bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.TU.702Role of cadaveric dissections in current medical education
Authors: Narayanasamy Sangara , Thomas Pradeep
Published: October 2021

Introduction

Today’s digital world has surplus educational resources for the students. Medical curriculum has changed the traditional way of teaching to audio-visual methods. Learning anatomy has changed from cadaveric dissection to specimen models, life models and three-dimensional models, which has raised questions as to whether cadaver dissection should be continued.

Multimodel Approach

Computer software with 3-D models is a useful tool for the beginners (Silen et al., 2008). Didactic lectures provide easy steps to be followed during dissection. Body paintings explain the surface anatomy in an appropriate way. Online videos are user friendly and personalized, so that one could review them repeatedly. Finally, live demonstration in theatre explains the structures and relations, with the flaws of only limited students benefited

Pros

Cadaver dissection creates interest to explore and learn detailed anatomy, to gain everlasting knowledge blending the theoretical knowledge with the practical and to involve in research. In addition, students develop the art of team work building their interpersonal skills.

Cons

Unpleasant smell of the formalin preserved cadaver, limited opportunities for everyone to learn, inadequate fund, inexperienced staff and psychological distress (Evans and Fitzgibbon, 1992).

Conclusion

Cadaveric dissection is a better method of learning (Winkelmann, 2007). Students understanding subjects precisely, make them better clinicians. Other teaching methods could be used as supplements.

Recommendations

Organize different teaching techniques helping diversity of students to learn anatomy based on their learning styles. Use of advanced technology like real time pictures, videos and imaging modalities to learn anatomy (Swamy and Searle, 2012).
EP.TU.825Virtual general surgery teaching for higher surgical trainees in KSS during COVID-19
Authors: O'Brien James , Obeid Noor , Tucker Sally , Hawkins Will
Published: October 2021

Aims

From the start of the coronavirus pandemic, it became clear that the traditional deanery teaching model for higher surgical trainees had to change. Face-to-face lectures and tutorials are not appropriate in light of UK government measures, social distancing and reduced non-essential travel. To replace deanery teaching days we established a once weekly programme of evening tutorials, delivered via Zoom by Consultant surgeons, covering a breadth of general surgical specialities. Each session was archived and a secure digital link provided for trainees to watch later if necessary. We conducted a survey of higher surgical trainees to assess response.

Methods

A 10-question web survey distributed to all general surgery trainees in West KSS. 24/38 trainees responded (response rate 63.2%).

Results

75% rated the teaching as very or extremely useful. Commute, personal responsibilities and late theatre/ clinic sessions were barriers to joining teaching live. 71% found it very or extremely enjoyable. 78% found it at least as good as traditional teaching days. 87% found it very or extremely relevant to their development as a surgeon. 42% would prefer the Zoom format was utilised for longer sessions, to further recreate the traditional teaching "day".

Conclusions

Feedback was broadly positive and the tutorials were well received, but probably need to run less frequently than once a week. Half day sessions could be considered. The teaching quality was rated overall better or at least as good as in-person teaching. There appears to be clear benefit in detailed, reflective surgical teaching delivered efficiently via Zoom.
EP.TU.826Using Indocyanine Green (ICG) during laparoscopic bowel resections for elective cancer patients reduces anastomotic leaks and length of stay
Authors: Bleakley Anna , Komolafe Olusegun
Published: October 2021

Introduction

Anastomotic leakage (AL) after colorectal surgery is associated with significant morbidity and mortality. Poor perfusion of bowel anastomosis is a significant contributing factor. ICG is a dye administered during laparoscopic surgery to assess bowel perfusion by fluorescent imaging – the aim of this study was to determine whether its use in our centre during elective laparoscopic colorectal cancer resections led to improved patient outcomes.

Method

Single-centre comparative study of all patients who underwent elective colorectal laparoscopic resections for cancer January 2019- January 2021. Primary outcome investigated was AL. Secondary outcomes: in-patient length of stay, clinical suspicion of AL and post-operative ileus. Cohorts compared with χ2 test.

Results

25 patients had resections with ICG, 60 without. None in ICG group, and three in non-ICG group (5%) had AL; p-value 0.29. The ICG group were less likely to have CT for suspected anastomotic leak 12% vs 23.3%, p-value 0.29; and, post-operative ileus 5.3% vs 19.6%, p-value 0.09. Statistically significant reduction in mean inpatient length of stay when ICG used (4.0 days, 95% CI 3.3-4.7) compared to when not used (6.7 days, 95% CI 5.0-8.3).

Conclusion

Only a small number of previous studies have compared AL rates with and without ICG, finding that its use leads to a significant reduction in AL. While sample size small, our findings supports this. Using ICG also led to a significant reduction in inpatient length of stay. ICG fluorescence angiography is now established as our normal practice for all colorectal resections as a safe, innovative, simple technology.
EP.TU.911Analysis of the outcomes following reversal of loop ileostomy
Authors: Lutfi Sawsan , Camilleri-Brennan John
Published: October 2021

Aims

A defunctioning loop ileostomy is constructed to reduce the incidence and the consequences of anastomotic leaks following sphincter-sparing colorectal resection. Its construction and reversal may be associated with complications. The aim of this study is to present a snapshot of the outcome of reversal of loop ileostomy in a teaching general hospital.

Methods

All patients whose loop ileostomy was reversed in 2018 were studied. Sociodemographic and clinical data were collected. The outcomes measured were length of hospital stay, return of bowel function, morbidity and mortality.

Results

Nine patients had reversal of ileostomy by experienced colorectal surgeons during this period. The patients, 5 males and 4 females, had a median age of 58 years (range 20 to 77 years). The main indications for construction of a loop ileostomy were low anterior resection for rectal neoplasia (7 patients) and iatrogenic rectal perforation during hysterectomy (1 patient), and total colectomy with ileoanal pouch reservoir for ulcerative colitis (1 patient). The ileostomies were reversed between 5 to 10 months following the main operations. The postoperative stay was between 2 to 12 days. The complications included one anastomotic leak, requiring immediate re-operation, 3 wound infections and 2 incisional hernias. There were no postoperative deaths.

Conclusion

In this study our overall complication rate was well within the range reported in the literature, with only one patient requiring immediate re-operation. The presence of a senior colorectal surgeon at operation as well as careful attention to detail is key to keeping complications to a minimum.
EP.TU.933Late enterocutaneous fistula formation after evisceration repair using intraperitoneal mesh
Authors: Rodicio Jose , Sanz Sandra , Vico Tamara , Amoza Sonia , Moreno Maria , Sanz Lourdes
Published: October 2021

Introduction

Intraperitoneal meshes pose a potential risk of complications, either due to the material itself or the method of fixation. Enteric fistulas are a rare but serious complication following the repair of an abdominal wall reconstruction using an intraperitoneal prosthesis.

Case report

We present a 59-year-old male patient, who underwent surgery 5 years previously for urothelial carcinoma with radical cystoprostatectomy and a Bricker-type urinary diversion, without subsequent radiotherapy. He presented an evisceration in the postoperative period treated with an inlay placement of an intraperitoneal mesh, without fascial closure. During these five years the wound did not present any complications, and spontaneous intestinal drainage began through the laparotomy. The physical exploration showed a 2cm hole in the abdominal infraumbilical midline, a wall defect of 20x20cm contained by mesh, no parastomal hernia, BMI 31.2 kg/m2. Thoraco-abdominal CT studies were completed that ruled out other pathologies, nasal culture and optimization were performed with parenteral nutrition and glycosylated hemoglobin control to achieve values below 6. The reconstruction of the abdominal wall was done with posterior component separation with transversus abdominis release, double mesh placement a BioA and PVDF mesh, with a final bridge measuring 8x5cm. The postoperative period was prolonged by an ileus, with an admission period of two weeks.

Discussion

Intraperitoneal meshes, some of which are no longer commercially available, represent a potential risk of complication. As long as we can optimize the patient for surgery, we will improve the results. Retromuscular repair with large mesh and PVDF material gives us good results.
EP.TU.991Developing as Future Leaders: A Systematic Review of Quality Improvement Training in Junior Doctors
Authors: Aseem Rabiya , Simillis Costas , Smith Jason , Arora Sonal , Pawa Nikhil
Published: October 2021

Aims

Quality improvement (QI) training in Junior Doctors (JDs) is essential for providing High Quality Care for patients and facilitating organisational success. The aim of this study was to systematically review the evidence on QI training in JDs and determine the impact and effectiveness of training methods.

Methods

A systematic review was conducted as per PRISMA guidelines. Searches were carried out using MEDLINE, EMBASE and HMIC for English-Language articles between January 2005 to December 2019. Selected articles underwent critical appraisal using the CASP criteria by two independent reviewers. A qualitative and thematic analysis was conducted.

Results

43 studies were identified in a range of medical and surgical specialities. Common QI methodology included theoretical and project-based curricula with content focussing on PDSA cycles, root causes analyses and project development. Majority of studies reported improved knowledge, leadership skills and satisfaction. Mentorship and coaching were highly valued, but few studies adhered to this practice. Few studies demonstrated increased QI engagement. Key themes identified (i) Effectiveness of QI training (ii) Barriers to engagement (iii) Organizational culture of fostering QI.

Conclusion

There is growing mandate for training JDs in QI practices to enhance patient care. QI curricula targeting JDs have demonstrated improved knowledge and leadership skills. Nonetheless, significant barriers in QI engagement endure. Additional research is required to combat disengagement and assess sustainability of QI interventions in JDs. We further aim to introduce a pilot QI training programme for surgical JDs to enhance leadership skills.
EP.TU.1069Improved Perioperative and Survival Outcomes for Minimally Invasive Rectal Surgery
Authors: Nnaji Martin , Khan Kashuf , Hughes Sam , Inani Mohit , Yassin Nuha A
Published: October 2021

Aim

Although laparoscopic colon cancer surgery has been widely embraced as current evidence demonstrates comparable oncological results with open surgery, similar evidence is lacking for laparoscopic rectal cancer surgery. We present the outcomes of patients undergoing laparoscopic and open total mesorectal excision (TME) for rectal cancer in our unit.

Methods

We retrospectively analysed data collected for patients who underwent laparoscopic and open TME from January 2014 to December 2018. Sociodemographic, perioperative, circumferential resection margin (CRM) positivity, locoregional recurrence and survival data were analysed.

Results

260 (144 laparoscopic and 116 open) were included. Median age in the laparoscopic group was 69 years and in the open group 68 years.

Neoadjuvant therapy was given in 21 patients (14.6%) in laparoscopic and 13 (11.2%) in the open group (p = 0.42). CRM was positive in 16 cases (11.1%) laparoscopic and 32 (27.6%) open (p = 0.0007;95%CI:6.9-26.2).

No statistically significant difference in anastomotic leak rate was observed both groups (4.9% laparoscopic vs 4.3% open;p=0.82). Surgical site infection was significantly more in open cases (13% vs 5.6% laparoscopic,p=0.04). Similar locoregional recurrence rates were observed in both groups (18% laparoscopic vs 19% open,p=0.84).

Median follow up was 34 months or more allowed for Disease-free (DFS) and overall survival (OS) to be analysed for 144 of 260 patients. DFS and OS were better in laparoscopic (73% and 94%) compared to open (68% and 85% respectively) (p = 0.40 and p = 0.015 respectively).

Conclusion

From an oncological perspective, laparoscopic surgery for rectal cancer is safe with additional perioperative and survival benefits compared to open surgery.
EP.FRI.9Meta-analysis of mortality risk in octogenarians undergoing emergency General Surgery operations
Authors: Hajibandeh Shahab , Hajibandeh Shahin , Antoniou George A , Antoniou Stavros A
Published: October 2021

Aims

To quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and non-octogenarians.

Methods

A systematic review was performed in accordance with the PRISMA statement standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The certainty of evidence was assessed using the GRADE system. Random-effects models were applied to calculate pooled outcome data.

Results

Analysis of 66701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% CI 18-34%) for all operations;29% (95% CI 25-33%) for emergency laparotomy,9% (95% CI 1-23%) for non-laparotomy emergency operations;21% (95% CI 13-30%) for colon resection;17% (95% CI 11-25%) for small bowel resection;9% (95% CI 7-11%) for adhesiolysis;6% (95% CI 5.9-6.8%) for perforated ulcer repair;3% (95% CI 2.6-4%) for appendicectomy;3% (95% CI 2.8-3.3%) for cholecystectomy;5% (95% CI 0.2-14%) for hernia repair. When stratified based on ASA status, the risk was 11% (95% CI 4-20%) for ASA 2, 22% (95% CI 10-36%) for ASA 3, 39% (95% CI 29-48%) for ASA 4, and 94% (95% CI 77-100%) for ASA 5. The  risk was higher in octogenarians compared with non-octogenarians (OR:4.07,95% CI 2.40-6.89), patients aged 70-79 (OR:1.21,95% CI 1.13-1.31), and patients aged 50-79 (OR:2.03,95% CI 1.68-2.45).

Conclusions

The risk of perioperative death in octogenarians undergoing emergency general surgical operations is higher than the risk in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.
EP.FRI.16 Use of Pulsed Lavage Reduces the Rate of Surgical Site Infection After Laparotomy
Authors: Bath Michael , Powell Jordan , Ismail Ismail , Machesney Michael
Published: October 2021

Aims

Surgical site infections (SSIs) are a preventable and common post-operative complication within general surgery. Intra-operative irrigation of surgical incisions is an inexpensive method to reduce post-operative SSI rates, however its use is currently limited to orthopaedic surgery. We aimed to assess the effects of pulsed lavage (PL) irrigation on SSI rates following elective and emergency laparotomies.

Methods

Elective and emergency patients who underwent a laparotomy between 2018 and 2019 were included. Relevant demographic and peri-operative risk factors collected retrospectively, following STROBE criteria. The primary outcome was rate of superficial SSIs within 30 days of the operation. Independent risk factors were assessed via multivariate logistic regression analysis.

Results

176 patients were identified, with an average age of 60.7 ±19.1 years. 82.4% (145/176) were emergencies and the mean ASA grade was 2.8. Fifty two patients (29.5%) had PL used during their operation. Thirty seven patients (29.8%, 37/124) in the control group developed a SSI, compared to seven patients (13.5%, 7/52) in the PL group (p = 0.022). At multi-variate analysis, the use PL conferring an Odds Ratio 0.36 (CI 0.12-0.94, p = 0.047) for developing a SSI.

Conclusions

PL appears to significantly reduced the rate of SSI following laparotomy. There remains scope to reduce the incidence of this common and expensive post-operative complication, and PL could provide a potential cost-effective means to deliver improved outcomes. Future prospective randomised trials are essential to fully assess its benefits and wider use within general surgery.
EP.FRI.34 Audit of management of shoulder dislocations against BOA Traumatic anterior shoulder instability Guidelines
Authors: Varasteh Amir , Hakim Zuned
Published: October 2021

Background

Traumatic anterior shoulder dislocation is associated with a high risk of shoulder instability, reduced functional outcome, and recurrence. We conducted an audit to assess the direct management, review in fracture clinic, and definitive imaging of patients with anterior shoulder instability in Southport and Formby Hospital.

Aim

To identify compliance with the 2015 BOA Traumatic anterior shoulder instability guidelines.

Method

Identified all patients from 01/01/2019 to 31/12/2019 who had shoulder dislocation coded for their diagnosis. We used imaging, scanned notes, and clinic letters where available to identify the clinical information. We excluded patients with a false diagnosis code, and those with non-local post codes from the analysis.

Results

We identified 67 patients who had an anterior dislocation. 88% of patients had x-rays in both AP and Lateral.  We identified that 8.9% of patients had pre-reduction x-rays in AP only, 11.9% had no pre-reduction x-rays, and 1.5 % had no post reduction imaging. 79% of patients were seen in clinic within 6 weeks but only 40.3% were seen by a shoulder specialist and only 43.3% had appropriate imaging. 16.4% of patients were not given fracture clinic follow up.

Conclusion

Although most patients were managed acutely according to the guidelines, the follow up and subsequent investigations of these patients can be improved. One method we suggest is renaming fracture clinic days from consultant names to sub-specialty clinic names. In addition, a dedicated session to review the guideline with senior orthopedic surgeons cold improve the compliance as well.
EP.FRI.36 Clinical outcomes for surgical management of unstable spinal fractures in polytrauma patients: A systematic review
Authors: Qayum Mohammed , Malik Atif , Nawaz Ghulam , Razzaq Ahsen , Sudarshan Veena
Published: October 2021

Aims

This systematic review seeks to identify and discuss clinical outcomes in polytrauma patients who undergo surgical fixation of unstable spinal fractures. Specifically, this review aims to address the question of whether one surgical treatment modality outperforms other surgical approaches.

Methods

PubMed and the Cochrane Library database were systematically searched for case reports and clinical studies using key words and MeSH terms. Titles and abstracts were skimmed, and relevant articles were identified for further analysis. A total of 96 results were returned, 16 of which were included for full-text review. 

Results

Six articles met the inclusion criteria. Four case reports, one case series, and one retrospective study published variable datasets, and each article failed to include highly relevant information. Thus, while conclusive statements about clinical outcomes in this population cannot be made, specific recommendations for future publications can. 

Conclusion

Limited studies, a small overall cohort, and inconsistent reporting of data preclude a comprehensive systematic review of clinical outcomes. However, this review serves to highlight the need for consistent and standardized reporting guidelines for this cohort. In addition, two cases were successfully treated with minimally invasive techniques, suggesting that viable surgical options exist for patients who cannot undergo open spine surgery. Finally, these data support early surgical intervention when medically possible.
EP.FRI.60 A complete audit cycle into the paediatric negative appendicectomy rate for children presenting to A&E with suspected appendicitis at a District General Hospital
Authors: Maroof Hanna , Khalifa Khalid , Bakr Ahmed , Shah Isran , Abuelgasim Mona , Sultan Tabinda
Published: October 2021

Aim

Determine compliance rate with a local policy implemented in 2017, and whether interventions from audit cycle 1 were successful. The policy stated that all children aged 6-18 with acute abdominal pain must initially be reviewed by the ED registrar/consultant and have a documented Alvarado score. 

Method

A closed loop audit on adherence to the 2017 policy and negative appendicectomy rate in children aged 6 to 18, with suspected appendicitis. The data were collected and analysed. Areas for improvement were discussed at the M&M meeting, alongside methods to achieve these improvements.

Results

The study included 67 patients aged 6-18 who underwent an appendicectomy in 2019. The study found that the Alvarado score had only 14.29% specificity. There was poor adherence to the 2017 protocol as only 36% had a documented Alvarado score and 55% had a senior ED review. Audit cycle 1 recommended improvement of ultrasound quality and increased use of CT scanning to reduce the negative appendicectomy rate. We found that only 2 patients had a CT. The negative appendicectomy rate in patients with and without an ultrasound remained at 8%, indicating no quality improvement. Nevertheless, our primary outcome showed that negative appendicectomy rates reduced from 28% to 11%.

Conclusion

These results demonstrate negligible impact of ultrasound and Alvarado scores. Good history-taking and clinical examination skills are key in reducing the negative appendicectomy rate. A specific ambulatory care pathway for children with suspected appendicitis has been implemented to lower inpatient stays and cost impact of unnecessary laparoscopies.
EP.FRI.96 Negative appendectomy rate in young females, between theory and practice. Full audit cycle
Authors: Hatem Fady , Mostafa Samir , Ross Rebecca , Chamali Basel , Ivanov Andrea , Sonsale Aniket , Kaldas Foad
Published: October 2021

Aims

Females of child bearing age are at higher risk of negative appendectomy rate, the accepted overall NAR is up to (20-25%). Presented is our study to examine the real NAR in the female’s cohort aged (15-45 years) in the form of quality improvement project to improve patient’s outcome.

Methodology

Retrospective study in the form of Full audit cycle over 18 months, the first cycle was conducted over 12 months period, followed by the action plan and reassessment over 6 months. Preoperative clinical, laboratory, radiographic and histopathological data were collected.

Results

Over the whole audit period 632 cases were analysed, 238 cases were females in the child bearing age included in our cohort. Over the first phase 419 appendectomy cases were performed, among those 156(37%) were females in child bearing age. Overall NAR was 29% and in our females cohort was 43.5%. Over the second cycle, 213 cases performed, out of which 82(38%) cases included in our cohort. Overall NAR reduced to 25% and in our cohort was 37%

Conclusions

Despite the advances in diagnostic modalities, Females are at significantly higher risk of NAR 37%. Our overall NAR reduced from 29% to 25% compared to the young females cohort, the rate dropped from 43% to 37%. specific consideration and regular auditing of results regards this cohort are highly recommended. Validation of appendicitis scores for risk stratification, Serial examinations and radiological adjuncts are possible solutions to reduce the NAR among this group.
EP.FRI.103 Acute Appendicitis in an Amyand Hernia – a case report and literature review
Authors: Ahmad Manal , Fazili Noureen , Chang Tou-Pin , Abdalla Hashim , Watfah Josef , Leo Cosimo Alex
Published: October 2021

Introduction

An Amyand Hernia (AH) is the presence of an Appendix within an Inguinal Hernia. We present here our clinical management of acute appendicitis in an AH and subsequent literature review. A 73 year old male patient presented with a two day history of right sided irreducible inguinoscrotal hernia with tender swelling on standing and walking. This was not associated with symptoms of bowel obstruction or fevers. Blood investigations revealed a raised C-Reactive Protein of 129m/l and White Cell Count of 15x 10^9/L. A Computed Tomography scan of the Abdomen and Pelvis revealed a right sided inguinoscrotal hernia arising lateral to the inferior epigastric vessels, containing an inflamed appendix and omental fat. The patient underwent an emergency open hernia repair with mesh and, considering that the appendix base was intra-abdominal, also underwent a laparoscopic appendicectomy. 

Method

We conducted a literature review on Pubmed and Medline using the MeSH terms ‘Amyand Hernia’ AND ‘Appendicitis’ from 1970-2020.  

Results

We longlisted 179 articles. Of these, 117 were excluded, as they were either paediatric cases, not relevant or mentioned in discussions. Finally, 62 relevant articles were included in the review. 

Conclusion

Acute Appendicitis in Amyand Hernias has an incidence of 0.07-0.13%. Most cases remain as incidental findings however, increased use of imaging techniques has allowed accurate diagnoses and attempts at classifications. There is also weak association with Situs Inversus and atypical appendiceal tumours including adenocarcinoma, carcinoid and neuroendocrine tumour. Their management varies according to the extent of inflammation, radiological and intraoperative findings.
EP.FRI.116 Bleeping Etiquettes
Authors: Sandhya Anu , Oyewole Bankole , Ng Vivian , Cheng Amanda , Ghani Anum , Mangat Shannon
Published: October 2021

Introduction

Bleeps are a vestige of decades old technology common place in NHS Trusts. No formal guidelines exist to regulate the use of the bleep leading to user frustration on both ends of the system. Many junior doctors reported a high number of inappropriate and disruptive bleeps. This quality improvement project aimed to formulate a guide for the use of the bleep system.

Methods

Formal interviews were conducted among clinical and non-clinical staff as to the expectations in the use of the bleeping system. A list of bleeping etiquettes was created following formal interview and formed the basis of a Trust survey to formulate a Bleeping protocol.

Results

The following bleeping etiquettes were agreed upon;

Conclusion

A formalized protocol for bleeping can lead to a more effective and stress-free bleeping system.
EP.FRI.132 Current practice in the investigation and management of post-operative ileus
Authors: English Camilla , Jakes Adam , Wheatstone Sarah
Published: October 2021

Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no national/trust guideline for investigation and management of post-operative ileus. 

Aim

To assess current practice in investigation and management of post-operative ileus. 

Method

All patients with a diagnosis of post-operative ileus on surgical wards at a London hospital between November - December 2020 were identified using clinical coding. Their clinical notes were reviewed and common themes explored.  

Results

16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Only 2 (12.5%) patients had documented auscultation of bowel sounds at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. Patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. 

Conclusion

There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.
EP.FRI.148 Profile and management of Hand injuries in a tertiary institute
Authors: Mago Vishal
Published: October 2021

Aims

To outline the demographic profile and outcome of hand injuries in a tertiary institution

Methods

This study was done over a period of 4 years in a tertiary institution in patients presenting with open hand injuries and management protocols will be discussed based on presentation in emergency and opd of burn and plastic surgery.

Results

Majority of patients were labourers or skilled artisans who sustained injury during operation of machines and right hand was predominantly affected. Maximum injuries occurred in night time. Traumatic amputations were commonly seen along with involvement of thumb in some patients. Various reconstructive options will be discussed based on the involvement of hand injury.

Conclusion

Proper knowledge of mechanism of injury can guide in the management of patients. Exposure to machines and hazard prevention should be taught in factory establishments or threshers for reducing this menace.
EP.FRI.194 Patellar height after Anterior Cruciate Ligament rupture reconstruction using the autologous bone-patellar tendon-bone graft technique in the Maltese population
Authors: Psaila Rachel , Bugeja Kristian , Attard Lucienne , Esposito Ivan
Published: October 2021

Aim

The primary aim of this study is to determine whether there is a change in patellar height after closure of the patellar tendon defect after a bone-patellar tendon-bone graft harvesting. The secondary aim is to evaluate clinical and functional outcomes. 

Method

A retrospective observational study was conducted. Patients who were diagnosed with ACL injury and underwent reconstruction of ACL using the bone- patellar tendon- bone graft technique from 2015 to 2020 were included (56 patients). All patients underwent the same procedural steps. All patients had pre- and post-operative knee radiographs (antero-posterior and lateral views). The Caton- Deschamps Index was used to measure patellar height pre- and post-operatively. The International Knee Documentation Committee-Subjective Knee Evaluation Form was used to assess functional outcome. Clinical outcome was assessed by reviewing patient records. 

Results

There was a change from the pre-op index 0.995 +/− 0.144 (mean +/- SD) to the post-op index 0.948 +/− 0.150. With a statistically significant decrease in index of 0.048 +/− 0.131 (p value 0.009) was found. The null hypothesis (that there is no change) is rejected and therefore the alternative hypothesis (a decrease in patellar height) is accepted. The mean IKDC-SKF score was 76.851 +/− 15.015 (SD) ranging from 40.2 to 100.

Conclusion

Performing ACL reconstruction using the B-pT-B technique, although predisposing to a decreased patellar height, it does not increase the incidence of patella baja. An overall good functional outcome was achieved, mean IKDC-SKF 76.85. However, no clear association between change in patellar height and PF symptoms could be demonstrated.
EP.FRI.204 Does Sarcopenia Increase the Risk of Needing a Stoma During Emergency Laparotomy?
Authors: Campbell Ross , Bradley Nicholas , Wilson Michael
Published: October 2021

Aims

Sarcopenia is a multisystem disorder which can be diagnosed clinically and radiologically. It is associated with impaired functional status and inferior perioperative outcomes, in particular increased mortality following emergency laparotomy. This study aimed to show whether sarcopenia, as defined by low psoas muscle area (PMA) on pre-operative CT, was associated with increased need for stoma formation. 

Methods

A retrospective analysis of consecutive emergency general surgical laparotomies over a 3-year period. PMA was measured on a single pre-operative CT image at L3 and normalized to vertebral body area to create a psoas muscle index (PMI). New stoma formation and perioperative outcomes were recorded from patient records. Cases were split by the median value into high “non-sarcopenic” and low “sarcopenic” PMI groups.

Results

299 patients underwent emergency laparotomy between 01/01/2016 and 31/12/2018. 46 patients (30.67%) in the low psoas index group required a stoma compared with 37 (24.83%) in the higher group (p = 0.159). Survival was inferior in the sarcopenic group with a mean survival of 42 months compared to 48 months in the non-sarcopenic group (p = 0.032). Median follow-up was 43 months. Patients in the sarcopenic group were significantly older (Mean age 68 compared to 54 in the non-sarcopenic group, p = <0.001) but there was no difference in other baseline variables.

Conclusions

Sarcopenia does not significantly increase the risk of requiring a stoma during emergency laparotomy but does reduce survival.
EP.FRI.221Safe delivery of emergency laparotomy using Personal Protective Equipment (PPE) during the first peak of the COVID-19 pandemic
Authors: O'Connor Adam , Bennett Jayne , Alam Imran
Published: October 2021

Aims

To evaluate emergency laparotomies and examine operating surgeon use of PPE as per guidelines in the first COVID-19 peak.

Methods

The NELA database for our hospital was interrogated to examine for emergency laparotomy cases between March to September 2020. Data was recorded on age, pathology, NELA mortality score, post-operative destination, mortality COVID-19 swab status as an inpatient and use of PPE.

Results

55 laparotomies were undertaken. The median age was 67 years. 48% had a Clinical Frailty Score >4. 53% of patients were 'high-risk' in their NELA mortality score (>5%). 56% were ASA >3. 44% went to intensive care post-operatively. 18% and 36% had significant cardiac and respiratory co-morbidities. The mean NELA mortality score was 10% pre-operatively. Mean post-operative risk of mortality score was 67%. Only 1 patient contracted COVID-19 whilst an inpatient and subsequently died of acute cerebrovascular accident unrelated to her COVID-19. PPE was available and used as per guidelines in all cases.

Conclusions

Our department remained busy throughout the first peak however there was a reduction in cases compared with 2019. Our population is generally heavily co-morbid based on ASA scores and cardiorespiratory co-morbidity. Nevertheless only 1 patient contracted COVID whilst an inpatient in this cohort. Access to adequate amounts of personal protective equipment is paramount to ensure safe and timely access to emergency laparotomy for patients and surgeons alike.
EP.FRI.229 The Role of Ultrasound in the Diagnosis of Paediatric Appendicitis
Authors: Armstrong Lará , McGuigan Conor , Yousaf Muhammad
Published: October 2021

Background

Acute appendicitis remains the most common acute surgical presentation among children and adults. Ultrasonography is a commonly used investigation for patients with right iliac fossa pain were the diagnosis is unclear, however in a district general hospital (DGH), appropriate radiologists are not often readily available. The aim of this study was to determine the value of ultrasonography in the diagnosis of appendicitis in children.

Methods

A retrospective review was carried out of all paediatric patients (aged 5-16), who underwent an appendicectomy in a single acute surgical unit, over a 6 month period.  An institutional database and up to date electronic care records were used to record preoperative ultrasound results, intraoperative findings and histopathology results.

Results

A total of 59 patients were admitted with possible appendicitis within the audit window, 31 of which underwent an appendicectomy, 58% performed laparoscopically.  38.7% underwent pre- operative ultrasound, 33.3% of which identified an acutely inflamed appendix. The remaining patients who did not proceed to theatre were successfully discharged with no re-attendance following a period of observation. Following histopathological confirmation, ultrasonography was found to have a sensitivity and specificity of 100%. Negative appendicectomy rate returned at 6.7%.

Conclusion

Ultrasonography is a low cost, highly sensitive diagnostic tool in appendicitis, where provisions are in place to do so. Visualising the appendix on ultrasound can reduce negative pathology rates. This is a small study within a DGH and access to ultrasound is limited. Better utilisation or the development of a protected ultrasound slot should be sought.
EP.FRI.247 Incidence and diversity of the primary appendiceal tumours in patients presenting with acute appendicitis: Our Experience
Authors: Aspari Ajay , Ayantunde Bolu , Ayantunde Abraham
Published: October 2021

Background

Primary appendiceal tumours are rare. Our experience with the incidental primary appendiceal tumours and their histological diversity.

Patients and Method

Operative and pathological databases of appendicectomies for presumed diagnosis of acute appendicitis between January 2015 and December 2020 were interrogated. Clinicopathological data were collected and analysed to present the incidence of primary appendiceal tumours, histopathological diversity and outcomes.

Results

1908 appendicectomies were performed over the study period. 22 patients with primary appendiceal tumours (incidence rate 1.2%) had a mean age of 45.6(15-97) years and M:F ratio of 1:1.2. Only six patients (27.3%) had appendiceal tumour suspected either before or during surgery. 91% of the patients underwent laparoscopic appendicectomy. Right hemicolectomy was performed as the first intervention and further surgical procedure in 1 and 5 patients respectively.

Histological tumour types included carcinoid(10), adenocarcinoma(4), low grade appendiceal mucinous neoplasm(4) mucinous adenocarcinoma & carcinoid(1), goblet cell carcinoid(2) and dysplastic serrated polyp(1). Tumours were located at the tip(10), body(10) and base(2). Median tumour size was 13(2.0-55.0) mm. Median hospital stay was 1.5(0-25) days.

The mean survival was 30.9(2.80-73.70) months. Disease related death was a 97-year-old lady with a T4 adenocarcinoma and peritoneal disease who stayed for 25 days and offered palliative supports post appendicectomy.

Conclusion

Primary appendiceal tumours are diverse in histological types and are of varying prognosis. Appendicectomy alone seemed to be adequate in most cases with early-stage disease. Further surgery such as right hemicolectomy was required for adenocarcinoma and other high-grade tumours.
EP.FRI.248 The bezoar, the bowel, and the blockage: A rare case of a spontaneously passed phytobezoar
Authors: McGuigan Conor , Davidson Sophie , Mark David
Published: October 2021

Background

Bezoar, from the Persian meaning antidote, denotes a trapped mass in the gastrointestinal system. There are several types, but here we present a case of phytobezoar.

A phytobezoar is one which is composed of undigestible plant material. While all bezoars account for less than 4% of intestinal obstruction, most occur within the stomach or small intestine. Phytobezoars causing large bowel obstruction appear to be extremely rare.

Case report

We present a case of a phytobezoar causing large bowel obstruction in a 29-year-old man. He presented with a four-day history of abdominal pain and distension with associated vomiting and no bowel opening.

An abdominal X-ray demonstrated significant dilatation of transverse colon. Subsequent CT revealed large bowel obstruction with transition point in the distal sigmoid. An intraluminal lesion, with mottled appearance, containing locules of gas – a phytobezoar – was noted as the cause.

The Patient was clinically well with no peritonism and planned for a flexible sigmoidoscopy in the first instance. However, the patient went on to pass two large, hard bowel motions leading to significant resolution of symptoms. A flexible sigmoidoscopy was carried out to exclude other pathology and demonstrated that the obstruction had been relieved. 

Conclusion

While it seems phytobezoar is an incredibly rare cause for large bowel obstruction, most of the literature suggests operative management of the problem by means of laparotomy and enterotomy. This case demonstrates the potential for conservative management and possibility for spontaneous resolution, despite emergency presentation.
EP.FRI.257 ELF 2: Defining the Denominator
Authors: McLennan Elizabeth , Price Angeline , Boyle Jemma
Published: October 2021

Introduction

The collaborative UK Emergency Laparotomy and Frailty (ELF) study was one of the first to investigate the older adult population undergoing emergency surgery. Despite accounting for almost half of emergency laparotomies and many considered high-risk, there remains a paucity of research in this population. One undefined area is the older patient who presents with acute abdominal pathology treatable by laparotomy but who do not undergo surgery.

Aims

The primary aim is to estimate the 90-day mortality in older patients presenting with acute abdominal pathology potentially treatable by emergency laparotomy who do not undergo surgery (NoLap). The secondary aims are the characterisation of this group, including frailty and sarcopenia with comparison to those older adults that have undergone emergency laparotomy (NELA and ELLSA). In addition, the decision-making process will be explored.

Method

Multicentre prospective cohort study via established research collaboratives (WelshBarbers, SSRG, OPSOC). ELF 2 requires at least 47 centres, recruiting 700 patients for 3months prospective data collection via REDCap of NoLap patients with the same NELA inclusion/exclusion criteria. This data will be compared with a matched cohort from NELA and ELLSA. ELF2 data collection includes demographics, co-morbidities, frailty and sarcopenia. Each patient will be followed up for 90-day and 1-year mortality. Heuristics behind the decision will be analysed.

Discussion

This trainee led collaborative project aims to improve understanding of the older adult population being considered for emergency laparotomy. With the ageing population being the dominant health users of the future, defining the denominator is essential for shared decision-making
EP.FRI.258 A closed loop audit of deep vein thrombosis prophylaxis in the acute surgical receiving unit of a large teaching hospital; reducing morbidity and mortality, and improving cost-effectiveness
Authors: Chen Jun Yu , Norman Fraser , Paterson-Byrne Paul , Nicholson Gary
Published: October 2021

Aims

Acute surgical patients have a significant risk of venous thromboembolism (VTE) due to factors such as surgery, immobility, dehydration, and existing comorbidities. All patients admitted to an acute surgical unit should have their VTE risk assessed. Our aim was to assess VTE prophylaxis practices.

Methods

We performed a closed loop audit on DVT prophylaxis using the Scottish Intercollegiate Guidelines Network proforma. Data on anti-embolic stockings (AES) and low molecular weight heparin (LMWH) were collected and presented at a local audit meeting. The intervention included reinforcing the importance of VTE prophylaxis compliance amongst junior doctors and nursing staff, and provision of posters within the department and on patient trolleys. Data was collected to complete the audit cycle.

Results

A total of 171 patients were included. Prior to the intervention, 13.9% did not receive LMWH when indicated and 37.4% were non-compliant with AES. Overall, 40% had insufficient DVT thromboprophylaxis. Post implementation, 8.9% did not receive LMWH when indicated and 46.4% were noncompliant with AES. Overall, 50% had insufficient DVT thromboprophylaxis. LMWH compliance was 5.0% higher on re-auditing however AES compliance was 9.0% lower.

Conclusions

Adherence to thromboprophylaxis regulations was below expected standards. Thromboprophylaxis is cost-effective and prevents considerable morbidity and mortality, so ongoing audits alongside analyses of potential causes should be encouraged. We acknowledge the data’s limitations in that the reasons for low compliance cannot be ascertained here, but results suggest that there exists room for more interventions aiming to encourage a marked improvement both in LMWH and AES compliance.
EP.FRI.306 The Mule who took us for a ride
Authors: El-Abbassy Islam , Perakath Benjamin
Published: October 2021

Introduction

Foreign body ingestion is not uncommon in patients with mental disorders, alcohol intoxication and for purposes of drug trafficking. Small objects pass spontaneously; however, larger ones may get stuck in the oesophagus, stomach or at narrow areas of the bowel. "Body packers" is a term used to describe persons who swallow or insert drug-filled packets into a body cavity. They are also called “swallowers”, “internal carriers” “couriers” or “mules”.

Case report

We report a 37 year old previous drug abuser who presented with dysphagia. Upper GI endoscopy showed an oblong foreign body covered in plastic in the lower oesophagus. This could not be extracted and hence was pushed into the stomach. Three weeks later, he presented with bowel obstruction that was shown on abdominal radiograph and confirmed by CT indicating multiple dilated small bowel loops with a transition point in the terminal ileum where the ingested package was identified. The package was then removed through a longitudinal enterotomy. 

Conclusion

Ingested foreign bodies causing dysphagia should ideally be extracted endoscopically. If not possible, then a watch and wait policy may be justified. While most ingested objects pass spontaneously, unusual and larger ones may require surgical extraction.

The contents, nature and reason for ingesting this strange object remain a mystery. With history of drug abuse and the consistent denial of knowingly swallowing that object, we can only conclude that the patient was trying to transport an illicit drug in the packet.

Keywords

Foreign body ingestion, bowel obstruction, body packers.
EP.FRI.309 Rib fractures – an overlooked part of general surgical take? An audit and creation of a local pathway
Authors: Mai Dinh Van Chi , Singh Anjana
Published: October 2021

Introduction

Battle et al  devised a validated scoring system to stratify patients with rib fractures (RF) at risk of complications based on age; number of fractures; oxygenation; respiratory illness and anticoagulation use. Risk of complications increases with score e.g. ≤10 and ≥31 give estimated complications risk of 13% and 88% respectively (2).

Method

We conducted a local retrospective audit of 45 patients admitted with RF over 26 months. Initial and subsequent analgesia was recorded. Four subgroups were created based on Batlle score: ≤10, 11-20, 21-30, ≥31. Outcomes included complications, length of stay (LOS) and mortality.

Results

Whilst overall median score was 18, we observed 20% (n = 9) scored ≥31. Initially, oral analgesia alone was given to 64% of patients; 66% went on to require lidocaine patch and 15% required patient controlled analgesia. Only 2.2% (n = 1) received regional analgesia. Despite 35.6% (n = 16) scoring ≥21, only four proactive critical care referrals were made.

Overall pneumonia rate was 20% (n = 9); 44% (n = 4) in the ≥31 group. There were two deaths overall, both in the ≥31 group. Median LOS was 3 days; however 44% (n = 4) of the ≥31 group required ≥7 days. 

Conclusion

One in five RF cases scored ≥31 and consequently had the worst outcomes. There was initial suboptimal analgesia, inadequate early escalation of higher risk patients to critical care and low rates of regional blocks. Consequently, we have created a local pathway based on Battle score (2) to standardise risk stratification and management of these patients in order to improve outcomes.