bluuebunny/crossref_metadata_2025 huggingface dataset:
SP6.7 Variation in UK anti-reflux surgery practice - A Collaborative Multicentre National Audit (ARROW study)
Authors: Pipe Michelle , Walker Robert , Currie Andrew , Wiggins Tom , Hollyman Marianne , Collaborators ARROW
Published: August 2023

Aims

There is significant variation in the work-up of patients for anti-reflux surgery. This study describes the current variation in UK work up and perioperative management for anti-reflux surgery (ARS), and adherence to clinical guidelines.

Methods

A 12-month UK-wide multicentre prospective national audit was undertaken using a secure online platform. Data collection included demographics, symptoms, pre-operative investigations, intraoperative details, and postoperative outcomes within 90 days. Audit standards (AS) were taken from BSG, ICARUS and AUGIS guidelines.

Results

630 patients from 38 centres were analysed. Patients had a median age 58 years (18-92, F:M 384:245), median ASA 2, and median BMI 29kg/m2.

Oesophageal manometry was performed in 332 patients (54%, AS 100%). Twenty-four-hour pH monitoring was performed in 319 patients (53%, AS 100%). Endoscopy was performed in 520 patients (83%, AS 100%). Laparoscopic or robotic surgery was recorded in 506 and 63 patients, respectively (99%, AS 95%). Two patients underwent open surgery and four laparoscopic cases converted to open. Only 3% (22) patients were day-cases.

Overall, 45 patients were re-admitted (7%, AS <10%); three units had a >10% readmission rate which corresponded with high day-case rates. Less than one percent of patients had an unplanned re-operation. Of those with recorded follow up (60%), 94% had recorded full/partial resolution of symptoms; 86% having nil further requirement for PPI.

Conclusions

There is wide variation in practice, especially regarding preoperative work up, adherence to existing guidelines and low day-case rates. More work is required to assess how the variation in practice affects patient outcomes.
SP6.8 A systematic review and meta-analysis of bag extraction versus direct extraction for retrieval of gallbladder in laparoscopic cholecystectomy: Is it necessary to use?
Authors: Wuheb Ali , Mohamed Hussam , Albendary Mohamed , Mohamedahmed Ali Yasen , Elshikhawoda Mohamed
Published: August 2023

Aims

To evaluate comparative outcomes of gallbladder extraction with bag versus direct extraction in laparoscopic cholecystectomy.

Methods

A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies comparing endo-bag versus direct extraction of gallbladder in laparoscopic cholecystectomy were included. Outcomes were surgical site infection (SSI), extension of fascial defect to extract the gallbladder, intra-abdominal collection, bile spillage and port-site hernia. Revman 5.4 was used for the data analysis.

Results

Eight studies were eligible to be included in this review with total number of 1805 patients divided between endo-bag [n=835] and direct extraction [n=970]. Four of the included studies were randomized-controlled trials while the rest were observational studies. The rates of SSI and bile spillage were significantly higher with direct extraction compared to bag extraction [odd ratio (OR)=2.50, P=0.006] and [OR=2.83, P=0.01], respectively. Conversely, extension of fascial defect was higher in endo-bag group [OR=0.22, P=0.00001]. Comparable results were observed regarding intra-abdominal collection [OR=0.01, P=0.51], and port-site hernia rate [OR-0.70, P=0.55] between the two groups.

Conclusion

Extraction of gallbladder with Endo-bag provides lower rates of SSI and bile spillage with no notable impact on postoperative abdominal collection. Despite the increased need to extend the fascial defect with Endo-bag, the rate of port-site hernia remains similar between both groups.
SP6.9 Presentation and Outcomes of Gallbladder Cancer: A Twenty-Year Experience from a Tertiary UK Centre
Authors: Bodla Ahmed Salman , Xiang Jinpo , Athwal Tejinderjit , Cheruvu Chandra
Published: August 2023

Aims

This retrospective observational study from a tertiary hepatobiliary centre sought to establish patterns in presentation and subsequent stage-dependent management and survival outcomes of gallbladder cancer (GBC) over a 20-year period. We also looked at recurrence rates and utilisation of chemotherapy in the adjuvant and palliative settings.

Methods

All cases of GBC between 2001 and 2021 were identified through clincial coding and locally maintained database. Relevant demographic, staging, management and outcomes information was gathered via electronic records. Patients with incomplete data were excluded.

Results

Conclusion

Out study provides a detailed picture of GBC incidence, management, and prognosis in England. GBC suffers from dismal survival outcomes due to advanced stage at presentation. T-stage has the strongest impact on survival since it determines the treatment offered. A significant proportion of patients are neither suitable for surgery due to locally advanced or mestatic disease, nor chemotherapy mostly due to poor performance status. R1 resection and post-operative recurrence pose additional problems in terms of long-term survival.
SP6.10 Preoperative antibiotic prophylaxis in acute cholecystectomy: a systematic review and meta-analysis of randomised controlled trials
Authors: Kaur Mandeep , Singh Anurag , Sains Parv , Swaminathan Christi , Singh Krishna , Sajid Muhammad
Published: August 2023

Objective

Laparoscopic cholecystectomy in patients admitted with acute cholecystitis is considered preferred, feasible and safe mode of managing gallstone disease. The objective of this study is to evaluate the role of single dose pre-operative prophylactic antibiotics in these patients undergoing acute cholecystectomy.

Materials and methods

All RCTs reporting the use of single dose pre-operative prophylactic antibiotics in patients undergoing acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.

Results

Standard medical databases search produced only 3 RCTs on 781 patients undergoing acute cholecystectomy. There were 384 patients in single dose pre-operative antibiotics group whereas 397 patients were recruited in the no-antibiotics group. In the random effects model analysis, use of single does preoperative prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate cholecystitis failed to demonstrate any extra advantage of reducing the risk of [risk ratio 0.69, 95%, CI (0.46, 1.03), Z = 1.80, P=0.70] infective complications. There was no heterogeneity (Tau2 = 0; Chi2 = 1.74, df = 2 (P = 0.42; I2 = 0 %) among included studies.

Conclusion

Preoperative single dose of prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate acute cholecystitis does not offer extra benefit to reduce infective complications.
SP6.11 Histological Findings in Routine Gallbladder Specimen for Benign Disease
Authors: Telfah Muwaffaq
Published: August 2023

Aim

Gallbladder is one of the most frequently analysed specimens in pathology departments. Non-selective approach is followed by most surgeons with its associated cost and time implications. This study aims to highlight the incidence of histological abnormalities that can be found in the specimen sent following cholecystectomy for benign pathology.

Methods

Retrospective review of histology reports over 10 years period (2010-2019) in district general hospital performed. Non-selective approach used by our surgeons to send specimen following cholecystectomy. Emergency and elective cholecystectomy in adult patients included. Any suspicious diagnosis preoperatively excluded. Histological diagnosis using SNOMED coding from pathology department used.

Results

6020 Histology reports reviewed. Chronic cholecystitis reported in 4113 case (68%), acute cholecystitis seen in 1587 cases (30%). Only 120 reports (2%) described abnormal histology which includes neoplastic and non-neoplastic lesions. Neoplastic lesions found in 90 cases: cancer=10 cases (0.16%) and dysplasia in 80 cases: high grade= 4 cases (0.06%), low grade= 73 (1.2%) and metaplasia in 3 cases (0.04%). Non-neoplastic lesions seen in 30 cases: adenoma= 7 (0.11%), polyp= 13 (0.21%), lipoma=2 (0.03%), cysts=2 (0.03%) and granulomatous cholecystitis in 6 cases (0.09%).

Conclusion

This study demonstrates the frequency of abnormal histology seen in routing specimen. This is an important information to quote during the consent process and also may help in adopting a selective approach for cholecystectomy performed for benign disease.
SP7.3 Development of a Patient Reported Outcome measure for GastroIntestinal recovery: The PRO-diGI study
Authors: Lee Matthew ,   PRODIGI STEERING GROUP
Published: August 2023

Background

Patients undergoing abdominal surgery often experience gastrointestinal dysfunction. Recovery of gastrointestinal function is poorly measured. There is a need for a patient reported outcome measure to assess gastrointestinal recovery. The first stage of development requires qualitative work to identify key concepts.

Methods

The PRO-diGI study consisted of three phases:

Phase 1: Qualitative interviews of patients admitted to hospital for major gastrointestinal, gynaecological, or urological surgery, or with intestinal obstruction.

Phase 2: Development of questionnaire and face validity testing with patients as in Phase 1, and expert clinicians internationally.

Phase 3: The questionnaire was distributed to eligible patients. Participants completed the questionnaire as soon after surgery as they were able. Exploratory factor analysis was performed to confirm the structure of the questionnaire and reduce the number of items.

Results

Phase 1: 29 patients were interviewed, and reported 26 key symptoms or experiences across 6 themes including impact on life, mental health, and general physical wellbeing, diet and appetite, abdominal symptoms, nausea and vomiting, and bowel function.

Phase 2: 18 patients and 15 clinicians assessed a 44-item questionnaire, confirming good face validity.

Phase 3: 297 participants were recruited. Factor analysis identified 20 questions related to enjoyment of food, ability to eat and drink, bowel function, nausea and vomiting, and general wellbeing, for inclusion in the final tool. The final tool shows correlation with self-rating of gut function, GI-2, and operative approach.

Discussion

This study has developed a multi-dimensional patient reported outcome measure which can be used in studies of gastrointestinal recovery.
SP7.6 Do we need Routine Histopathological Examination of Gall Bladder Specimens after Cholecystectomy?
Authors: Rauf Fatima , Asif Hira , Zafar Nowera , Rauf Sidra
Published: August 2023

Aims

Gall bladder diseases usually manifest as gall stones, inflammation of gall bladder and gall bladder cancer. There had been a constant debate over the years regarding selective vs. routine histopathological assessment of all gall bladder specimens. This study was aimed to assess the safety of adopting the policy of selective histopathological examination of those gall bladder specimens with pre-operative and/or intra-operative suspicion of malignancy without risking patient safety.

Methodology

A descriptive, cross-sectional study was conducted. All 1285 cases of gall bladder biopsies done after elective cholecystectomies, during a period of 2 years from 1st January, 2018 to 31st December 2019, were reviewed retrospectively.

Results

During the study period, a total of 1285 gall bladder specimens were submitted for histopathological analysis. Chronic cholecystitis was found in 1020 (79.3%) patients, acute cholecystitis in 198 (15.4%), gangrenous gall bladder in 19 (1.47%) patients and gall bladder carcinoma (GBC) in 26 (2.02%) patients. Pre-operative or intraoperative diagnosis of GBC was made in 22/26 patients. The remaining 4 patients had either stage Tis or T1 stage carcinoma and did not require revision surgery.

Conclusion

In areas with low incidence of gall bladder carcinoma, a selective approach of histopathological examination of gall bladder specimens may be considered safe. Such selective approach is more economical and reduces the work burden of pathologists without risking patient safety.
SP7.7 Evaluation of predictive models of common bile duct stones and the use of biliary investigations
Authors: Albendary Mohamed , Mirza-Davies Anastasia , Malik Jasmin , Pankan Bibi , Ong Ling , Bhandari Santosh
Published: August 2023

Aims

This study identifies clinical, biochemical and radiological factors that may predict CBD stones prior to cholecystectomy to reduce costs and delays of non-indicated biliary imaging.

Method

Retrospective data of patients underwent cholecystectomy over 6 months was collected, including first presentations, liver function tests (LFTs), and imaging. Data was tested against guidelines from European Society of Gastrointestinal Endoscopy (ESGE, 2019), American Society of Gastrointestinal Endoscopy (ASGE, 2019) and literature models (Gurusamy-2015, Isherwood-2014).

Results

322 included patients had LFTs and US scans in first presentations with symptomatic gall stones. 52 of them had repeated biliary imaging (US, MRCP or CT) without showing any new findings in 92% of cases.

118 patients had MRCP prior to cholecystectomy, with only 22 cases of confirmed CBD stones. After applying the above-mentioned guidelines and predictive values, new criteria, combining cut-off values of 30 µmol/L for bilirubin and 180 IU/L for Alkaline phosphatase, showed the highest sensitivity (72.73%) and specificity (81.25%), while maintaining high positive predictive value (PPV) (46.99%) and accuracy (79.66%). (Table 1)

Conclusion

Using clinical and radiological findings to guide the need for definitive biliary imaging, commonly MRCP, can reduce unnecessary radiological investigations and costs. Our new suggested combined cut-off values of Bilirubin and ALP can complement the clinical judgement.
SP7.9 Correlation between Altmetric score and number of citations in 12 high impact factor medicine, surgery and anaesthesia journals
Authors: Adiamah Alfred , Kandiah Kaveetha , Wong Tiffany , Dada Omolade , Igboin Jasmine , Lobo Dileep
Published: August 2023

Introduction

The citation count is traditionally used to measure the impact of scientific publications. The Altmetric attention score (AAS) by contrast, measures the digital dissemination of articles across social media platforms to determine their audience reach. However, whether the AAS correlates with citation counts is currently not well defined. This study, aimed to discern the correlation between citation counts and AAS in medical journals.

Method

We identified 12 highest impact journals in Internal Medicine, Surgery and Anaesthesia and included original articles, systematic reviews, meta-analyses, editorials and research letters published between 1 January 2019 and 31 December 2019. Up-to-date citations and AAS for each article were obtained between 1 and 7 January 2023 using a linked research information dataset, Dimensions Citation Data (https://app.dimensions.ai/discover/publication).

Results

We identified 2790 published manuscripts with median (IQR) AAS and citation scores of 39 (10-152) and 19 (7-56) respectively. Both scores differed by journal specialty, with the highest scores identified in Medicine and lowest in Anaesthesia journals. Randomized clincial trials had both the highest citations and AAS, with research letters having the lowest. There was a positive correlation between AAS and citations (ρ=0.4538; P<0.001). Other factors found to correlate with the citation scores were journal specialty (ρ=0.2047, P<0.001), journal impact factor(ρ=0.4538, P<0.001) and the type of study (ρ=0.4566, P<0.001).

Conclusion

This cross-sectional study, across 12 high impact factor specialty journals found that the AAS correlated with the citation count, suggesting that audience engagement via social media may influence the overall clinical and academic impact of publications.
SP7.11 Outcomes of Elective and Emergency Surgical Repair of Incisional Hernia - A Comparative Observational Study
Authors: Omar Islam , Townsend Abby , Hadfield Oliver , Khogali Moataz , Wilson Jeremy , Magee Conor
Published: August 2023

Aims

Incisional hernia (IH) is a common complication after abdominal surgery. This study aims to describe and compare the outcomes of IH's elective and emergency surgical repair.

Methods

A single-centre comparative retrospective study including all patients who had surgical repair of IH. The patients were divided into Group I (Emergency) and Group II (Elective). A comparison was made between the two groups.

Results

262 patients were identified with a mean age of 61.8 SD±14.2 years, and 152 (58%) were females. More than 58% had at least one comorbidity. 169 (64.5%) had elective, and 93 (35.5%) had emergency repair. Patients undergoing emergency repair of IH were significantly older and had higher BM, p= 0.031 and 0.002, respectively.

The overall complication rate in the full cohort was 46.2%, and the significant complication rate (Clavien-Dindo III and IV) was 9.54%. The 30-day and 90-day mortality rates were 6 (2.3%) and 7 (2.68%), respectively.

In the emergency group, the complications, 30-day and 90-day mortality rates were significantly higher than in the elective group, p= <0.001, 0.002 and 0.001, respectively. The emergency group had a significantly longer hospital stay, and more of them needed a higher level of care, p= <0.001 each.

Overall, 42 (16.1%) developed wound complications, 25 (9.6%) patients had a recurrence, and 41 (15.71%) had 90-day readmissions without significant differences between the two groups.

Conclusions

IH is associated with medical comorbidity and high BMI. Emergency repair of IH is associated with higher complication rates and mortality compared to elective repair.
SP7.12 One stop multi-speciality Chronic Postoperative Inguinal Pain Clinic – implementation outcomes
Authors: Cocciolo Federica , Birch Alice , Al-Abbasi Iea , Pawlak Maciej
Published: August 2023

Aim/Objective

The aim on this presentation is to assess patients’ feedback as well as the outcomes of individualised treatment plans for patients assessed in the multidisciplinary team (MDT) clinic. The primary endpoint was quality of life and pain improvement 3 months after receiving treatment.

Material and methods

All patients reviewed in MDT CPIP clinic in the Comprehensive Hernia Centre between July 2021 and July 2022 were included in the study. Patients feedback as well as MDT individualised treatment plans were assessed. The outcomes, Visual Analogue Scale (VAS) and modified Activity Assessment Scale (mAAS) 3 months post intervention have been audited against data collected prior to intervention.

Results

We have received 57 referrals during the investigated period. 40 patients underwent MDT assessment with 55% receiving treatment and entering follow-up stage. In that group 26% had surgery, 35% had invasive non-surgical treatment (local injections and radiofrequency ablation), 39% were qualified for pharmacological treatment, together with physiotherapy and psychological support. Follow up data was collected for 19/22 patients. All patients had reported moderate to significant pain (VAS 4-10) on initial assessment and a significant reduction in pain (> 50% improvement in VAS) after treatment. Mean baseline mAAS score was 20.3± 7.3 (range 8 to 40). Mean change was - 10.6±2.6 with all patients reporting significant improvement (> 50%). Moreover, on a scale from 0 to 5, the average satisfaction score was 4.5.

Conclusion

Developing a multidisciplinary clinic to assess patients presenting with CPIP improved patients’ experiences and outcomes. Enhancing patient-centred care.
SP8.2 Management of Acute Surgical Abscesses (MAGIC): National prospective audit
Authors:   White Rose Surgical Research Collaborative (WRSC)
Published: August 2023

Aim

Subcutaneous abscesses are common, accounting for 2% of all emergency attendances. The aim of this project was to describe the management and outcomes associated with the management of subcutaneous abscesses in surgical practice.

Method

A national, prospective audit was undertaken. Adult patients presenting to an acute general surgical service with a subcutaneous (non-perianal) abscess between September and December 2022 were included. Data relating to their presentation, management, and outcomes were collected. Outcomes of interest included rates of recurrence, readmission, and complications within 60 days of treatment. A centre-level survey was administered to gather data on clinical resource use and sustainable practices.

Results

A total of 1247 patients were included across 55 centres. The most common abscess locations were pilonidal (18.8%), posterior thorax (14.5%), and buttock (11.7%). The majority (84.4%) were treated with incision and drainage and half (51.9%) of these also received antibiotics. Surgery was mostly performed with general (65.2%) or local (33.0%) anaesthesia. The rates of recurrence (5.7% vs. 6.7%) and readmission (14.0 vs. 10.3%) were broadly similar, respectively. A quarter (26.6%) of hospitals incorporated dedicated abscess management pathways. The majority of hospitals used single-use items for abscesses drained in ambulatory/ward areas (90.2%) but not in the operating room (13.7%).

Conclusions

Wide variation exists in the management of subcutaneous abscesses. These data, along with other preparatory work, may justify a trial of general and local anaesthesia in appropriately selected patients.
SP8.4 National variation in the management of pancreatitis and the effect on patient outcome
Authors: Javanmard-Emamghissi Hannah , Knight Stephen , Kosti Angeliki , Hollyman Marianne ,   PANC Study
Published: August 2023

Aim

Pancreatitis is one of the most common general surgical presentations, but there is variation in how patients are managed. Our aim was to assess the degree of variation across the United Kingdom (UK) and how it affects patient outcomes.

Method

A multicentre, observational cohort study was carried out across the UK between March-April 2021. Admission variables including whether the unit was a district general or specialist unit were recorded. Imaging and operative details were collected with 30-day outcomes.

Results

Data from 113 hospitals were recorded, including 2580 patients. 24(21%) of these hospitals were specialist units. Imaging rates varied between sites, with ultrasound performed within 24 hours of admission on between 14 and 100% of patients and CT between 22 and 100% of patients. Between 0% and 100% of patients received a laparoscopic cholecystectomy within 30 days. Median length of stay was 5 days, but increased to 6 days in low volume centres (p=0.01).

Variation in access to ultrasound and to surgery were related to hospital volume, but not whether they were a tertiary unit. Mortality and readmission rates were not correlated to hospital volume but unplanned readmission was higher in non-specialist centres (18.1%v14.4%, p=0.024).

Conclusions

There is significant inequity in accessing best practise pancreatitis care in the UK, based on admitting hospital. Case volume at a hospital was more significantly associated with access to imaging and surgery, than being a specialist centre, however specialist centres achieved lower rates of unplanned readmission.
SP8.5 Emergency laparoscopic and open right hemicolectomy for right colonic malignancy: A retrospective comparative single centre study
Authors: Hussain Mohammad Iqbal , Sakib Najmu , Stefan Samuel , Khan Jim
Published: August 2023

Aim

Minimally invasive surgery has gained wide acceptance in general surgery and is being increasingly used to treat colon cancers. However, there are no randomized controlled trials comparing laparoscopic against open emergency colectomies. This study aims to compare the clinical and pathological outcomes for laparoscopic and open right colectomy in the emergency setting.

Methods

This single-centre study involved a total of 201 patients who underwent emergency laparoscopic and/or open right hemicolectomy for right colonic malignancy between 2009 and 2019.

Results

A total of 201 right colectomies were performed. Among these procedures, 84 were operated laparoscopically and 117 with an open midline laparotomy. In the laparoscopic group, 13 were converted to open procedures. Patient demographics were similar across both groups with regard to age, sex, BMI, ASA grade, and tumour stage. Patients in the laparoscopic group had significantly shorter hospital stays [Median = 8 vs. 13 days], higher number of lymph nodes harvested [Median = 22 vs 18]. Postoperative ileus was less common in the open group than in the laparoscopic group [9(7.7%) vs 7(8.3%), P= 1.000]. There was no significant difference in major complications, anastomotic leak, and mortality. Median 5-year DFS for the laparoscopic group was 9.9 months in comparison to 9.7 months. Median OS for the laparoscopic group was 15.6 months compared to 12.3 months in the open group.

Conclusions

Emergency laparoscopic right hemicolectomy seems to be safe with equivalent oncological outcomes to open surgery. Randomized control trials are required to further investigate the role of laparoscopy in emergency surgery for right colon cancers.
SP8.6 Postoperative recovery - is there a psychological impact? Evaluation of psychological impact following emergency surgery
Authors: Kho Jason , Fitzpatrick Stephanie , Ward Jeremy , Date Ravindra , Rajendran Ilayaraja
Published: August 2023

Aim

Undergoing ‘Emergency operation’ (EO) is a stressful event for patients however, the impact on mental health has not been studied. Study aims to evaluate the psychological impact during early postoperative period following EO using the standardised Patient Health Questionnaire-4 (PHQ-4).

Methods

Prospective study from hospital database. Age>18years who underwent emergency general surgical procedures between November-December 2022 were included. Procedures were classed as major(laparotomy) or moderate/minor. Patients were contacted two to four weeks postoperative to answer four questions within PHQ-4, assessing mood, anhedonia, anxiety and nervousness. Frequency of experiencing those negative emotions was graded from 0 (not at all) to 3 (nearly everyday). Data was analysed to identify potential factors associated with higher PHQ-4 scores. P-value<0.05 was statistically significant.

Results

19 patients participated in the survey; 10(52.6%) male and 8(42.1%) female. Median age was 45±40years. Overall, nearly one-third of patients experienced some psychological impact during early postoperative period. 4(5.3%) patients reported feeling nervous, 6(31.6%) reported anxiety, 7(36.8%) reported anhedonia and 5(26.3%) reported feeling low. 2(10.5%) patients reported feeling these emotions nearly everyday. 6(31.6%) patients underwent major surgery. Higher PHQ-4 scores were found in the major group(n=6/19(31.6%), 5±8) vs non-major(n=13/19(68.4%), 3±1; p=0.051). There was a positive correlation between postoperative length of stay and PHQ-4 score (Spearman coefficient R=0.67, p=0.0016).

Conclusion

Psychological impact was more pronounced in patients undergoing major surgery, particularly those with protracted recovery. Although limited by sample size, study reveals the need for formal psychological support for patients undergoing EO.
SP8.8 Necrotising fasciitis: A retrospective single-centre 10-year experience
Authors: Prentice Erin , Geropoulos Georgios , Damaskos Dimitrios
Published: August 2023

Aims

Necrotizing fasciitis (NF) is a life-threatening condition with early diagnosis and goal-directed resuscitation critical to improve perioperative outcomes. The aim of this study is to review our experience and define trends in the incidence, presentation, morbidity, mortality and management of NF cases.

Method

Case notes from 1st October 2012 to 30 September 2022 were retrieved. Data was collected in regard to the patient demographic, risk factors, initial presentation, laboratory findings, surgical approach, length of stay in the intensive care unit (ICU), additional operation requirements and 30-day mortality.

Results

Medical records of 59 patients were reviewed. 58% of patients were male and patient age ranged from 24 to 84 years old with average age of presentation 53.

91% of cases had one or more risk factors identified with 36% of patients being diabetic, and 54% of patients obese. At initial presentation 51% were tachycardic, 46% had a fever and 32% were hypotensive with average CRP 313 and WCC 20. Computerized tomography (CT) was completed prior to surgical debridement in 39% of cases of which 74% of CT scans showed subcutaneous gas. 91% of cases were polymicrobial. 80% of patients required ICU support postoperatively with average length of stay of 9.8 days. 24% required defunctioning stomas and in 39% of cases, VAC dressings were applied. 30-day mortality was 10%.

Conclusion

Necrotising fasciitis carries a significant morbidity and mortality risk. Systemic upset is not always present at initial presentation and clinical suspicion should be increased with high CRP and WCC in the presence of known risk factors.
SP8.11 The EXTEND trial: EXTENDed antibiotics to improve outcomes in patients with complicated Intra-Abdominal Infection (cIAI)
Authors: O'Connor Olivia , Ahmed Shadia , Kirby Andrew , Burke Dermot , Pinkney Thomas , Szakmany Tamas
Published: August 2023

Introduction

Complicated intra-abdominal infections (cIAI) pose a major challenge in surgical patients. Despite the heterogenous aetiology they have a common disease process, which is bacterial infection of the peritoneal space. Hence, all cIAIs are managed with source control, plus antibiotic therapy. However, there is uncertainty regarding the optimal antibiotic treatment strategy in order to prevent relapse or extra-abdominal spread of infection1. At present, there is no UK guidance on the management of cIAIs2. For other serious infections outside the abdomen microbiologists often advise at least 28-days of antibiotic therapy. Currently the effectiveness of extended duration antibiotics in patients with cIAI is unknown. This trial aims to compare the clinical and cost effectiveness of 28-day duration antibiotics with standard care with respect to rate of treatment failure in patients with cIAIs. Secondary outcomes include complications and quality of life.

Method

A multicentre, open label, two-arm, parallel group, pragmatic, randomised controlled trial with internal pilot. A total of 1166 consenting adult patients with cIAI will be recruited over 3 years and randomised on a 1:1 basis between 28-days antibiotics and standard care antibiotics. Patients will be recruited from ICUs and hospital in-patient wards across 30 sites. Recruitment commenced September 2022.

Trial management and funding

EXTEND is sponsored by University of Leeds and hosted by York Trials Unit. It is funded by the NIHR. The Trial Management Group will oversee design and running of the trial. Each site will have a Principal Investigator (PI) with local responsibility. The NIHR Associate PI scheme will be adopted to enable trainees to participate in the trial.
SP9.1 Increasing use of non-operative management in high grade splenic trauma
Authors: Clymo Jonathon , Platt Esther , Tekle Kifle , Kashef Elika , Batting Sarah , Frith Dan
Published: August 2023

Aims

The aim was to review the success of non-operative management (NOM) in the management of splenic trauma at our Major Trauma Centre (MTC).

Methods

We performed a retrospective data collection of all adults presenting to a London MTC with radiological evidence of splenic injury between 2014 and 2021. Electronic patient records were reviewed. Splenic injury was graded by a consultant radiologist. Patients too unstable to undergo a pre-operative CT for radiological injury grading were excluded from the analysis.

Results

Data was available for 337 patients, of which 28 patients went straight to theatre without imaging. 234 (75.7%) patients had AAST grade I-III splenic injury, 52 (16.8%) had grade IV and 23 (7.4%) had grade V injury. Successful NOM was achieved in 88.5% of patients with grade I-III splenic injury, 78.8% grade IV and 26.1% grade V injury. Patients with grade IV injury were more likely to undergo NOM without embolisation compared to grade V injury (OR=13.14, p=0.00058). The proportion of NOM grade IV injury increased significantly from 2017 to 2021 (OR= 16.94, p=0.001). There was also a significant difference between the rate of successful embolisation between grade IV and V splenic injury (OR=9.27, p=0.0003). Of patients undergoing operative management, grade I-III patients had a significantly higher chance of spleen salvage compared to grade IV-V patients (OR=34.5, p<0.00001).

Conclusions

This data demonstrates our increasing confidence in NOM for successful management of high-grade (IV-V) splenic trauma. Further research is required to identify specific patient characteristics associated with successful use of NOM.
SP9.3 A 5-year retrospective review of “Code Red” traumas requiring immediate surgery in a regional major trauma centre
Authors: Winter Jonathan , Canny John , Harbinson Daniel , Yoong Susan
Published: August 2023

Aim

Trauma is a major cause of mortality leading to over 16,000 deaths annually in England and Wales alone. Code red traumas are the most extreme of these and a proportion will require immediate operative intervention. The aim of this study was to review the outcomes of patients presenting to a regional major trauma centre as code red traumas requiring immediate transfer to theatre and to identify a pathway to facilitate this process.

Methods

Data were reviewed for all Code Red Traumas requiring immediate operative intervention between April 2017 and April 2021. Electronic records were searched to identify aetiologies, transfer times and post-operative morbidities and mortalities. Datasets were collected and analysed using Microsoft Excel software.

Results

57 patients were identified and included. The average age was 39 years old. CT was performed in 52/59 patients (88.1%) and median time to CT was 32 minutes. All patients proceeded to theatre with an overall median time to theatre of 144.5 minutes. In hospital mortality was 19.3% (n=11). Primary operating speciality varied with general surgery making up the majority with 30 cases. A consultant surgeon was present in 72% of cases and a consultant anaesthetist in 81% of cases. 84% (n=48) of patients were admitted to ICU post-operatively.

Conclusions

Major trauma remains a significant cause of mortality in our cohort. We have developed a pathway for those requiring direct access to theatre. It is envisaged that this will facilitate expediated transfer to theatre and lead to improved patient outcomes.
SP9.4 Improving time to initial consultant review for emergency general surgery admissions at a major trauma centre
Authors: Ingram-Walpole Shannon , Bailey Rob , Macutkiewicz Christian
Published: August 2023

NHS England’s Seven Day Services Clinical Standards and NCEPOD Guidance recommend 100% of emergency admissions to hospital should receive an initial consultant review within 14-hours of hospital admission. An audit of time for initial consultant review for emergency general surgery (EGS) admissions at a Major Trauma Centre revealed only 75% of patients were reviewed by a consultant surgeon within the 14-hour target, with longest time to review 20 hours and 56 minutes.

Aim

To assess and improve compliance of time to initial consultant review for EGS admissions with the recommended standard by implementing twice daily versus once daily post take ward rounds (PTWR).

Standard

100% of EGS admissions should have a consultant review within 14-hours of hospital admission.

Methods

Retrospective review of admission data and progress notes on the electronic medical record for all patients admitted under EGS from 00:00 Monday 26/9/2022 – 23:59 Friday 30/9/22 (identified from general surgery take list) three weeks post intervention. Data inputted onto a single audit tool and analyzed in Microsoft Excel in comparison to initial audit data (one month prior to intervention).

Results

Twice daily compared to once daily PTWRs improved compliance with the audit standard by 25%; 100% of patients reviewed within 14-hours. Longest time for initial consultant review decreased by 11hr 04min (20hr 56min to 09hr 52min). Number of patients reviewed in the emergency department by a consultant increased from 25% to 50%.

Conclusions

100% of EGS patients can receive an initial consultant review in line with the nationally recommended timeframe with the introduction of twice daily versus once daily PTWRs.
SP9.7 A Quality Improvement Project to Optimise the Emergency Department to General Surgery Referral Process
Authors: Bangi Shifa , Boardman Charlotte , Ihedioha Ugochukwu
Published: August 2023

Introduction

Optimising the process of referrals from the Emergency Department (ED) can improve patient care. Currently, referrals to General Surgery (GS) are accepted by the Senior House Officer (SHO) and Registrar (SpR) on-call. This leads to two ongoing lists of referrals and the possibility of patients being missed. ED uses symphony to track referrals, but GS does not currently use this system.

Method

A survey was sent to all GS SHOs/SpRs to assess the process and tracking of referrals. Symphony was implemented as a virtual system to streamline the referral process. A repeat survey to evaluate the effectiveness of this intervention was conducted 1 month later.

Results

In the pre-intervention survey, 36% of doctors used a paper list to track referrals. The referral system was rated on average as 2.6/5 (1 – terrible, 5 - excellent). 50% reported feeling that patient safety had been compromised >5 times in the last month due to miscommunication between ED and GS. In the post-intervention survey, there was a significant decrease in the number of times patient safety was reported as being compromised in the last month (p=0.047). Pre-intervention, the theme of the majority of suggestions for improvement included an electronic system for tracking referrals, whereas post-intervention, most suggestions were about the history/ investigations done for each referral.

Conclusion

The use of the same system, symphony, by ED and GS has improved patient safety, although the Symphony program itself as well as the quality of referrals could be improved.
SP9.9 Protocolised Care Pathways in Emergency General Surgery: A systematic review and meta-analysis
Authors: Harji Deena , Griffiths Ben , Stocken Deborah , Pearse Rupert , Blazeby Jane , Brown Julia
Published: August 2023

Background

Emergency abdominal surgery is associated with significant post-operative morbidity and mortality. The delivery of standardised pathways in this setting may have the potential to transform clinical care and improve patient outcomes.

Methods

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. Comparative studies reporting on care pathways in emergency laparotomy in adult patients were included. Risk of bias was assessed using the ROBINS-I for non-randomised studies and the RoB-2 for randomised controlled trials. Meta-analysis was performed using a random effects model.

Results

Seventeen studies consisting of 20,927 patients were included, with 12,359 patients undergoing protocolised care pathways and 8,568 patients undergoing standard care pathways. Thirteen unique protocolised pathways were identified, with a median of 8 components (range 6 – 15), with variable compliance of 24-100%. Protocolised care pathways were associated with a shorter hospital stay compared to standard care pathways (SMD -2.028, 95% CI -3.28 – -0.88, p = <0.01). Protocolised care pathways were associated with reduced mortality (OR 0.78, 95% CI 0.71 – 0.86, p<0.00001)) and morbidity (OR 0.80, 95% CI 0.649 – 0.94, p=0.005), including post-operative pneumonia (OR 0.43 95% CI 0.29 – 0.64, p<0.0001) and surgical site infection (OR 0.43, 95% CI 0.29 -0.65, p<0.0001). There were no observed differences in re-operation (OR 1.24, 95% CI 0.72 – 2.16, p=0.44) or readmission rates (OR 1.15, 95% CI 0.83 – 1.59, p=0.41).

Discussion

Protocolised care pathways in the emergency setting currently lack standardisation, however, despite this are associated with short-term clinical benefits.
SP9.13 Biological or synthetic mesh for parastomal hernia repair: An evidence synthesis by a systematic review
Authors: Shafique Muhammad Salman , Tahir Irtesam , Qasim Muhammad , Sains Parv , Baig Mirza Khurrum , Sajid Muhammad S
Published: August 2023

Objective

Parastomal hernia (PSH) is a common colorectal condition which needs surgical repair. The objective of this study is to compare the postoperative surgical outcomes in patients undergoing PSH repair using biological versus synthetic mesh.

Materials and methods

Comparative studies reporting postoperative outcomes in patients undergoing PSH repair using biological versus synthetic mesh were selected from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.

Results

Four comparative studies (one RCT, one retrospective and two prospective studies) on 252 patients were found suitable for meta-analysis according to the inclusion criteria. In the random effects model analysis, surgical site infection rate [risk ratio 0.84, 95%, CI (0.54, 1.31), Z = 0.76, p < 0.46], mesh erosion leading to re-operation rate [risk ratio 1.01, 95%, CI (0.21, 4.89), Z = 0.01, p = 0.99] and PSH recurrence rate [risk ratio 1.06, 95%, CI (0.61, 1.86), Z = 0.21, p = 0.83] were statistically similar between biological mesh and synthetic mesh groups. There was no heterogeneity (Tau2 = 0.00; Chi2 = 1.38, df = 3; (p = 0.71; I2 = 0 %) between included studies.

Conclusion

PSH repair may be performed by using synthetic mesh without higher risk of infective complications and mesh erosion. However, stronger evidence in the form of major, multicentre, randomised, controlled trial is needed before recommending a routine use of synthetic mesh in PSH repair.
SP9.14 “Happy to close?”: The relationship between surgical experience and incisional hernia rates following abdominal wall closure in colorectal surgery
Authors: Smith Laurie , Coxon-Meggy Alexandra , Shinkwin Michael , Cornish Julie , Fegan Greg , Torkington Jared
Published: August 2023

Introduction

There is an association between surgeon volume and outcomes in hernia surgery, yet little evidence regarding impact of the experience of the surgeon performing abdominal wall closure (AWC) on IH rate.

Our aim was to assess the rates of IH at 1 year following surgery between Registrar and Consultant surgeons in patients undergoing elective colorectal surgery.

Methods

Patients undergoing elective surgery for colorectal cancer between 2014-2018 were identified through the Hughes Abdominal Repair Trial (HART). Grade of surgeon performing AWC was categorised into “Trainee” and “Consultant” and compared with IH detected at clinical examination at 1 year following surgery.

Results

663 patients were included. 44% were closed by registrars (n=289). Groups were comparable in BMI, previous surgery and pre-operative IH. The rate of IH in patients closed by registrars was significantly higher than those closed by consultants (20% vs 12%, p<0.01). Patients who underwent AWC by a registrar were 88% more likely to develop IH at 1 year (OR 1.88, 95%CI 1.23-2.86, p<0.01). When comparing AWC methods, IH rates were significantly higher in the Hughes closure arm (20% vs 12%, p=0.03), but not high enough in the mass closure arm to reach significance (21% vs 13%, p=0.05).

Conclusion

Patients who undergo AWC by a registrar have an increased risk of developing IH compared to those closed by a consultant. This work suggests the importance of training during AWC. Further work is needed to determine the impact of supervised and un-supervised trainees on IH rates, but AWC should be treated as training time rather than coffee time.
SP9.15 Rates of COVID-19 infection and mortality following elective surgery at a tertiary NHS Trust in relation to operative caseload
Authors: Lewis-Lloyd Christopher , Humes David
Published: August 2023

Aims

Elective surgery globally has been halted by COVID-19 due to apparent significant mortality rates with changes in planned surgery pathways. This audit examines COVID-19 infection and mortality rates at key intervals throughout the UK COVID-19 pandemic in relation to operative elective caseload at an NHS Trust.

Methods

Prospective cohort of elective surgical patients at a tertiary NHS Trust between March 2020-March 2022, examining three time periods. Period 1: 1st UK Lockdown (April-July 2020). Period 2: 2nd-3rd UK Lockdowns (November 2020-March 2021). Period 3: Omicron wave (December 2021-February 2022). Post-operative PCR positive COVID-19 infection rates within 30-days, proportion fully “double-jabbed” vaccinated, 90-day mortality and any COVID-19 related deaths are reported. Audit registration 20-190C.

Results

Between March 2020-2022, of 50,247 operations, 518 (1.03%) developed COVID-19 infection of which 62 (11.97%) died giving an overall COVID-19 death rate of 0.12%. Between Periods 1 and 3, despite a 53% increase in operations per week (294 to 450) the proportion of COVID-19 infected patients remained similar (1.12% and 1.14%). Between Periods 2-3, despite an almost 6-fold increase in fully vaccinated patients (9.80% to 57.74%), the proportion of vaccinated COVID-19 positive patients increased (4.20% to 55.38%). However, the overall proportion of COVID-19 infections decreased (2.53% to 1.14%) as well as the mortality of those infected (15.97% to 9.23%).

Conclusions

Overall COVID-19 infection and mortality rates are low. These have been maintained despite increases in operative caseload, suggesting further sustained elective surgery can re-commence. This may relate to an increase in fully vaccinated patients undergoing surgery.
SP9.17 Adherence to fluid guidelines in surgical patients and impact on complication rate
Authors: Wong Tiffany , Murugan Veylamuthen , Adiamah Alfred , Sanyal Sudip
Published: August 2023

Aims

Up to 95% of intravenous fluid prescription requests for surgical patients are executed by Foundation Year-1(FY1) doctors. This, notwithstanding the plethora of studies suggesting FY1 doctors are inadequately equipped to be prescribing fluids unsupervised. Poor intravenous fluid therapy is associated with an approximate 20% complication rate, including electrolyte abnormalities, dysrhythmia and fluid overload.

Methods

A closed-loop audit was performed at a large teaching hospital to examine compliance with fluid prescribing guidelines and associated complications. This involved a 4-week retrospective review of drug prescription charts against NICE guidelines followed by a targeted intervention that involved a dedicated teaching session on fluid management in the surgical patient, alongside posters and crib sheets of fluid management on surgical wards. The re-audit using the same criteria compared proportion of prescription errors, over- or under-hydration, and total complications before and after intervention.

Results

308 patient records were reviewed (pre-intervention n=185; post-intervention n=123). Documentation of fluids indication (31% vs 46%(p<0.0414)), contingency plans (3% vs 38%(p<0.0001)) and glucose prescription for nil per os patients on maintenance fluids (10% vs 25% (p=0.0029)) improved post-intervention. Fluid balance monitoring (29% vs 9%(p=0.0001)) worsened. The proportion of patients receiving insufficient potassium (91% both rounds), excess sodium (90% vs 92% (p=0.6212)), and the average rate of complications (1 in 1.67 vs 1 in 1.54, p=0.4652) remained unchanged.

Conclusion

Didactic educational intervention for FY1 doctors on fluid therapy improved documentation on fluids indication, but failed to resolve significant prescription failures and resulted in similar complication rates pre-and post-intervention.