bluuebunny/crossref_metadata_2025 huggingface dataset:
1135 Evaluation of Management of Fifth Metatarsal Fractures in University Hospitals of North Midlands Fracture Clinics from March to May 2021
Authors: Nasr H , Banks T , Narayana Murthy S , Ali A
Published: August 2023

Aim

The primary objective is to ascertain if fracture clinic follow-up of simple, isolated fifth metatarsal fractures is required, or if discharging patients from Accident & Emergency and Minor Injury Units with clinical advice and a contact number is a safe, cost-effective alternative. We also aim to design a protocol and treatment pathway to enable safe discharge and patient-initiated follow-up (PIFU) where required.

Method

All patients with metatarsal fractures between March and May 2021 had their radiographs, e-records and clinic letters retrospectively reviewed with a one-year follow up. Patients with neuropathy, open fractures and polytrauma patients were excluded. The remaining patients with simple, isolated fifth metatarsal fractures were evaluated.

Results

75 patients with an isolated fifth metatarsal fracture were reviewed across three months, with 165 appointments dedicated to them (in person and via telephone). 72% were treated with a metatarsal shoe and 17.3% with a walker boot. One patient required surgery for non-union. £12,018 was spent by the trust for the above appointments, either in person (£152 per unit) or via telephone (£20 per unit).

Conclusions

Simple, isolated fifth metatarsal fractures should be discharged directly from A&E in a metatarsal shoe with an information leaflet and PIFU. Neuropaths, open fractures or polytraumas should follow a referral protocol which has been designed for our department based on our findings.
1180 Indications for Day One Postoperative Blood Tests After Emergency Appendicectomy
Authors: Kho J , Kuan J Y , Derbyshire C , Ward J , Rajendran I
Published: August 2023

Aim

Appendicitis accounts for 47,000 admissions/year in England, and commonly involves patients aged 10 to 65 years. A cost-effectiveness study was conducted to assess the need for routine ‘day-one postoperative’ (D1) blood tests following ‘emergency appendicectomy’ (EA).

Method

Retrospective review of all EAs was carried out between January 2022 and October 2022. Data was collected from local hospital database. Elective appendicectomies were excluded. D1 blood tests were deemed necessary in complicated EAs, with clear documentation of the indication for blood tests. Costs of blood samples (FBC = £12, U&E, LFT and bone profile = £23 and CRP = £12) were verified by local/national (NICE and CCG) sources.

Results

Fifty EAs were reviewed. 39 (78%) cases were completed laparoscopically, 9 (18%) were laparoscopic converted to open and 2 (4%) were open appendicectomies. 36/50 (72%) patients had D1 bloods, 30 (83%) of which had an uncomplicated recovery. 6 (17%) patients developed postoperative complications; diabetic ketoacidosis (DKA) (n = 1), ileus (n = 2), superficial wound dehiscence (n = 1) and infected intra-abdominal collection diagnosed two weeks post-op (n = 2) (one patient was managed conservatively with intravenous antibiotics and the other underwent radiological-guided drainage). Only 1 (2%) patient (postoperative DKA) had a clear clinical indication for D1 bloods. This translates to potential cost savings of £2350.

Conclusions

Study demonstrates potential significant cost savings if clinicians rationalise blood test requests following EAs. These findings may be extended to other emergency and elective cases. In a resource-constrained environment, it is worth considering the need for postoperative tests, which could influence length of hospital stay and further cost savings.
1258 Audit of Environmental Costs for Bariatric Face to Face Clinics: A Single Centre Study – Interim Findings
Authors: Sow K , Wallace A , Malek H , Kourounis G , Musbahi A
Published: August 2023

Aim

The NHS has committed to delivering a net zero national health system by 2045. Patient travel accounts for approximately 20% of carbon footprint amongst resource use within outpatient appointments. The increased acceptability of digitalized healthcare during the COVID-19 pandemic has helped in reducing this. The study aims to look at the carbon cost of in-person bariatric clinics over a two-month period.

Method

A prospective review of all in-person bariatric clinics in a single high-volume bariatric center was carried out from October 2022 to December 2022. Patient’s postal codes were used to estimate mileage and duration of travel to the hospital via Google Maps. The Centre for Sustainable Healthcare Patient Travel Emission Calculator was used to estimate carbon dioxide emissions of different travel modes. Calculations were adjusted for the number of people attending with the patient and mode of travel.

Results

Between October and December 2022, there were a total of 48 in-person bariatric clinics. Of which, 87.5% traveled by car and 4.2% by bus or taxi. The total distance traveled was 2727 km, equivalent to 58.5 hours of travelling time. The total CO2 emissions and estimated travel-related costs were 277.4 kg and £534.98. Travels by car had the highest impact on travel costs and carbon emissions, followed by taxi and bus.

Conclusions

Significant cost and emission reduction could be potentially achieved by remote consultation rather than in-person clinics. Data collection is ongoing with the aim of collecting information from at least 100 patients.
1169 Zinc and Copper Deficiency in Bariatric Patients: Time to Revise Guidelines?
Authors: Kainth R , Burton K , Sufi P
Published: August 2023

Aim

The number of bariatric surgeries performed is increasing due to the rising incidence of obesity. It is known that mineral deficiencies can occur in the postoperative period for these procedures. We examined the prevalence of zinc and copper deficiencies before and after various bariatric procedures, with the aim of assessing the relevance of current recommendations, specifically the American Society for Metabolic & Bariatric Surgery (ASMBS) and the British Obesity and Metabolic Surgery Society (BOMSS) guidelines, regarding monitoring and supplementation.

Method

We retrospectively analysed data of 327 patients who underwent one of three bariatric operations: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and mini-gastric bypass (MGB) between January 2018 and December 2019. Copper and zinc serum levels prior to surgery, and at 3-, 6-, and 12-months post-operation were collected.

Results

Preoperatively, 56.7% of patients undergoing bariatric surgery were zinc deficient and 32.4% had hypercupraemia. Twelve months post-surgery, 42.9% of RYGB, 35.3% of SG, and 57.7% of MGB patients with preoperative zinc deficiency presented again with a zinc deficiency requiring supplementation. Only 1 patient displayed copper deficiency preoperatively, and 6 postoperatively.

Conclusions

Screening for zinc and copper deficiencies at 6 and 12 months postoperatively, rather than at 3 months, is a more clinical and cost-effective strategy.
153 The Martin-Gruber Anastomosis: Prevalence and Morphology
Authors: Dennis D , Choudhury B
Published: August 2023

Introduction

The Martin-Gruber anastomosis (MGA) is an anatomical variant characterised by an anastomotic branch between the median and ulnar nerves in the forearm. The MGA can cause changes to the innervation of the hand in 6% to 47.3% of the population. However, this change in innervation remains asymptomatic unless the MGA co-exists with a peripheral neuropathy, such as carpal tunnel syndrome (CTS).

Aim

This study aimed to investigate both the prevalence and morphology of the MGA in a cadaveric population.

Method

Fourteen embalmed right-upper limbs were dissected to the level of the MGA, using standard dissecting techniques, and evaluated for the presence of the characteristics of the MGA.

Results

The results showed the MGA was present in 14.4% (2/14) of the population. One case was found to originate directly from the median nerve. The second case originated from the anterior interosseous nerve.

Conclusions

This study emphasises the need for medical professionals to recognise and understand the implications of the anastomosis on common peripheral neuropathies, particularly CTS, whose co-existence can create unusual innervation of the upper limb.
190 Relationship Between Tumour Characteristics and Margin Involvement for Skin-Sparing vs Simple Mastectomy: A Single Institution Experience
Authors: Cheah W , Ang K S , Ang K L , Rizkalla S , Luther A , Cutress R I
Published: August 2023

Aim

Skin-sparing mastectomy (SSM) are increasingly performed to facilitate breast reconstruction. Published data shows varying rates of margin involvement with SSM. We reviewed the relationship between clinicopathological characteristics and margin involvement after SSM versus simple mastectomy (SM).

Method

Retrospective case-series of breast cancer patients who underwent SM between June 2021-2022 or SSM (Dec 2019-Mar 2022) in a single tertiary centre. Demographic and clinicopathological data were retrieved from Trust systems. Margin involvement was defined as <1mm. Student’s t-test and Chi-square test were used to compare continuous and categorical variables.

Results

Study included 156 patients (n = 59 vs 97 [SSM vs SM]). Patients undergoing SSM tend to be younger (mean age = 47 vs 63, p<0.001 [SSM vs SM]), less often had high grade disease (22% vs 38% G3, p = 0.04) and involved lymph nodes (19% vs 48%, p<0.001), more often had DCIS only (24% vs 15%, p<0.001). Mean tumour size was similar (40.6 vs 38.7mm, p = 0.32[SSM vs SM]) as well as receptor status (61% vs 61% ER+, p = 0.125; 10% vs 18% HER2+, p = 0.21; 12 vs 16% triple negative, p = 0.43 [SSM vs SM]). Both groups had similar tumour margin involvement (8.47% vs 6.19%, p = 0.588).

Conclusions

The SSM cohort tend to be younger, had lower incidence of nodal involvement and higher rates of DCIS. The SSM and SM cohort showed similar mean tumour size, receptor distribution and tumour margin involvement rates. With appropriate planning, SSM does not increase the likelihood of margin involvement.
207 Does Adjuvant Radiotherapy Lead to Increased Survival in Patients with Adenoid Cystic Carcinoma of the Breast? a Systematic Review and Meta-Analysis
Authors: Lastoria D A
Published: August 2023

Aim

Adenoid cystic carcinoma (ACC) of the breast accounts for approximately 0.1% of all breast tumours (Zhang et al, 2021). The aim of this systematic review and meta-analysis was to determine whether adjuvant radiotherapy provides an additional benefit when compared to surgery alone in terms of overall survival in patients with ACC.

Method

A total of 3,330 records were identified and screened following database, conference proceedings, and currently registered studies search. Data from 5 case series was extracted. A random-effects meta-analysis of overall survival (OS) at 1, 2, 3-, 4-, 5- and 10-years post-intervention was performed.

Results

Adjuvant radiotherapy and surgery alone led to similar OS at all points post-intervention. For instance, 5-year survival following use of adjuvant radiotherapy was 92.8% (95% CI: 90.5%-94.7%), compared to 88.7% (95% CI: 81.9%-94.2%) with surgery alone. The confidence intervals overlap, which was the case for all points post-intervention.

Conclusions

Similar OS for both adjuvant radiotherapy and surgery alone (and overlapping confidence intervals), suggest the former may not provide an additional benefit in terms of OS in patients with ACC. Considering the negative side effects of radiotherapy, it could be argued that surgery alone should be used for the treatment ACC. However, this conclusion is hindered by the low number of studies included in this meta-analysis and their low level of evidence. This could be attributed to the low incidence of ACC. Further data should be collected to more reliably determine their optimal treatment.
620 Re-Operation Following Initial Breast Conservation Surgery for DCIS and Invasive Breast Cancer at ELHT Breast Unit, in 2021
Authors: Ahmed A , Jamal S , Yip C
Published: August 2023

Aim

Breast conserving surgery (BCS), as an alternative to mastectomy, in appropriately selected patients with early-stage breast cancer is recommended. Cancer specimens from BCS can be reported as involved or close margins; this finding might increase patients’ future risk of local and distant recurrence.

Association of Breast Surgery advises re-excision of breast if disease is present at radial margins (<1mm). The reported (2014-2018) national re-excision rates for invasive disease and DCIS were 13% and 22% respectively. This audit reviewed our Breast Unit BCS re-excision rates in 2021.

Method

All breast procedures performed at ELHT in 2021 were retrospectively reviewed. Patients who underwent BCS for invasive and DCIS were included in our audit. We examined the total number of patients who required further surgery following BCS, secondary to incomplete excision margin and reviewed their subsequent pathological finding and management following their re-excision surgery. Patients who had incidentally found invasive/ DCIS disease at diagnostic excision were excluded.

Results

633 breast procedures were performed in the study period: 232 were BCS for invasive disease and DCIS. Re-excision rate for invasive disease was 15.1% (31/205) and 33.3% (9/27) for DCIS. Some patients (7.5%) required more than one re-excision surgery. Among these patients, a few opted for completion mastectomy.

Conclusions

We reported a comparable BCS re-excision rate for invasive cancer but higher than national standard re-excision rate for DCIS. This might be explained by the overall small number of BCS for DCIS. We aimed to make changes to our practice and re-audit.
907 An Audit of Breast Ultrasonography in Patients Under 35
Authors: Fagbemi O , Khan M , Jafferbhoy S , Marla S , Narayanan S , Gopalan V , Soumian S
Published: August 2023

Introduction

Breast Ultrasonography (USS) is a major part of the triple assessment for breast presentations in those under 35 years. Currently, most institutions are running targeted separate U-35 clinics. The aim of this study is to audit the outcome of breast USS in patients under 35 years.

Method

Over a 5-month period, December 2021- May 2022, retrospective data was collected across 3 clinics. In total, 300 patients were analyzed.

Results

The age distribution was as follows: 16-20 years (30), 21-25 years (51), 26-30 years (107), 31-35 years (104). Of the 300 patients, 68% of referrals to clinic were for breast lump (fibroadenoma, cysts and on one occasion papilloma), with the 26-30 age group being the majority at 36%. Half of the patients had USS, with the most common indication being lumps, followed by nodularity at 28%. Other indications for ultrasound included: nipple discharge, palpable nodes, eczema, nipple inversion. The radiological findings were fibroadenoma 21% (32), cysts and abscess with 15% (23) and 2.6% (4) respectively. No cancers identified. Fifty four percent had no identified lesions.

Conclusions

Our studies showed that of those referred for USS, only 46% had a lesion detected. No cancers diagnosed. Thus, these targeted clinics are effective in meeting demand for services. To increase efficiency, it might be a worthy consideration to have even clearer guidelines on ultrasonography specifically for patients under 35 years.
703 Parsonage Turner Syndrome After COVID-19 Vaccination – a Systematic Review
Authors: Manoharan G , Gandhbir V , Jose J , Van Liefland M
Published: August 2023

Aim

Parsonage Turner Syndrome (PTS) is a rare acute neuritis usually reported after an antecedent event like surgery, infection, trauma, medication or immunisation. PTS presents as sudden, often unilateral, severe shoulder pain with progressive weakness and altered neurology. The global mass COVID vaccine program has resulted in increased reporting of post-vaccine PTS. The aim of this review is to report the outcomes of PTS after COVID-19 vaccination.

Method

A systematic review was conducted according to the PRISMA statement. An electronic search was performed on Medline, PubMed, Embase and CINAHL databases using the keywords ‘COVID-19’, ‘Coronavirus’, ‘Parsonage Turner Syndrome’, ‘Brachial neuritis’, ‘Neuralgic Amyotrophy’, ‘Vaccine’, ‘Immunisation’ and ‘Shoulder’.

Results

16 articles with a total of 35 patients, 24 males and 11 females, were reviewed. The mean age was 52 years. The median time to develop symptoms was 7 days, with 69% patients reporting ipsilateral symptoms to the vaccinated arm. 91% patients presented with sensory and motor symptoms. MRI scan was normal in 26% while denervation muscle oedema was present in 20%. 37% patients were treated with physiotherapy and rest, while 63% received steroid therapy. 23% showed no improvement while 69% showed partial or complete improvement. The mean follow-up time was 3 months (range one week to six months).

Conclusions

PTS is a rare complication described with vaccines like influenza, tetanus and hepatitis. PTS is also associated with the COVID vaccine. The limited reports suggest the treatment and recovery are consistent with that for other aetiology. This complication is not a reason to avoid the COVID vaccine.
949 ‘Host Stage Migration’ in Newly Diagnosed, Operable Colorectal Cancer During the First Wave of the COVID-19 Pandemic – A Multicentre Comparative Cohort Study
Authors: Brown L R , Gardner E , Thompson J J , McGovern J , Abbass T , Dolan D , Davenport R P , Boardley R S J , McMillan D C , Skipworth R J E , Hendry P O
Published: August 2023

Aim

The COVID-19 pandemic caused immeasurable disruption to cancer pathways across the United Kingdom, resulting in many patients presenting with more advanced stages of disease. This study explores whether migration of ‘host-stage’ was evident amongst patients who underwent resection for colorectal cancer during this period.

Method

Consecutive patients who underwent a potentially curative resection, for colorectal cancer newly diagnosed between 23/03/2020 and 23/12/2020, were identified from prospectively maintained databases. A cohort from the same dates in 2019 were sought for comparison. CT body composition analysis, at the L3 vertebral level, allowed calculation of skeletal muscle index (SMI) and density (SMD). Neutrophil-lymphocyte-ratio (NLR) was selected as a composite marker of systemic inflammation. The primary outcomes of interest were host body composition and systemic inflammatory response.

Results

Overall, 280 patients underwent a colorectal resection during 9-month periods in the COVID-19 pandemic (n = 117) and preceding year (n = 167). Age, ASA, sex, and tumour location were all comparable between cohorts. More patients in the COVID cohort had a T3/4 malignancy (83.6% vs. 67.7%, p = 0.04). Median SMI (42.4 vs. 44.3cm2/m2) and SMD (33.6 vs. 33.1 HU) were similar in COVID and pre-COVID populations. NLR was higher amongst patients during the pandemic (median 3.6, IQR: 2.2-5.8) than those in the previous year (median 3.3, IQR: 2.1-4.6, p = 0.05).

Conclusions

A higher proportion of patients who underwent resection of a colorectal cancer during the COVID pandemic had a locally advanced tumour. While CT-body composition was comparable between cohorts, higher levels of pre-treatment systemic inflammation were evident. This may be suggestive of ‘host-stage’ migration.
1008 Impact of COVID-19 Vaccination-Based Triaging on Recovery of Services for Plastic Surgery Hand Trauma in a Plastic Surgery Tertiary Referral Centre
Authors: Ishak L , Bramhall R , Murphy A
Published: August 2023

Aim

Evaluate the impact vaccination-based-triaging on recovery of operative services.

Method

Data was collected retrospectively on 120 patients who underwent surgical management for closed hand fractures, nerve injuries, and tendon injuries. Forty were in the pre-covid group (Jan-Mar 2019), 40 in the post-covid pre-vaccine group (Jan-Mar 2022), and 40 in the post-covid post-vaccine group (Jul-Sep 2022).

Outcome measures:Average number of days between decision to operate and operation (operative delay)Adherence to operative timing requirements, as set by the British Society for Surgery of the Hand (BSSH)

Results

In the post-covid post-vaccine group, operative delay was shorter than in the post-covid pre-vaccine group for hand fractures (3.6 vs 3.9) nerve injuries (3.8 vs 2.5), and tendon injuries (2.1 vs 2.2). Overall, the difference was not statistically significant (3.3 vs 2.7, p = 0.2526).

BSSH operative timing requirements were met in a higher proportion of patients for hand fractures (93% vs 85%), nerve repairs (100% vs 87%), tendon repairs (89% vs 85%) and overall (89% vs 85%).

In the pre-covid group, operative delay was shorter than both post-covid groups for hand fractures (2.5), nerve injuries (1.8), and tendon injuries (1.4). Overall, the difference was statistically significant compared to the post-covid pre-vaccine (1.9 vs 3.3, p = 0.0024) and pre-covid post-vaccine groups (2.7 vs 1.9, p = 0.0238).

Overall, BSSH operative timing requirements were met for a higher proportion of patients than both pre-covid groups (100% vs 89%).

Conclusions

Plastic surgery hand trauma services have not yet fully recovered. Further interventions are required to aid recovery to pre-pandemic standards.
1030 Impact of COVID-19 on Operative Timing for Plastic Surgery Hand Trauma in a Plastic Surgery Tertiary Referral Centre
Authors: Ishak L , Bramhall R
Published: August 2023

Aim

To evaluate the impact of COVID-19 on operative timing for hand trauma in a plastic surgery tertiary referral centre.

Method

Data was collected retrospectively on 80 patients who underwent surgical management for closed hand fractures, digital nerve injuries, and tendon injuries. Forty patients were in the pre-covid group (Jan-Mar 2019) and 40 in the post-covid group (Jan-Mar 2022).

Outcome measures:Mean number of days between decision to operate and operation (operative delay time)Adherence to the operative timing requirements, as set by the British Society for Surgery of the Hand (BSSH)

Results

There was a statistically significant difference in operative delay time between the pre-covid group and the post-covid pre-vaccine group for hand fractures (2.5 vs 3.9, P = 0.0503), tendon injuries (1.4 vs 2.2, p = 0.016), and overall (1.9 vs 3.3, p = 0.0024). There was no significant difference between the 2 groups for nerve injuries (3.8 vs 1.8, p = 0.3062).

In the post-covid group, BSSH operative timing requirements were met for a lower proportion of patients than the pre-covid group for hand fracture fixations (85% vs 100%), nerve repairs (87% vs 100%) tendon repairs (85% vs 100%). Overall, there was a statistically significant difference between the 2 groups (85% vs 100%, p = 0.0214).

Operative delays were documented as being related to COVID-19 in 100% of patients who did not meet BSSH operative timing requirements.

Conclusions

COVID-19 has had a significant impact on operative timing for plastic surgery hand trauma. Further studies are needed to evaluate the usefulness of various interventions in the recovery of services following the COVID-19 global pandemic.
712 Improving Post-Op Length of Stay (PLOS) in First-Time Coronary Artery Bypass Graft (CABG)- a Closed Loop Audit
Authors: Amo-Afful S , Ali S
Published: August 2023

Aim

To identify and improve our average PLOS for first-time CABG compared to the national average of 7.9 days.

Method

A baseline audit was performed by retrospective analysis of first-time CABG betwen June-August 2022. A re-audit was done in November following recommendations such as encouraging early nurse-led mobilization of post-op patients.

Results

Our cardiothoracic unit recorded an average of 9.4 days after first-time CABG over the period. Major contributors of increased length of stay were attributed to lesser physiotherapy sessions and post-op complications. After interventions, PLOS improved to 8.5 days in the re-audit.

Conclusions

Post-op length of stay can be functionally improved if more staff could encourage patient to mobilize with targets daily. Nurse-led mobilization will reduce the burden on physiotherapist and influence the outcomes of discharge.
1016 A Quality Improvement Project Addressing the Healthcare Dimension of Effectiveness in a Large Cardiothoracic Surgery Department by Ensuring the Contents of the Current Emergency Surgical Chest Drain Boxes Are Correctly Stocked Through Additional Rigorous Checks by June 2022, by Using the Model for Improvement Approach
Authors: Evans N
Published: August 2023

Background

Emergency chest drain insertion on cardiothoracic wards is frequent occurrence due to complications such as pneumothorax. The emergency insertion requires the immediate availability of a significant amount of sterile equipment. A box containing all the equipment on the ward was checked and restocked by the ward nursing staff, however, data suggested missing equipment was prevalent. This has implications for clinical effectiveness, timely intervention, and ultimately patient safety.

Aim

This project establishes the frequency of missing items and aims to reduce this frequency through more rigorous checks of the emergency chest drain box contents.

Method

Retrospective analysis of the box contents was performed over 3 months to establish baseline data. Thoracic surgery doctors completed a questionnaire, before and after the changes, about their experiences with the emergency chest drain boxes and missing items. A revised stock checklist was produced in collaboration with the project champion, the audit lead for thoracic surgery, and the procedural document team. The checklist introduction used transformational leadership. Subsequent completeness data was collected, in addition to a follow-up questionnaire.

Results

There was an 81% reduction in the 3-month average number of reported missing items following implementation; and a 92% increase in perceived confidence that the box will be correctly stocked.

Conclusions

An 81% reduction using two Plan Do Study Act (PDSA) cycles represents an improvement in effectiveness. There are plans to implement a single-use, pre-packed emergency chest drains insertion pack. The ongoing third PDSA cycle introduces the single-use pack, ongoing improvement will be demonstrated with repeat audits.
1053 An Insight into Cardiac Tumours Using Over 20 Years of Up-to-Date Historical Data.
Authors: Navarro A , Hara N , Rossi A , Smith A , Sheaff M , Lawrence D , Oo A , Shipolini A , Yates M
Published: August 2023

Aim

Cardiac tumours are uncommon and frequently incidental findings. The study aims at analysing the demographics, presentation, histological prevalence and outcomes for cardiac tumours over the past 21 years.

Method

An observational retrospective data analysis on an SCTS database of all patients undergoing cardiac surgery at 3 different centres in the UK was performed. Further data was collected through operative summaries, pathology reports and outpatient letters.

Results

207 patients underwent an operation for a cardiac tumour between 2001 and 2022, 66.2% were female and 33.8% male. Mean age was 62 years (17- 86 years). 62.3% were urgent procedures, 21.3% elective and 16.4% emergencies. 44 patients presented with chest pain, 29 stroke, 18 palpitations/arrhythmias, 15 shortness of breath and 7 syncope. In 51 patients the finding was incidental. Average cardiopulmonary bypass time was 80 minutes, and the average cross clamp time was 52 minutes. In 80.2% of cases the left chamber was involved, 10.6% right atrium, 1% left ventricle and 0.5% right ventricle. The final pathological specimen was reported as myxoma in 80.2% of cases, fibroelastoma in 3.9%, thrombus in 7%, sarcoma in 2.9 % and 1% calcified mass. Other histologies included osteosarcoma, lymphoma, granulation tissue, infected mass, cardiac fibroma, and lipoma. In-hospital mortality was 1.5%.

Conclusions

Despite the rarity of cardiac tumours and the lack of presenting symptoms, the study demonstrated that surgical mortality is low and although the overwhelmingly the commonest histology was confirmed to be myxoma, sarcoma is also an important differential as are the other histologies, which may be surprising.
1234 Enlarging Pericardial Cyst Compressing the Right Ventricle
Authors: Kho J , Shan A , Rizzo V , Sabetai M
Published: August 2023

52-year-old Indian builder initially presented to his General Practitioner with exertional breathlessness but no angina. His medical history included previous tuberculosis infection, Type 2 Diabetes Mellitus and hypothyroidism. He was referred to the cardiologist to exclude coronary artery disease.

Stress testing found T-wave inversion in the inferior electrocardiogram leads and transthoracic echocardiogram showed reduced right ventricular (RV) function with basal wall hypokinesia. Cardiac Magnetic Resonance Imaging (MRI) revealed a 5cm x 2.5cm pericardial cyst (Figure 1a). As imaging suggested minimal RV compression and no venous obstruction, the patient was investigated for other causes of breathlessness.

Repeat computed tomography (CT) two years later demonstrated enlargement of the cyst (6cm x 3.6cm) with contrast reflux into the inferior vena cava (IVC) (Figure 1b). Due to worsening breathlessness, surgical excision was offered.

Surgery was attempted through a lower hemi-sternotomy. However, due to limited access to the cyst and thickened pericardium, median sternotomy was performed. The cyst measured 10cm x 7cm and was heavily adherent to the RV wall, right atrium and IVC preventing complete excision. The cyst was therefore unroofed, releasing cheese-like material suspicious of a tuberculous cyst (Figure 2). Adhesiolysis was undertaken to remove remaining cyst wall. Prior to closure, inflamed pericardial tissue was excised.

Histopathology revealed a chronically inflamed pseudocyst with necrotising and non-necrotising granulomatous inflammation. Ziehl-Neelsen, Grocott, Gram and periodic acid-Schiff-diastase stains were negative. Intraoperative and histological findings and history of tuberculosis suggested a diagnosis of tuberculous pericardial cyst.

The patient recovered uneventfully with significant symptomatic improvement at 2-month follow-up.
66 Central Palmar Necrosis Following Steroid Injections for the Treatment of Carpal Tunnel Syndrome - a Case Report
Authors: Hassan M R , Brennan C , George S
Published: August 2023

Aim

Steroid injections are commonly used as a diagnostic tool or an alternative to surgical management of carpal tunnel syndrome (CTS) and are generally safe. Ischaemia is a rare complication with very few cases reported in the literature.

Method

We report a case of a 50-year-old female that presented with a necrotic wound to her left palm one month after a steroid injection into the carpal tunnel. She had a 2-year history of CTS in her left hand that was treated with six previous steroid injections in primary care during this period. The wound evolved from a blister to a necrotic ulcer which led to a painful, hollow defect in the centre of her palm. She did not report any history of trauma, nor did she have any co-morbidities. Clinical photographs were taken.

Results

On examination she had a 0.5cmx1cm defect in the palm of her left hand down to aponeurosis. There was purulent discharge in the wound with surrounding erythema but no spreading cellulitis. She had full function of her fingers but was very tender on movements and at rest.

She was admitted for intravenous antibiotics and underwent a debridement, washout and carpal tunnel release the next day. The defect was packed to heal by secondary intention and has now fully healed one-month following her operation.

Conclusions

This is an extremely rare complication of steroid injections to the carpal tunnel and may have been avoided by earlier referral for surgery rather than treatment using multiple steroid injections.
138 Case Report: Frontal Sinus Mucocele Following Frontal Bone Fracture
Authors: Hassen A , Hundia R , Tighe D
Published: August 2023

Introduction

Giant frontal mucocele of the frontal sinus is a rare benign pathology caused by retention of mucous secretions. They develop when the opening of a paranasal sinus becomes obstructed due to trauma, infection, chronic sinusitis, polyps, malignancy, bony tumours, or congenital anomalies.

This case reports a giant mucocele of the frontal sinus caused by conservative management of frontal bone fracture 30 years ago.

Presenting case

64 –year- old male was referred by his GP to the maxillofacial department after noting a slow growing lesion between his eyebrows resulting in him not being able to wear his glasses. He reported a history of horse-riding trauma 30 years ago, resulting in a frontal bone fracture, which was managed conservatively. This lesion has been slowly growing over 30 years.

Medically he suffers from uncontrolled hypertension and has had a metallic aortic valve replacement and coronary artery bypass grafting.

MRI and CT imaging demonstrates a 2cm cystic lesion consistent with a mucocele with proteinaceous or hyperdense fluid.

Discussion

Fractures of the frontal bone, which involves the frontal sinus, are relatively uncommon injuries, comprising up to 5% of all maxillofacial injuries.

Mucocele development is a long-term complication, which can arise or persist 6 months to decades after. Management of these cases require a joint surgical approach with Ear, Nose and Throat for removal of the mucocele and Maxillofacial for reconstruction of the frontal sinus and frontal bone via endoscopically using a frontal balloon or an osteoplastic flap/spectacle incision.
181 Lessons Learned from Complex Abdominal Wall Reconstruction for the Management of Giant Paraoesophageal Hernia - a Case Analysis
Authors: Yip J , Hicks G , Chan D , Fisher O
Published: August 2023

Aim

In this case report, we present a new method in the management of a giant hiatus hernia: the use of crural relaxing incisions. This new method in combination with previously known strategies including botox and preoperative optimisation for surgery with weight loss and prehabiliation can result in a more effective surgical hiatus hernia repair and subsequently lead to a reduced risk of hiatus hernia recurrence.

Case Presentation

71yo man admitted to hospital with a one-week history of generalised abdominal pain, nausea, vomiting and chest pain. He had a background of a known large hiatus hernia for the last 10 years. An abdominal CT showed a large type IV hiatus hernia containing the stomach, transverse colon, pancreatic body, and pancreatic neck.

CT guided botulinum toxin A injections were given by interventional radiology during which the muscle bellies of the transversus abdominus, internal and external obliques were targeted. The patient was placed on a meal replacement (Optifast) diet.

A laparoscopic thoraco-abdominal hiatus repair was performed finding a giant hiatus hernia containing the entire stomach, first part of the duodenum, left lobe of liver, transverse colon, small bowel and distal pancreas. Due to the size of the hiatus hernia and the potential tension likely to result from a repair, both right and left crural relaxing incisions were made to facilitate closure. Crural closure was reinforced with a Bio A mesh secured in a C configuration covering the right crural relaxing incision. The patient recovered well postoperatively. Follow up imaging did now show recurrence.
222 Pediatric Pulse Oximetry to Monitor the Post-Operative Integrity of Free Flaps
Authors: Scampos M , Brady C , Nikkhah D
Published: August 2023

Introduction

The post-operative monitoring of free-flaps can be a challenge, particularly for junior staff on-call and in patients with darker or mottled skin. We present a case employing paediatric pulse oximetry to monitor a free flap where clinical assessment was challenging, illustrating its value as an adjunct to existing techniques such as doppler.

Case

A 23-year-old patient underwent tenolysis to his anterior right leg compartment due to a painful, tethered scar following injury. He subsequently had a superficial circumflex iliac perforator (SCIP) flap anastomosed end-to-side to his posterior tibial artery. The operation was technically challenging, but the flap had a strong doppler and remained clinically well until day 4 post-op, where it became mottled but remained warm and soft. Clinical assessment was equivocal, and a paediatric pulse oximeter was taped to the flap, consistently showing saturations >95%, providing reassurance out-of-hours and facilitating the decision to delay haematoma evacuation for the following day. The flap survived and the patient did well.

Conclusions

The use of paediatric pulse oximetry to assess free flaps is a useful technique for clinically ambiguous cases where re-exploration could compromise survival. It is cheap, widely accessible and can be easily employed by junior clinicians and nurses who may be relatively inexperienced in their assessment of flaps’ clinical condition.
265 Granulomatosis With Polyangiitis Manifesting as Acute Otitis Media: A Case Report and Review of Literature
Authors: Aboulhosn R , Cooper F , Ah-See K
Published: August 2023

Granulomatosis with polyangiitis (GPA) is a rare necrotising vasculitis of unknown aetiology affecting small and medium-sized vessels of the upper respiratory tract, lungs, and other organs. It is the most common anti-neutrophil-cytoplasmic-antibody (ANCA) associated vasculitis disorder. While otologic manifestations are identified in up to 70% of cases, it is occasionally misdiagnosed in this cohort of patients. We present a case of GPA which initially manifested as isolated acute otitis media. A 52-year-old female with a history of type 2 diabetes presented with a 6-week history of bilateral otalgia, otorrhea, and hearing loss. She denied facial paresis, sensory deficit, arthralgia, myalgia, visual symptoms, rashes, or diarrhoea. Examination revealed a right tympanic membrane perforation and an erythematous left tympanic membrane. The patient was treated with different courses of oral and topical antibiotics for a diagnosis of otitis media with effusion, to no avail. Subsequent serum analysis revealed a C-ANCA pattern, in keeping with GPA. The patient is being treated accordingly and is making stable progress. Less commonly, GPA may manifest as isolated otolaryngologic symptoms as seen in this case. Mindfulness of this entity helps reduce the risk of irreversible organ damage and patient morbidity.
428 Progressive shortness of breath in a post CABG patient: Thinking beyond the obvious
Authors: Sain B , Chakraborty R , Varma A , Sarkar K
Published: August 2023

Background

Post-coronary artery bypass graft (CABG) chylothorax is rare accounting for 0.06-0.09% of the cases.

Case presentation

A 62 year old male patient presented with progressive shortness of breath (mMRC grade 1 to 3) for 6 months. He underwent CABG surgery 7 months prior due to ischemic heart disease. Clinical examination supplemented with radiological imaging revealed evidence of progressive bilateral pleural effusion. Pleural fluid aspiration showed bloody appearance of fluid on right side. Lipid analysis of the aspirate confirmed presence of chylomicrons along with a raised triglyceride level(138mg/dL).

Clinical outcome

A diagnosis of right-sided post CABG chylothorax with left sided transudative fluid was made. Patient was managed with ICD insertion on the right side and started on total parenteral nutrition (TPN). This was followed by permissible carbohydrate intake and TPN for 11 days. Gradual decrease in collection was noticed in the follow-up x-ray with no recurrence of symptoms.

Discussion

Most likely that the anterior mediastinal lymphatic chain got injured during the harvesting of internal mammary artery causing leakage of chyle into the thoracic cavity leading to dyspnoea and chest discomfort.

Conclusion

Lipid measurements may be indicated in all patients with undiagnosed pleural effusion in order to rule out chylothorax. Chylothorax can meet criteria of transudate if associated with congestive cardiac failure, cirrhosis, or nephrotic syndrome. However, the colour of pleural fluid is not always indicative of a chylothorax. While most of the patients can be managed conservatively, surgery is recommended if drainage lasts for more than 1-3 weeks, and daily drainage is 200-500mL.
437 Appedicular Endometriosis – a Rare Intra-Operative Finding
Authors: Kaur M , Singh A , Tonsi A
Published: August 2023

Endometriosis is a known gynaecological condition in young women of reproductive age group. It presents with many different symptom complexes, most common presentation being pain abdomen especially during menstruation. Pelvis is the most common site for endometrial deposits. Gastrointestinal endometriosis is rare, appendicular endometriosis is rarer. There have been only a few case reports of endometriosis causing appendicitis.

We came across a case of perforation peritonitis in a young girl with a background history of endometriosis. Patient presented with sign and symptoms of acute appendicitis and on USS was found to have inflamed appendix. During diagnostic laparoscopy she was found to have gangrenous perforated appendix and a hard nodule, which on histopathology revealed endometriosis. Another important fact revealed on histopathology was bleeding into the endometrial tissue. This patient underwent laparoscopic right hemicolectomy. Postoperative recovery was uneventful. Patient was discharged from the hospital on 5th postoperative day.

We did literature research to find out that there have been only two cases reported in the literature of appendicular perforation caused by endometriosis.
504 A Curious Case of a Slow-Growing Intra-Oral Swelling in a Paediatric Patient
Authors: Budhdeo R , Graham A , Vaidyanathan M , Kabban M
Published: August 2023

Background

A 15-year-old male attended the paediatric dental department as an urgent self-referral. Clinical examination revealed a large, firm lesion in the right maxilla which had been slowly increasing in size for the past year. No altered sensation and facial numbness was detected. The upper right central incisor (UR1) was missing however, a primary central incisor was extracted at the dentist three months prior.

Investigations

An orthopantomogram (OPG) at initial presentation illustrated a well-defined radiolucency extending from the upper right first molar (UR6) to the upper left central incisor (UL1) with root displacement of adjacent teeth. A subsequent cone beam computed tomography (CBCT) scan identified a well-defined corticated radiolucency with an area of radioopacity of mixed density in the posterior-medial aspect. Buccal expansion and root displacement in the premolar segment were noted. The unerupted UR1 was extremely displaced, lying horizontal and just inferior to the nasal cavity.

Diagnosis/Management

Differential diagnoses for the anterior right maxilla radiolucency included calcifying epithelial odontogenic tumour, adenomatoid odontogenic tumour and an odontome. The histopathology of the cystic lining taken under general anaesthetic during enucleation and curettage revealed the diagnosis of a calcifying odontogenic cyst.

Discussion

Calcifying odontogenic cysts are very rare developmental lesions occuring due to proliferation of odontogenic epitheluim and scattered nest cells. As in this case, these cysts are usually associated with unerupted/impacted teeth. Awareness of dental eruption timelines is essential in identifying impacted teeth and associated pathology. Slow growing lesions in the maxilla should be identified early and investigated within multidisciplinary teams.
520 Malignant Melanoma: A Rare Primary Bladder Tumour
Authors: Desouky E , Al-Salti W , Jallad S
Published: August 2023

A 60-year-old male patient who has been referred by his GP to our ‘one stop hematuria clinic’ due to episodes of visible hematuria for 3 months.

The patient is Caucasian, non-smoker, drinking alcohol socially with no related family history of cancer. There is no occupational exposure to any carcinogens.

Flexible cystoscopy that showed a dark coloured bladder mass arising from left side of the bladder base. CT urogram that showed evidence of soft tissue lesion in the urinary bladder with upstream mild left hydro-uretero-nephrosis.

TURBT was performed carefully. Following complete resection of the tumour lesion, left ureteric orifice became visible.

The morphology and immunohistochemistry profile were consistent with malignant melanoma. The presence of in situ component indicated a bladder primary origin rather than metastatic deposit.

The case was discussed in our urology Multi-Disciplinary Team (MDT) meeting. Referral for dermatological consultation and radiological correlation were strongly advised in order to exclude any cutaneous or another mucosal primary malignant melanoma. The patient had no suspicious skin lesions.

There was no evidence of soft tissue lesions on CT scans. In addition, further PET CT scan failed to show any other malignant lesions except for the bladder.

After Histopathologic, dermatologic, and radiologic evidence; the diagnosis of primary urinary bladder malignant melanoma was established.

Patient declined radical cystectomy and opted to go for immunotherapy.

After completing a course of Nivolumab and Ipilimumab, patient is on a regular follow up cystoscopy with no evidence of recurrence.
567 Chest Wall Resection for Desmoid Fibromatosis with Neo Rib Reconstruction Using 3D Printing: A Case Report
Authors: Cohen C , Chandrashekara N , Raj Patil V , Hindiskere S , Chinder P S
Published: August 2023

Background

Desmoid fibromatosis, also known as desmoid tumor, is a locally aggressive tumour that develops from fascia and musculoaponeurotic tissue. Chest wall desmoid fibromatoses represent 10-20% of all fibromatoses. Surgery is a successful treatment option for desmoid fibromatosis; however it can be difficult depending on the tumour's location or local spread, and post-resected chest wall reconstruction is becoming a new challenge for surgeons in cases involving ribs.

Method

we present a rare case of chest wall desmoid fibromatosis involving right sided 9th rib in a 35-year-old male, which was discovered due to a thoracic wall mass. The patient underwent wide tumour surgical excision of the 9th and part of the 10th rib. To reconstruct a neo rib 3D printing of the rib lesion with 1:1 ratio was done in order to obtain a good orientation. Two cannulated cancellous screws were fixed between the two ends of the resected ribs. A simple sternal wire was anchored between the two screws and bone cement was moulded similar to the rib architecture over the sternal wire.

Results

Post operatively margins were free and lung expansion was satisfactory. 5 year post operative follow up showed no local recurrence.

Conclusions

This case report sheds light on rare tumour of the rib and provides a comprehensive approach towards its surgical management which includes reconstruction of a neo rib with no major complications.

Implications

This technique has helped in reconstruction of the chest wall with very limited and easily available resources.