated conservatively. Among those who were treated conservatively, all recovered with conservative management. The patient's preference was the reason for surgery in the patient who was not treated conservatively. As part of conservative management, antibiotics were used in 48% of patients. The mean length of hospital stay was 10 days

Conclusions

AAC caused by EBV infection is a rare condition that occurs in young patients and is more common in females and in European countries. EBV-associated AAC has a very good clinical prognosis and can be treated conservatively without a need for antibiotics or surgical intervention.