bluuebunny/crossref_metadata_2025 huggingface dataset:
744 Indications for Emergency Department Resuscitative Thoracotomy in Blunt and Penetrating Trauma: A Survey of UK Major Trauma Centre Guidelines
Authors: Oliver M , Bennet J , Nassr N , Marson B , Freij R , Brooks A
Published: November 2022

Aim

Traumatic Cardiac Arrest (TCA) is a potentially fatal consequence of penetrating or blunt trauma. Emergency-Department Resuscitative Thoracotomy (ED-RT) is the last resort procedure to restore cardiac output following TCA. This study reviews current UK guidelines of Major Trauma Centres (MTCs) to identify common indications for ED-RT and chest compressions following TCA.

Method

Departmental policies were requested from all UK MTCs. Data was extracted by three reviewers. A planned subgroup analysis was performed for blunt/penetrating trauma.

Results

20 guidelines were identified covering 22 MTCs. All guidelines included recommendations regarding indications for ED-RT.

Time thresholds from loss of output to undertaking RT in blunt trauma were given in 12 (60%) guidelines. Ranging from 5 (25%), 10 (50%) and 15 minutes (10%). Prehospital loss of output was a contraindication for blunt trauma ED-RT in 6 guidelines.

ED-RT in penetrating trauma was indicated within 10 (50%) or 15 minutes (45%) from loss of output. Fewer than 50% of guidelines identified specific contra-indications including massive head injury and asystole.

3 guidelines stated chest compressions were not indicated in TCA. 8 stated that chest compressions may not be contra-indicated and 1 advised chest compressions to be restricted to blunt trauma.

Conclusion

In a survey of UK guidelines, we have found inconsistency in the indications for ED-RT, particularly associated with blunt trauma. A maximum time from loss of output to ED-RT for penetrating trauma of 15 minutes is compatible with most guidelines. This is less consistent with findings for blunt trauma. There is little consensus regarding use of chest compressions.
767 Group & Save- Are They Required for Laparoscopic Appendicectomies?
Authors: White F , Armstrong L
Published: November 2022

Aim

Laparoscopic appendicectomy (LA) is the gold standard surgical management of appendicitis. Serious intraoperative complications, including bleeding, are rare, however in the absence of a local established guideline, it is standard practice to send two group and save (G&S) samples prior to theatre. We aimed to review our post-operative transfusion risk for LA and to establish if routine group and save testing is required as part of the preoperative workup.

Method

All patients who underwent a laparoscopic appendicectomy in a single centre were reviewed over a 3-month period (April- June 2020). Data was retrieved from an institutional database and up to date electronic records were reviewed for operative details and transfusion history.

Results

Forty-three appendicectomies performed during audit window, twenty-one of which were laparoscopic. 100% of cases had a single group and save recorded pre-operatively, with 76.2% having a second sample sent, totalling 37 samples. Zero patients in the cohort required a post-operative transfusion. Average cost of a group and save equals £26, a total cost of £962 over a 3-month period.

Conclusion

Whilst a small study, we have illustrated LA to be a safe procedure with zero incidence of blood transfusion. There are clear benefits of producing a local guideline that G&S are not routinely required for LA, including financial and resource savings, potential reduction in theatre delays, and reduction of workload for staff.
812 Evaluating the Impact of Surgical Subspecialisation on Patient Outcomes Following Adhesional Small Bowel Obstruction
Authors: Stienstra R , Green L , Brown L , McLean R , Crumley A , Hendry P
Published: November 2022

Aim

Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions frequently remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation.

Method

Data was collected for patients admitted acutely with SBO across Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality.

Results

2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance (55.9%), while age and comorbidity increased significantly over time (both p<0.001). The proportion treated conservatively decreased (47.1% vs. 40.4%, p=0.009), as did the time to operation (median 2 vs. 1 day, p<0.001). There was an increased propensity for patients to be managed by gastrointestinal (colorectal & upper gastrointestinal) subspecialists (69.9% vs 51.6%, p<0.001). While a trend towards laparoscopy was evident (p=0.005), particularly amongst gastrointestinal subspecialists, uptake remained limited. Length of stay (p<0.001) and 30-day mortality (p<0.001) have improved over time, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality.

Conclusions

Outcomes following adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.
951 Boerhaave's Outcome in a Single Tertiary Oesophago-Gastric Centre Over 5-Years
Authors: Hashi A , Gutale A , Elnour A , Madhavan A , Singh P , Preston SR , Abbassi-Ghadi N
Published: November 2022

Aim

To present modern day outcomes for Boerhaave's in a single tertiary oesophago-gastric centre.

Method

This study retrospectively analysed the records of consecutive patients diagnosed with Boerhaave's between June 2016 and June 2021.

Results

In this case series (n=18) patients were included, male (n=14) and female (n=4), with a mean age of 61. Treatment was commenced within 24 hours of symptom onset in (n= 7;38.8%), and after (n=11; 61.1%).

All Patients had an OGD performed on arrival in theatre to plan operative management. The site of the oesophageal perforation was identified as: distal third (n=14;77.8%); middle third (n=4;22.2%). Majority of patients were treated surgically (61.11%), with only seven non operatively. Within the surgical group the most common operative technique was primary repair over T-tube with intercostal drains via Thoracotomy (n=8;72.72%), followed by a trans-hiatal primary repair via a laparotomy (n=2;18.18%) or laparoscopy (n=1;9.1%).

There were three major complications requiring unplanned return to theatre. One patient required a redo-thoracotomy, decortication, and evacuation of an empyema. One patient had a consistent leak post primary repair from oesophageal perforation requiring Eso-sponge vacuum therapy for further healing and closure of the tear. Another patient required a revision of feeding Jejunostomy.

There was zero mortality both in hospital and in 30- and 90-days following admission. The average hospital stay was 34 days, of which 11 days was in Intensive care.

Conclusion

With this data, we can conclude that aggressive medical management coupled with surgical management as well as mediastinal debridement and washout resulted in no mortality.
1022 Early Cholecystectomy in the Ageing Population
Authors: Sturges P , Gupta A , Rashid U , Rupasinghe SN , Adjepong S , Parampalli U , Kirby GC , Jain RK , Rink J , Riera-Portell M , Pattar J
Published: November 2022

Background

The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy.

Method

Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality.

Results

41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2–5 days) and the median admission to surgery time was 6 days (range 5–12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation.

Conclusion

Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.
295 Open Minimally Invasive vs Video-Assisted Minimally Invasive Parathyroidectomy for Solitary Adenomas: A Systematic Review and Meta-Analysis
Authors: Saleki M , Abul A , Ashhad Noor M , Alhajri M
Published: November 2022

Aim

To conduct a meta-analysis comparing two minimally invasive techniques; Video Assisted Minimally Invasive Parathyroidectomy (VAMIP) and Open Minimally Invasive Parathyroidectomy (OMIP).

Method

A systematic review and meta-analysis were carried out in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. Databases from MEDLINE, EMBASE, CINAHL identified Randomised Controlled Trials (RCTs), cohort and observational studies that compared VAMIP and OMIP. The primary outcome measures assessed were the VAS score 24 hours after surgery, conversion of the operation to open, failure rates and analgesic consumption. Secondary outcomes were operative time, hospital stay length, and scar length. These studies' data were extracted and statistically analysed.

Results

The literature search yielded 104 studies of which 4 were included, enrolling 903 patients in this analysis. A significant difference was found regarding rates of conversion to open parathyroidectomy between the two groups, with the OMIP group demonstrating fewer conversions (MD= 3.52, CI= (2.04–6.08), P< 0.00001). No statistically significant differences were found between the two groups when comparing VAS score post-op 24hrs (MD= -1.75, CI= (-9.8–6.3) P= 0.67), consumption of analgesia (OR= 0.49, CI= 0.07–3.54, P=0.48) or failure rates (OR= 1.81, CI= 0.58–5.72, P= 0.31). OMIP had quicker operative times and similar complication rates and scar lengths to MIVAP.

Conclusions

OMIP was seen to require less need to convert to open parathyroidectomy with shorter operative times and similar complication rates and scar lengths to MIVAP. More studies are required to evaluate the superior technique for parathyroidectomy.
307 Primary Hyperparathyroidism: Patient Outcomes and Success of Repeated Imaging After Initial Negative Radiological Parathyroid Localisation
Authors: Karunaratne N , Kirkland P , Sathiskumar P , Howlett D
Published: November 2022

Aim

Radiological localisation imaging may achieve gland localisation in primary hyperparathyroidism, thereby allowing minimally invasive surgery. However, initial imaging sometimes fails to identify the abnormal gland. This study explored the outcomes of patients undergoing repeated imaging at our institution, after a negative initial set of scans.

Method

Data was retrospectively collected and analysed for patients undergoing repeated imaging between 2015 and 2020 at an institution providing parathyroid endocrinology services.

Results

45 patients who had repeated localising scans after a first localising scan that was negative, were identified. Of these, 39 did not undergo surgery. 11 out of these 39 patients (28%) had subsequent positive localisation scans, but no particular patient factors were predictive of gland localisation success. A large proportion of patients were managed conservatively, despite repeated sets of negative scans being done. Patients undergoing three or four sets of scans did not have imaging or surgical success.

Conclusion

A dedicated, streamlined parathyroid pathway should be followed whereby patients should be triaged for suitability for surgery prior to repeated imaging. A second set of scans should be offered when patients are unsuitable for conservative management and are willing and fit to undergo surgery. There is no merit to repeating scans more than twice.
461 A Retrospective Audit of the Success Rate and Complications of Parathyroidectomy in Primary Hyperparathyroidism
Authors: Sandhar P , Bidaye R , Ahmed I
Published: November 2022

Aim

Primary hyperparathyroidism (pHPT) is a clinical disorder which presents with hypercalcaemia. The definitive management for such cases is a Parathyroidectomy. Few centres have reported their success rate for this procedure. We conducted a retrospective review to compare the success rate and complications in Parathyroidectomy at our centre.

Method

After approval from the ethical committee, data was collected from the case files of the patients. Inclusion criteria was a Parathyroidectomy performed for pHPT between 2013 and 2020 at our institute. The Data included the demographics with pre- and post-operative Calcium / Parathyroid hormone levels to calculate the success rate. The procedure was defined as successful if the calcium levels returned to normal ranges (<2.6 mmol/L) according to NICE guidelines.

Results

246 pHPT patients with a mean age of 61 years were included. 222 patients (90.24%) had their calcium level return to normal indicating a successful procedure. 24 cases (9.75%) had persistence or recurrence of hypercalcaemia indicating a failure of the surgery. The rate of success was significantly higher (96.84%) in the last 2 years (2019 – 2020) of the audit suggesting an improvement in outcomes.

Five patients (2.03%) out of the 246 had complications related to the surgery. Two patients reported post-operative cord paresis, two had a post-operative neck haematoma and one experienced hypocalcaemia from hungry bone syndrome.

Conclusions

The surgical outcomes especially in the last 2 years are comparable to other specialized centres mentioned in the review. This Audit helps us demonstrate the improvement in the surgical results over the years at our centre.
858 Parathyroid Adenoma Manifesting as Acute Pancreatitis: A Case Report and Literature Review
Authors: Ayathamattam J , Rotherham M , Bosman D
Published: November 2022

Introduction

Pancreatitis is commonplace on the acute surgical take. It is usually caused by gallstones or alcohol excess. Parathyroid adenoma causing hypercalcaemia is a rare cause of pancreatitis.

Case report

Here we describe a case of a 45-year-old gentleman with no past medical history who presented with epigastric pain and vomiting. A CT scan revealed acute pancreatitis. After a normal biliary tree ultrasound scan, the cause was initially proposed to be alcohol although he reported an average intake of only 4–6 units/day. However, on closer inspection of blood tests, it was apparent that he had a severe hypercalcaemia at 3.45mmol/L and a hypophosphataemia. This raised the suspicion of a primary hyperparathyroidism. Accordingly, a parathyroid hormone level was measured and shown to be 90pmol/L! An ultrasound scan of the neck confirmed the underlying cause to be a parathyroid adenoma. Due to the severity of electrolyte imbalances, this adenoma was excised during the same admission. The patient's symptoms resolved, and he was discharged with planned follow up after genetic testing for multiple endocrine neoplasia syndromes.

Literature review

There have been many similar cases reported in the last 10 years but primary hyperparathyroidism causing pancreatitis remains rare. Multiple cases involved recurrent acute pancreatitis before parathyroid lesions were diagnosed.

Conclusion

This case highlights the importance of investigating other causes of pancreatitis where gallstones and alcohol excess have been ruled out. Furthermore, it is pertinent for surgical trainees, who usually check blood tests initially, to be able to interpret electrolyte imbalances in the context of surgical disease.
215 Examining the Benefits of One-To-One African Caribbean Mentoring for Prospective Medical Students
Authors: Carey C , Jordan C , Wheatle M , Edward S
Published: November 2022

Aim

African Caribbean people are underrepresented in UK medical schools. African Caribbean Medical Mentors (ACMM) is a UK registered charity that provides one-to-one mentoring to prospective African Caribbean medical students. Mentors consist of current African Caribbean medical students and doctors. This study aimed to investigate the specific benefits provided by ACMM and the attributes of successful mentoring relationships.

Method

Participants were identified using ACMM's database of mentees and mentors enrolled within the last 3 years and an online questionnaire was distributed via Qualtrics. Questions were scored on a scale between 1 and 10 and participants were asked to explain their rankings.

Results

11 mentees and 7 mentors responded to the surveys. 63.6% and 72.7% of mentees gave a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. All mentees reported satisfaction with their mentor, with 45.5% citing individualised interview practice and 63.6% reporting mentor support and availability as positive aspects of their mentoring relationship.

All mentors reported being satisfied with the program, with 57.1% and 71.4% giving a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. 42.9% of mentors reported that improved methods and proactivity with communication could have improved their mentoring relationship.

Conclusion

This study suggests that one-to-one mentoring between African Caribbean mentors and mentees was helpful during medical school applications. Interview practice proved particularly useful, whilst methods and timescales of communication represent areas for improvement.
226 Temporal Variation in Consent Litigation in General Surgery
Authors: Sebastian A , Wyld L , Morgan J
Published: November 2022

Aim

Issues with consent is one of the most common causes of litigation within General surgery. The guidance surrounding informed consent in surgery has changed following the Montgomery vs Lanarkshire Health Board (2015) court ruling. The aim of this study was to examine the time trends in medico-legal cases related to consent between 2011–2020.

Method

Data on the numbers of litigation cases in general surgery were obtained from NHS resolutions for the period of 2010–2020. Chi-squared analysis was performed using SPSS to compare the proportion of litigation cases that were due to consent before and after 2015.

Results

There were a total of 10,027 general surgery claims made between 2010–2020, of which 580 (5.8%) were related to issues with consent. The number and proportion of claims related to consent rose during the study period, with 208/2817 (3.76%) consent-related cases before 2015, versus 372/3267 (8.12%) after 2015; a 116% increase (p<0.001).

Conclusions

These data illustrate a significant rise in medico-legal claims related to consent in General surgery in the post-Montgomery era. This may be due to legal precedent being established following the Montgomery case, and the increased awareness of these issues as a result.
578 Is the Scope of the Physician's Duty to Warn the Patient About the Risks Associated with a Surgery Sufficiently Clear?
Authors: Kazzazi F , Noton T , Magill H
Published: November 2022

Aim

To critically analyze the concepts and cases that led to the seminal rulings in Montgomery and Sidaway

Method

A medical and legal literature review was performed. Case history was identified and critically analysed to understand the progression of consent law in England.

Results

The physician's duty to warn the patient about the risk associated with medical intervention has been developed through the cases identified to involve:

The process of consent is of chief importance in surgery and yet only a single case (Chester) directly involves consenting during a surgical procedure.

Conclusion

The definition of material risk is expected to cover a plethora of medical interventions from minor procedures to major surgery. It was generated predominantly from non-surgical cases. The physician's scope to disclose risks to patients is broad and encompasses a skillset that incites core clinical skills of empathy, honesty, and information transfer. It has evolved alongside advances in medical and legal judgement, albeit reactively to cases of inadequate care. With regard to its clarity, one has to consider the acceptable boundary of prescriptivism that both respects patient autonomy and creates a transparent working environment. It can be argued that the current scope is not direct enough for healthcare professionals.
723 Should Radiation Exposure and Surgeon Safety Be Considered in Decision Making? a Single Centre Retrospective Analysis of Radiation Exposure During Intra Medullary Nailing of Proximal Femur Fractures
Authors: Noton T , Khanom S , Bagouri E , Abd Wahab EH , Vasireddy A
Published: November 2022

Aim

Short intra medullary (IM) and long intra medullary nails are fixation methods used for proximal femur fractures. Both require fluoroscopic assistance within the operating theatre, therefore exposing the surgeon and patient to ionising radiation. There is minimal literature investigating radiation exposure. Aims of this study are to compare the radiation doses in each procedure and to estimate a normalised dose.

Method

Retrospective data analysis was carried out for patients who underwent surgical management of proximal femur fractures with IM nail fixation over a 3-year-period. Data was sourced using electronic operative records and Sectra PACS imaging software. Radiation dose parameters collected were the cumulative dose in milligrays (mGy), cumulative dose area product (DAP) (Gy.cm2) and time of exposure in minutes and seconds. Statistical analysis was performed using SPSS statistical software.

Results

A total of 108 patients were included in analysis. 42% were treated with a short IM nail (TFNA - Synthes), while 58% had a long IM nail (RAFN, LFNA or TFNA - Synthes). Mean cumulative radiation dose for the short IM nail group was 7.350mGy versus 10.915mGy for the long IM nail (P=0.012). Mean exposure time was 01:32 for short IM nail compared to 02:32 for long IM nail.

Conclusions

The results confirmed a significant difference in radiation dose and exposure time between both procedures. As the radiation exposure in long nails is almost two-fold, we recommend the use of the short IM nail when the fracture pattern and clinical scenario allow.
964 Cheques and Balances: A Five-Year Review of Surgical Settlements
Authors: Clements C , Bezzaa S , Curwen O , Vance-Daniel J , Lewis T , Nehra D
Published: November 2022

Aim

The litigious burden in the NHS has been increasing yearly, costing an estimated £2.5 billion per year in financial settlements. We investigated the causes of general surgical settlements and attributed costs at a district general hospital over a five-year period.

Method

A retrospective analysis of all general surgical claims between 2016–2021 using the NHS Resolutions Case Management System. Selected cases were those which resulted in out of court financial settlements; whilst these claims have been settled, the trust admitted no negligence in each case.

Results

A total of 12 settlements were made with a total cost of £249,918 (£8000-£60,000, mean £20,827). Eight of the claims (67%) related to elective cases with four (33%) emergency cases. Of the total cases, 41% and 33% related to management of gallstones and appendicitis respectively.

The majority of claims (58%) related to delays in treatment with a total cost of £103,500 (£8000-£35,000), accounting for 41% of total settlement costs. Five cases (42%) were due to harm with a combined total of £146,418 (£9000-£60,000), 59% of the total settlement. Of the claims due to harm, 80% suffered recognised complications of the procedure.

Conclusions

Increasing litigation in the NHS over the last decade now accounts for 2% of the total NHS budget. The majority of settlements reviewed here were for avoidable delays in elective treatment, with higher financial settlements for well documented surgical complications related to the consent process. Better access to investigations, earlier clinical review, and reductions in delays to elective surgeries may reduce the financial burden of litigation.
991 5 Year Re-Operation Rates Following Implant Breast Reconstruction: The Ethical Consideration for Individual Patients and Healthcare Systems During a Global Pandemic
Authors: Walshaw J , Nargund A , Wilkins A
Published: November 2022

Aim

To compare the reoperation and implant loss rates following implant breast reconstruction after 3 months and 5 years in a single unit cohort included in the large multicentre iBRA study1.

Method

Patients undergoing implant breast reconstruction for breast cancer or risk reduction mastectomy were recruited as per the iBRA protocol. Electronic patient records were reviewed in December 2021 and reoperation and implant loss was recorded.

Results

The records of 26 patients were analysed, all were recruited to the iBRA study. 3-month implant loss (9%) and reoperation rates (18%) were similar to the initial overall study. By 5 years, implant loss rates and reoperation rates had increased to 19% and 77% respectively. 10 patients (39%) underwent 2 or more further operations during this period, with 3 of these patients requiring 5 operations. We acknowledge this cohort is small and any revision procedures performed outside our trust would be missed.

Conclusions

Following Montgomery Vs Lanarkshire2 and the Paterson Inquiry Report3, it is vital that patients are aware of any material risk during the consent process before surgery. Quoting 3-month implant loss and reoperation rates in isolation is potentially misleading and there is a need for robust real-life data to guide informed consent. Covid-19 related disruption to elective surgery is inevitable4 and difficult prioritisation decisions are required. Patients undergoing breast reconstruction in 2022 may experience similar complications to the 2016 cohort, however access to revision surgery is uncertain.
117 Comparative Study Between Laparoscopic and Open Rectosigmoid Cancer Resection in Two Laparoscopic Naïve Centers in a Middle-Income Country
Authors: Balbola M , El-Ramah AF , Ibrahim AMR
Published: November 2022

Aim

The aim was to compare the short-term, oncologic, outcomes of laparoscopic and open resection for recto-sigmoid /upper rectal cancer in two centers with relatively newly adopted laparoscopic techniques in cancer.

Method

Our patients were recruited from two centers in Damietta, Egypt; one of them is a laparoscopic naïve center which has not introduced MIS surgery until recently and the other has the main laparoscopic experience reserved primarily for benign Upper GI and Bariatric work. 50 patients with recto- sigmoid and upper rectal cancer diseases in the period between December 2016 and December 2018 were included. Patients were randomly divided into two groups: (LR Group: “25 patients”) subjected to laparoscopic interventions, and (OR Group: “25 patients)” subjected to open surgery. Data were collected and Short-term outcomes were analyzed.

Results

The mean operative time was significantly increased in the LR group than OR group (LR 198.88± 18.7, OR 183.4± 20.5 minutes, p =0.01) as well as the hospital stay (LR 8.8± 2, OR 7.4± 2.9 days, p =0.013).

However, LR group was quicker to recover in term of mobilizing early, recovery of bowel function, and early toleration of diet and fluid and this difference was only statistically significant for oral fluid but not for diet (p= 0.078; 0.17 respectively). There was no significant difference between both groups in tumor characteristics as locations, gross tumor morphology, staging, and distance to the distal margin. Also, both groups had comparable intraoperative and post-operative adverse events.

Conclusion

Laparoscopic technique represents a feasible and sound oncological approach and should be considered as standard in low resource setting.
284 Effectiveness of Webinar to Provide an Insight on the UK Surgical Training Pathways for the International Medical Graduates (IMGs) From Lower- & Middle-Income Country (LMIC)
Authors: Karki BB , Gurung D , Bista A , Raj Shrestha O , Limbu R , Malla S , Khanal P , Aryal K
Published: November 2022

Aim

To provide an insight on the UK- Surgical Training Pathways for the International Medical Graduates (IMGs) from Lower- & Middle-Income Country (LMIC's). To eliminate the barriers for the effective and safe patient care.

Method

A webinar “PLAB & Beyond” was organised by Nepalese Doctors Association-UK on 11thDec.2021 to provide an insight on various aspects of NHS and Training application process for Aspiring Surgeons from LMIC's. Virtual sessions were designed to share the first-hand experience by IMG's on varied NHS roles. A tailored session on Surgical Training pathways and application process was delivered by the IMG currently on the General Surgery Training Pathway.

Results

There were 70 participants of various grades joining from 3 different continents. The pre-webinar questionnaire suggested that almost 85% of the IMG's were not oriented regarding the General Surgery Training Pathways. Only 30% had a very limited idea about the Surgical-Portfolio Scoring system. 55% thought it was impossible to get into the Surgical Training Pathway in the UK for an IMG. Post webinar feedback suggested that majority of the attendees (∼95%) acknowledged that the webinar enhanced their understanding of NHS and Surgical Training Pathway meeting the aims & learning outcomes.

Conclusion

As IMGs from LMIC's contribute to major work force in the NHS, proper orientation to the training pathways must be added during local hospital induction. These session in broader sense will also aid to provide improved and equitable surgical care across international health system advocating Global Surgery, the ‘Neglected stepchild of global health’.
584 Characterisation of Global Gastric Cancer Surgery Epidemiology: An International Prospective Cohort Study
Authors: Riad A , Knight S , Skipworth R , Griffiths E , Griffin M , Harrison E
Published: November 2022

Aim

We aimed to characterise the global surgical gastric cancer population and variability in disease presentation across different resource settings.

Method

GlobalSurg3 was a multicentre, international prospective cohort study of patients undergoing surgery for cancer. Primary outcomes were death or major complications (Clavien-Dindo III/IV) within 30 days of surgery. Income levels were defined using the World Bank classification. Patient characteristics, presentation and disease factors were analysed across income levels. Multilevel logistic regression models were used to explore the effect of patient factors on outcomes.

Results

This analysis included 1337 patients from 263 hospitals (high income countries (HICs) N = 712, upper middle income countries N = 289, low and lower middle-income countries (LMICs) N = 336). Most patients presented with gastric adenocarcinoma (81.4%, N=1088) in the distal third of the stomach (43.2%, N=578). Patients undergoing surgery were on average 10 years younger in LMICs compared to HICs (55.4 vs 67.4), and proportion presenting with >10% weight loss was double (64.3%, N=216 vs 30.8%, N=219). Patients in LMICs were twice as likely to require emergency surgery (10.7%, N=36 vs 4.2%, N=30), as did those operated on with palliative intent (21.1%, N=71 vs 11.1%, N=79). Having an increased Eastern Cooperative Oncology Group performance status (ECOG) was associated with significantly increased 30-day mortality (ECOG 2 aOR= 7.99 (2.67–23.94, p<0.001), ECOG 3/4 aOR= 13.31 (4.04–43.89, p<0.001)).

Conclusion

Functional status is independently associated with 30-day mortality after cancer surgery. Variation in outcomes across income levels may be influenced by inherent differences between surgical populations.
261 The Adequacy of Consenting for Inguinal Hernia Repair Relative to Surgeon's Grade of Training
Authors: Quefferus M , El Boghdady M
Published: November 2022

Aim

Inguinal hernia repair is known to be one of the most commonly performed general surgery procedures in the UK. Pre-operative consenting is essential to be aware of potential complications and for patients to make fully informed decisions. We aimed to assess the adequacy of consent for elective inguinal hernia repair in a UK-teaching hospital.

Method

A 4-months retrospective data analysis of consent forms was performed. Elective open and laparoscopic inguinal hernia repairs were reviewed for consent forms, including demographic data, date of surgery, grade of consenting surgeon, re-admissions, and complications.

Results

A total of 132 operations were included, 108 open and 24 laparoscopic. The most commonly recorded risks were bleeding (97%) and recurrence (96%). Serious testicular complications such as testicular artery injury/orchidectomy were consented in 35% of patients. The consultants consented 63% of overall complications, specialist registrars (SpR) 66.9% and senior house officers (SHO) consented the most with 77.1%. Testicular complications were mostly consented by consultants 66.7% vs registrars 16.3% and 12% SHOs. Consultants consented for the fewest complications overall (63.7%). Six patients were readmitted with postoperative complications, 2 were readmitted for orchidectomies, 3 haematoma and 1 had recurrence.

Conclusion

There are significant shortcomings in consenting patients for serious testicular inguinal hernia complications. SHOs consented for the most complications, followed by SpRs then consultants with the least. To mitigate these shortcomings, we would envisage having a standardised format for consenting, including patient information leaflets provided to the patients prior to their operations.
502 Emergency Giant Hiatus Hernia Surgery: Experiences with Post-Operative Complications
Authors: McKechnie I , Alasmar M , Chaparala R
Published: November 2022

Aim

Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair is shown to reduce the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery.

Method

A retrospective study was done looking at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications, and mortality.

Results

Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had symptomatic recurrence of the hiatus hernia that required operative correction either during index admission or a subsequent admission. Median length of hospital stay was 8 days (IQR 5–16). There was a positive correlation between number of complications and length of stay. Post-operative mortality was 9%.

Conclusions

Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.
813 Giant Inginoscrotal Hernias: Considerations for Optimisation of Patient Outcomes
Authors: Madhavan A , Sheng Z
Published: November 2022

Giant inguinoscrotal hernias (GISH) are unique and complex surgical challenges due to their rare presentation in the western world and the high risk of post-repair complications such as abdominal compartment syndrome and multi-organ failure. They are defined as inguinoscrotal hernias that extend below mid inner thigh. Due to the potential complications, optimising these patients throughout their hospital admission is crucial.

Here, we present a 30-year-old Caucasian male who was admitted to our surgical unit in a public health system with a painful giant inguinoscrotal hernia, the complications he encountered and the lessons we learned.

His CT scan demonstrated a strangulated hernia, for which he underwent an emergency open mesh repair. Post-operatively, he experienced severe respiratory compromise due to lower lobe collapse, which was attributed to the concomitant pneumonia present on admission, sub-optimal utilisation of analgesia and loss of domain. The complications were compounded by anxiety about medical intervention which delayed investigations and treatments.

We highlight the importance of early identification of GISH, ensuring cardio-respiratory function is optimised pre- and post-operatively, and a multi-disciplinary approach to improve compliance with treatment including extensive counselling to increase engagement with healthcare services.
1061 Is There Potential for Prevention of Emergency Open Hernia Repairs?
Authors: Yang P
Published: November 2022

Aim

Emergency hernia repairs are associated with increased post-operative complications. We aim to compare symptoms and healthcare contacts prior to surgery in patients undergoing emergency hernia repair to those who underwent elective hernia repair.

Method

Retrospective study of all patients with acutely strangulated/obstructed hernias between October 2019 and October 2021. Emergency repairs were compared with cohort of elective repairs carried out over the same study period.

Results

41 patients required emergency open hernia repairs. The median age was 79(range 44–91) years. 25 were inguinal hernias, 7 para-umbilical, 4 incisional, and 4 femoral. 14/41(35.4%) patients had healthcare consultation for hernia prior to acute presentation. Of these, 11(27.1%) were already awaiting elective surgery.

25/41(60.4%) patients were asymptomatic prior to acute presentation. 28/48(68.7%) patients were not aware of hernia diagnosis prior to emergency surgery.

There was significantly higher presence of hernia symptoms, healthcare contact, and awareness of diagnosis, in the elective patients compared to the emergency group (P<0.05).

There was significantly higher rate of in-patient stay and need for small bowel resection in emergency patients (P<0.001). We found significantly higher rates of wound infection, haematoma/seroma, and urinary retention in emergency repair patients compared to the elective group (P<0.01).

Conclusion

Early diagnosis and hernia repair is required to prevent need for emergency surgery and reduce risks of post-operative complications. Improved patient education regarding early presentation would allow earlier detection and intervention. Lack of symptoms prior to incarceration, however, would hinder early presentation, and therefore potential for emergency surgery prevention remains limited.
323 Post-Take Pause Quality Improvement Project
Authors: Noyes J , Crozier J
Published: November 2022

Aim

To introduce a structured review of important clinical factors on the post-take surgical ward round for each patient, to reduce their risk of adverse events.

Method

In a surgical assessment unit of a district general hospital, QI methodology was used to gather baseline data from 31 post-take interactions; monitoring 13 clinical domains. Additionally, surveys were circulated among staff. Cycle two implemented the ‘Post-Take Pause’, a ten-point checklist requiring a consultant signature, with all medical staff receiving information about its use. Cycle three incorporated further involvement of the nursing and advanced nurse practitioner team. The final fourth cycle implemented a revised checklist based on feedback from users.

Results

Baseline data collection and surveys showed that a number of important clinical factors were not being routinely reviewed on the post-take surgical ward round. Areas of particular concern included: medicine reconciliation, venous-thromboembolism prophylaxis, and prescription chart review. Inadequate time for documentation was also highlighted. Cycle two and three reviewed 21 post-take interactions each and found completion of 33% and 66% respectively. Cycle four reviewed 18 interactions with 72% of checklists completed. Common themes identified through the Post-Take Pause included: anticoagulant and steroid use, missed thromboprophylaxis and regular medicines, hyperglycaemia, ECG review and escalation plans.

Conclusions

The Post-Take Pause ensures a consultant led systematic review of important clinical information in the post-take surgical ward round. Our results show that the involvement of the wider surgical team, alongside checklist edits based on feedback, significantly improved the compliance of the Post-Take Pause.
366 Using a Serious Incident and Methods from High Reliability Organisations to Make Communications Safer Between A&E and Surgery
Authors: Gami M , MaCafferty S , Emmanuel J
Published: November 2022

Aim

Healthcare is a high-risk environment and for patients’ safety, requires high reliability. Poor communication is one of the leading causes of healthcare error worldwide and was one of the reasons that led to an adverse event in A&E. High Reliability Organisations (HROs) have set in place effective standards of safety where the probability of serious errors is very low. What translatable features can make the job of a Junior Surgical Doctor receiving patients from A&E safer?

Method

The root cause analysis of the serious incidence was discussed in a Surgical Morbidly and Mortality meeting. Focus groups and observational studies were carried out over a period of 6 months. The results formed the basis of a Task Analysis. A literature review of the evidence of safe communication method was performed and its translatability to healthcare.

Results

A “work as done” against “work as imagined” task analysis of the handover process showed multiple areas of potential “work system” error with references to the SEIPS 101 model. Combining the literature review and task analysis, standardisation (using SBAR), a handover checklist, read-back, dual-modality communication and a handover zone may prove to increase redundancy and slack in the system – making it safer.

Conclusions

There are HRO evidenced methods in making communication safer in healthcare. The aviation industries “sterile cockpit” and “crew management resource” methods are proven and effective. Their use of the above techniques can be implemented in healthcare communication. A designated “Handover Zone” could address potential errors. A QI project is required hereafter.
972 Communication During the Pandemic
Authors: Herron J , Radotra I , Kay A
Published: November 2022

Aim

Since the COVID-19 pandemic facemasks have become compulsory in UK hospitals impacting on the visual and vocal (93%) aspects of communication. This QIP looks at the difference a clear mask made to patients.

Method

ClearmaskTM was used in place of a surgical mask and patients were asked to rate the difference on a likert scale. 100 patients were seen at two appointments, once with a Clearmask and another with a surgical mask. Dragon voice recognition software was used as a control.

Results

95% of patients rated communication better with the clearmask, Patients felt more engaged and were more likely to engage with the clinician. The effect was amplified when English was not the first language.

Conclusions

Clear facemasks improved communication and allow patients to become more engaged in consults and are more likely to allow information to be divulged to a clinician.
66 Multicentre Study on Management of Right Iliac Fossa Pain in Young Females: A Need for Recommendation
Authors: Mackenzie K , Baban A , Elamin A , Shalli K
Published: November 2022

Introduction

Right iliac fossa (RIF) pain in young women remains a diagnostic challenge. It is one of the commonest surgical emergency presentations, however a sub-group of patients have no definitive diagnosis. Current tools used includes observations, routine investigations, ultrasound, and laparoscopy. Specific recommendations for a better management of this cohort are required.

Method

Retrospective multi-centre (two different cultural backgrounds) analysis of females aged 17 to 35 acutely admitted with RIF pain over a five-month period was conducted. The length of stay, current tools used for investigation (including laparoscopy) and cost were calculated. Pregnant women and those with a definitive picture of appendicitis were excluded.

Results

A total of 154 patients with RIF pain were studied. 77 (50%) were sent home within 24 hours. Of the remaining 77 patients, 21 laparoscopies were performed, 10 had positive findings (47.6%), 9 appendicitis and 1 carcinoid tumour. Only two CT scans were performed, both indicated positive cases that required surgery. Patients without a definitive diagnosis had an average hospital stay of 4 days compared to 2 when successfully managed conservatively. Cost calculated for negative laparoscopy was £2915 and £469 for CT scan combined with one-day stay.

Conclusion

This study demonstrated that a sub-group of young females with RIF pain would benefit from early CT scan, to definitively diagnose or rule out appendicitis. This would be more cost effective and help to avoid un-necessary invasive procedure and prolonged hospital stays. Guidelines are needed for more timely diagnosis and optimization of management in this cohort.
214 Laparoscopic Cholecystectomy: Most Primeval and Pervasive Yet Least Congruent
Authors: Kuzman M , Bhatti KM , Islam O
Published: November 2022

Aim

Laparoscopic Cholecystectomy is one of the commonest surgical procedures performed worldwide. However, there is considerable variation in laparoscopic cholecystectomy practice, and a lack of robust data on variations in practices.

Method

A 45-item electronic survey was designed to capture global variations in practice of laparoscopic cholecystectomy. The survey was disseminated to the global community of surgeons performing laparoscopic cholecystectomy through professional surgical and training organizations and social media.

Results

638 surgeons from 70 countries completed the survey. Pre-operatively 5.6% routinely performed an endoscopy to rule out peptic ulcer disease. Cholecystectomy theatre lists were provided acutely by 58.6%, with 61.2% (n=389) performing index admission cholecystectomy for gallstone pancreatitis. Peri-operative practice included the use of prophylactic antibiotics (n=362) and elastic compression stocking routinely by over half of the respondents. However, 69.7% do not use pharmacological DVT prophylaxis preoperatively.

Open juxta umbilical is the preferred method of pneumoperitoneum (n=410, 64.6%). The most common approach to difficult Calot's triangle is retrograde dissection from fundus (49.2%, n= 312). Transection of the gallbladder in the middle and retrograde dissection is practiced by about 18% of surgeons (n=114).

Local anesthetic is instilled into the gallbladder bed by 14.2% of surgeons. Half of the surgeons discharge their patients on the following day, while around 44% would discharge them on the same day.

Conclusions

This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy and stressed on the need for developing consensus guidelines.