bluuebunny/crossref_metadata_2025 huggingface dataset:
EGS P20 Registrar-led theatre lists: A safe and effective way to provide a consistent Hot Gallbladder service
Authors: Chhabra Raunaq , Lorenzi Bruno , Bhatti Sumbal
Published: November 2023

Background

Dedicated Hot Gallbladder lists are proven to be cost effective and provide greater patient satisfaction. Unfortunately, the high volume of cases and the lack of available hospital resources make it very challenging to provide a consistent service. The aim of this study is to evaluate the safety and efficacy of the Registrar/SAS doctor led Hot Gallbladder service introduced in our Hospital over a year ago.

Methods

A system was developed with a middle grade doctor reporting to an UGI consultant surgeon and one SPOC in the waiting list office to streamline the service. A dedicated scoring system questionnaire (GalBAG form – Galbladder Booking and Grading form) was validated in retrospective and prospective series, and subsequently used to assess and grade patients into GOLD, SILVER & BRONZE cases based on expected difficulty and predicted length of the operation. Cases were listed based on surgeon compatibility. Outcomes measured include complications, unplanned admissions and re-admissions, need for further procedures, efficiency of the theatre lists and compared to national averages.

Results

Our registrar-led lists have successfully performed over 100 hot laparoscopic cholecystectomies. Complication rates, unplanned admissions, readmissions, and need for additional procedures align with national averages. Only one biliary injury occurred but was successfully treated endoscopically. The efficiency of the lists has improved with time as well as the ability to schedule progressively more complex cases Theatre utilization increased for patients referred through the Hot Gallbladder pathway. The GalBAG form accurately predicted difficulty and aided decision-making. Our Hospital now offers a secure and reliable Hot Gallbladder service, receiving positive feedback from patients and GIRFT.

Conclusions

In the current climate of increased waiting lists and lack of resources to provide dedicated urgent surgical services, a Registrar-led theatre list service with adequate backup/supervision could represent a safe, efficient, consistent and cost effective model to offer a Hot Gallbladder service.
EGS P28 Analysis of referring process from the emergency department to general surgery
Authors: Marchese Salvatore , Abdelrahman Abdelrahman , Dias Rachel , Uzkalnis Aleksandras
Published: November 2023

Background

Referring patients from the emergency department to specialty doctors is a crucial but often frustrating process. The aim of this study was to identify discrepancy and common ground in the referring process between emergency doctors and general surgeons.

Methods

A prospectively daily-maintained database of surgical referrals was statistically analysed. In addition, a ten-question survey was sent to both emergency and surgical doctors who had referred or had been referred to during the month of the study.

Results

In May 2021, at our Trust, 280 patients were referred to general surgery. 52 referrals were deemed inappropriate (19%), with a rate as high as 50% in 24 hours. The most common inappropriate diagnosis was appendicitis (23%), followed by small bowel obstruction (15%).

The survey showed frustration with the referral process was reported more by surgeons (P <.05). They believed patients are not yet sufficiently assessed when referred (P <.05). However, focused assessment on the patient’s main complaint would seem mutually well-accepted. Eventually, there was a common consensus on the need for specific criteria to guide surgical referrals.

Conclusions

Improvement of communication is recommended, especially with regard to the attitude used during referrals. Specialties’ relevance for specific conditions needs to be clarified. Criteria and guidelines on common surgical presentations should be designed to define appropriateness of referrals. Eventually, a specific system is required to formally report inappropriate referrals and unprofessional behaviour.
EGS P30 Audit on the assessment of upper abdominal pain for cardiac and respiratory differentials (AUPCR)
Authors: Lakshmipathy Gokul R , Wiggins Tom
Published: November 2023

Background

In multi-morbid ageing population, cardiac and respiratory differentials of upper abdominal pain should be ruled out. In patients presenting to surgical units with upper abdominal pain, we evaluated proportion undergoing chest assessments and in patients older than 40, we identified proportion having Electrocardiograms (ECGs.) We planned to install quality improvement strategies and close the audit loop.

Methods

According to our trust’s protocol, all patients with upper abdominal pain require chest assessment, and those older than 40, require ECG. We collected data retrospectively from patients’ notes between January and February 2022. We educated healthcare staff to perform chest assessments and interpret ECGs. We circulated the trust protocol as flyers and affixed posters in A&E and SAU. We changed patient’s electronic system so that ECGs can be uploaded. Re-audit happened between May and June 2022.

Results

100 patients were included in first cycle and 75 patients in the second. Three-quarters of patients were female and one-quarter were male. Around two-thirds of patients were older than 40. The most common region of pain was the right hypochondrium followed by the epigastrium. Proportion of patients having chest assessments rose from 48% to 85% in re-audit. Number of patients older than 40 having ECGs more than doubled from 28% to 61% in the re-audit.

Conclusions

We identified that chest assessments and ECGs were not being performed to adequately investigate patients with upper abdominal pain. We trained staff, used visual aids and made changes to electronic systems; which resulted in significant improvement in assessment of differentials for upper abdominal pain. No life-threatening cardiac or respiratory conditions were missed in the re-audit.
EGS P31 Small bowel obstruction in an elderly female secondary to congenital Ladd’s band. A rare case presentation
Authors: Adnan Naqqash , Agarwal Prachi , Zagorac Zoe , Jamal Zohaib , Alam Imran
Published: November 2023

Background

Intestinal malrotation is a congenital anomaly which arises during embryonic development. This can be associated with peritoneal tissue known as Ladd’s bands which can cause predisposition to intestinal obstruction. The incidence of intestinal malrotation is reported to be approximately 0.2% in the adult population [G]. Cases of intestinal obstruction secondary to malrotation commonly present in the paediatric population, but rarely may only be detected at adulthood. We present an elderly women who presented with features suggestive small bowel obstruction.

Methods

We present a rare case of a 78 year old female presenting with a three day history of coffee-ground vomiting, abdominal pain and dizziness. The patient had a notable background of a hiatus hernia and atrial fibrillation for which she was being treated with edoxaban. An abdominal X-ray film showed faecal loading. CT imaging revealed a high-grade small-bowel obstruction with an acute transitional point at the terminal ileum secondary to congenital Ladd's band which was confirmed at laparotomy. Subsequently, a Ladd’s procedure was performed and the patient was discharged after making a good recovery.

Results

In this case report, we highlight the importance of considering congenital anomalies in patients presenting with symptoms of bowel obstruction. We discuss the importance of appropriate investigations as well as multidisciplinary care to help facilitate early diagnosis.

Conclusions

Congenital Ladd’s band is a rare cause of small bowel obstruction in an elderly population. Although the diagnosis of intestinal malrotation can be challenging in adulthood, congenital anomalies should be considered as a differential in patients presenting with symptomatic obstruction.
EGS P32 Audit for evaluation of using the National Emergency Laparotomy Audit (NELA) as risk assessment calculator for high-risk surgical patients undergoing emergency laparotomy
Authors: Hobeita Wesam , Mohamed Hussam , Karar Karar , Di-Rollo Domenic
Published: November 2023

Background

A high-risk surgical operation called an emergency laparotomy has significant mortality and morbidity rate up to 10 times greater than the one performed electively. This entails a significant clinical and financial burden. The National Emergency Laparotomy Audit (NELA) was established in response to the aforementioned data in order to enhance the quality of care for patients having emergency laparotomies and to assist surgeons in reaching the best possible medical choices for their patients. The Emergency, Laparoscopic and Laparotomy Scottish Audit (ELLSA) is an equivalent system in Scotland. However, ELLSA is still not widely used as NELA.

Methods

This is a single-centre, retrospective audit to evaluate proper risk assessment and NELA registration for patients who had an emergency laparotomy in CEPOD between January 2022 and December 2022. The data was gathered from electronic clinical records via the hospital portal system. This analysis has included the following clinical data (Age, gender, indication of laparotomy, CEPOD form completion, NELA Score, hospital stay, and postoperative surgical outcome). The data was retrieved and analysed using a standard Excel data collection sheet. This audit aims to review and appraise our practise in relation to the NELA guidelines for risk assessment and emergency laparotomy.

Results

This analysis includes a total of 58 patients.35(60.3%) Males,23(39.7%) females. The included patients had an average age of 62. Almost 48% of these individuals had longer hospital stay more than 10 days. Approximately 21% of CEPOD booking forms had a recorded NELA score. A missing NELA registration form/risk assessment score was found in up to 97% of patient files and operation notes. A retrospective NELA assessment revealed a mortality rate of more than 20% for some included patients. The mortality rate was found to be high, at 21%, for NELA score of >20% mortality and >70% morbidity.

Conclusions

This Audit has shown that in order to completely comply with NELA guidelines, our practise must be significantly improved. We also need to give risk assessment documentation in patient records more consideration. The high death rate is attributed to patient and family requests for last-ditch surgical interventions, which can be difficult for surgeons to pull off.
EGS P34 CEPOD Booking Audit in General Surgery
Authors: Kitsikosta Loukiani , Diaz Maria Hernandez , Galides Chloe , Morsi Mai , Morrison-Jones Victoria , Rahman Saqib , Berry David
Published: November 2023

Background

Repeated internal audits suggested 20% of patients booked into the emergency general surgery theatre list failed to achieve their allotted time to theatre. We wished to investigate this further, identify potential reasons and whether any delay resulted in patient harm.

Methods

We retrospectively reviewed 760 consecutive adult patients over a 12 month period booked for appendicectomy, hernia repair, laparoscopic cholecystectomy or abscess I+D. We excluded laparotomies and patients under 18yoa.

We recorded pre-operative CEPOD classification, adherence to the timeframe and reasons for delays. Outcome measures included total length of stay(TOLOS), post-op length of stay (POLOS) and unexpected intraoperative findings.

Results

Of 760 emergency procedures, 638 (84%) achieved the desired time frame and 122 (16%) were delayed. Of the 122 delayed cases, 99 (81%) were appropriately booked (clinical review). Most delays were caused by a higher priority emergency but in one third of delays no reason was recorded.

There was no difference in median POLOS or unexpected findings between the two groups of those achieving expected time to theatre and those delayed.

Conclusions

Despite our initial concerns regarding delays to theatre this only occurred in 16% of the study group with no discernible difference in outcomes as measured.

The repeated clinical review of potentially delayed emergency patients accessing the operating theatre appears to be safe.
EGS P35 Spontaneous rupture of the spleen: Is it caused by COVID?
Authors: Khan Rehan , Osborne Vaz , Krishnamohan Nitya , Pursnani Kishore , Ward Jeremy , Paul Turner , Shetty Vinutha
Published: November 2023

Background

Spontaneous rupture of spleen (SSR) is rare but known entity in patients with underlying pathology of spleen1. However, there are reports of spontaneous splenic rupture in patients with no known underlying pathology2. With the onset of COVID pandemic, rising incidence of various disease conditions were linked to either COVID infection or vaccine. Similarly, we are presenting three cases of spontaneous splenic rupture managed by our team in last one year which could be attributed to COVID infection or vaccine.

Methods

The data of all the patients admitted in an urban tertiary Upper GI Unit with spontaneous splenic rupture in last one year was collected prospectively from online data storage software called Flex Prod. The data was extracted from this software and analysed retrospectively maintaining patient confidentiality throughout the process.

Results

Three patients of spontaneous splenic rupture received treatment post COVID in this trust. 2 out of 3 patients had COVID infection in the past and all three had received vaccine. Two patients presented to A&E with hypotension and tachycardia, were appropriately resuscitated, and then underwent successful angio-embolization. Both were monitored in the critical care in the periprocedural period and subsequently transferred to the ward. Third patient presented to A/E with upper abdominal pain and tachycardia, CT scan showed high grade rupture of spleen with low haemoglobin. Hence, angioembolization was carried out, patient recovered well postoperatively and was discharged.

Conclusions

Spontaneous rupture of spleen is rare but potentially life-threatening condition more common in patients with underlying spleen pathology3. The etiology of SSR is uncertain, however, recent case reports of patients with COVID presenting with spontaneous splenic rupture4 has led to increased interest in COVID as a cause of SSR in the post COVID era.
EGS P40 Validating the Alvarado Score as a Diagnostic Tool for Acute Appendicitis in a UK District General Hospital
Authors: Gupta Sakshi , Sheth Hemant , Soggiu Fiammetta
Published: November 2023

Background

Acute appendicitis (AA) remains one of the most common causes of an acute abdomen, requiring surgery. However, ruling out AA remains clinically challenging and has both economic and medico-legal implications for hospital trusts. The 2019 World Society of Emergency Surgery (WSES) guidelines endorsed the use of the Alvarado score to limit diagnostic uncertainty. Particularly, a score below 5 was deemed sufficiently sensitive to exclude AA without imaging. This audit aimed to retrospectively assess the use of the Alvarado score to exclude AA in patients referred with suggestive symptoms to the on-call general surgery team at a UK District General Hospital.

Methods

All patients referred to the on-call general surgery team between 2nd January 2023 and 5th February 2023 with right-lower-quadrant (RLQ) abdominal pain or an incidental diagnosis of AA were included. Patient demographics, clinical data, and an admission Alvarado score were retrospectively collected. An average admission Alvarado score was calculated for patients with confirmed AA and those without. As recommended in the WSES guidelines, a cut-off score of < 5 was employed. The sensitivity and specificity were then calculated in order to validate the Alvarado score’s use as a diagnostic tool in patients with suspected AA.

Results

Of the 63 patients referred with RLQ abdominal pain, one self-discharged and 11 (17.7%) had confirmed AA on imaging or histology (Figure 1). The average Alvarado score was 4.9 (95% CI 4.2 – 5.5). In patients with confirmed AA, the average score was 7.5, statistically significantly ≥ 5 (p-value <0.01). Patients without AA averaged a score of 4.3, statistically significantly < 5 (p-value = 0.013). The sensitivity and specificity were 91% (95% CI 58.7% – 99.8%) and 47% (95% CI 32.9% – 61.5%), respectively. The positive and negative predictive values were 27% (95% CI 13.8% – 44.1%) and 96% (95% CI 79.7% – 99.9%), respectively.

Conclusions

This retrospective audit highlighted that the Alvarado score could have been safely used to exclude AA in patients with scores below 5, avoiding the need for further investigations and treatment. A second, prospective study will aim to further validate and implement the routine use of the Alvarado score in the department to improve the diagnostic work-up of patients with suspected AA. The economic impact of its use should also be investigated with a health economics multi-centric study.
EGS P42 Prospective diagnostic accuracy of Alvarado score and CT scan in evaluation of suspected appendicitis
Authors: Adnan Naqqash , Khan Jahangir Sarwar , Jamal Zohaib
Published: November 2023

Background

Appendicitis is most common general surgical emergency with a life time risk of 7%.Appendicitis is considered as disease of the younger age group with only 5-10% of cases occurring in the elderly population. Ultrasound and CT scan are helpful in diagnosing acute appendicitis.The rationale of this study is to find out the group of patients based on the Alvarado score that will certainly benefit from the use of city scan. As CT is the preferred imaging modality in diagnosing acute appendicitis. Alvarado score is used to stratify patients into a subgroup that will certainly benefit from CT use.

Methods

Cross-sectional validation study was conducted for six months from (30/03/2017) to (30/09/2017) in Surgical unit-1, holy family hospital, Rawalpindi. Alvarado score was calculated, and the patients then underwent a contrast-enhanced CT scan. For the data of CT scan, patients were divided into two groups Positive and negative of appendicitis. All selected patients underwent an appendectomy. Histological specimens were collected and interpreted. All the collected data was entered and analyzed on SPSS version 19.

Results

The mean age of the patients was 28.93±10.21 years. The male to female ratio was 1:1.1. The mean Alvarado score was 6.05±0.68. The sensitivity, specificity and diagnostic accuracy of CT scan for diagnosing acute appendicitis was 84.75%, 78.69% & 81.67% respectively taking histopathology as the gold standard.

Conclusions

According to our study CT scan is a reliable and useful diagnostic tool at Alvarado score of 5-6 in males and 6-7 in females, in predicting acute appendicitis keeping histopathology as a gold standard.
BS P03 The burden of bariatric tourism on the Health and Social Care System in Northern Ireland: a descriptive analysis
Authors: Hraishawi Ihab , Abduljalil Aalaa , Caldwell Sharon , Harris Andrew , MacAulay Graeme , Kennedy Raymond , Kennedy Andrew
Published: November 2023

Background

The lack of public bariatric surgical services in Northern Ireland has favoured the growth of bariatric tourism. This retrospective study aimed to analyse the data extracted from the records of bariatric patients who presented with complications to Belfast Health and Social Care Trust following their surgery abroad and investigate the costs associated with managing these complications. It also aimed to explore other factors, such as emotional trauma, that may be associated with bariatric tourism.

Methods

This was a retrospective study including all patients, who had their bariatric procedure abroad, presenting acutely to our hospital between August 2016 and February 2023. Data were collected from hospital records and included demographic characteristics, type of surgery, nature of complications, and costs associated with managing these complications. Descriptive statistics were used to analyse the data.

Results

42 patients included in the study. Majority were female (n=35, 83.3%) with a mean age of 46.6 years. Sleeve gastrectomy was the most common surgery (n=22,52.3%), followed by AGB (n=11,26.1%), Gastric bypass (n=6,14.2%) and Gastric balloon (3,7.1%). Operations were performed in 7 countries, majority were done in Turkey (n= 22). The most common complication was leak (n=14), followed by band erosion (n=7) and nutritional failure (n=7). The total cost was estimated to be (£737,126), which includes hospital-stay costs (£553,179), non-surgical intervention (£55,607), scans (£41,728), and surgical intervention (£75,413). The total cost of dietetic inputs were about £17,390,including 410 hours.

Conclusions

Most patients experienced emotional trauma related to lack of adequate perioperative care, and difficulties in communication with their overseas surgeons. The results of this study highlight significant costs associated with managing such complications in Northern Ireland. The findings suggest investing in public bariatric surgical services may be more cost-effective than relying on bariatric tourism. Furthermore, Bariatric care is delivered by MDTs which are actively involved in management of these patients throughout their care-pathway. The study highlights lack of perioperative care and follow up needed to minimize complications and associated costs, as well as addressing the emotional trauma of those patients.
OGBN P03 Surgeons’ perceptions of elective laparoscopic cholecystectomy in the post-COVID era
Authors: Shivarajan Amber , Siddiqui Midhat
Published: November 2023

Background

The COVID-19 pandemic has significantly impacted healthcare systems worldwide, leading to modifications in surgical practices. Laparoscopic cholecystectomy (LC), a common elective procedure, has faced challenges in the post-COVID era, with increased waiting times and episodes of acute gallstone disease in patients awaiting their procedure. This poses the question as to whether modifications to routine practice should be made. This study aims to explore surgeons' perceptions on performing laparoscopic cholecystectomy in the current post-pandemic landscape.

Methods

An anonymous survey was conducted among general surgeons with expertise in LC across multiple healthcare institutions nationally. The survey included questions relating to surgeons’ speciality, and their experience with elective LCs, intraoperative cholangiograms (IOC) and laparoscopic common bile duct exploration (LCBDE) in post-COVID era. Further opinions were sought on complicated intraoperative findings, rate of aborting procedure, rate of conversion to open and number of elective LCs completed by trainees. The data obtained was analysed using descriptive statistics and Fisher’s exact test for statistical significance calculations.

Results

40 surgeons with varying levels of experience with LC completed the survey: 8 (20%) <50, 16 (40%) 100-500 LCs,10 (25%) 500->1000. Overall, 21 (53%) perceived LC to be more challenging. Analysis between the different groups found no significant difference (p = 0.68) between those who performed <50 LCs (6/8) and 500- >1000 LCs (6/10). 8 (20%) respondents found no increase in complicated intraoperative findings. Of those not working in specialist centres, 11/36 perceived an increase in referral to a hepatobiliary unit. 14 (35%) perceived an increase in unplanned admission. 21 (53%) perceived a reduction in completion of LC by trainees.

Conclusions

This study demonstrates that a significant proportion of respondents believe that LC has become more technically challenging. In patients with increased time till surgery or episodes of acute gallstone disease, MRCP should be considered at pre-assessment. Furthermore, during challenging LCs, options to ‘bail-out’ or convert to open should be considered. This study also raises awareness on the reduction in training opportunities and the need to ensure trainees progress appropriately. Limitations include small sample size and subjective nature of responses. Further research on patient outcomes is required to provide strong recommendations to optimise surgical practice of LC in the post-pandemic era.
OGBN P04 Achalasia: A single-centre experience of surgical management over 14 years
Authors: Cheung Tiffany , Al-Ardah Mahmoud , Clarke Michael
Published: November 2023

Background

Achalasia is a rare motility disorder of the oesophagus with likely autoimmune aetiology, characterised by absent oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. Typical symptoms include dysphagia, regurgitation and weight loss. Different treatment modalities are available, predominantly aimed at improving quality of life.

No UK guidelines currently exist for the management of achalasia; the US-based SAGES guidelines (2011) do however provide evidence-based recommendations, albeit of varying strength. A published survey of UK surgeons revealed variation in certain aspects. We sought to explore our institution's experience in management of achalasia, primarily focusing on surgery (laparoscopic Heller’s cardiomyotomy).

Methods

An electronic database search was performed to identify all patients either newly diagnosed with achalasia and / or who received treatment for achalasia at our institution between 2009 and 2022. Patients who had already received endoscopic, radiological or surgical treatment prior to 2000, or at another institution at any time were excluded. Demographics, diagnostic investigations, treatment (Botox injection, dilatation, cardiomyotomy) and surgical outcomes were retrospectively recorded in a database and analysed.

Results

128 patients met the inclusion criteria above; 127 were adults, 66 male.

70 patients (54.7%) underwent laparoscopic Heller’s cardiomyotomy with anterior fundoplication. All patients had OGD, 63 (90.0%) barium swallow and 54 (77.1%) high resolution manometry pre-operatively.

Major intra-operative bleeding occurred in one patient from lower oesophageal ulceration. 12 patients had mucosal breaches, repaired intra-operatively. Iatrogenic oesophageal perforations occurred in two patients requiring return to theatre. No mortalities occurred.

31 patients (44.3%) experienced long-term symptom resolution post-operatively. 8 patients (20.5%) with recurrent symptoms had laparoscopic re-do surgery, 11 Botox (28.2%) and 11 dilatation (28.2%) - several had combination of modalities.

Conclusions

Access to regional, then latterly local, high resolution manometry has facilitated full diagnostic assessment, as SAGES strongly recommends all patients undergo along with OGD and barium swallow.

Surgical management of achalasia at our institution over this 14-year period has been very standardised, owing to the operations being performed by two consultant surgeons only.

A good proportion of operated patients had a successful outcome with long-term resolution of symptoms. Serious complications in our cohort were rare; these patients required re-operation and ultimately recovered. Laparoscopic Heller’s cardiomyotomy with anterior fundoplication can be a safe and effective management option for achalasia.
OGBN P08 Increasing Cholecystostomies: Is this a reflection of COVID, change in indications, or an easy option?
Authors: Jindal Anushka , Ftaieh Fares , Shanti Hiba , Patel Ameet G
Published: November 2023

Background

Percutaneous cholecystostomy has been utilized in septic patients with non-malignant biliary pathology who are frail, where surgery is deemed too high risk or conservative management has failed (NICE guidance). The COVID-19 pandemic and the decreased access to surgery may have led to a rise in cholecystostomies. The aim of this study is to evaluate over the last decade, the changing trends, indications, and outcomes of cholecystostomies in our institution.

Methods

We retrospectively reviewed a prospective database of all patients who had cholecystostomy at our two sites; a Tertiary center and an associated district general hospital, between 2012 and 2022. Exclusion criteria included paediatric patients and biliary malignancies. Patients were grouped as Non-Septic (N-S: cholelithiasis, uncomplicated cholecystitis, choledocholithiasis), and Septic (S: complicated cholecystitis, empyema, systemic sepsis, MODS). Data collected for patient characteristics, co-morbidities using Charlson Co-morbidities Index (CCI), length of stay, duration of cholecystostomy, 90-day morbidity and mortality.

Results

Cholecystostomies were performed in 150 patients, median age 72 years, 52% female. There was an exponential rise of cholecystostomies over the decade. The overall mortality was 5% (8/150). Patients with CCI score <5 & ³ 5, were compared for mortality (2/98 vs 6/52, p<0.05). The cohort included two groups: N-S (n=105/150, 70%) and S (n=45/150, 30%). All mortalities were in the S group (n=8/45 p<0.001). During COVID interval, there was a rise in non-septic patients getting cholecystostomies, which has persisted post pandemic (figure 1). Cholecystostomies stayed in situ for a median of 76 days (0-830), with subsequent cholecystectomies in 77%.

Conclusions

There is an exponential rise in the number of cholecystostomies in the last decade, this persisted during and post COVID. The ratio of S: N-S patients getting cholecystostomies was much greater pre-pandemic, then peri- or post-pandemic. The latter may reflect a change in practice. With the increasing pressure of waiting times, need to achieve “hot gallbladders” targets; has cholecystostomy indications changed or does this reflect an easy option and at what cost?
OGBN P10 Fenestrating versus reconstituting subtotal cholecystectomy for difficult gallbladder: A systematic review and meta-analysis
Authors: van Veelen Maria , Hajibandeh Shahab , Laing Richard , Athwal Tejinderjit , Sutcliffe Robert , Hajibandeh Shahin
Published: November 2023

Background

To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder.

Methods

A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool.

Results

Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n=353) or reconstituting (n=237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR:2.47, p=0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD:-0.02, p=0.86) or with (OR:1.84, p=0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD:-0.02, p=0.16), need for postoperative ERCP (OR:1.36, p=0.49), wound infection (RD:0.03, p=0.27), re-operation (OR:0.95, p=0.95), gallbladder remnant cholecystitis (OR:0.21, p=0.09) or need for completion cholecystectomy (RD:0.01, p=0.59) between two groups.

Conclusions

Although fenestrating STC increases risk of bile leak compared with the reconstituting approach, this can be managed successfully with postoperative ERCP if not resolved spontaneously. We encourage low threshold for fenestrating approach in difficult situations, considering its relatively benign postoperative course and long-term outcomes.
OGBN P11 Robotic Benign Upper GI Surgery: A Systematic Review
Authors: Harris Matthew , Watton Leo , Peters Christopher
Published: November 2023

Background

Robotic surgery has gained popularity in General Surgical units for resectional procedures, however its use in ‘benign' operations is limited in the UK. We aim to review the current literature for common benign UGI operations.

Methods

Using PRISMA guidelines, we completed a literature search of MEDLINE and EMBASE including all evidence for Robotic Cholecystectomy (RC), Robotic Heller Cardiomyotomy (RH), Robotic Fundoplication (RF), Robotic Hiatus Hernia Repair (RHHR).

Data was extracted and synthesised by independent reviewers.

103 studies were included. 55 for RC, 12 for RH, 20 for RF and 14 for RHHR. The majority of these studies were cohort and case-control studies (53%). There were only 9 RCTs.

Results

Due to significant heterogeneity in patient population, study design and outcome reporting, meta analyses were not appropriate.

Trends observed for RC suggested that the robotic method can lead to improved post-operative pain and cosmesis, especially in single-incision robotic cholecystectomy (SIRC). However 2 cohort studies stated a small increased risk of CBD injury.

Evidence for RH show shorter operative time and reduced risk of oesophageal perforation, with other outcomes equivalent.

Studies for RF showed equivalence between laparoscopic and robotic methods. In more complex hiatus hernia repair or re-operative operations (RHHR), studies showed shorter operative time, reduced complication rate and equivalent recurrence.

Conclusions

This systematic review has highlighted the paucity of high quality evidence for robotic Upper GI procedures. Studies show at least equivalence between robotic and laparoscopy for less complex procedures, with some strong trends towards superiority for more complex procedures such as RH and RHHR.
OGBN P18 Surgical Intervention in Patient with Oesophageal Absent Contractility
Authors: Miah Ismail , Wong Terry , Gossage James , Zeki Sebastian , Jafari Jafar
Published: November 2023

Background

Absent contractility (AC) is a major motility disorder with poor prognosis. Surgical management for associated comorbidities of AC are often challenging such as in GORD patients where antireflux surgery may be contraindicated or undiagnosed achalasia manifesting with normotensive integrated relaxation pressure would be deprived of surgical myotomy. Thus, it’s crucial to explore potential surgical interventions for patients with AC from both ends of the spectrum. This study will investigate the two extremes of AC and seek to determine suitable strategies for patient selection and offer insights into the management of AC through surgical intervention.

Methods

This is a retrospective study of patients undergone high-resolution manometry (HRM) between January 2022 to June 2023 and were diagnosed with AC based on ten 5ml water swallows. Patients were followed-up with provocative multiple water swallowing (MWS) and solid bolus swallow (SBS) assessments. Peristalsis invoked by MWS with Distal Contractile Integral (DCI) >100mmHgscm or SBS with DCI >405mmHgscm are adequate peristaltic vigour for consideration of floppy Nissen fundoplication. Patients with absolute AC on provocative stimulation and without peristaltic remnants during the HRM recording underwent oesophageal transit testing in consideration for Heller’s myotomy.

Results

Total of 115 patients were included (female:male=59:56, mean age 56 years old) with 43 patients (37.4%) demonstrating peristalsis on adjunctive testing (SBS assessment provoking peristalsis was greater by 3.2 folds to MWS [p=0.0004]). In 72 patients with failed adjunctive testing, 6 patients (8.3%) invoked peristalsis (DCI>100mmHgscm) from dry swallows (largest DCI observed: 1000) and 29 patients (40.2%) demonstrated peristaltic remnants (DCI<100mmHgscm). 37 patients (32.2%) had absolute AC with 21/37 patients (56.7%) were diagnosed with achalasia on transit testing (7 patients are still pending tests). AC in 9 patients originate from aetiologies where surgery would not benefit the patients.

Conclusions

Approximately 37.4% of patients with AC were suitable for floppy Nissen fundoplication, while 32.2% required Heller's myotomy. Surgical intervention was postponed if peristaltic remnants was observed and pending complete diminishment or recovery with prokinetic therapy. Overall, surgical intervention may be considered in nearly 70% of patients with AC.
OGBN P19 Innovative use of Weerda diverticuloscope for removal of an impacted sharp foreign body mimicking malignancy in the cervical oesophagus
Authors: Peter Vaz Osborne , Rodrigues Rodney , Chaudhury Madhu , Stockwell Robert , Turner Paul D , Bruce Ward Jeremy , Pursnani Kishore G , Daya Shetty Vinutha
Published: November 2023

Background

Chronically impacted sharp foreign bodies (FB) of the cervical or upper thoracic oesophagus can present a diagnostic dilemma .Fifty percent of sharp objects tend to lodge in the upper oesophagus and frequently cause perforation.A multidisciplinary approach is warranted. Eventually, surgery by cervical oesophagotomy/thoracotomy may be required. The Weerda diverticuloscope offers excellent endoscopic visibility and access to the lumen of the upper oesophagus allowing for removal of FBs and mitigating risks of a major surgical procedure.

Methods

We report an interesting case of a 27 year old gentleman being investigated for dysphagia. The patient was radiologically diagnosed as having T4 malignancy but consecutive biopsies suggested Actinomycosis. Patient interestingly recollected having lost his dentures after a fist fight. This triggered the use of the Weerda diverticuloscope, a bivalved rigid diverticuloscope ( Karl Storz, Tuttlingen, Germany). It has a distal fibreoptic illumination that is designed for trans-oral stapling of pharyngeal pouches.The patient notes were obtained from the electronic patient records. The radiological images were sourced from the picture archiving and communication system (PACS) and endoscopy from stored images.

Results

Under general anaesthesia, the Weerda diverticuloscope was introduced into the cervical oesophagus .The tips of the jaws positioned just proximal to the embedded dental prosthesis. The diverticuloscope was suspended for stabilisation in the same manner as for endoscopic stapling of a pharyngeal pouch and the jaws were distracted to allow endoscopic access. A 5mm rigid telescope was passed alongside a pair of heavy endoscopic scissors and the prosthesis was divided into 3 parts. The central intraluminal component was removed first using endoscopic forceps, followed by gentle disimpaction and extraction of the remaining two components embedded in the oesophageal wall.

Conclusions

Chronically impacted FBs in the oesophagus can rarely mimic cancer or chronic granulomatous diseases. A multidisciplinary approach is occassionally recommended in their management. There have been a few published reports of the use of the Weerda diverticuloscope to remove upper oesophageal FBs successfully. It’s use, however,is not often considered routinely. We recommend the use of this technique at centres where expertise in endoscopic management of Zenker’s diverticula is available and when endoscopic retrieval has failed.
OGBN P20 A Clinician Delivered pH Manometry Service
Authors: Salem Rola , Wijesinghe Janaka , Atkins Rosa , Hale Emily , Poulton Theodore , Bowling Kirk
Published: November 2023

Background

Gastroesophageal reflux disease (GORD) has an influence on patients’ health related quality of life, affecting 20% of adults in high income countries (1)(2). Despite first line therapy, proton pump inhibitors, approximately 20-30% of patients have persistent symptoms (3). Anti-reflux surgery is by its very nature a lifestyle related procedure, thus there must be a robust and duplicatable method for assessment of the severity of symptoms to facilitate patient selection. We launched a clinician delivered high-resolution pH oesophageal manometry and ambulatory pH impedance service in January 2021 at our Specialist Anti-Reflux Centre. Here we present our preliminary data.

Methods

This is a retrospective analysis of patients who underwent ambulatory pH manometry within our department between January 2021 and June 2023. Analysis to date was undertaken of patient’s outcomes from their pH manometry. Patients with previous anti-reflux surgery were excluded. We reviewed those who were offered surgery versus those who were not. Each group had further analysis of the DeMeester score, Symptom Index (SI) and Symptom Association Probability (SAP). A two sample T-test was performed, with p<0.05 considered statistically significant.

Results

Of the 141 patients that underwent ambulatory pH manometry, 62% (n=88) had sufficient data for analysis. 33% (n=29) of these were subsequently offered surgical intervention; 14 underwent fundoplication (48%) and 12 LINX procedures (41%); the remaining patients, 1 referred for POEM, 1 awaited surgical planning and 1 required Gastroenterology review. Those who progressed to surgery had a greater DeMeester score than those who were not offered surgery (45.2 vs 28.5). Patients in the surgical group also had a higher mean SI than those in the non-surgical group (57.0% vs 38.6%, p=0.01), and higher SAP (94.1% vs 80.3%, p=0.03).

Conclusions

This clinician-led in-house clinic has had significant impact upon our service. It has enabled collation of quantitative data to facilitate the decision-making process in the provision of anti-reflux surgery, thus aiding appropriate patient selection. Going forward, further work is being undertaken into quality of life questionnaires post anti-reflux surgery, both before and after introduction of our new service.
OGBN P25 A systematic review and clinical evaluation of Morphine Versus pethidine as a good drug choice to control for biliary colic before and after cholecystectomy
Authors: Khougali Mohamed Hussam , Di Rollo Domenic , Shahzad Khan Khurram
Published: November 2023

Background

The most commonly recommended pharmaceuticals for biliary and pancreatic pain are arguably morphine and pethidine, both of which can elicit varying effects at the gallbladder, common bile duct, and sphincter of Oddi levels. Morphine stimulates Oddi's sphincter motility, causing upper abdominal pain and biliary distress symptoms in certain patients. Pethidine is thought to have less consequences on the sphincter of Oddi than morphine. This analysis aims to evaluate the comparative outcomes and effect of morphine versus pethidine on the sphincter of Oddi and biliary colic control.

Methods

A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library and Science Direct. Comparative studies comparing effect of morphine versus pethidine on sphincter of Oddi pressure were included. Revman 5.4 (Cochrane, London, United Kingdom) was used for the data analysis.

Results

The results show four studies were eligible to be included in this review with a total number of 151 patients divided between morphine group (n=111) and pethidine group (n=40). Two prospective studies and two clinical trials were included in this review. The rate of sphincter of Oddi pressure was significantly higher in morphine group compared to pethidine group: odds ratio (OR)=1.39, and (OR) =7.82, p=0.005, respectively.

Conclusions

The analysis shows significant difference in sphincter of Oddi pressure when morphine used as analgesic drug to control the biliary colic compared to pethidine which seems to provide low pressure at the level of sphincter of Oddi and good control of biliary colic than morphine, however more studies and clinical trials are needed.
OGBN P26 Institutional initial experience and outcomes for the first 100 Upper gastrointestinal Cases: A single tertiary center results
Authors: Brooks Benjamin , Harrington Bertram , Elshaer Ahmed , Athanasiou Antonios
Published: November 2023

Background

Robotic surgery is widely spreading in many centers across the United Kingdom. Potential benefits include shorter admissions, fewer complications as well as better surgeon ergonomics and dexterity. Evidence suggests that robotic surgery has a rapid learning curve when first implemented with the number of cases linked to operative time. In this study, we report our preliminary results after implementation of robotic surgery at our upper gastrointestinal unit.

Methods

This retrospective study included all robotic elective upper gastrointestinal cases since the introduction of robotic surgery at our unit. All cases were performed by two surgeons using Da Vinci XI starting in August 2022. The first 100 cases were completed in 10 months. Both surgeons completed Intuitive training prior to initiating their independent operating lists. Cholecystectomy and anti-reflux surgeries were the main surgeries performed during the study period. Demographics, number of cases per list, console timing and postoperative complications were collected and analysed. Console timing was obtained by Intuitive software. Postoperative complications were graded using the Clavien-Dindo scale.

Results

100 UGI robotic surgery cases were analysed consisting of 86 cholecystectomies and 14 anti-reflux operations. Females represented the majority of cases (68%). Mean age was 53.0 years (18-78) while mean ASA and BMI were 2 and 30.3 kg/m2 respectively. Mean console time was 53.3 minutes. Cholecystectomies required 43.0 minutes and anti-reflux surgeries required 119.3 minutes on average. The mean length of stay was 0.90 days for cholecystectomies, and 1.46 days for anti-reflux surgery. There were two readmissions post cholecystectomy for pneumonia and liver bed collection. One cholecystectomy patient developed a Clavien-Dindo grade >3 complication for port site hernia repair.

Conclusions

Our initial experience has shown favourable outcomes of robotic surgery. There was a noticeable rapid learning curve, encountering only one major post-operative complication. This high effectiveness should stimulate the swift introduction of robotic surgery to other hospitals.
OGBN P27 Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital
Authors: Ahuja Manish , Soggiu Fiammetta , Goutham Meera , Drymousis Panagiotis , Pore Naresh , Raje Durgesh , Jawad Zaynab , Abdalla Sala , Sheth Hemant
Published: November 2023

Background

Laparoscopic cholecystectomy is the mainstay for treatment of symptomatic gallstones and its associated complications. Emergency cholecystectomy rates in the United Kingdom (UK) remain low despite NICE guidelines recommendations to offer surgery within 7 days for acute cholecystitis and index cholecystectomy for mild gallstone pancreatitis. We analysed our data over last 10 years to assess the safety and feasibility of providing an emergency cholecystectomy service in a London District general Hospital with a specialist Upper Gastrointestinal / hepatobiliary consultant workforce in line with NICE guidelines.

Methods

Data of 663 consecutive patients undergoing index admission emergency cholecystectomy during 2013-2023 from a prospectively maintained database was reviewed. Patient demographics, duration of hospital stay, complications, need for further interventions and re-admission rates were collected and analysed.

Results

Six hundred and sixty-three consecutive patients underwent emergency cholecystectomy gallstone disease and associated complications. The conversion rate was 5.2% (n=35). The median time from presentation to surgery was 2 days (Range 0-63), overall length of stay was 6 days (Range 1-91), and post-procedure stay was 2 days (Range 1-89). Overall complication rate was 7% (n=45), bile leak was observed in 8 patients (1.2%) with no evidence of major biliary injury. One patient had postoperative haemorrhage requiring laparotomy (No bleeder identified) (grade IVa) and 1 patient died within 90 days for reasons unrelated to the operation. The re-admission rate was 10.2%.

Conclusions

Index admission emergency laparoscopic cholecystectomy in district general hospitals is feasible and safe when performed by a specialist consultant workforce, leading to compliance to guidelines and a low rate of complications and readmissions to hospital.