bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.WE.859Pain management in critical limb ischaemia patients: a clinical audit
Authors: Bagga Rahul , Imsirovic Anja , Almond Genevive , Elahwal Mohamed , Caruana Mario
Published: October 2021

Aims

Critical Limb Ischaemia (CLI) patients often present with ischaemic rest pain and uncontrolled pain can impact on quality of life. To improve pain control, a set a of trust-wide guidelines were developed to standardise pain management for CLI patients.

Methods

This was a prospective cross-sectional audit, which initially involved 30 patients admitted under vascular surgery at a tertiary centre with CLI between May and June 2020. The improvements implemented included an analgesia education session for junior doctors, inclusion of an analgesia dosing table in the vascular clerking proforma and a simplified analgesia table as a poster. The re-audit included 22 patients with CLI between September and October 2020. Data was collected from drug charts and Fisher’s exact test was used for the statistical analysis.

Results

Baseline data suggested poor compliance with guidelines with only 3% of patients prescribed the guideline recommended PRN opiate doses. This improved post-intervention to 52% (p < 0.05). Following the interventions, naloxone prescribing significantly improved from 37% to 91% (p < 0.05). Standard dosing of opiates was seen irrespective of age or renal function. 14% of patients with renal impairment were prescribed opiate analgesia above the initial ranges indicated by the guidelines; compared to 33% in the first cycle (p = 0.58).

Conclusion

This audit has demonstrated the successful implementation of targeted changes to improve compliance with trust pain management guidelines for patients with CLI. The challenge remains of overcoming the unknown eGFR at time of prescription and unknown background analgesia that can lead to over and under prescribing.
EP.WE.913Evaluation of upper GI cancer diagnosis in suspected patients referred for OGD directly by GP vs Two Week Referral pathways
Authors: Abdelwahed Ahmed , Slezak Izabela , Witting Sarah , Kumar Narayanan Vinod , Zach Rudolf , Warren Hugh
Published: October 2021

Aim

To assess whether the new direct pathway (requested by GP) has improved OGD accessibility and time of diagnosis for patients with suspected UGI cancer. The new system aimed to bypass a formal referral to UGI clinic.

Methodology

Retrospective study, compared two groups of patients (total 329). Group A (173 patients, TWW referral to UGI clinic who had endoscopy between March and May 2017), and Group B (156 patients, Direct access pathway by the GP to have the endoscopy between March and May 2018). inclusion criteria includes patients referred directly by the GP between March and May 2018, TWW patients referred March-May 2017. Patients who had OGD with suspected diagnosis other than UGI cancer were excluded. Data was compared in terms of gender, age, interval time between referral and OGD, and cancer findings.

Findings

Time between presentation and diagnosis in patients referred via Direct Access pathway was shown to be significantly shorter compared to patients admitted via TWW. The difference was 7 days in favor of the Direct Access pathway which was statistically significant (p value 0.001).

Recommendations

Direct access pathway has decreased the waiting time, expedited the management, potential money saved, more available clinic space and less administrative work.
EP.TH.74An incidental finding of liver haemangioma on diagnostic laparoscopy for right sided abdominal pain in a young woman
Authors: Elsllabi Mohamed , Shams Muhammad
Published: October 2021

Introduction

Cavernous liver haemangiomas or hepatic haemangiomas are the most common benign neoplasm of the liver. They are more common in women with a male to female ratio of 2.5-5.1- likely due to estrogenic influence. They are composed of hepatic endothelial cells and are usually small in size (< 4 cm). They are asymptomatic in most of the cases and incidentally discovered on diagnostic tests. Occasionally haemangiomas can exceed a size of 5 cm where they can cause symptoms such as nonspecific abdominal pain. Their exact aetiology is not well understood; they are thought to be vascular malformations with hormonal or congenital background. Haemangiomas belong to ‘Incidentaloma’ tumours, since they can be found incidentally while investigating for other unrelated pathologies. Although rare, but rupture and hemorrhage of liver hemangiomas can be fatal.

Case presentation

A 33-year-old woman was presented with abdominal pain which was started in central abdomen and then shifted to right lower abdomen abdomen. No other significant symptoms at presentation or past medical history.

On serial physical examination, the patient was more tender at the right lower quadrant of the abdomen. Although her inflammatory markers were normal the decision was made to proceed with diagnostic laparoscopy to rule out acute appendicitis.

During laparoscopy normal appendix was found with multiple liver lesions. Appendix was not removed.

Postoperatively CT Thorax, Abdomen and Pelvis with contrast and CT Liver Triple Phase was performed which confirmed benign liver haemangioma.

The patient recovered well after surgery and was discharged home with no routine surgical follow up.
EP.TH.96Recurrent Retroperitoneal Liposarcoma Presenting as Irreducible Inguinal Hernia
Authors: Farooqui Marryam Riaz , Bhatti Hamza Waqar , Chaudhary Noman Ahmed , Khan Huma Sabir , Hanif Muhammad
Published: October 2021

Introduction

Retroperitoneal sarcomas protruding though the groin are extremely rare with only about 12 cases reported in the past 31 years to our knowledge. . As the retroperitoneal space communicates with the inguinal canal, large lipomatous tumors, may protrude through this natural weak spot which may present as irreduciible inguinal hernia.

Case Report

We report a 43 year old male, previously operated for retroperitoneal liposarcoma with 4 cycles of adjuvant chemotherapy and 5 cycles of radiotherapy 4 years back now presented with irreducible inguinal hernia. On examination, a firm fixed mass of about 15 x 10 cm, with indistinct margins was palpable in right hemiabdomen, abdomen was soft with audible bowel sounds. A firm swelling of 8 x 5 cm in right inguinal region extending into scrotum with no cough impulse was also present. On CT imaging a large mixed density lesion noted in Right lower abdomen measuring 16.2 x 14.8 x 23.5 cm. It showed internal fat and solid components and recurrence with herniation through right inguinal canal which is a rare entity. The patient was treated symptomatically, bilateral DJ stenting was done by the urology team and the patient was prepared for debulking surgery. Patient was classified as ASA IV. Unfortunately, the patient died 6th post admission day secondary to cardiopulmonary arrest.

Conclusion

A retroperitoneal tumor especially a liposarcoma should be ruled out in a large, painless, non-reducible inguinal mass with abdominal complaints. Patients need regular follow up after resection of retroperitoneal liposarcoma for early detection of recurrence.
EP.TH.177Safety profile of SurgiMend Acellular Dermal Matrix and Mentor implant assisted immediate breast reconstruction – Our experience at the Princess Royal University Hospital
Authors: Shaaban Gamal , Khan Maryam , Ragad Lilia , Norman Carol , Kasem Abdul , Uhercik Michal
Published: October 2021

Background

ADM (Acellular Dermal Matrix) assisted implant-based immediate breast reconstruction (IBR) is a common technique worldwide. Various ADMs are available manufactured from different sources. The Surgimend ADM (fetal bovine dermis) is fenestrated and rich in type I/III collagen; it is claimed to reduce fluid accumulation and promote healing.

Methods

Retrospective observational analysis exploring safety profile using combination of SurgiMend MacroPorous (MP)/SurgiMend PRS and Mentor CPG/Mentor Siltex implants between January 2018 to December 2019. Patients with unilateral/bilateral IBR following Nipple sparing (NSM) or Skin sparing mastectomy (SSM) were included. The primary outcome was minor complications (seroma (>100ml on USS), hematoma, wound infection and infected seromas). Secondary outcome was major complications (flap necrosis, capsular contracture, implant explantation and Red Breast Syndrome).

Results

Six (16.2%) bilateral and 31 (83.8%) unilateral IBR were performed in 37 patients. Mean age was 53.78 years.

No major complications were recorded.

Conclusions

The Surgimend ADM and Mentor implant combination demonstrate a good safety profile. Higher rates of seroma in this study could be explained by overdiagnosis and treatment at our unit, which in turn might imply as a result that no major complications were detected and no implant loss.
EP.TH.267Gastroesophageal Reflux Disease after sleeve gastrectomy
Authors: Khan Shujhat , Asad Sima Al
Published: October 2021

Aim

A prominent complication of a sleeve gastrectomy is gastroesophageal disease (GERD). Symptoms include chest pain, dysphagia, heartburn, regurgitation, chronic cough, and laryngitis. With the rise in obesity, and the already high prevalence of GERD in these populations, this is a significant cause of morbidity in western populations and is likely set to worsen.

Method

The literature search was carried out using Ovid MEDLINE and PubMed databases to search for keywords and MeSH terms including “bariatric surgery”, “sleeve gastrectomy”, “complications”, “gastroesophageal reflux disease”, “GERD”, “GORD”, and “obesity”.

Result

Approximately 20% of patients who undergo SG will develop de-novo GERD whilst 19% will have an increase in reflux symptoms. The exact mechanism of GERD in both obesity and post-operatively following SG is unclear. However, it can involve several different mechanisms. This includes poor surgical technique, disruption to physiological anatomy, increase in gastric pressure, increased risk of hiatus hernia, and disruption to normal hormonal balance. An effective approach to treat GERD includes the Stretta procedure with studies showing 72% of patients being symptom-free after 10 years. If this fails, conversion of SG to Roux-en-Y is effective but there is an increased risk of gastro-jejunal anastomotic leak (3% vs 1%). Alternatively, addition of hiatoplasty and 180° cardioplication can also be effective.

Conclusion

More evidence and international collaborations would help determine which patient groups require counselling and will benefit from novel management to minimise complications.
EP.TH.386Management of acute gallstone-related complications at Great Western Hospital
Authors: Castelhano Rute , Bartlett Jessica , Wooler Harry , Mahmoud Ahmed , Theofilis Aris , Shamali Awad
Published: October 2021

Aim

Gallstone-related disease accounts for a third of the admissions to the Surgical Department. In June 2019, an audit was undertaken at Great Western Hospital assessing the number of patients who underwent cholecystectomy, following initial diagnosis, in accordance to current guidelines. The results demonstrated a very low number of patients had cholecystectomy, within the targeted timeframe, which led to the implementation of a dedicated operative “hot gallbladder” list weekly. In June 2020, we re-audit the service to evaluate the impact of the change implemented.

Methods

A retrospective observational analysis of patients admitted to the Hospital in June 2020 with gallstone-related disease. Data was collected using the Surgical on-call lists, these were analysed and patients selected according to the reason for admission. Only gallstone related issues were considered in this analysis. Finally, via Medway, the time from admission to surgery was assessed.

Results

Despite the disruption in service provision due to COVID-19, the implementation of the “hot gallbladder” list led to a 10.7% increase in timely cholecystectomies, bringing the overall compliance to 14%. There was also a significant reduction in biliary related re-admissions, from 58% to 37%. Despite 47.3% of patients were still awaiting surgery, the waiting list was reduced by 5.2% in only 1 year.

Conclusions

This study demonstrated that the implementation of the “hot gallbladder” list has improved the compliance with the current guidelines. The change has brought us in line with the national average of 15%, as estimated by RCSEng, therefore demonstrating the efficacy of the weekly list.
EP.TH.507An Audit of Consent Documentation and Chaperone Use in Patients Presenting to Acute Settings with Breast Complaints
Authors: Dunlop Hannah
Published: October 2021

Aim

To compare current practice of documenting consent and offering chaperones when performing breast examinations in the acute setting, with standards set by regulatory bodies (General Medical Council, Royal College of Emergency Medicine and Royal College of Surgeons).

Method

Data was collected retrospectively from all patients presenting with breast complaints to either the emergency department (ED) or the surgical assessment unit (SAU) over a 34-month period. From the clerk-in notes, the role (Dr/Nurse), grade (FY1 to consultant) and gender of the examiner was noted, as well as whether consent was documented and if a chaperone was offered.

Results

Of the 64 patients presenting in this time frame, consent was documented in 7 sets of notes (11%). Furthermore, 17 were offered a chaperone (27%), of which examiners correctly documented the name and role of the chaperone on 11 occasions.

Results also demonstrated that ED trainees were most likely to offer a chaperone and GP trainees were the best at recording consent. It also revealed that although male examiners offered a chaperone 50% of the time compared to 6% of female examiners, women examiners were better at documenting consent when compared to their male counterparts.

Conclusion

The audit results indicate that there is significant room for improvement across all roles, grades and genders with regards to documentation of consent and the use of chaperones within the acute setting, in order to meet current standards of practice as set out by regulatory bodies.
EP.TH.515A Case of mucinous adenocarcinoma of the breast in a young male patient presenting with a subcutaneous axillary lump
Authors: Suliman Amna , Latif Ahmed , Metafa Anna , Uhercik Michal
Published: October 2021

Aims

Mucinous adenocarcinoma of the breast is rarely encountered clinically, and makes up only 0.01% of Breast cancer (BC) cases and < 1% of male breast cancer (MBC). We describe an extremely rare case of mucinous carcinoma in accessory axillary breast tissue in a male.

Case details

A 48-year old male presented with a subcutaneous lump in his left axilla. Ultrasound described a 30mm hypoechoic mass and core biopsy confirmed mucinous adenocarcinoma, strongly positive for oestrogen and progesterone receptors, HER2 negative. A solitary enlarged axillary node in was sampled (C2) and mammogram reported a 32mm spiculate mass (M4) on the left. PET scan showed uptake only in the known axillary mass.

Management

Wide Local Excision and Sentinel Lymph Node Biopsy (SLNB) was completed. Histology showed a 27 mm grade 2 mucinous carcinoma, and the patient completed adjuvant radiotherapy and was commenced on tamoxifen.

Conclusions

MBC is rare, and accounts for only 1% of all BC. Men tend to be diagnosed at an older age (mean is 67 years) and usually have genetic/hormonal risk factors. Histologically, invasive ductal carcinoma makes up 95% of MBC. In every regard therefore, our case breaks the mold since, he was young, had no genetic/family history and no background of gynaecomastia (present in 6-38%). Literature review suggests that this is only the second case of its kind and from it we can learn to be vigilant for MBC in accessory axillary breast tissue as well as the more typical presentations.
EP.TH.531Occult breast cancer: Breast conservation or Mastectomy in terms of recurrence. A single center experience
Authors: Javed Muhammad Rizwan , Abidi Syeda Sakina , Vohra Lubna Mushtaque
Published: October 2021

Aim

We sought to compare breast conservation therapy & mastectomy as treatment of occult breast cancer in terms of recurrence.

Methods

It is a retrospective cross sectional study conducted on patients diagnosed to have occult breast cancer and going for either breast conservation therapy or mastectomy at The Aga Khan University Hospital Karachi between January 200o to December 2018, patients will be divided into two groups, first group will be consisting of patients who underwent breast conservation therapy and 2nd one will be of patients who had mastectomy. Patients will be included by consecutive sampling technique. Hospital database will be used to identify patients and data collected on a self designed tool using files and electronic patient records. Patients in both groups will be followed to see local recurrence from date of diagnosis to 2 years post operatively in hospital data base and their files, and then their data will be compared with the reference studies reported in this article.

Results

Awaited as the study is ongoing.

Conclusions

Awaited as study is ongoing.
EP.TH.691Necrotic Liver Abscess secondary to Duodenal Perforation caused by ingestion of a Fish Bone – A Case Report
Authors: Surtee Shazmeen , O'Connor Adam , Fani Mazyar , Hassan Ahmed , Satyadas Thomas , Jamdar Saurabh
Published: October 2021

Introduction

Ingestion of foreign bodies are not uncommon, however enterohepatic migration of fish bones causing liver abscesses remains a rare phenomenon.

Case Report

We present the case of a 58-year-old female admitted with 11 days history of fever, rigors, shortness of breath and malaise associated with vomiting and diarrhoea. Her COVID-19 rapid antigen test was negative. She was tender in the left lower quadrant of her abdomen and inflammatory markers were markedly high so initial differential diagnosis included colitis and diverticulitis.

Contrast Computed Tomography of the abdomen and pelvis showed an 8.1cm irregular hepatic lesion initially thought to be a multi-loculated abscess, malignancy or complex cyst. She was started on broad-spectrum antibiotics, escalated to Intensive Care Unit (ICU) and discussed at the hepato-biliary multi-disciplinary team (MDT) where magnetic resonance images demonstrated a perforated duodenum from a 2.5cm fish bone penetrating from the duodenal wall into the liver parenchyma causing a necrotic abscess.

She underwent percutaneous drainage of the hepatic abscess. Endoscopic retrieval was then attempted; however, the fish bone was not visualised. Definitive management followed with laparoscopic removal of the fish bone and primary duodenal repair.

Discussion

Identification of the cause of the abscess during MDT discussion enabled prompt source control which was key in managing intra-abdominal sepsis – radiological drainage in the first instance prevented secondary peritonitis from a potentially ruptured abscess and enabled the patient to be de-escalated from ICU. Previous literature suggests endoscopic retrieval however, laparoscopic surgery remains safer for managing complications following removal of sharp foreign bodies.
EP.TH.747Audit of antibiotic prophylaxis in groin hernia repair
Authors: Patel Maitreyi , O'Balogun Aleem , Kirmani Naveed
Published: October 2021

Aims

To review practice of antibiotic prophylaxis in patients undergoing groin hernia repair against the International guidelines for groin hernia management 2018, in order to improve compliance with International Guidelines. We also assessed the risk category of patients.

Methods

Retrospective data of all patients undergoing groin hernia repair from November 2019 to March 2020 was collected using hospital software. Data collected included patient demographics, details of hernia repair including; primary/recurrent hernia, emergency/elective, laparoscopic/open repair and use of mesh. The details of antibiotic prophylaxis were recorded. Descriptive statistics was used. Data was analyzed using Microsoft Excel.

Results

67 patients were included, of which 38(57%) were high risk. 62 (92.5%) primary repairs were done, of which 48(72%) were open. 62(92.5%) were operated electively. 46(69%) patients underwent open repair with mesh, 6(9%) had open repair without mesh, while 15(22%) had laparoscopic repair with mesh. A total of 45 (67%) patient received antibiotic prophylaxis. Adherence to International guidelines for groin hernia in open hernia surgery was 82.67%, while that for laparoscopic surgery was 60%. Overall adherence to the Guidelines was 56.67%.

Conclusions

The audit reflects the need for improved understanding and adherence to the International Guidelines. Data collection of surgical site infection can help inform and influence practice to minimize the risk for surgical site infection and assist in better communication with patients regarding risk. Risk assessment for surgical site infection of patients prior to procedure helps to identify those with indication of antibiotic prophylaxis.
EP.TH.756Post-operative sepsis: Is CT reliable in diagnosing the cause of post-operative sepsis?
Authors: Chidambaranath Rajesh , Rajebhosale Ramprasad , Thomas Pradeep
Published: October 2021

Aim

To assess the reliability of computerised tomography in post-operative sepsis in patients who previously underwent laparotomy in the same hospital admission.

Introduction

Method

This study was done on re-operations following an abdominal operation from April 2012 to April 2016 at a district general hospital. Data regarding demography, initial operation, post-operative problems, pre-operative diagnosis, and use of computed tomography, the findings on CT, and operative findings were collected. A comparison was made between the CT findings and findings on re-laparotomy. Also noted was the number of patients who did not have a re-laparotomy following CT.

Result

There were 87 patients, of whom, 10 had no accessible notes and were removed from the list. Of the remaining 77, 53(68.8%) had CT scans, 24 did not (31.2%). Of these that had CT, 29 (54.7%) had findings which matched with intra-operative findings on re-laparotomy, in 12 (22.6%) CT findings did not match 4(7.5%) had minor findings not needing surgery and 8(15.5%) had normal or insignificant findings.

Conclusions

We found in this study that, CT did have a significant contributory role in the arsenal of methods to aid source control in those patients that are septic following an abdominal operation, and this should be used as a pre-operative diagnostic modality.
EP.TH.919Developing A Fast Track Paediatric Herniotomy Service In A District General Hospital
Authors: Chituku Tsitsi , Gupta Pradip , Bartholomew Karen , Moncrieff Michael
Published: October 2021

Introduction

Previously to 2011, babies presented as emergency to our Trust with irreducible inguinal hernia at a rate of 1 baby/year. They were referred to our regional tertiary centre for surgery because there is no out of hours Paediatric Surgeon or Anaesthetist. Usually, patients were either, awaiting an appointment to see surgeon or on an 18-week waiting list. The aims of this SIP were to: expedite elective surgery for paediatric inguinal hernias, and prevent emergency paediatric inguinal hernia referrals to our tertiary centre.

Method

Referrals to paediatric surgical clinics were triaged by the clinic sister. Hernia referrals were expedited to the next available clinic. A provisional date for surgery was arranged ASAP with an identified surgeon and anaesthetist whilst in clinic. Patient demographics and data collected retrospectively.

Results

A 73% reduction in waiting time for surgery, 1 baby (1.4%) presented as emergency and was referred to our tertiary centre for surgery, the post-op complication rate fell from 6.5% to 0%.

Conclusion

The success of the fast-track paediatric herniotomy service at our DGH shows that it is possible to provide timely and safe surgery in a DGH in line with the recommendations of the Paediatric Critical Care and Surgery in Children Review (November 2019).
Moy.02Using aboutmyop.org as an alternative method for post-operative follow-up after elective laparoscopic cholecystectomy – a feasibility study
Authors: Daliya Prita , Carvell Jody , Rozentals Judith , Ubhi Maria , Lobo Dileep , Parsons Simon
Published: October 2021

Introduction

The majority of institutions no longer offer routine post-operative follow-up after elective laparoscopic cholecystectomy. National guidelines however recommend the use of post-operative hotlines or planned telephone follow-up for day-case procedures. At a time when NHS resources are limited, a digital solution may provide a safe alternative to telephone or physical follow-up. Our aim was to identify if digital follow-up with aboutmyop.org; a digital data-sharing platform, was equivalent to telephone follow-up.

Method

Study participants were invited to use aboutmyop.org before and after surgery. Patients were given free choice on whether they opted to use post-operative digital follow-up or routine post-operative care (no follow-up or telephone follow-up). In addition to follow-up compliance, the outcomes measured included 30-day post-operative complications, readmission, and re-operation.

Results

Of 597 laparoscopic cholecystectomy patients who were offered follow-up, 16.4% opted for digital follow-up, and 33.3% phone follow-up. Over 5 times as many patients who opted for telephone follow-up missed their appointment when compared to those who chose digital follow-up (5.6% vs. 30.9%, p < 0.001). Digital follow-up had a high sensitivity (68.2%-100%) and specificity (100%) for identifying complications at 30-days post-operatively and was completed significantly earlier than phone follow-up (median 6 days vs. 13.5 days, p = 0.001) with high patient acceptability.

Conclusion

This feasibility study demonstrates that digital follow-up utilising the aboutmyop.org platform is an acceptable alternative modality to telephone follow-up in elective laparoscopic cholecystectomy patients. Future work should aim to compare matched cohorts of patients undergoing digital follow-up, telephone follow-up, and no follow-up as a randomised controlled trial.
BJS.01Antibiotics as an alternative to appendicectomy in uncomplicated adult appendicitis: analysis of a prospective, multicentre cohort study
Authors: Javanmard-Emamghissi Hannah , Doleman Brett , Hollyman Marianne , Lund Jonathan , Moug Susan , Tierney Gillian
Published: October 2021

Aims

Recent randomised controlled trials have shown that non-operative management of acute appendicitis with antibiotics can prevent the need for surgery in 71-84% of patients within 90-days.  Changes in the management of appendicitis, brought about by the COVID-19 pandemic, have allowed for this large-scale observational study, which aims to report the outcomes of operative and non-operative management of appendicitis, including non-operative management rates at 90-days.

Methods

This prospective, multicentre cohort study at 97 sites across Great Britain and Ireland included adult patients with a clinical or radiological diagnosis of appendicitis. Propensity-score matching was conducted using age, sex, BMI, frailty, co-morbidity, adult appendicitis score and CRP. Outcomes in the non-operative group were 90-day treatment failure, and in the matched groups 30-day complications and length of hospital stay (LOS).

Results

This analysis included 3420 patients, of whom 1402 (41%) had initial non-operative treatment and 2018 (59%) had operative management. The success rate of non-operative management was 80% (1116) at 90-days, with 18 patients (6%) that failed non-operative management having a histologically normal appendix. Following propensity score matching, 2444 patients were included in the outcomes analysis. In the propensity score matched groups, there was a reduction in complications in the non-operative management group compared to the operative group (OR 0.36; 95% CI 0.26 to 0.50) and a shorter median LOS (2.5 vs 3 days, p < 0.001).

Conclusions

Non-operative management of appendicitis is associated with fewer complications, a shorter LOS, and avoids surgery in the majority of patients.
NELA.01The Impact of Laparoscopy on Emergency Surgery for Adhesional Small Bowel Obstruction: Prospective Single Centre Cohort Study
Authors: Darbyshire Alexander , Kostakis Ina , Pucher Phil , Toh Simon , Mercer Stuart
Published: October 2021

Aims

Laparoscopic adhesiolysis is being increasingly used to treat adhesional small bowel obstruction (ASBO). However, concerns regarding iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre’s experience of adopting laparoscopy as the standard operative approach for ASBO.

Methods

A single centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; 01/01/2015-31/12/2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and in-hospital outcome data were compared between different surgical approaches. Linear regression analysis was performed for length of stay.

Results

Of 299 cases, 76.3% were started laparoscopically and 52.2% successfully completed. Rates of attempted laparoscopy increased over the 5 year period. Patients treated laparoscopically had lower P-POSSUM-mortality (2.1 vs 5.7%, p = <0.001), shorter post-operative LOS (4.2 vs 11.3 days, p = 0.000) and lower in-hospital mortality (2 vs 7 deaths, p = <0.001). In regression analysis, laparoscopy had the strongest association with post-operative LOS ( 8.51, p = 0.002).

Conclusion

Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is now the standard approach in our centre, with 83.3% of cases started laparoscopically in 2019. It is associated with reduced post-operative length of stay with no impact on complications or mortality. This challenges the widely held view that laparoscopy should be for selected, straightforward cases.
NELA.02Trends in management and outcomes for patients presenting acutely with inguinal hernia
Authors: Clyde Danielle , Li Lucy , Swan Rebecca , McLean Ross , Brown Leo
Published: October 2021

Aims

Rates of emergency inguinal hernia presentations are increasing as ‘watch and wait’ management approaches become more popular. This study aimed to review current practice regarding clinical management of patients admitted acutely with an inguinal hernia in the North of England.

Methods

Patients ≥18 years admitted acutely with an inguinal hernia between 2002-2016 to North of England NHS trusts were identified. Data on demographics, investigations and operative interventions was collected. Outcomes analysed included rate of bowel resection, length of stay (LoS) and 30-day postoperative mortality.

Results

A total of 4698 patients presented acutely with an inguinal hernia, and 2588 patients (55.0%) underwent emergency surgery. Pre-operative CT scanning increased from 1.0% (2002-2006) to 12.1% (2012-2016) (p < 0.001). Patients who had a pre-operative CT were less likely to undergo repair than those who did not (42.2% vs. 56.0%, p < 0.001). Rates of bowel resection were higher in patients who had a CT (9.6% vs. 2.7%, p < 0.001). Of those presenting with obstructive symptoms, only 5.7% required bowel resection, 85.7% of these being small bowel. Bowel resection was associated with increased LoS (p < 0.001) and 30-day postoperative mortality (18.8% vs. 2.0%, p < 0.001). Laparoscopic repair, used in 119 procedures (4.6%), was associated with shorter mean LoS compared with open repair (3.0 vs 4.4 days, p < 0.001) but no difference in 30-day mortality (p = 0.169).

Conclusions

Emergency inguinal hernia repairs, requiring bowel resection, are associated with significantly increased LoS and a 9-fold increase in 30-day mortality. These findings raise important aspects to be discussed with patients during the consent process.
EP.TU.19Are virtual journal clubs a viable alternative in the Covid-19 era?
Authors: Morris James , Jenney Heloise , Park Chang , Scarborough Alexander , Antoniou Vaki , Anakwe Raymond
Published: October 2021

Introduction

During the COVID-19 pandemic, face to face journal clubs have been curtailed due to Governmental guidance for social distancing. We present an example of a virtual journal club set up for Orthopaedic senior house officers (SHOs) & trainees in the North West Thames (NWT) Deanery from April to August 2020.

Methods

Our aims were to establish a regular online journal club for orthopaedic trainees in NWT that successfully met the objectives of the more established face to face meetings. Assessment of each session was evaluated using a post attendance survey created using an established online generator.

Results

64.4% (16/25 participants) had not attended a virtual journal club before, with 100% (33/33) reporting that they would attend another virtual journal club. 39.4% (13/33) of attendees agreed or strongly agreed that they could participate in sessions over more conventional meetings. 24.2% (8/33) of participants reported experiencing technical issues during the sessions. 90.9% (30/33) of respondents reporting the virtual model to be more convenient than standard journal clubs.

Conclusion

The potential benefits of significantly increased accessibility, increased visiting expert contribution whilst still adhering to government guidelines; weighed against marginally less effective teaching nonetheless results in an overall benefit
EP.TU.54Surgical curriculum concordance: requiem for the educational dream
Authors: Luton Oliver , James Osian , Mellor Katie , Eley Catherine , Egan Richard , Lewis Wyn
Published: October 2021

Aim

This study aimed to analyse the degree of relative variation in specialty-specific competencies required for Certification of Completion of Training (CCT) set by the UK Joint Committee for Surgical Training (JCST) 2021 curriculum.

Methods

Regulatory body guidance related to operative and non-operative surgical skill competencies required for CCT were analysed and compared.

Results

Wide inter-speciality variation was demonstrated in the minimum number of logbook cases (median 815; range 54-2100), indexed operations (8; 5-24), Procedure Based Assessments (35; 6-110). Academic competencies related to peer reviewed publications, communications to learned societies, and audits were aligned at zero, zero, and three across specialties respectively. Mandatory courses have been standardised with Advanced Trauma Life Support (ATLS) being the sole pre-requisite CCT for all.

Discussion

JCST certification guidelines have broadly standardised competency domains, yet large discrepancies persist regarding operative indicative numbers, and assessments. This article serves as a definitive CCT guide regarding prevailing changes.
EP.TU.55Increased Communication within hospitals enhances Catheter Care for Colorectal patients
Authors: Bernstein Darryl , Hemaya Maria , Chia Jenny , Subhani Benjamin , Nunn Rebecca , Gupta Vivek
Published: October 2021

Audit Aims

1. To quantify staff compliance in documenting catheter insertion using newest (2019) vs older (2011) Catheter Care Plans (CCPs) in our hospital.

2. To assess completion of CCPs against NICE Quality Guidelines on Infection Prevention and Control1.

3. To action (and measure the impact of) interventions to improve CCP completion.

Methods

CCPs for all emergency and elective colorectal surgery patients with a urinary catheter inserted in our hospital, over a three-week period, were analysed. Interventions (including distributing new CCPs and placing posters) were implemented to raise awareness of desired documentation standards. Post-intervention, the audit loop was closed via a two-week analysis of a similar cohort.

Results

Pre-intervention, 25% of the 20 CCPs were new. The average completion rate of new and old CCPs, respectively, was 63.48% ±9.53% and 49.28% ±7.65%. Post-intervention, 66.6% of the 18 CCPs were new. The average completion rate of new and old CCPs, respectively, was 49.28% ±18.48% and 42.75% ±3.27%. Aside from one uncompleted, new CCP post-intervention, which skewed the results, we were 100% compliant with overall guidance on NICE1.

Conclusions

Increased communication between the wards and theatre teams is pivotal to ensure optimal catheter care for patients. Improvement points include: replacement of residual old forms with new CCPs, and more education to ensure correct completion of new CCPs. Further progress requires both awareness and availability of patient advice leaflets and catheter passports, as well as reminding staff of NICE Quality Guidelines1.
EP.TU.141A 5-year Post Colonoscopy Colorectal Cancer audit with focus on root cause analysis and performance at York Teaching Hospital
Authors: Elsayeh Karim , Brown Alexander , Chintapatla Srinivas , Lim Michael
Published: October 2021

Introduction

Post colonoscopy colorectal cancer (PC-CRC) is an important benchmark of endoscopy performance. Previous publications have reported significant variations between institutions. We chose to perform the root cause analysis (RCA) and the impact of traditional performance indicators on the likelihood of PC-CRC.

Methods

A retrospective analysis was performed on all PCCRC at York Hospital. Electronic endoscopic records and case-note review was performed to identify appropriate cases. Root cause analysis was performed on all identified cases. Performance data and annual procedural volumes of endoscopist were recorded. Adjusted PC-CRC/5-year period allowed endoscopist to be divided into good (<4 PC-CRC) and poor performers (³4 PC-CRC). Mann Whitney U test used to compare groups. P-value of < 0.05 deemed significant

Results

32 (24 male) patients with a PC-CRC were identified . Median age was 72 (IQR 63-79) years. Table provides PCCRC rate for the 5-year period. Root cause analysis identified that most plausible cause was missed lesions despite adequate bowel preparation (76%). The commonest subtype was non interval C (38%). Three out of 18 endoscopist had a higher 5-year adjusted PC-CRC rate and were poor performers. Median withdrawal times, CIR and ADR did not differ between good and poor performers.

Conclusion

The overall PC-CRC rate at our institution is within an acceptable rate. We have noted significant variation of performance between endoscopist, the exact reasons for this observation require further examination.
EP.TU.160Does a foundation interim year one post improve confidence in the care of the dying of general surgical patients in a tertiary centre?
Authors: George Jayan , Mathew Alok , Botsford Edward , Al-Mukhtar Ahmed
Published: October 2021

Aims

1. Understand the confidence levels of current foundation year one (FY1) doctors.

2. Understand whether an interim foundation year one (FiY1) post improves confidence.

Methods

FY1s were surveyed throughout August – December 2020. Six questions used Likert scales (1 to 5: not at all confident to very confident) over some common palliative care themes. Data was initially inputted using Google Docs and analysed in Microsoft Excel.

Results

26.7% (28/105) of FY1s completed the survey. 28.6% (8/28) did not undertake a FiY1 post and 71.4% (20/28) did.

Confidence levels were higher for FY1s who did have a FiY1 post compared to those that did not in managing pain control, psychological distress, spiritual health, speaking to family and the patient in the last days of life.

Confidence levels were similar for all FY1s for dealing with social issues.

Conclusions

FY1s who have had a FiY1 post in a tertiary centre have more confidence in most areas but not all. This data shows the value of the FiY1 post however work needs to be done to improve the experience to the role.
EP.TU.169Gender Representation in the Authorship of Surgical Journals
Authors: Arshad Serish , Gallivan Elisha , Skinner Helen , Burke Joshua , Young Alastair
Published: October 2021

Aims

Despite the increase in female doctors graduating from medical schools internationally, gender disparity in surgery remains. This disparity is also evident in academic surgery. This study aims to quantify the extent of gender disparity in the authorship of articles in major surgical journals.

Methods

The Top 10 Surgical Journals were identified using SCImago Journal Rank indicator. Authorship details for papers published in 2019 were collected. Authors were assigned as female, male or unknown using Gender API software (Gender API, Germany). For each journal, the percentage of first author, last author, corresponding author and all authors split by gender was interrogated. Gender differences by publication type were also identified.

Results

9 of the 10 journals had full names publicly available. Overall, 2414 manuscripts were interrogated which included 16,277 number of authors. Respectively, females and males accounted for 29.8% [22.9-34.9%] (N = 655) and 62.4% [56.3-70.2%] (N = 1419) of first authors, 20.6% [11.8-27.1%] (N = 453) and 74.2% [65.6-84.1%] (N = 1706) of last authors, 23.9% [14.9-29.6%] (N = 510) and 69.9% [60.5-79.3%] (N = 2341) of corresponding authors and in total 27% [19.4-31.6%] (N = 4298) and 65.5% [58.6-73.4%] (N = 9982) of all authors. The wide range in these results could be due to various factors.

Conclusion

This study has identified a gender imbalance in authorship positions, with the greatest difference observed in the most senior author position. Whether this is reflective of the current disparity observed in senior academic surgery positions or due to gender discrimination is unclear.
EP.TU.170Audit to assess the management of patients presenting with lower gastrointestinal (LGI) bleeds in the Trust
Authors: Venkatesh Ashwini , Keeler Barrie , Khanna Achal
Published: October 2021

Aims

To identify presentations of LGI bleeds, assimilate learning and make appropriate recommendations to improve management in hospital.

Methods

336 patients with ‘PR bleed’ on their coding summary in 2019 were identified. Data obtained through eCare and EDM was analysed as outlined:

Results

69% were emergency presentations of LGI bleed and the remaining 31% were elective admissions. 5% of emergency LGI bleed patients were discharged on the same day as compared to 97.4% of elective patients.

The remaining 80% of emergency patients went on to have outpatient investigations. Positive cases included haemorrhoids, inflammatory bowel disease and diverticulitis.

Conclusions

All emergency presentations occurred during inpatient stay creating disparities in manner of presentation and duration of admission between cohorts. However, outcomes between the cohorts were broadly similar, suggesting absence of significant disparities in management.

Colonoscopy is the gold standard diagnostic investigation in LGI bleeds however, flexible-sigmoidoscopy can be considered in under 50’s. 80% of patients had a colonoscopy during admission as per guidelines. No reasoning was documented for patients who underwent other methods of investigation as first-line, thus creating a need for improved documentation when deviating from guidelines.

Recommendation to re-audit in 1 year to assess changes.
EP.TU.193Omental band - A unusual cause of mechanical small bowel obstruction in a virgin abdomen
Authors: Loganathan Santhosh , O'Connor Adam , Singh Amal , Fani Mazyar
Published: October 2021

Introduction

The small bowel obstruction in a non-operated abdomen is rare, and the most common causes are hernia and neoplasm. The complete mechanical small bowel obstruction due to an omental band in a patient with no previous abdominal surgery is rare, and less than five cases have been reported in the literature.

Case presentation

We report a 65 year old male patient presented to the emergency department with complaints of abdominal pain, distension, vomiting and obstipation for four days. On clinical examination, his abdomen was distended, diffusely tender, guarding. The blood investigations showed elevated White blood cells and neutrophils with normal CRP and the Serum lactate. The Abdominal X-ray was suggestive of SBO. The Computed tomography of the abdomen and pelvis showed marked dilatation of the jejunum, the ileum is entirely collapsed, the impression of a double beak sign in the mid-abdomen which would suggest closed-loop obstruction due to a possible internal hernia. We proceeded with emergency diagnostic laparoscopy converted to laparotomy, which showed omental band causing closed-loop proximal small bowel obstruction. The bowel loops appeared congested with the constriction band due to omental band. The omental band was divided, and the obstruction was relieved. Postoperatively patient recovered well and was discharged on day three post-op.

Discussion

The timely diagnosis and intervention could prevent complications like strangulation, ischemia and gangrene. Though the omental band is rare, it should still be suspected as an aetiology in patients without prior abdominal surgery.
EP.TU.201Evaluating and Improving the Management of Tonsilitis in an A+E Department: An Educational Intervention
Authors: Koslover Nicolas , Levene Tamara
Published: October 2021

Aims

Tonsilitis is one of the most common presentations to the A+E department. We aimed to assess whether patients presenting with tonsilitis are being managed in-line with current guidance. We then set out to educate A+E staff about tonsilitis management and then assessed for improvement in management.

Methods

All patients presenting to A+E in one fortnight with a documented diagnosis of tonsilitis were included. We reviewed the notes to assess the choice of treatment in each case and whether a clinical score was used to guide choice of treatment (in accordance with NICE guideline [NG84]). We designed and delivered an educational intervention for A+E staff covering tonsilitis guidelines. The audit was repeated two weeks later.

Results

Over the study period, 49 patients were included; only 35% (n = 17) had either a clinical score documented or had all components of a score recorded. In total, 39% (n = 19) were treated with antibiotics. Of these, 63% (n = 12) should not have been prescribed an antibiotic and 37% (n = 7) were prescribed an inappropriate antibiotic.

At re-audit, (n = 50 cases), 58% (n = 29) had a clinical score documented and 28% (n = 14) were treated with antibiotics. Of these, 29% (n = 4) should not have been prescribed antibiotics and 21% (n = 3) were prescribed an inappropriate antibiotic. Thus, after this teaching session, there was a significant improvement in antibiotic prescribing practices (63% vs 29%, p = 0.026).

Conclusions

A+E assessment and management of tonsilitis frequently deviated from guidelines, but a single teaching session vastly improved clinical scoring and antibiotic prescribing practices.