bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.FRI.464 Application of the Oakland score to a real world lower GI bleeding patient population
Authors: McKenzie Emily , Bradley Nicholas , Kynaston James , Torpey Greig
Published: October 2021

Aims

Lower GI bleeding (LGIB) is a significant burden on healthcare resources with an estimated 21120 UK annual admissions. The Oakland score was developed in 2017 and allows patients to be triaged based on clinical and laboratory parameters to predict safe discharge; an Oakland score <8 predicts safe discharge with a 98.4% sensitivity. We aim to describe our experience at applying this scoring system to our practice. 

Methods

This retrospective single centre study included 25 consecutive emergency LGIB referrals to a busy district general hospital. Oakland score was retrospectively calculated from case notes and clinical outcomes followed up. 

Results

The average age of the patient group was 72.8 years, 56% were male. 64% of our patients were referred from ED with the remainder from GP. Mean Oakland score was 16.68. 40% of patients were on anti-platelets or a DOAC. The average length of stay was 2.56 days. 76% of these patients did not receive a blood transfusion and 73% did not undergo any imaging or endoscopy while an inpatient. Only 5 of the patients were sent home directly from the surgical assessment unit. 

Conclusions

Our preliminary real world experience suggests that routine use of the Oakland score will allow for safe rationalisation of inpatient services. Further prospective data collection is required to validate this approach. Our data represents only patients admitted to hospital, therefore the low-scoring patient population is not represented; these patients will be included in prospective analysis.
EP.FRI.472Building the ‘LIEGS’ way – Establishing an ambulatory Rapid Access Theatre Service for those patients with acute surgical pathology requiring operative management
Authors: Amtul Nasira , Ahmad Aman , Mutyavaviri Lindsay , Peckham-Cooper Adam , Toogood Giles , Smith Andrew
Published: October 2021

Aim

LTHT is the largest acute surgical unit in the UK and has seen an annual 11% increase in attendances with often 90 patients assessed daily. 40% patients present with acute biliary pathology but despite this there has been no dedicated operating list for this cohort of patients. Rapid Access Theatre (RAT) lists were created to manage these patients. We report our early results.

Method

In October 2020 the trust appointed four EGS Consultants forming a dedicated acute general surgical service. Emphasis was placed on creating ambulatory pathways and those patients safe to be managed at home but requiring surgical intervention are placed on a day case RAT list. COVID-19 has restricted the broad use of this service for all emergency admissions but biliary pathology continues to be amenable to these pathways. Data was collected retrospectively using in-house coding and electronic patient database systems.  

Results

34 day case laparoscopic cholecystectomies were performed in the first 10 weeks. Mean age was 44(17-67) with a male:female ratio of 1:1. Mean wait time from clinical review to theatre was 11(3-23) days. 1 patient required overnight admission but there were no readmissions and no reported complications at 30 days.  

Conclusion

Despite isolation restrictions resulting from COVID-19, the service has allowed patients to be assessed and treated in a timely, safe fashion. The new service has resulted in significant reductions in bed stays and improved patient experiences. Financial savings have been clearly delineated and as such expansion of the model is underway.
EP.FRI.476 Routine group and save sampling prior to elective laparoscopic colorectal cancer resection – Is it necessary?
Authors: Yang Peiming
Published: October 2021

Introduction

Laparoscopic colorectal cancer resection (LCCS) has been shown to reduce blood loss when compared to open surgery. There are no national guidelines regarding need for pre-operative group and save(G&S) sampling in LCCS patients. Our study aims to assess the necessity of G&S samples through identifying rates of post-operative transfusion following LCCS. 

Methods

Retrospective study of all patients who underwent LCCS between 1st January 2019 and 31st December 2019.

Results

Of 102 surgical procedures, 42 right hemicolectomy, 21 anterior resection, 19 sigmoid colectomy, 12 left hemicolectomy, and 8 APER. The median age was 67(range 56-86) years. All received two valid G&S samples. 13 cases were converted. 

The median pre-operative haemoglobin was 127g/L, and median post-operative haemoglobin was 114g/L. The median blood loss was <100mls. Only 4(3.9%) patients required post-operative transfusion, 3 of whom were converted due to intra-operative bleeding. The fourth case had decreased haemoglobin post-operatively without need for return to theatre. A significant difference was evident in pre-operative haemoglobin level in patients who needed transfusion compared to those who did not (P = 0.031).  

A total of 9 units were transfused. Twenty-one pre-operative cross-matched units were not used.

Conclusion

Evidently, blood transfusion is most likely required in open conversion cases due to intra-operative blood loss, as well as in patients with low pre-operative haemoglobin. A patient specific approach to assessing requirement for pre-operative G&S in elective LCCS patients is required to improve cost-effectiveness, particularly taking into account those with normal pre-operative haemoglobin.
EP.FRI.580 Negative appendectomy rates at a district regional hospital
Authors: Al-Azzawi Marwa
Published: October 2021

Aim

Emergency appendectomy is one of the most common emergency procedures done. Negative appendectomy rates vary and the aim was to identify the rate of it at a DGH.  

Method

Appendectomy cases at a small regional hospital were during a 2-year period (2017-2018) were included.  Elective and interval appendectomies were excluded.  Histopathology findings were noted. 

Results

78 patient had an emergency appendectomy, of which 87% (n = 68) had it done laparoscopically. 

Normal appendix on pathology was found in 13.8% (n = 12) of the removed appendices. They were all removed laprascopically. The majority were females (n = 11) compared to males (n = 1).  58% of the normal appendix (n = 7) were identified as a macroscopically normal appendix.  36% of the females were mid-cycle (n = 4).  The mean WBC on admission was 9.5 (4.8-13.6 x109/L) . All of the females had a transabdominal USS as initial investigation but was inconclusive. 

Conclusion

Negative appendectomy rates are still high in female patients, whether doing further scans such as TVUSS or CTAP might reduce the risks of getting a negative appendectomy, needs to be discussed and tailored to each case, as the majority are young patients in the reproductive age group.
EP.FRI.596 A Tale of Two Ultrasounds
Authors: Blenkharn Christopher , Anwar Baseerat , Rao Praveen , Islam Jawad Ul
Published: October 2021

Background

Testicular torsion is a common cause of acute testicular pain, which requires immediate investigation and treatment. We describe a unique presentation of testicular torsion, which required the operating surgeon to assess the viability of a clinically dead testis through surgical manipulation, 16 hours after onset of pain.

Case Report

A 19 year old male presented with a 12 hour history of pain and swelling in the left scrotum. Examination revealed the left testes was hard, swollen and tender with a palpable spermatic cord. Clinical diagnosis of testicular mass or epididymo-orchitis was suggested and scrotal ultrasound was organised. This reported no blood flow in the left testis, and so torsion was suspected. Patient was taken immediately to theatre. Examination was performed under general anaesthetic, which revealed a hard, swollen testis, with no torsion clinically. Midline scrotal incision was made. On visual examination, left testis was black and hard, but there was no obvious torsion in the cord. However, during manipulation, the testis softened and started to change colour, eventually becoming dusky. A small incision into the testis showed bright red blood, and the decision was made to replace the testis and fix both testes. The patient made an excellent recovery post-operatively. Repeat ultrasound showed return of testicular vascularity.

Conclusion

This case showcases the importance of considering salvage in patients who have presented even after the generally accepted 6-8 hour time window. It also highlights the value of an experienced surgeon’s judgement in unusual presentations and with unexpected events intraoperatively.
EP.FRI.616 Novel Technique of Gastrojejunostomy Tube Insertion to Control Retracted Proximal Stoma
Authors: Allen Neill , McBride Rachael , Wallace William , Lyndsay Richard
Published: October 2021

Introduction

Extensive small bowel resection for ischaemia can require formation of a proximal jejunostomy. Depending on length of remaining jejunum, a major potential complication is stoma retraction with resultant peritonitis, intra-abdominal sepsis and enterocutaneous fistula formation.

We describe a case using a novel technique of inserting a retrograde gastrojejunostomy tube to gain control of an acutely retracted stoma in a 61 year old patient who developed an enterocutaneous fistula shortly after major resection due to ischaemia. 

Method

Under fluoroscopic guidance, the retracted proximal limb of the jejunostomy was cannulated antegradely by guide wire. A gastro-jejunostomy tube was inserted retrograde over the guide wire and the tip placed within the stomach. The proximal tube fenestrations were sited within the duodenum and the balloon was inflated to limit enteric content spilling into the peritoneal cavity. 

Conclusion

This technique enabled drainage of gastroduodenal fluid, minimised spillage into the peritoneal cavity, reduced fistula output and controlled sepsis. This allowed time for nutritional optimisation, better glycaemic control and endovascular revascularisation in preparation for restoration of intestinal continuity at an appropriate time.

This method offered a useful alternative to surgery, in a patient for whom emergency re-exploration of the abdomen would carry significant risk of morbidity or mortality.
EP.FRI.692 Gender differences in the age and outcomes of appendicectomy patients
Authors: Al-Azzawi Yassir , Khan Khurram , Miller Gillian , Lowrie Joanna , Thomas Rachel , Macdonald Andrew
Published: October 2021

Aims

Appendicectomy is one of the commonest emergency General Surgical operations performed. However, there exists minimal published literature exploring whether there are differences between males and females undergoing appendicectomy.  This study aimed to investigate the demographics, pre-operative investigation, intra-operative findings and clinical outcomes between both genders having an emergency appendicectomy.

Methods

A multicentre retrospective cohort study of all patients who had an emergency appendicectomy within four UK hospitals between September 2019 and November 2020. Electronic records were interrogated and patients dichotomised by gender and the results compared.

Results

559 emergency appendicectomies (315 (56.4%) male and 244 (43.6%) female patients) were included.  Males undergoing appendicectomy were younger (median age: 33 vs 41 years, p < 0.001).  American Society of Anaesthesiologists classification was equally matched.  Whilst no difference in mean white cell or neutrophil count was identified, C-reactive protein was lower (mean 108 vs 137, p = 0.001) and bilirubin higher (mean 21 vs 15, p < 0.001) in male patients pre-operatively.  Pre-operative imaging was performed more often in females: ultrasound (16.0 vs 1.3%, p < 0.001) and CT scan (69.3 vs 60.3%, p = 0.029).  Male patients underwent more open surgery (13.7 vs 8.2%, p = 0.043).  The intra-operative severity of appendicitis was equally matched.  No differences in overall hospital length of stay (median 3 vs 3 days, p = 0.183), post-operative complication rates or 30-day readmission rates were identified.

Conclusions

This study demonstrates that differences exist between males and females who have emergency appendicectomy in terms of age, use of pre-operative imaging and operative approach, however, clinical outcomes are similar.
EP.FRI.749 Facial augmentation surgery: Perception vs. Reality
Authors: Saber Kashan , Mumtaz Shadaab , Oikonomou Chrysavgi
Published: October 2021

Background

In recent years, aesthetic surgeries have gained significant momentum. A recent audit identified that more than 28,000 cosmetic surgeries were performed in the United Kingdom (UK) in 2018.1. We present an unfortunate case of morbid complications related to the use of malar implant for cosmesis.

Case Presentation

A 63-year-old Caucasian female presented to the Emergency department with sepsis related to a large painful, tender swelling of the right side of the face. There was discharge of pus from two cutaneous sinuses with additional ectropion/chemosis of the right eye. An orocutaneous communication due to infection/migration of the implant was also noted. The patient reported a history of bilateral malar implants placement three years ago. The patient initially required emergency drainage & subsequent removal of the infected malar implant.

Discussion

Malar implants provide suitable volume enhancement providing structural and aesthetic benefits including the ‘high cheek bone’ appearance. It is generally considered to be a safe surgical technique with multiple approaches possible to insert the implant. including transoral approach). Spadafora (1971) & Hinderer (1972) first described the use of malar implants for facial augmentation.2,3 Rayess et al.(2017) conducted a 10 year review of complications related to facial implants & noted that 75% of complications related to malar implants were due to infection with 38% of these implants needing removal.4

Conclusion

There is a surge in presentations of complications related to cosmetic facial surgery and knowledge of these adverse effects is essential to appropriately manage these patients & their concerns.
EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit
Authors: Stefanova Irena , O'Brien James , Pencavel Timothy
Published: October 2021

Aims

Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. 

Methods

Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged <16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. 

Results

Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p < 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478).

Conclusions

Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.
EP.FRI.815 Hartmann’s at 100: Relevant or Redundant?
Authors: Frakas Nicholas , Conroy Michael , Harris Holly , Kenny Ross , Baig Mirza
Published: October 2021

Introduction

Henri Albert Hartmann first described resection of the rectosigmoid colon and exteriorization of the bowel with a colostomy in 1921. As we approach the centenary anniversary of Hartmann’s procedure we feel it is the appropriate time to discuss this significant surgical advancement and its relevance in modern day surgery.   

Methods

We provide a contemporary overview of the literature, highlighting various aspects of the Hartmann’s procedure applicable to both today’s clinical practice and that of tomorrow.

Results

Hartmann’s procedure was initially performed for colorectal carcinoma in 1921. One hundred years on, the Hartmann’s procedure remains a safe and effective option in select patients with colorectal cancer and at high risk of anastomotic failure. In recent years, the majority of Hartmann’s procedures have been performed for benign disease and the majority of these cases are in the emergency setting. As hospital admissions with acute diverticulitis continue to rise steeply, the importance of the Hartmann’s procedure in the field of surgery continues. Hartmann’s procedure has adapted as surgery has advanced. Hartmann’s is now performed both laparoscopically and robotically with good postoperative outcomes.  

Conclusions

In 1921, few would have predicted how modern day medicine and surgery is today. Hartmann’s procedure has survived the surgical test of time, and its key principles remain the same. As we look to the future, it is unlikely that it’s role will be lost to surgical advances, but to alternative management modalities in disease prevention.
EP.FRI.943 Time to surgical review in NELA patients
Authors: Kenny Laura , Waqas Ahmed , Hall Elizabeth
Published: October 2021

Introduction

The Royal College of Surgeons standards on unscheduled surgical care state that an ST3 or above should review emergency cases within 60 minutes of referral from the Emergency Department (ED).

Method

Data was gathered from all admissions (n = 50), from 01/9/19 to 31/10/19, registered on the National Emergency Laparotomy Audit (NELA).  After exclusions, there were 20 patients who were admitted to surgery from ED.  14 of these had both time of referral and time of review documented.

Results

On average, patients were reviewed 2 hours and 23 minutes after referral.  9 of these patients (64%) were referred overnight (20:00-08:00) and their average time to review was longer; 2 hours and 49 minutes. 7 of all 50 NELA patients (14%) were never referred to surgery from ED.

Conclusion

Limitations include that ED doctors did not document what time patients were referred to surgery, and a small sample size; partially due to poor documentation.

The recommended 60 minutes time to registrar review is not being achieved but data is limited. To improve this, surgical registrars will be asked to document time of referral. Data on time to review will continue to be gathered. An abdominal pain pathway will be introduced to improve ED’s recognition of surgical patients. A re-audit which will encompass patients admitted via ED and ambulatory care, as well as including data on time to decision to operate is currently underway.
EP.FRI.1030 Splenic rupture in an obstructed colorectal cancer
Authors: Gok M A , Shams O , Ftaieh F , Sadat M M
Published: October 2021

Aims

A case report of a splenic rupture resulting from an obstructed sigmoid cancer in a 62 year old patient.  Patient presented with colorectal cancer symptoms, suddenly developed severe abdominal pain and hypotensive shock, a diagnosis of splenic rupture resulted in early surgical intervention (splenectomy, Hartman’s resection).

Conclusion

Atypical presentations could have adversely delayed the diagnosis of splenic rupture. Serial clinical assessments and observations, supported by serological and radiological tests is crucial in the management and can lead to early surgical intervention in an unstable patient.  Prompt resuscitation and imaging facilitated an early diagnoses and surgical management.

CT scan showed large volume of haemo-peritoneum with evidence of splenic rupture. Spleen histopathology was generally normal, with a potential of angiomatosis, but no metastatic disease.

Emergency colorectal cancers still accounts for 20% of all colorectal cancers. Splenic rupture is a rare complication in an obstructed colorectal cancer, but under-reported. Traumatic splenic rupture accounts for approximately 75 % whilst atraumatic represents less than 12 %. Splenic rupture can occur in the presence of splenic neoplasms as either primary or secondary disease.  

This is caused by excessive traction on the spleno-colic ligament causing avulsion and tear of splenic capsule, heamatoma and subsequent spleen rupture. This can be considered as internal trauma to a viscus organ. Awareness of such a mechanism of splenic rupture in an obstructed sigmoid cancer can lead to an earlier diagnosis and get better outcomes, in the absence of trauma.
SP1.1.2Perineal reconstruction following extralevator abdominoperineal excision of rectum - Is IGAP flap a feasible option
Authors: Thambi Prem , Dzihni Wafa Abdul Muiz , Jha Trisha , Siddiqui Haroon , Jha Madan
Published: October 2021

Aim

Extra-levator abdomino-perineal excision for low rectal cancer has been shown to reduce tumor perfoation rates and incidence of local recurrence when compared to a conventional abdominoperineal excision. This is however associated with increased wound complications. This study was done to evaluate the feasibility of an inferior gluteal artery flap in patients undergoing ELAPE.

Methods

This was retrospective analysis was done at tertiary centre for all patients who underwent an ELAPE over a period of 7 years (December 2013 to July 2020). Patient demographic, relevant co morbidities and the data regarding chemotherapy and radiotherapy were analysed.

Results

A Total of 33 patients underwent ELAPE with an IGAP flap wound reconstruction. The mean age was 68 (44-86) with a mean BMI of 27 (25-45). 26 patients out of 33 (82%) received neoadjuvant treatment for cancer. The mean LoS was 11 days (6-31). The perineal wound complications were graded as per Clavein Dindo classification and 56 % had no wound complications recorded. 07/33 had Grade I and 06/33 had Grade II complications.

Conclusion

IGAP flap closure for perineal defects, does offer the advantage of compatibility with both minimally invasive and open procedures and the avoidance of using irradiated tissue. This case series does demonstrate the feasibility of IGAP flaps as viable option to cover perineal defects following radical low rectal cancer surgery with low morbidity.
SP1.1.6Incidence of post colonoscopy colorectal cancer, are we compliant with national guidelines?
Authors: Mohamed Eyas , Srikumar Bhairavi , Shishkin Bronwyn , Kulkarni Nikhil
Published: October 2021

Aims

To investigate the incidence of post colonoscopy colorectal cancer (PCCRC) at a district NHS trust and assess compliance with UK key performance indicators and quality assurance standards for colonoscopy guidelines endorsed by JAG and the ACPGBI

Methods

We conducted a retrospective review of our trust colorectal MDT database to identify patients diagnosed with colorectal cancer in the period between January 2016 till June 2019 who underwent a colonoscopy within 6-36 month prior to their diagnosis with colorectal cancer.

Patient demographics, indication of colonoscopy, date of cancer diagnosis, procedure related factors such as quality of bowel preparation, presence of diverticular disease, prior history of inflammatory bowel disease, previously diagnosed polyps and also grade of endoscopist were extrapolated.

Results

1323 patients were diagnosed with colorectal cancer during the study period, out of these there were 111 patients who underwent a colonoscopy within 6-36 month prior to their diagnostic colonoscopy. After exclusion of cases with anastomotic recurrence (n = 2) and cases with no PCCRC (n = 82), there were 27 patients with confirmed PCCRC in accordance with WEO classification (PCCRC 2.8%, acceptable target 5%)

Upon review of the 27 cases with PCCRC, there was equal gender distribution while the majority were 71-80 years old. There was evidence of diverticular disease in 44% and previous colonic polyps in 48%. The quality of bowel preparation was recorded as good in 25 cases while grade of endoscopist was consultant (n = 24), associate specialist (n = 1), nurse endoscopist (n = 2)

Conclusions

The incidence of PCCRC in our trust falls within national guidelines.
SP1.1.7PBX4 functions as a novel oncogene and promotes angiogenesis in colorectal cancer: A comprehensive analysis of the PBX gene family
Authors: Martinou Eirini , Moller-Levet Carla , Bagwan Izhar , Simpson Guy , Meira Lisiane , Karanjia Nariman
Published: October 2021

Aims

Pre-B-cell Leukaemia (PBX) genes are important in organ development during embryogenesis. To date, four members of the PBX family (PBX1, PBX2, PBX3, PBX4) have been identified to be involved in human cancers, but little is known about their role in colorectal cancer (CRC). The aim of this study was to determine their differential expression, prognostic role and function in CRC.

Methods

Molecular and overall survival (OS) data from 614 patients with CRC were obtained from the National Cancer Institute, Tissue Cancer Genome Atlas (TCGA) database. To investigate the differential PBX gene mRNA expression, we performed a comparative cancer to normal computational analysis in edgeR. To determine PBXs prognostic value, we conducted Kaplan-Meier survival analysis and COX regression, selecting 10-year OS as primary outcome. Lastly, to explore the effect of PBX4 in CRC cell growth and angiogenesis, we performed gene expression modulation experiments using a PBX4-overexpressing plasmid-vector. Cell proliferation and VEGFA angiogenic factor expression were defined as primary and secondary in vitro outcomes respectively.

Results

Among PBXs only PBX4 was significantly upregulated showing a 4-fold increase in CRC vs normal colon (p < 0.0001). Survival analysis showed that only high PBX4 mRNA expression was associated with increased risk for worse OS in patients with CRC (HR:1.3 95%CI:1-1.6, p = 0.02). Functionally, overexpression of PBX4 significantly increased CRC cell proliferation in vitro (p < 0.001) and markedly upregulated the expression of VEGFA (p < 0.0001).

Conclusions

Comprehensive analysis of the PBX gene family identifies that PBX4 may function as a novel oncogene and may promote angiogenesis through VEGFA in CRC.
SP1.2.12A meta-analysis of the impact of rectal washout on local recurrence following anterior resection for rectal cancers
Authors: Hidayat Hena , Connelly Tara , Agarwal Anil , Gill Talvinder , Shanmugam Venkatesh , Etherson Kevin
Published: October 2021

Background

Standardisation of surgical technique in form of total mesorectal excision (TME) and the use of preoperative radiotherapy have led to improved oncological outcomes in rectal cancer. However, the effectiveness of rectal washout in reducing local recurrence (LR) following anterior resection remains debatable. The aim of this meta-analysis was to evaluate the effectiveness of rectal washout in reducing incidence of LR after anterior resection for rectal cancer.

Methods

A literature search of electronic databases including PubMed, Embase, Scopus and Cochrane was performed for studies that compared rectal washout to no washout after anterior resection using TME for rectal cancers. The review included all articles reporting oncological outcome of local recurrence. Meta-analysis was carried out using random effect model.

Results

A total of 5 studies involving 5315 patients were included in meta-analysis. Median follow-up was 60 (range 33–60) months. Overall local recurrence rate was 6.6 % with no significant difference in LR rate between the rectal washout and no washout groups (5.23% vs. 9 %)(P = 0.93; RR 0.97; 95% CI 0.52- 1.83).Similarly in subgroup analysis including prospective studies only no significant difference in LR was seen after washout (P = 0.06) or in group of patients treated with a curative intent(P = 0.50). LR was significantly lower in patients who had a rectal washout with normal saline (P < 0.00001; RR 0.59; 95% CI 0.47-0.74).

Conclusion

This meta-analysis shows that there is no benefit of rectal washout in reducing incidence of local recurrence after anterior resection for rectal cancers.
SP2.1.12Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training
Authors: Beamish Andrew J , Rabie Mohamed , Johnston Maximilian j , Harries Rhiannon L , Mohan Helen , Gokani Vimal J
Published: October 2021

Introduction

Operative cases recording is essential to demonstrate experience. However, indicative numbers may incentivise overstatement or misrepresentation of experience. This study aimed to determine the perceptions of eLogbook use by UK trainees.

Methods

An anonymous online questionnaire was disseminated electronically using a yield-maximization strategy. Mixed methods evaluation of quantitative and qualitative data was used. Based on the results of this survey, a modified Delphi process was conducted within the Council of the Association of Surgeons in Training to develop recommendations for eLogbook improvement.

Results

Analysis included 906 complete responses (34.8% female) from all UK specialities and all training grades. More than two-thirds (68.5%) believed that overstatement of case involvement occurs and almost a third (32.7%) had witnessed overstatement. A fifth (20.8%) witnessed trainees logging cases not participated in, yet few (15.1%) had raised such an issue with a supervisor.

Feeling pressured to overstate involvement and number recorded was reported by more than a quarter (28.6% and 28.1%) of respondents. Almost a third (31.5%) felt that indicative case numbers were not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for training completion were achievable (p = 0.005).

Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity.

Conclusions

Inaccurate operative recording was widely reported, largely in response to perceived pressure to achieve career progression targets. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.
SP2.2.3How to make the perfect tweet: exploring factors which affect retweetability of surgical research
Authors: Mahendran Ashuvini , Perin Giordano , Baker Megan , Hanton Alice , Lumley Emma , Saha Arin
Published: October 2021

Aims

Twitter is a powerful platform for sharing information. Retweets allow users to reach a wider audience quickly. Our aim was to determine what tweet and twitter-account related factors affect the “retweetability” of surgical publications.

Methods

All papers published (in print) in Annals of Surgery, BJS and JAMASurgery in 2019 were selected. We identified each paper’s first appearance on Twitter and analysed characteristics of the posting twitter account and the tweet itself. The association between such characteristics and the number of retweets was investigated.

Results

413 papers were selected. Median number of retweets was 3 (range, 0-121). The first tweet created about a paper was usually from a reader (42%) with only a minority created by the journal (17%) or the authors (20%).

Use of visual abstracts (22/413, p<0.001), pictures (145/413, p<0.001), hashtags (149/413, p<0.001), mentions (183/413, p<0.001), number of followers (p < 0.001), age of twitter account (p = 0.003) and authors as creators of the first tweet (p < 0.001) were associated with higher retweets. When the journal created the first tweet, retweets were also increased (P < 0.001). Posting the title of the paper alone attracted fewer retweets (p < 0.001).

Multivariate analysis confirmed visual abstracts (p < 0.001), hashtags (p=p.008), pictures (p < 0.001) and authors as creators of the first tweet (p < 0.001) were predictive of increased retweetability.

Conclusions

Authors and journals should create the first presence on social media to improve engagement with their papers. Such tweets should use visual abstracts or pictures, relevant hashtags and avoid solely posting the paper title to make their research more widely shared.
SP2.2.12Safety and Quality using GIRFT parameters; the use of hospital coded data as a quality measure
Authors: Fifer Helen , Hussain Muhammad Ibrar , Grey Tamsyn , Saha Arin , Peter Mark
Published: October 2021

Aim

Several indicators measure performance of hospital departments. Despite keeping accurate personal logbooks, surgeons rarely interrogate hospital-level data though these are used nationally (such as on HES databases) to assess performance. This study assessed the accuracy of hospital-level data.

Methods

Patients who were recorded as having had a length of stay (LoS) of > 7 days, readmissions and patients who had a return to theatre were identified. A weekly ‘Safety and Quality (SnQ)’ governance meeting was established where consultant general surgeons assessed and analysed these data. Differences between hospital level data and outcomes after consultant review were compared.

Results

Over a six month study period, there were 306 patients (32 elective, 274 acute) who had a LoS of > 7 days. After review, just 33 patients (13%) had a prolonged LoS due to a complication whereas the majority were due to non-surgical reasons.

There were 789 coded readmissions. Most coded readmissions were actually planned with 318 patients (43%) having an unplanned readmission. There were 47 recorded cases of a ‘return to theatre’ but after review, one-third (15 cases) were for planned central venous access and 22 cases were planned returns.

Conclusions

This responsive and accurate clinical governance system can assess performance beyond standard morbidity and mortality review. Hospital-level data often miss nuance; in this study, most coded readmissions were planned rather than unplanned and these discrepancies may reflect poorly on the department if entered onto national databases. Engagement with these data can help units improve outcomes and accuracy of their performance metrics.
SP3.1.9 Building the ‘LIEGS’ way – The development and delivery of ambulatory surgical services in the busiest acute surgical unit in the UK
Authors: Peckham-Cooper Adam , Giorga Andrea , Amtul Nasira , Ahmad Aman , Toogood Giles , Smith Andrew
Published: October 2021

Background

Managing unplanned surgical care presents enormous challenges to trusts and continues to be resource intensive. Significant patient numbers can be managed in novel ways preventing admission with effective triage to alternative flow streams using outpatient/ambulatory models. Leeds Institute of Emergency General Surgery (LIEGS) reports its early experience.

Methods

Patients requiring assessment or admission from primary care are triaged directly by a consultant. GP’s are offered advice or patients are directed to appropriate assessment/triage pathways. A number of alternative pathways exist depending on pathology and patient demographics. Prospective data for all patients referred are captured and retrospective analysis of outcomes collected. We report our experience from October-November 2020.

Results

Consultant triage and early senior decision-making has streamlined patient pathways and flow. 51%(237) of all GP referrals(465) were assessed primarily in ASC, 8%(36) required advice only and 10%(44) were directed to other specialities. 30%(139) were seen on the Surgical Assessment Unit ward representing a reduction of 70% compared to the previous year. Outcomes from those patients seen in ASC were discharge after imaging (87,18.7%), discharge without imaging (74,15.9%), hospital admission (65,14%), acute operation (63,13.5%), referral to other specialty (64,13.8%) and Rapid Access Theatre for day case operation (32,6.9%).

Conclusion

71.7% of all acute surgery primary care referrals were managed on in an ambulatory fashion providing an invaluable resource. Early senior decision making, a one-stop clinic for investigations and day case Rapid Access Theatre (RAT) lists can significantly improve the patient pathways and experience.
SP3.2.1 Consultant-led Urgent Ambulatory Management of Righted-sided Lower Abdominal Pain: Prospective data collection
Authors: Hussain Mubashar
Published: October 2021

Aims

To study if right lower abdominal pain could be managed safely on ambulatory basis when referred from emergency department or primary healthcare as suspected acute appendicitis to surgical ambulatory unit (SAU).

Methods

Data collated prospectively involving 586 patients, who presented with right iliac fossa/right-sided pelvic pain from january 2019 to January 2021.

Results

0ut of 586 patients, 234 (40%) were admitted and 352 (60%) managed in ambulatory settings after being reviewed by Consulant-lead surgical oncall team. Age ranged from 3 to 92 years. Male to female ratio was 3:2. Their management included clinical history/and examination, urinalysis and blood tests. 157 (44%) patients had scans, 43 (12%) had CT scans and 114 (32%) had pelvic USS the same day or the following morning/day and were reviewed by oncall-surgeons and 107 (30%) patients had repeat blood tests. 39 (11%) out of 352 paitents were admitted the following day review, of which 18 (5%) patients underwent laproscopic appendicectomy (LA) and 8 (2.2%) patients treated conservatively. 9 (1.98%) patients represented with persistent/or worsening symptoms and 5 (1.4%) patients of these had LA and 2 (0.56%) patients had pelvic collection, drained radiologically and 2 (0.56%) had wound infections treated with antibiotics. Complications rate in ambulatory patients compared to in-patients was insignificant, P-value set at 0.05% using Mann-Whitney U test.

Conclusions
SP3.2.15 Patient demographics and outcomes following emergency presentation with a groin hernia; a 15-year retrospective cohort study from the North of England
Authors: Clyde Danielle , Li Lucy , Swan Rebecca , McLean Ross , Brown Leo
Published: October 2021

Aims

Over 70,000 groin hernia repairs are performed in the UK annually. While most are performed in day-case settings, emergency presentation remains common and has a high associated morbidity and mortality. This study aims to report on patient demographics and outcomes following emergency presentation with a groin hernia.

Methods

Data was collected for all patients >18 years admitted acutely with an inguinal or femoral hernia to NHS trusts between 2002-2016 in the North of England. This included patient demographics and operative interventions. Outcomes of interest were thirty-day inpatient mortality and length of stay (LoS).

Results

Overall, 6165 patients presented as an emergency with a groin hernia (76.2% inguinal) over the 15-year study period. There was a male preponderance (n = 4469, 72.5%) with a median age of 73 years (IQR: 58,82). No changes in the distribution of age or gender were noted over the study period. Comorbidity, as measured by Charlson score, increased over time (p < 0.001). Median LoS was 2 days (IQR: 1,5), increasing with age and comorbidity (both p < 0.001). Emergency surgery was performed for 3904 patients (63.3%). The thirty-day mortality rate of 3.1% rose to 3.7% in the subgroup of patients undergoing operative repair and 5.6% in those with associated bowel obstruction. Greater comorbidity and advanced age were again associated with increased mortality (both p < 0.001).

Conclusions

This study highlights changing patient demographics more comorbid patients presenting acutely with groin hernias. These patients must be counselled regarding their increased mortality risk as part of the shared decision-making process.
SP3.2.18 Reducing the negative appendicectomy rate in children as part of the ‘improving emergency surgery’ quality improvement programme: an assessment of outcomes and balancing measures for unintended consequences
Authors: Chitre Vivek , Woods Robert , Lal Roshan
Published: October 2021

Aim

To describe methodology of the quality improvement programme.

To assess outcomes and balancing measures.

Methods

This paper describes how Kotter’s 8-step improvement model was applied in a District General Hospital.

The primary outcome (negative appendicectomy rate) was assessed using GIRFT data over 6 years.

Reducing negative appendicectomies might conceivably result in delayed surgery (with a potentially increased incidence of perforated/gangrenous appendicitis), increased length of stay (LOS) and increased readmissions due to delay-related complications. These were assessed by a retrospective audit of appendicectomies performed over the same 8-week period in 2016 and 2019.

Results

The negative appendicectomy rate in children fell from 16% in 2016-2017 (England average 12%) to 4% in 2017-2018. The improvement was sustained at 6% in 2018-2019 (England average 11%).

The incidence of perforated/gangrenous appendicitis decreased by 6% from 23% in 2016 to 16% in 2019.

Average LOS decreased from 4 days in 2016 to 3 days in 2019.

There was 1 (3%) readmission within 7 days in 2016, and 2 (6%) in 2019. Reasons for readmission were postoperative small bowel obstruction due to omental band adhesion(1) and persistent pain (2). None were caused by delayed operation.

Conclusions

A sustained improvement in negative appendicectomy rate can be achieved by adopting a systematic quality improvement approach.

Against expectations, the reduction in negative appendicectomy rate was associated with a slight decrease in average LOS and reduced frequency of perforated/gangrenous appendicitis.

There was no significant increase in readmissions, and none were due to delayed operations.
SP4.1.1 The impact of the SARS-CoV-2 (COVID-19) crisis on surgical training: a global survey and a proposed framework for recovery
Authors: Yiasemidou Marina , Tomlinson James , Chetter Ian , Biyani Chandra Shekhar , Collaborative REINS
Published: October 2021

Background

The SARS-Cov-2 pandemic had a profound impact on surgical services, potentially causing a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and develop a framework for recovery.

Methods

A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees prior to dissemination.

Results

608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruptions in all aspects of training. The impact was highest for conferences (525/608) and hands-on courses (517/608), but less for in-patient care related training (268/608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (O.R 0.148, 95% C.I -2.443, -1.378) or Australia (O.R 0.097, -2.981, -1.678) (c2= 87.162 p < 0.001). Alternative training resources (webinars: 359/608, educational videos: 234/608) have emerged, although trainees expressed some dissatisfaction with them.

The collective responses generated a five-pillar framework for training recovery: that involved; prioritisation of trainee and public safety; guidance from training stakeholders with the involvement of trainees; prioritisation of training especially the roles of senior surgeons/trainers; provision of access to alternative/new teaching methods and measures to address trainee anxiety.

Conclusions

Training has been greatly affected. The introduction of new teaching methods and focus on training after the pandemic are imperative.
SP4.1.5The use of Faecal Immunochemical Testing (FIT) and Minimal Preparation Computed Tomography (MPCT) during COVID-19 for Urgent Suspected Cancer (USC) referrals in patients with lower gastro-intestinal symptoms
Authors: Tang A M , Chandler S , Reeves N , Silva L , Harris D A , Dhruva Rao P K
Published: October 2021

Aims

The COVID-19 pandemic necessitated introduction of revised diagnostic pathways for assessing Urgent Suspected Cancer (USC) referrals. Combinations of FIT and MPCT were used to manage referrals and prioritise access to clinical services or invasive tests. The effectiveness of these pathways are evaluated in this study.

Methods

All consecutive patients referred from primary care on the USC pathway between 15th March – 15th June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations and timelines and patient outcomes up to 90 days following initial referral.

Results

816 patients across 8 sites in Wales were included in this initial analysis. 52.7% of patients were female with median age 69 (21 – 97) years. Of the 50.7% who had first-line clinical review, 70.5% were virtual consultations. 49.3% had primary investigations, with FIT in 31% of patients and MPCT in 18.3%. This was compliant with locally agreed pathways for 77.3% of referrals. COVID-response pathways achieved a 28.5% reduction in use of colonoscopy as first-line investigation and 84.3% of patients avoided face-to-face consultations altogether during this first wave of the pandemic.

Overall, 5.6% of USC referrals were diagnosed with CRC. Median timescale from diagnosis to treatment for CRC was 82 (4 – 175) days. The NPV for FIT in this cohort was 99.5%. MPCT as the first modality had a NPV of 99%.

Conclusion

A modified investigation pathway maintained cancer diagnosis during the pandemic with improved resource utilisation to that used previously.
SP4.1.6 Introduction of Concentric digital and remote consent into clinical practice during the COVID-19 pandemic
Authors: John Edward St , Loughran Dafydd
Published: October 2021

Introduction

Paper-based consent processes are associated with errors of omission, illegibility and unwarranted variation. During the COVID-19 pandemic the Royal College of Surgeons (England) released guidelines supporting the use of remote consent. The aim was to evaluate the introduction of Concentric, a digital consent application, into clinical practice.

Method

Between April 2020-Jan 2021, Concentric was used optionally for medical consent during registered service evaluations. Data was obtained from Concentric analytics. User and patient feedback was obtained via optional satisfaction surveys.

Results

3417 Concentric consent episodes for 356 unique procedures were performed by 170 clinicians across 16 specialties from 13 healthcare providers. Patients were aged 7-101years, (median 58, IQR 30). Of the completed consent episodes (n = 2799), consent was given; remotely in 23% of episodes, and on the day of surgery in 67%. Consent form information was shared digitally with 82% of patients. Average patient user experience was 8.8 out of 10 (1 very poor - 10 excellent, n = 594). 546/594 (91.9%) patients agreed that Concentric provided all the information they needed to know. Clinicians (n = 23) rated the quality of the consent process with Concentric as 4.8 out of 5 with all supporting the use of Concentric across the Trust.

Conclusion

Concentric has been successfully introduced into clinical practice. Patients and clinicians report high satisfaction scores. Remote consent is feasible and trends in consent practice, such as day of surgery consent can be easily identified and can guide quality improvement work. The introduction of digital consent solutions should be considered for all units.