bluuebunny/crossref_metadata_2025 huggingface dataset:
SP2.1.3 Effect of laparoscopic sleeve gastrectomy on vasoactivemediators in obese hypertensive patients: A prospective study
Authors: Salman Mohamed , Noureldin Khaled , Issa Mohamed , Badawi Marwa , Tourky Mohamed
Published: November 2022

Introduction

The relationship between obesity and high blood pressure is established; however, detailed pathways for such association are still under research. This work aims to assess the changes in neprilysin, vasoconstrictor and vasodilatory molecules in obese hypertensive patients undergoing laparoscopic sleeve gastrectomy (LSG).

Patients

Prospective study was done on 59 hypertensive obese patients in whom LGS was performed. Blood pressure, as well as blood samples for neprilysin, angiotensinogen, angiotensin II, renin, endothelin-1 “ET-1”, aldosterone, atrial natriuretic peptide “ANP” and B-type natriuretic peptide “BNP”, were assessed before and 15 months after surgery. Patients were divided into two groups according to the remission of hypertension (HTN).

Results

After 15 months, remission of hypertension was seen in 42 patients (71%). The declines in the following measurements were higher in patients with remission than those with persistent HTN: aldosterone (p = .029567), angiotensin II (p < .000001), angiotensinogen (p = .000021), n eprilysin (p = .000601), renin(p = .000454) and endothelin-1(p = .000030). There was a significantly higher incrementin ANP (p = .000002) a nd a n on-significant increment i n B NP (p = .081740).Angiotensin II 15 months after LSG and Δ ANP % were significant independent predictors of persistent HTN.

Conclusion

In setting of LSG, aldosterone, angiotensinogen, angiotensin II, renin and neprilysin were significantly lower in patients with remission of HTN after 15 months than those with persistent HTN, and natriuretic peptides were significantly higher. lower postoperative level of angiotensin II and a larger percentage increment of ANP are independently associated with hypertension remission after LSG.
SP2.2.4 Structured prehabilitation reduces physical deconditioning and improves emotional and physical well-being during neo-adjuvant chemotherapy prior to surgery for oesophageal cancer
Authors: Knight William , Zylstra Janine , White Greg , Lane Andy , Browning Mike , Davies Andrew
Published: November 2022

Introduction

Neo-adjuvant chemotherapy (NAC) prior to oesophagectomy is associated with a decline in cardiovascular fitness, sarcopenia and reduced health related quality of life. This study aimed to determine if a structured exercise programmed mitigated these effects.

Methods

A prospective non-randomised trial compared a standard care pathway to a structured prehabilitation exercise programme undertaken before and during NAC and surgery for oesophageal cancer. Cardiopulmonary Exercise Testing (CPEX), body composition analyses and Health Related Quality of Life questionnaires were performed at multiple time points.

Results

Comparison of the Intervention (n=22) and Control (n=20) groups demonstrated a decline in patient fitness following NAC, measured by VO2peak. This was blunted by 7.86% in patients undergoing the structured exercise prehabilitation program (-21.40% Control vs -13.54% Intervention p=0.02). Fat Free Mass increased (intervention 16.1 vs. 17.3 kg/m2; control 15.4 vs. 14.8 kg/m2, p=0.056) and Fat Mass Index to Fat Free Mass Index ratio (-5.51% Intervention, 10.74% control p=0.043) decreased in the treatment group. An overall improvement in Mental Wellbeing and Cognitive and Emotional function in HRQL after neo-adjuvant chemotherapy was seen in the intervention group.

Conclusion

A structured exercise programme prior to neoadjuvant chemotherapy blunts cardiopulmonary deconditioning, reverses sarcopenia and improves the quality of life in patients undergoing a highly debilitating treatment regimen. Further studies will be needed to validate these findings.
SP3.1.10 The use of predictive severity scoring for lower gastrointestinal bleeding in a tertiary colorectal unit
Authors: Yao Sarina , Balfour James , Boyle Connor , Ventham Nicholas
Published: November 2022

Introduction

Lower GI bleeding (LGIB) has an estimated 1-year prevalence of 10% in the UK, accounting for 3% of emergency surgical referrals. The British Society of Gastroenterology (BSG) recommend risk scoring for LGIB to categorise severity and plan management. Experience in a tertiary colorectal centre suggests this potentially overestimates the severity of bleeding and the requirement for inpatient admission.

Method

Data was retrospectively collected for all patients referred from primary care or emergency departments with LGIB from 01/05/20–01/04/21. Demographics and an Oakland score (OS), recommended in BSG guidelines, were collected. OS >8 suggests admission. Outcomes following referral, including admission, discharge, blood transfusion and radiological/surgical intervention, were assessed.

Results

294 patients were assessed. 176 patients (59.9%) were admitted for further management. The median OS for admitted patients was 12 (IQR 9–17). 30 patients (10.2%) required blood transfusion, 3 required radiological/surgical intervention (1%). 118 (40.1%) patients were discharged. The median OS was 10 (IQR 8–12). 80 patients discharged had a score >8, recommending admission; 4 patients required readmission (5.0%), however, none required intervention. 38 patients were discharged with a score ≤8; again, 4 patients (10.5%) required readmission for LGIB, with none requiring intervention. Fisher's exact test showed no statistical significance between OS and readmission (p=0.22).

Conclusion

Risk assessment scoring recommended admission for a large cohort of patients safely discharged after initial assessment in our centre. A small number required readmission, however, none suffered significant adverse outcomes. Further investigation should assess whether such scoring systems are too cautious for use in specialist colorectal centres.
SP4.2.1 Emergency management of lower GI bleeds: a full-cycle audit of practice at a district general hospital
Authors: Khanderia Esha , Patel Riana , Chandegra Rohit , Gass Harriet , Doshi Akshay , Morsy Hesham , Cheetham Drostan
Published: November 2022

Introduction

Lower GI bleeds (LGIB) are a common cause of emergency surgical admission. National Guidelines on the management of LGIB were published by the British Society of Gastroenterologists (BSG) in 2019. The aim of our audit was to determine whether local practice of managing LGIB adhered to these guidelines.

Method

Our initial audit cycle retrospectively reviewed 47 patients with LGIB who had presented to our Hospital. Subsequently, a departmental teaching session was conducted and posters outlining BSG guidelines were placed on surgical wards and the surgical assessment unit. A re-audit of local practice was prospectively undertaken with 30 patients.

Results

In the initial audit cycle 37/47 (78.7%) patients had a major LGIB (Oakland score >8) where admission is advised. Of these, 6 (16%) were discharged on the same day. Of the 10/47 (21.3%) patients who had a minor LGIB, 6 (60%) were discharged on the same day. In the re-audit cycle, 29/30 (96.7%) patients had a major LGIB and 1/30 had a minor LGIB, none of these patients were discharged on the same day. The re-audit population had a higher rate of inpatient endoscopy, 66.7% vs 14.9%. 50% of unstable patients had a CT angiogram on admission in the re-audit vs 0% patients in the first cycle.

Discussion

Following education, compliance to BSG guidelines improved. Discharges in patients with major LGIB reduced to zero following this audit and more patients received appropriate inpatient investigations. Further work is required to see if change in local practice has an impact on clinical outcomes.
SP10.2.1 The FLIP Study – Fluid Resuscitation in Pancreatitis
Authors: McGovern Julia , Tingle Sam ,   Northern Surgical Trainees Research Association (NOSTRA), Moir John , Robinson Stuart
Published: November 2022

Aim

Acute pancreatitis (AP) is an emergency surgical presentation which can range in severity from mild to life-threatening. Intravenous fluids are the cornerstone of management. However, there is poor quality evidence regarding optimal intravenous fluid administration. We aimed to establish clinical practice regarding intravenous fluid administration in AP and the effect this has on mortality.

Methods

Prospective multi-centre audit of patients with AP. Data was collected on intravenous fluid administration within 72-hours of admission. Primary outcome was 30-day mortality and multivariable logistic regression was used to identify predictors of this.

Results

254 participants were included. Volume of intravenous fluid delivered over the first three days (median and range) are as follows; Day 1=2L (0–10.5L), Day 2=1L (0–5L), Day 3=0L (0–7.5L). Those with severe pancreatitis (Glasgow score>=3) received more fluid; median 5.7L versus 4L in 72hrs (P=0.003). The following factors were significant predictors of 30-day mortality in our multivariable model: age, Glasgow score, CRP, IHD and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality in this model (adjusted OR=0.932;0.766–1.134;P=0.483). However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity (interaction term P=0.042). In the severe pancreatitis group increased volume of intravenous fluid was associated with significant reductions in mortality (OR=0.655;0.459–0.936;P=0.020).

Conclusion

In severe pancreatitis more aggressive fluid prescribing is associated with decreased mortality. This is not the case in milder disease. The lack of published literature regarding the impact of fluid regime on outcomes in acute pancreatitis is reflected by the variation of fluid prescribing.
TU5.4 ‘Learning lessons, inspiring change and driving improvements’ - A review of morbidity and mortality meetings in General and Vascular surgery
Authors: Byrne Hannah , Krishnan Arya , Couderq Delphine , Marcu Vasilica , Paseda Bim , Zayda Ayman
Published: November 2022

Aim

According to RCS/ASGBI guidance all surgeons should regularly attend Morbidity and Mortality meetings (M&Ms), as they are a key activity for reviewing the performance the team and ensuring quality of care. We aimed to review General and Vascular Surgery M&Ms at our site – are they in keeping with guidelines and can improvements be made?

Methods

A retrospective review of General and Vascular Surgery M&Ms was performed. Presentations were assessed against 12 key performance indicators (KPIs) as recommended by RCS/ASGBI. Following audit Cycle 1, a standardized M&M presentation proforma and an M&M outcome form were introduced, with subsequent second and third audit cycles completed.

Results

In comparison to Cycle 1, overall improvements were seen in 9/12 KPIs in both General and Vascular Surgery M&Ms. 100% compliance was demonstrated in both General and Vascular Surgery M&Ms in 7 KPIs. Improvements can still be made in the completion of Clavien-Dindo scoring, NCEPOD classification, as well as M&M outcome forms. Literature review discussions were not included in any General Surgery M&Ms in either cycle and in only 14% of Vascular Surgery cases.

Conclusion

Significant improvement in RCS/ASGBI compliance was demonstrated with the introduction of an M&M presentation proforma. Emphasis and encouragement should still be placed on the importance of literature reviews to promote learning, although we appreciate time limitations can have an impact on this. By improving the quality of M&Ms, surgical teams can learn lessons, inspire change and drive improvements.
TU5.7 The Nutritional Management of Emergency and Elective Surgical Patients – Are we doing enough in the COVID-19 pandemic?
Authors: Desai Chaitya , Hern Daniel , Ghassemi Nader , Veliah Supanki , Rao Vittal
Published: November 2022

Aim

Malnourished patients make poor surgical candidates, with an increased risk of post-operative complications. We assessed the peri-operative nutritional status of patients undergoing elective and emergency general surgical operations.

Methods

Data was collected from 1 September 2021 to 1 November 2021. The inclusion criteria included: underwent surgery for gastro-intestinal pathology, length of stay ≥5 days, and high risk of malnutrition as per the Malnutrition Universal Screening Tool (MUST).

Results

50 emergency patients were identified. In the pre-operative to post-operative period, these patients had a mean albumin decrease from 30.5 to 23.7, against a decrease in CRP of 146 to 105.5, suggesting worsening nutrition rather than worsening inflammation. 48% of these patients had dietician referrals in-place with 54% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral, with wound infection the most common cause (n=4).

50 elective patients were identified. 40% of these patients had dietician referrals in-place with 70% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral with the most common complication being acute kidney injury followed by wound infection.

Conclusion

Optimal nutrition is key to optimal recovery. Most patients with dietician referrals had a plan of oral supplementation. This intervention can be commenced by the immediate surgical team. 56% of patients meeting the MUST tool criteria for high risk of malnutrition had no dietician referral. This can be addressed through early consideration for dietician referral, teaching sessions and educational posters distributed across surgical wards.
TU6.2 A review of feedback on simulation sessions while following Covid-19 SOPS
Authors: Gulnaz Nadia , Siddique Khurram
Published: November 2022

Aims

To assess the usefulness of simulation sessions with social distancing in managing critical issues on a surgical ward.

Methods

Simulations sessions were run from September 2020 to April 2021 for the foundation doctors and medical students following standard social distancing rules and using mannequins for patients. A feedback questionnaire was sent over to the candidates after each session and the data was analyzed.

Results

4 sessions were held with a total of 20 participants. The feedback response rate was 100%. On the Likert scale of 0–10, the majority (Score range 9–10) responded that they were likely to recommend these sessions. 90% were likely to change and improve their daily practice based on their responses.70% rated the sessions as excellent and all the rest as very good no negative response was received. A 100% agreement was seen among all participants on the arrangements to be well co-ordinated and organised.95% found the training staff very helpful.75% of the participants thought the allocated time was just about right while 15% thought it was slightly short. In response to an open question, the majority of participants appreciated the concept of simulation while following social distancing rules and enjoyed the session as a whole.

Conclusions

Overall we received positive feedback. Although the number of participants was limited in each session but positive responses from the participants imply that sessions could be easily carried out with social distancing without compromising the learning outcome. Carrying out more sessions was strongly favored by a vast majority.
WE1.2 Introducing the “Safe-Anastomosis” Checklist to Reduce Overall Anastomotic Leak Rates post Right Hemicolectomies
Authors: Alamin Nadeen , Jeyarajah Maathusha , Cook Esther , Harinath Gandra , Shrestha Ashish
Published: November 2022

Aims

The ‘Safe-anastomosis’ Quality Improvement Intervention has been demonstrated with an overall reduction in anastomotic leak rates post right colectomy. Our study aims to demonstrate this reduction rate at a district general hospital.

Methods

This is a retrospective analysis of post-anastomotic leak rates in the hospital prior to the introduction of the anastomotic checklist as part of an international collaborative study (EAGLE study). Patient eligibility criteria included patients aged 18 and above who underwent a right hemicolectomy between February 2019 and June 2021. The inpatient mortality, 30-day re-admission and 30-day re-operation rates were included in the analysis. Results were compared with the prospectively collected EAGLE Study intervention data.

Results

A pre-interventional cohort of 57 patients was included. 12% (5 elective, 1 non-elective) were found to have an anastomotic leak. The median length of inpatient stay was 8 days. No patients were re-admitted within 30 days. 11% were re-operated on within 30 days. Mortality rate was 6% (none associated with a leak). When compared to the EAGLE study results, there was a 46.9% reduction rate in anastomotic leaks. No change was demonstrated in inpatient mortality rates.

Conclusion

Post-surgical anastomotic leaks create a drastic health and economic burden on hospitals. Working on reducing their rate can significantly improve outcomes. Hence, introducing the anastomotic safety checklist is an effective intervention which may reduce anastomotic leak rates. Hopefully, EAGLE study final outcomes may be able shade a light on this matter.
WE7.13 Blunt Hepatic Trauma at a Major Trauma Centre in the North West of England between 2000 and 2020
Authors: Reader Harriet , Lunevicius Raimundas
Published: November 2022

Background

Our institution became a Major Trauma Centre (MTC) in 2012, currently serving a population of 2.3 million. This study aims to evaluate the trends in blunt hepatic trauma (BHT) and the changes in management strategy over time (pre- and post- MTC era).

Methods

This was a single-centre, retrospective cohort study. Data were obtained from the Trauma Audit and Research Network (TARN) database across a 20-year period (2000–2020).

Results

209 patients presented with BHT: 31 in 2000–2011 and 178 in 2012–2020. The median age was 35.6 and M:F ratio was 2.8:1. Road traffic accidents (RTAs) were the most common mechanism (n=124, 59.3%), followed by fall from height (n=44, 21.1%). Patients had a median ISS of 25 (range 4–75). 109 patients were managed conservatively (52.5%), with 10 of these patients having angioembolisation. Although 100 patients (47.8%) underwent operative management, only 7 patients underwent liver surgeries such as liver laceration repair (n=7, 3.3%) or resection (n=2, 1%). Mortality rate was 13.8% (n=44) in the conservative group and 21% in the operative group. The overall mortality was 16.7% (n=35). The subgroups analyses revealed no significant difference in mortality for patients managed non-operatively.

Conclusions

BHT patients frequently present as a polytrauma. Only 3.3% required a laparotomy and intervention to the liver parenchyma. The establishment of the MTC was associated with a significant increase in BHT presentations. The proportion of conservatively managed patients was similar pre- and post-MTC eras. The mortality rates were not significantly different.
TH2.2 Optimum Timing of Emergency Cholecystectomy for Acute Cholecystitis - A Single Sited Retrospective Cohort Study
Authors: Ravi Prabhu , Husain Najam , Marzook Himaz , Muras Zbigniew , Thomas Pradeep
Published: November 2022

Aim

To evaluate timing of emergency cholecystectomy performed at one of the hospital in West Midlands.

Methods

This is a retrospective single centre study conducted from September 2019 to August 2020. The patients were divided into two groups with those operated within 1 week as emergency group (EG) and those operated after a week but within 6 weeks as delayed group(DG). The outcome is to evaluate post-operative complications, conversion to open, re-admissions, hospital stay, intra-operative blood loss, surgery duration and level of surgeons.

Results

Among 176 patients, only 88 patients underwent LC. Only 40.9% (36) underwent LC within 1 week of index admission and 12.5% (11) underwent LC after 1 week but within 6 weeks of admission. The remaining 46.5% (41) underwent delayed LC after 6 weeks. 10.6% (5) developed post op complications. Among which only one developed complication in EG and 8.5% (4) developed in DG. Total number of readmissions after LC in both group was 5.5% (5) and 10.2% (9) respectively. Median Length of hospital stay in days (4.03 versus 8.72 days respectively), Duration of surgery was 81(23–153) mins versus 69 (28–122) mins respectively), Intra operative blood loss (64 ml versus 166 ml respectively). Level of surgeon by consultant and Registrar in both groups were 21:6 and 15:5 respectively. None of the patients were converted to open surgery in both group.

Conclusion

Early LC within 1 week can be performed safely in most patients with AC to minimise the intra-operative blood loss, total hospital stay, post-op complication and readmissions rate.
TH5.1 The compliance and utility of Abdominal X-ray in acute general surgical admissions
Authors: Nolan Oscar , Anderson Robert , Gall Lewis , Khan Khurram
Published: November 2022

Aims

Most acute surgical admissions have abdominal symptoms, with many having an Abdominal X-ray (AXR) performed. Primary aim was to audit the indication(s) of AXR against Royal College of Radiologists (RCR) iRefer guidelines. Secondary aim was to analyse the proportion of patients who had further imaging.

Methods

A retrospective cohort study of consecutive adult patients with acute surgical admission who had AXR in a busy tertiary hospital. The study period was from 1st October 2021 to 30th November 2021. Patient's demographics, indication for AXR and further imaging within 7 days were analysed. The indications were audited against the RCR iRefer guidelines (8th edition, 2017).

Results

456 patients were included; 252 (55.3%) were female and median age was 63 years (16–96). 200 (43.9%) were performed out of hours. The indications for AXR were: perforation/obstruction 70.0%; renal stone/foreign body 17.9%, constipation 5.9%, acute exacerbation of IBD 1.3% and palpable mass 0.7%. Overall, 95.2% AXR requests were compliant with iRefer guidelines.

196 (43.0%) patients had further imaging within 7 days of admission: 164 (36.0%) had CT scan, 35 (7.7%) had abdominal and/or pelvic ultrasound and 12 (2.6%) had MRI.

Conclusions

The compliance with RCR iRefer guideline is very high. However, a large proportion of patients had further imaging, with over one third of patients subsequently undergoing a CT scan. We suggest that in cases where further cross sectional imaging is likely, clinicians should consider omitting AXR. This will prevent delays, reduce radiation exposure and maximise the utility of resources.
TH5.6 Communication not technology: How an electronic patient referral process affects patient care in acute general surgery
Authors: Magnisio Simone , Howitt Annabel , Lockwood Sonia Louise
Published: November 2022

Introduction

The Royal College of Surgeons (RCS) high-risk general surgical patient guidelines recommend that a patient who needs emergency surgical assessment must be seen within 30 minutes in the case of a life-threatening emergency, and within 60 minutes for a routine emergency referral. The aim of this audit was to assess the efficiency of a new electronic referral system in expediting surgical assessment compared with direct referrals to the surgical oncall team.

Methods

The study assessed the referral process and time to surgical review over two weeks. We included patients assessed in SAU and excluded patients reviewed in the emergency department (ED). Referrals were received from ED, general practitioners (GP) or surgical outpatient clinics.

Results

A total of 214 patients were included, 54% (116) referred from ED, 32% (69) from GP, 12% (26) from outpatients clinic, 1% (3) self -presenting. The median waiting time was 108 minutes. Direct referrals had a median waiting time of 84 minutes (RR 0–347). Patients allocated to the electronic transfer list waited for a median of 120 minutes (RR 6–720).

Conclusion

All patients waited longer for review than recommended by RCS guidelines. The electronic transfer system failed to expedite surgical review and may have contributed to delays in some cases. Communication between colleagues, not technology, is imperative to ensure timely assessment of the acute surgical patient.
1019 Collaborative Surgical Team Training in Virtual Reality Is Superior to Individual Learning: A Randomised Controlled Trial
Authors: Edwards Thomas , Gupta Shubham , Soussi Daniella , Patel Arjun , Khan Sikandar , Liddle Alexander , Cobb Justin , Logishetty Kartik
Published: November 2022

Aim

This study aimed to assess if multiplayer virtual reality training was superior to single player training for acquisition of both technical and non-technical skills in learning complex open surgery.

Method

40 participants (20 novice surgeons and 20 novice scrub nurses) were enrolled in this study and randomised to solo or team virtual reality training learning anterior approach total hip arthroplasty. Solo participants trained with virtual avatar counterparts, whilst teams trained in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and solo participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. The primary outcome was team performance as graded by the NOTECHs II score. Secondary outcomes were procedure time, technical errors from an expert pre-defined protocol and acetabular component positioning.

Results

Teams outperformed solo trained participants in non-technical skills in the real-world assessment (NOTECHS-II score 50.3 ± 6.04 vs 43.90 ± 5.90, p=0.0275). They completed the assessment 28.11% faster than solos (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), and made close to half the number of technical errors when compared to the solo group (12.9 ± 8.3 vs 25.6 ± 6.1, p=0.001).

Conclusions

Multiplayer training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills.
760 Investigating Theatre Cancellation Rates in a London Hospital
Authors: Giles R , Murray CE , Basu A , Dharmasekara B , Surendran S
Published: November 2022

Aim

Theatre cancellations are a major source of system inefficiency, placing an unnecessary financial burden on the NHS. The aim of this audit was to investigate the reasons for cancellations in elective surgery at a London hospital and to assess the general preoperative process.

Method

We undertook a retrospective audit of all elective theatre cancellations from the day surgery unit over a three-month period in 2021. 78 cancellations were identified, and their cause was investigated. Furthermore, we reviewed theatre lists over one month to calculate the proportion of cancelled procedures per specialty. Also, to gain a further understanding of the present protocol, we reviewed the current preoperative process.

Results

The main reason for cancellations was patients being physiologically unfit for surgery, accounting for 28.2% of all cases. The next biggest reason for cancellation, at 16.7%, was failure to comply with COVID protocol. The specialty with the largest proportion of cancellations was General Surgery, at 17.7%.

Conclusions

We believe many reasons for cancellations were avoidable. Therefore, we propose a change to the preoperative process to target multiple reasons for cancellation. We suggest a more comprehensive pre-admission phone call five days prior to surgery which includes discussions around medication compliance and changes in condition. We also suggest a set of observations and routine bloods are taken when patients come in for their COVID swab. This allows any potential cause of cancellation to be identified and rectified, or the patient could be rescheduled. This should increase efficiency of the day surgery unit.
889 An Audit of Indications for Emergency Abdominal X-Rays
Authors: Masoodi S , Van PTM , Farzaneh SB , Cribb E , Pawa N
Published: November 2022

Background

Historically, abdominal X-rays (AXRs) have played an essential role in diagnosis of the acute abdomen. With the advent of other imaging modalities and the increasing need for efficiency in time, the utility of AXRs has been clarified by the RCR iRefer guidelines.

Aim

To assess the congruence between indications of AXR requests and the recommendations provided by the RCR iRefer guidelines.

Method

All AXRs performed over a 6-week period in the trust were identified retrospectively from our electronic database. Initial indications were subsequently compared with the current guidance and consultant radiologist reports.

Results

Out of 575 AXRs performed, 36 (6%) had no indication documented on the request. Of the remaining 539, 364 (68%) of AXRs performed met the RCR iRefer guidance. Furthermore, 496 (86%) of AXRs performed were reported as normal. 35% of AXRs that met the guidance underwent further imaging, of which 60% showed abnormality. Of those that did not meet the current criteria, abdominal pain and toxic megacolon were the most frequently documented indications.

Conclusions

One third of AXRs did not meet the RCR iRefer guidelines and were therefore requested inappropriately. Despite the remaining two thirds of requests being appropriate, over one third required further imaging in the form of CT/US. Moreover, less than one fifth of the total scans were interpreted as abnormal. This questions whether the current guidance requires revision and whether this imaging modality is over utilised with little effect on clinical outcomes.
552 Benign Pilomatricoma with Osseous Metaplasia: A Rare Case
Authors: Bhatti N , Ramchandani J , Chong W , August S
Published: November 2022

Pilomatricomas are a frequently misdiagnosed benign neoplasm of the skin derived from hair matrix cells. Pilomatricomas may undergo calcification and ossification although the latter is rare and poorly documented, with only eight cases reported since 2006. We present a case of pilomatricoma with osseous metaplasia arising from the scalp in an 87-year-old female patient. She was referred by her general practitioner via the two-week pathway, for a suspicious lesion.

On examination, there was a 2×1cm nodule, with protruding hardened yellow sebaceous material, on the right side of the patient's occipital scalp. The lump was hard, non-tender and had been present for 17 years. The surrounding area was bleeding and slightly ulcerated. A clinical diagnosis of a ruptured epidermal cyst was made, and the patient was prepared for excision under local anaesthetic.

The excised lesion of 23×18×10mm with 22×9mm of skin was sent for histology. This revealed a partially ulcerated dermal lesion composed of islands of keratin with ‘ghost cell’ outlines. Foreign body granulomas, transition to mature lamellar bone and foci of calcification were noted. There were no definite populations of basaloid cells and features of malignancy were not seen. These findings are consistent with benign pilomatricoma with osseous metaplasia. The patient was discharged 4 weeks later with satisfactory wound healing.

Differentiating this tumour from other commonly encountered benign masses remains a challenge, as seen in this case which was initially mis-diagnosed as a ruptured epidermal cyst.
959 A Double Case Review: Arteria Comitans Nervi Ischiadici, Two Rare Presentations of Persistent Sciatic Artery Aneurysm
Authors: Ford A , Downing R
Published: November 2022

Background

In the embryo, the blood flow of the lower limb bud originates from the umbilical artery and becomes the sciatic artery following the course of the sciatic nerve. By the 12th week, the sciatic will involute, in rare instances that this fails it is referred to as ‘arteria comitans nervi ischiadici’. This variant is rare with an incidence of 0.01%-0.05% is of the utmost surgical significance as failure to accurately diagnose and treat can ultimately threaten limb loss.

Cases

1. A middle aged gentleman who presented with a 9-month history of posterior thigh pain with sensations of pressure related to posture and back pain following heavy lifting. Initially this patient was managed conservatively for claudication symptoms until they represented to clinic 4 years later with a 5month history of left buttock discomfort when sitting in the absence of claudication. An endovascular intervention with coil embolisation was undertaken reasons with a satisfactory outcome.

2. A young female with AVM to the left thigh and bilateral PSA's, presented with a painful swelling of the upper inner aspect of the mid-thigh, with a normal venous examination. On representing, despite repeated sclerotherapy, the patient had developed increasingly severe discomfort at the site of the thigh malformation, posterior aspect of the left leg. The patient was referred to a tertiary centre for reassessment.

Conclusion

Due to the variety and evolving nature of clinical presentations, a high degree of clinical suspicion is an important factor in providing a diagnosis. We also highlight the advantages of endovascular intervention.
9 Complications of Bone-Anchored Hearing Aids (BAHA) in Patients
Authors: Omar A , Khan H
Published: November 2022

Aim

BAHA implants utilise bone conduction to treat hearing loss. The aim of the study was to understand the complication rate of patients receiving the implant compared to other studies and to identify any causative factor. Recommendations would therefore be made to reduce these complications.

Methodology

A retrospective cohort study was undertaken on 134 patients who received a BAHA implant performed by a single surgeon at Salford Royal NHS Foundation Trust between 01/01/2016 to 31/12/2018. Data collected identified complications of the surgery, whether or not the abutment was still in situ and whether the patient had any comorbidities or history of smoking

Results

33.6% of the patients had no complications after surgery with the remaining 66.4% having at least one complication. BAHA connect devices had a 67.2% complication rate, attract devices had a 33% complication rate. 13.6% of BAHAs were extruded. There was no positive correlation between either smoking or diabetes and poorer complication rate.

Conclusion

Implant extrusion can be prevented with irrigation cooling of the drill site. Immobilisation of the implant, proper wound care with brushing and using an Allevyn Acticoat 7 wound dressing improves outcomes. Attract systems have fewer complications rates so must be maximised where appropriate.
154 ‘You’ve Lost Your Tuning Form’ – Don't Worry I Have the Solution…
Authors: Chaudhry N , Qureishi A
Published: November 2022

Background

Patients are frequently referred to ENT emergency services with sudden hearing loss. Differentiating sensorineural from conductive losses is paramount in establishing the urgency of review and when to commence urgent steroid therapy. Tuning fork tests are useful for this, but they are not always readily available in primary care or the emergency room.

Aim

To identify and evaluate an alternative method to Weber's test for differentiating conductive from sensorineural hearing loss.

Method

A pilot prospective diagnostic accuracy study was designed to include 10 individuals with unilateral conductive and 10 with asymmetrical sensorineural hearing loss. Each individual was subjected to a pure tone audiogram (PTA), Weber's test and the new index test.

Results

The new index test showed 100% correlation (r=1) with Weber's test and 90% sensitivity, specificity and overall accuracy when compared to Weber's test for diagnosing conductive and sensorineural hearing loss.

Conclusion

This new test may be used as an alternative to Weber's test when a tuning fork is not available. It might even replace the need for Weber's test when PTA testing is readily available. This test could be used to triage referrals and differentiate conductive from sensorineural hearing loss.

Conflicts

There are no conflicts to declare.
596 Can Improved Awareness of Intersectionality in Surgery Make Us Better Allies to Female Surgeons?
Authors: Abdul Kader N , Morrison TEM , Islam R , Suresh S , Palepa A , Mohamed S , Gooch D , Burns S , Dixon S ,   Support Us Group
Published: November 2022

Aim

Presently, 38% of trainees and 14% of Surgical Consultants are female. Despite progression from 3% female Consultant Surgeons in 1991, with over 50% of medical students now identifying as female, gender equality in Surgery still lags. While female surgeons may share this minority intersection and statistic, the experience of every female surgeon is unique. Therefore, while we seek gender equality, it is important to consider the role of intersectionality and how the simultaneous possession of other under-represented characteristics may present significant barriers to female surgeons.

Method

Female surgeons of various grades were approached about their experiences and barriers they have faced as women in surgery. Additionally, healthcare providers were asked for their opinions on how we can be effective allies to female surgeons.

Results

Positive use of power and privilege, equitable access to opportunities, mentorship and professional, personal or peer support were cited as important contributors. The importance of cultural competency, creating an inclusive environment of mutual respect, avoiding assumptions, addressing bias, listening to the barriers to progress and experiences of women in surgery, improving adaptability of the workplace, self-education, raising the profile of organisations who support the progression of female surgeons and normalising the place of women in leadership positions were quoted.

Conclusion

To achieve effective allyship, as well as identifying shared needs and concerns, we must acknowledge and embrace individual differences and recognise that everybody has different starting blocks. More research is needed on the barriers for and outcomes of female surgeons who possess under-represented characteristics.
50 A Closed-Loop Clinical Audit on Surgical Documentation at a Tertiary Level Hospital in India: Where Do We Stand?
Authors: Sinha AV , Kadam S
Published: November 2022

Aim

To perform an audit to check Quality & Compliance of Surgical documentation using STAR Score at a tertiary hospital in India.

Method

A total of 90 case files were studied and assessed in detail from all surgical departments. The audit was done for a period of 1 month at a tertiary hospital in India. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were then compared with standard guidelines and analyzed. A series of departmental training and implementation meetings were carried out. After 2 weeks, a re-audit was performed.

Result

The overall compliance score of the hospital was found to be 74%. Departments of General surgery and orthopedics showed a higher rate of compliance, each constituting 82% while the Department of Neurosurgery showed the least compliance of 62%. It was also seen that the maximum percentage of missing information consisted of anesthetic records and subsequent entries. After the re-audit, a considerable improvement was observed, with the compliance rate improving to 90% in all departments.

Conclusion

We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.
673 The Role of the First Postnatal Ultrasound Scan to Predict Outcome in Children with Antenatally Diagnosed Hydronephrosis
Authors: Zia BB , Godse A , Niyogi A
Published: November 2022

Aim

We aimed to determine if the renal pelvic diameter on the first postnatal scan can predict the need for surgical intervention in children with antenatally diagnosed hydronephrosis.

Method

Data of all babies with antenatal hydronephrosis born in our centre from 2009–2015 were obtained from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). The medical records were analysed retrospectively for diagnosis, investigations, and interventions. Mean follow-up was 7 (4–10) years. The results were expressed as mean and percentage. Statistical data analysis was performed on GraphPad.

Results

224 babies were included in the study. 162 (72%) were males, and 92 (39%) had bilateral hydronephrosis. 163 (73%) had spontaneous resolution of hydronephrosis. The resolution rates were similar for unilateral and bilateral cases. The mean renal pelvic diameter was 6.2mm in the resolved group and 16.2mm in the persistent group (p<0.01). The highest renal pelvic diameter undergoing spontaneous resolution was 24mm. Of the 61 (27%) children with persistent hydronephrosis, 38 (17%) children required surgery. Pyeloplasty for pelviureteric junction obstruction was the most common procedure. 23 (10%) patients continued to have persistent dilatation but needed no intervention. Renal duplex was the most common diagnosis in this group, followed by vesicoureteric reflux. All babies with a pelvic diameter of 25mm or above on their first postnatal ultrasound required surgical intervention.

Conclusion

The majority of antenatal hydronephrosis resolves spontaneously. However, interventions are necessary if the pelvic diameter is above 25mm.
130 Surgical Repair of Cleft Lip: Comparison of Neonatal and Standard Time Repair
Authors: Walsh K
Published: November 2022

Aim

Cleft lip and palate (CLP) abnormalities are the most common congenital orofacial anomalies, affecting 1 in 700 live births per year in the United Kingdom. Cleft lip is present in approximately 55% of all CLP deformities. The aim of this study is to compare standard and neonatal cleft lip repair.

Method

Advanced literature searches were carried out using Medline ALL (1946 to date) and Embase (1974 to date), 11 articles were deemed relevant and included in this study.

Results

Aesthetic results showed excellent outcomes with neonatal repair with regards to the appearance of the scar, facial (lip and nasal) symmetry but those aesthetic results are no better than those achieved at standard time.

Conclusions

Early intervention can be beneficial as early repair takes place when the cleft is less severe and when the tissues are more malleable, making the surgery less challenging and when some aspects of foetal scar healing remain. Early repair has a positive impact on the development of the alveolar projections and can assist in reducing an alveolar cleft if present, improving the aesthetic outcome. Neonatal surgery carries with it no greater risk than surgery carried out at 6 months and will allow feeding to begin at an early stage promoting recovery. Early repair also brings with it a positive psychosocial impact where infants and mothers can build a normal relationship from an early stage. Later in life, children and adults will be less self-conscious following good aesthetic repair. In conclusion, neonatal repair may be recommended over standard time repair.
616 Addressing Challenges to Enable Better Use of Routinely Collected Clinical Photographs: Evaluating the Largest Cleft Dataset for Machine Learning Analysis
Authors: Turnbull C , Macleod A , Esposito S , Gorantla R , Seth S , Ramamoorthy R , Mehendale F
Published: November 2022

Aim

Orofacial clefts are the most common congenital anomaly to affect the craniofacial region. Surgical repair is usually performed in infancy; however, there are concerning inequalities in access to and quality of surgical care. Scoring aesthetic results after surgery is crucial when determining the success of a repair. A reliable and accurate scoring system utilising large numbers of unstandardised 2-dimentional (2D) photographs of ethnically diverse patients, which is inexpensive, widely accepted and easily applicable, does not exist. Artificial Intelligence (AI) has been applied in various surgical specialities with beneficial results; however, its advantages have not yet been harnessed in cleft care.

We aimed to evaluate the potential use of routinely collected 2D photographs of patients with an orofacial cleft and determine if non-standardised data could be used for machine learning (ML) analysis in cleft research.

Method

A database comprising over 5 million photographs, collected over 20 years, and developed by the international non-governmental organisation Smile Train, was described, and analysed using RStudio and Microsoft Excel.

Results

Description and analysis of the dataset demonstrated that it is the largest and most ethnically inclusive and diverse dataset that currently exists. Preliminary AI analysis confirmed that ML could be used to analyse the data.

Conclusion

The quality of routinely collected data presents challenges for use in research. Addressing such challenges helps ensure that findings are more representative of global burden of disease and will deliver outcomes that are more relevant to a diverse global population. Evidence based minimum standards to optimise future data collection have been identified.
541 Pre-Operative Assessment of Patients Undergoing Elective TURBT or Rigid Cystoscopy + Bladder Biopsy: Is a Group & Save Clinically Required?
Authors: Mak Q , Madden J , Ahmed Z , Kum F , Makanjuola J , Cakir O
Published: November 2022

Aim

Group & Save (G&S) is conducted prior to Transurethral Resection of Bladder Tumour (TURBT) or Rigid Cystoscopy + Bladder Biopsy (BB) during pre-operative assessment (PoA). Each G&S costs £7.54 and 2 samples are required. The aim of this audit was to determine whether G&S is clinically required for these two procedures.

Method

This two-cycle audit reviewed the PoA components of patients undergoing TURBT or BB over a 6month period prior to the COVID-19 pandemic (July-Dec2019), in which PoA were face-to-face, and a subsequent re-audit during telephone PoA (July-Dec2020), where it was deemed unnecessary to have a G&S.

Results

1st Cycle: 64 patients were included, 32.8%(21/64) had a preoperative G&S. 98.4%(63/64) had Hb measured. Mean Hb was 131.56 (79 – 165) g/l. 25%(16/64) were on anti-coagulants, of which 50%(8/16) were continued. No patients required a peri or post-operative blood transfusion.

2nd Cycle: 48 patients were included and 6.25%(3/48) had a G&S within the 1 month preceding their operation. 70.8%(34/48) had their Hb measured, with mean Hb being 135.18 (86 – 168) g/l. 22.9%(11/48) were on anticoagulants, of which 36%(4/11) were continued. There were no complications requiring a blood transfusion.

Conclusions

We found no requirement of blood transfusions following TURBT or BB, therefore routine G&S is not clinically indicated for this series. This reflects departmental savings of £964 over 6months (based on 64 cases). In addition, a relationship between continuing anti-coagulation or a low Hb and post-operative transfusion was not observed.