bluuebunny/crossref_metadata_2025 huggingface dataset:
1144 Audit of Microbiological Sampling in Patients with Diabetic Foot Infections Presenting to a Tertiary Vascular Centre in the North-East of England
Authors: Sillito S , Woodmass M , Nesbitt C , Arkle J
Published: August 2023

Aim

To identify the practice of microbiology sampling in patients presenting to a Tertiary Vascular Centre in the North East of England in accordance with NICE guideline (NG19) ‘Diabetic foot problems: prevention and management’ and the ‘International Working Group on the Diabetic Foot guidance on the diagnosis and management of foot infections in diabetes’.

Method

A two-part retrospective audit was completed before and after the introduction of a podiatrist-led 'Hot Foot Clinic'. Patients were identified from the surgical-take handover and admission database by using keywords ‘diabetic’, ‘cellulitis’, ‘erythema’, ‘pain’, ‘wet necrosis’, ‘collection’, 'osteomyelitis’. Route of admission, timing and type of microbial samples and date of antibiotics prescribed were recorded.

Results

In the first cycle 56.8% (21/37) patients had microbiology samples sent. 47.6% (10/21) of these were sent before antibiotic prescription. 8.1% (3/37) had both a swab and tissue sample taken. 35.1% (13/37) had tissue samples and 21.6% (5/37) had swabs. In the second cycle 74.2% (23/31) had microbiology samples sent. In patients who had tissue samples taken, 23.5% (4/17) were prior to antibiotic initiation. All patients (3/3) admitted from a podiatry-led ‘Hot Foot Clinic’ had microbiology taken prior to antibiotics. 6.3% (1/16) patients admitted through the clinician-led Emergency Admissions Suite had microbiology taken before antibiotics.

Conclusions

Despite introducing a podiatrist-led clinic, reinforcement of correct microbiological sampling in diabetic foot infections is required for accurate diagnosis and optimal treatment. Further specialist input and audio-visual educational material is being developed to improve practice amongst all staff.
1268 An Audit of the Time to Surgery Following Diagnosis of Gallstone Pancreatitis
Authors: Sekyi-Djan M N , Agnihotri A , Goian L
Published: August 2023

Aim

To assess the compliance of our trust with the British Gastroenterology guidelines (BSG) on the management of gallstone pancreatitis which recommends that patients should undergo definitive treatment of laparoscopic cholecystectomy during the index admission or within 2 weeks of discharge to prevent readmission with biliary complications.

Method

This was a retrospective study of patients admitted with gallstone pancreatitis over a 3-month period between January 2021 and March 2021. We collected data from electronic medical records (EPR) and collated them on Microsoft Excel. Data was gathered on patient demographics, diagnosis at presentation, number of days to surgery, rate of readmission and the reasons for this.

Results

A total of 21 patients were admitted with gallstone pancreatitis. The median age was 50 years and 52% of them were male. 14 (67%) patients had laparoscopic cholecystectomy and only 9 (64%) of these had it within the 2-week window. 7 (33%) patients did not have surgery. Of these, 4 of them were not eligible, 1 went private and 2 patients are still awaiting surgery. The median wait for surgery was 3 days. The average time to surgery was 64 days. There were 6 readmissions whilst waiting for surgery with pain being the most common reason.

Conclusions

64% of patients had definitive treatment of laparoscopic cholecystectomy within the 2-week time frame demonstrating poor compliance with the BSG guidelines. We have introduced a semi-emergency theatre list once a week to accommodate definitive management of patients with gallstone pancreatitis and will re-audit the data to evaluate for improvement.
1326 Temporal Artery Biopsy for Giant Cell Arteritis (GCA): A Ten-Year Retrospective Audit in an Irish Hospital
Authors: Westby K
Published: August 2023

Aim

To assess if temporal artery biopsies (TABs) were carried out in accordance with American college of rheumatology (ACR) guidelines. To establish if there is correlation between ESR and histological samples positive for GCA.

Method

Retrospective chart review of all patients who underwent TAB in Sligo University hospital 2010-2020. Patients identified using histopathological department database.

Results

A total of one hundred and fifty-five patients underwent TAB (mean age 70.5yrs, 68% female, 32% male). 27 (17.4%) of samples were positive for GCA. 128 (82.6%) samples were negative for GCA in patients with a clinical diagnosis (P < 0.001). There was no correlation between ESR and biopsy result (r = 0.12). 107 (69%) met the guidelines for GCA.

Conclusions

The low numbers of positive samples may reflect a number of issues e.g., sample length, presence skip lesions, sampling patients already on steroid treatment. There are many new non-invasive modalities e.g., US doppler, which can diagnose GCA.
47 Awareness of Obesity and Morbid Obesity Amongst General Population: A Pilot, Cross-Sectional Survey Study
Authors: Patel A , Iqbal A , Ganguly G , Bandyopadhyay S
Published: August 2023

Aim

The aim of this study is to ascertain level of awareness regarding morbid obesity (MO) in patients visiting a GP surgery.

Method

A seven-question survey was created to assess population awareness of obesity. The questions assessed participant awareness of the BMI definition, causes, management, and co-concomitant diseases related to obesity. The participants were recruited on a voluntary basis at a GP surgery in Manchester.

Results

A total of 226 participants completed the obesity awareness survey. 73.1% of respondents reported that they were aware of obesity being a disease. However, only 59.29% felt that they knew the difference between obesity and MO. The correct BMI range defining obesity was selected by 28.34% of respondents. Majority of the respondents chose “multifactorial” (44.69%) as the cause of obesity, followed by overeating (34.07%), lack of exercise (27.43%), and hormonal imbalance (5.31%). 59.29% felt that MO should be treated aggressively with majority selecting a combined treatment approach (Surgical + Medical + Lifestyle changes) (54.87%). Diabetes (86.73%), depression (73.45%), obstructive sleep apnea (54.52%), and chronic obstructive pulmonary disease (54.54%) were selected most commonly as diseases-related to MO. Only 38.94% and 36.73% thought that reflux disease and hypertension were related to MO, respectively. Interestingly, only 0.88% picked all four MO-related diseases accurately, while 35.40% picked at least three diseases correctly.

Conclusions

Obesity awareness in the general population appears to be suboptimal. There is a need to introduce appropriate interventions to improve the knowledge of public regarding obesity with the view of reducing the prevalence of obesity and subsequently related healthcare costs.
180 Does Preoperative Cognitive Behavioural Therapy Improve Postoperative Weight Loss Outcomes in Patients Undergoing Bariatric Surgery? a Systematic Review and Meta-Analysis
Authors: Hughes J , Hughes R , Musbahi A , Kourounis G
Published: August 2023

Aim

Bariatric surgery is an effective intervention in treating obesity. However, some patients experience weight regain or early weight stabilisation. It is thought that psychological comorbidity may contribute to this. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) to determine if preoperative cognitive behavioural therapy (CBT) would improve weight loss outcomes in patients scheduled for bariatric surgery.

Method

Medline, PsychINFO, Scopus and EMBASE were searched from their origin to 20th March 2022 for articles comparing preoperative CBT to standard care. Primary outcome was weight loss at least 1 year postoperatively. This review was registered on PROSPERO (CRD42022326336).

Results

Of 144 articles, 2 met inclusion criteria. They included a total of 187 patients randomised between CBT (n = 95) and control (n = 92). One paper included 1 year follow up whilst the other included 1 and 4 year follow up. Our random-effects meta-analysis found no significant difference in weight loss outcomes between the two groups at 1 year, p = 0.43. There was high heterogeneity between the studies, I2 = 90%.

Conclusions

Currently, RCTs do not show a significant difference in postoperative weight loss between CBT and control groups although case specific CBT may still be beneficial. Our study was limited by few eligible studies and high heterogeneity between the studies. One study also demonstrated selection bias by excluding patients who had previously undergone psychotherapy from the analysis.
637 Can Metabolic Surgery Lead to Hypertension Remission? Our Experience
Authors: Mahendran V , Ricart P , Eymech O , Wadley M
Published: August 2023

Aim

To evaluate the rate of remission (RR) from hypertension after Laparoscopic Roux-en-y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy and determine any difference between the groups.

To analyse if the patient’s age, sex, BMI and number of anti-hypertensive medications (AHMs) taken preoperatively affected remission after surgery.

Method

Retrospective cohort analysis of all patients on AHMs who had undergone LRYGB or LSG as their primary procedure at Worcestershire Royal Hospital (WRH) between 1/01/2012 and 31/12/2019 were included in the study. We excluded patients who underwent other types of Bariatric procedures or took AHMs for any other reasons

Hypertension

Defined as usage of AHM(s) at least 18 months before surgery.

Remission from hypertension: defined as no prescribed AHMs for one year after surgery.

Results

475 patients underwent bariatric surgery at WRH between 1/01/2012 and 31/12/2019; 193 patients met the inclusion criteria; LRYGB 52% (n = 101) Vs LSG 48% (n = 92). RR after LRYGB - Year 1: 40% and Year 2: 43%; Vs LSG -Year 1: 40.8% and Year 2: 43.1%. Number of preoperative AHMs, 1 AHM: 53% RR; 2 AHMs: 36% RR and ≥ 3 AHM: 18% RR; (P value = 0.0009). Age ≤45 years: 58% RR Vs >45 years: 37% RR; (P value = 0.024). RR in ≤ 45 years after LRYGB: 77.8% Vs LSG: 39.3% (P value = 0.0085).

Conclusions

There was no significant difference in RR between LRYGB Vs LSG, sex or BMI. Patients ≤ 45 years and those taking fewer AHMs before surgery had a significantly higher RR. Patients ≤45 years who underwent LRYGB had maximum RR from HTN.
1073 Roux-en-Y Gastric Bypass or Sleeve Gastrectomy Versus Medical Therapy in the Management of Obesity in Patients with Type 2 Diabetes Mellitus: Systematic Review and Meta-Analysis
Authors: Shirke M , Sreejith G , Ravikumar N , Roy S , Nizam M Z , Tuli K
Published: August 2023

Aim

Bariatric Surgery has proven to be effective in achieving diabetic control in morbidly obese patients. Advances in Roux-En-Y Gastric Bypass (RYGB) and Sleeve gastrectomy procedures have influenced this majorly. This review aims to analyse the clinical outcomes by comparing the two procedures and medical therapy, in morbidly obese patients with Type 2 Diabetes Mellitus (T2DM).

Method

A systematic literature review was conducted in accordance to the PRISMA guidelines to identify relevant articles that compared RYGB, sleeve gastrectomy and medical therapy for obesity in diabetic patients. Primary outcomes included BMI and HbA1c.

Results

Seven studies were identified enrolling 900 patients. Participants were predominantly female (61.31%) with a mean follow up of 2.71 years. A greater reduction in BMI and HbA1c was noted with both procedures compared to medical therapy. Sleeve gastrectomy was better in reducing BMI than RYGB (SMD = 19.23 [15.61 – 22.84], p<0.01). HbA1c (SMD = -2.37 [-2.72 – -2.02], p<0.01) and Triglycerides (SMD = -0.87 [-1.65 – -0.08], p = 0.03) were statistically significantly in favour of RYGB. No differences were noted between the two procedures in other outcomes including fasting glucose, weight and Blood pressure. Both procedures compared to medical therapy were considered to be superior statistically across all outcomes measured.

Conclusions

Overall, the study shows the superiority of Bariatric surgery to medical therapy in managing T2DM in obese patients. No significant differences were noted between the types of bariatric surgery, however, there exists a need to perform studies with longer follow up and compare the feasibility of these procedures.
763 De-Escalation of Axillary Treatment. Have We Fully Explored the Options for Those Patients Who Undergo Primary Reconstruction with Implants?
Authors: Davies B , Mirghani D , Ooi J
Published: August 2023

Aim

Treatment of the malignant axilla is a contentious area within breast cancer management. The POsitive Sentinel Node (POSNOC) Trial represents one of the largest trials into axillary treatment for the malignant axilla and includes surgical clearance of the axilla (ANC) or axillary radiotherapy (ART).

Patients who undergo primary reconstruction with implants are not excluded from the POSNOC Trial. Yet, data surrounding the risks of axillary radiotherapy to patients with breast implants is scarce. This project aimed to collect and analyse the data of those Trust patients who had undergone immediate reconstruction with an implant and axillary radiotherapy, to review any potential complications, increased risks, and impact on decision-making.

Method

Retrospective study, looking at the five years of data (2017-2022).

Results

21 patients were identified as having breast implants with axillary node metastasis. Of these, eight patients had axillary treatment due to macro-metastasis. Five of these patients had ANC and the remaining three patients had axillary radiotherapy. Out of these patients one patient (33%) had to have their implant removed post radiotherapy, due to capsular contracture. Within the limitations of this small study, we can see that in patients with primary implant reconstruction are more likely to have ANC rather than radiotherapy. Additionally, in three patients with implants 33% had complications that could be related to radiotherapy.

Conclusions

Further research into the impact of axillary radiotherapy in patients with implants is vital, so that patients can be adequately informed to make decisions about their treatment options.
54 Is Nicotine Replacement Therapy (NRT) Offered and Prescribed to Current Smokers Admitted to Thoracic Surgery?
Authors: Nelson A , Crawford A
Published: August 2023

Background

Cigarette smoking is a well-known habitual risk factor for lung cancer. Lung cancer resections make up the majority of BRI Thoracic Surgery admissions. Smoking has a negative impact on long term survival and disease progression of lung cancer patients increasing risk of recurrence and secondary tumours following surgery with curative intent.

Method

Retrospective analysis of all patients discharged from thoracic surgery during December 2021, February 2022 and March 2022. Interventions were implemented following thoracic surgery team meetings in January and February. Data was obtained from pre-operative assessments, inpatient clinical notes, discharge summaries and discharge medications. Interventions included team discussions and education, implementation of NRT prompts in EPR pathway and NRT prescribing stickers in drug charts.

Results

The majority of admissions were for lung cancer resections reaching 49% of admissions in February and March. In December, February and March: 70%, 55% and 50% of patients respectively had no documented discussion of smoking cessation/ NRT during admission and were not discharged with NRT.

Conclusions

78% of patients who were offered NRT as an inpatient accepted and were discharged with appropriate NRT. The number of patients who had no documented discussion about smoking cessation, and subsequently no NRT prescribed on discharge improved over the months (70%, 55% and 50% respectively). 16% of patients had no smoking status documented at pre-op or during admission. There is room for improvement in NRT discussions on the ward, allowing prescription of NRT to promote smoking cessation on discharge.
423 Up Against the Wall - Emergency Double Myocardial Rupture Repair
Authors: Ravi R , Unsworth-White J , Sinha S , Dunlop C
Published: August 2023

Background

Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together ("double myocardial rupture" (DMR)), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient.

Case presentation

Our 57-year-old male patient self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA).

He was rapidly transferred to our regional cardiac surgical unit, arriving at the theatre in cardiogenic shock but conscious before arresting and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple ITU complications to be eventually transferred, neurologically intact, on postoperative day 66 to a peripheral unit to complete his rehabilitation. He has been discharged from the rehabilitation centre 88 days after the operation, and He is now able to ambulate with a walking frame.

Conclusions

Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. We hope patients with meagre probabilities, such as the patient seen in this case, are not given up on; hence, our final message from this report is to persevere and persist against all odds.
589 Medication Prescribing for Patients Undergoing Cardiac Surgery with Heart Failure with Reduced Ejection Fraction (HFrEF) and Review of Left Ventricular (LV) Function Documentation - A Departmental Audit
Authors: Le H B T , Clark L , Campbell C , Lang P
Published: August 2023

Aim

This study aims to audit the prescribing practices for patients with heart failure with reduced ejection fraction (HFrEF) who have undergone cardiac surgery at our department in accordance with European Society for Cardiology (ESC) guidelines for titrating heart failure medication in this cohort of patients.

Method

Data was collected from patients (n = 217) who have undergone cardiac surgery at our department between 20 May 2021 to 20 August 2021. This was collected from Tomcat Systems (Philips) and left ventricular ejection fraction (LVEF) was noted. ESC guidelines define HFrEF as LVEF≤40% and 15 patients met this criterion. These patients had their medications and electronic patient records reviewed to assess whether they are prescribed, considered for titration, or had a contraindication to the following medications (grouped as compliance rate) as per the 2016 ESC guidelines: ACE-inhibitor (or Angiotensin Receptor-Neprilysin Inhibitor - ACEi/ARNI), beta-blocker (BB) and mineralocorticoid receptor antagonist (MRA).

Results

This audit found a compliance rate of 67% (10/15) patients for ACEi/ARNI, 80% (12/15) patients for BB and 67% (10/15) patients for MRA. Following a departmental meeting, significant barriers were identified to optimal prescribing of these medications including lack of LVEF information readily available for ward round, lack of awareness and miscommunication of responsibility.

Conclusions

Having identified the challenges to optimal titrating of these medications, we have implemented interventions to improve communication of LVEF status to the clinical team. We have also encouraged the referral of these patients to heart failure clinic. The next cycle of audit will assess the efficacy of these changes.
1171 Post-Operative Length of Stay Following Anatomical Lung Resection
Authors: Leiberman C , Kostoulas N
Published: August 2023

Aim

This project aimed to identify reasons for a post-operative length of stay (LOS) more than 3 days in patients who have undergone VATS or RATS anatomical lung resections.

Method

Theatre records for VATS and RATS anatomical resections over a one-month period were examined with ones that were converted to open surgery excluded. The patients were then categorised into 3 groups: Group 1 – patients staying 1-2 days post-operatively, Group 2 – patients staying 3-5 days, and Group 3 – patients staying more than 5 days.

Results

A total of 17 patients were identified. Of these, 4 (24%) had a LOS of 1-2 days, 9 (52%) had a LOS of 3-5 days, and 4 (24%) had a LOS of 5 days or more.

In Group, 3 (33%) stayed due to a post-operative air leak, 2 (22%) stayed due to post-operative pain. Case notes were missing for 2 (22%) of these patients.

In Group 5, 3 (75%) stayed longer than 5 days due to a post-operative air leak, and 1 (25%) stayed due to a new arrhythmia.

Conclusions

The most common reason for a prolonged length of stay was due to a post-operative air leak following anatomical lung resection. Further studies could compare other months, compare VATS against RATS, or include data from resections via thoracotomy. A possible way to reduce post-operative LOS, if the cause is an ongoing air leak, could be to discharge more patients with an ambulatory bag.
1266 Haemostasis Checklists-Are They an Effective Tool?
Authors: Amien B , Al-Jumaili Z , Harky A , Soppa G
Published: August 2023

Aim

Haemostasis checklists have been developed to decrease re-bleeding rates following cardiac surgeries. These checklists aim to identify the most common sites of bleeding, as well as reasons for coagulopathies and prevent them by early identification during surgery. The aim of this study is to Evaluate the effectiveness of the haemostasis checklist as a tool for reducing the rate of Re-exploration for bleeding in Liverpool heart and chest Cardiothoracic Centre.

Method

Retrospective study carried over the period of 2019 and 2022 (pre and post checklist implementation). This study included all patients who underwent elective cardiac surgery, 614 cases in each year. Data was analysed and classified into 3 categories: Number of Re-exploration cases in each year, Bleeding sites identified and the Number of post-operative days at which re-bleeding was noted.

Results

Total number of Re-exploration cases for bleeding in 2019 were 39(6.35%), as compared to 14(2.28%) cases in 2022. 60% of the re-bleeding cases in 2019 were identified within first 24 hours post-operative, while 77% were identified in the first 24 hours in 2022. Most common sites of bleeding identified in 2019, were no clear site (38%) and sternal wires (19%). While in 2022, no clear site (46%) and sternal wires (23%) were most identified during re-exploration.

Conclusions

Significant reduction of 64% was witnessed between the year of 2019 and 2022 after implementation of the checklist, therefore, Haemostasis checklist proved to be an effective tool in reducing the rate of Re-exploration for bleeding in cardiac surgery.
43 Case Report: A Novel Technique of Reconstruction Following Second and Third Ray Amputation and Excision of Lateral Sesamoid for Synovial Sarcoma of the Foot
Authors: AlSumadi M , Ogbuagu C , Chandrasekar C
Published: August 2023

Synovial sarcomas primarily occur in soft tissues close to the joints and extremities. When they arise close to the hallucal sesamoids, which play a role in the static and dynamic weight process of the foot, present a management dilemma.

We report a case of a soft tissue synovial sarcoma of the foot in a previously fit and healthy 17-year-old individual without any history of trauma. MRI of the foot showed the tumour near the lateral sesamoids. Histology obtained by ultrasound guidance confirmed a diagnosis of primary synovial sarcoma.

After radio-chemotherapy, Patient had an en-block excision of the second and third ray of the foot as well as excision of the lateral sesamoid and lateral stabilizing structures of the first metatarsophalangeal joint with transposition of the extensor hallucis longus of the second toe to the cavity of the excised lateral sesamoid.

Following recovery, with a preserved first ray, patient is still able to walk, run and tiptoe walk. Patient also remains tumour-free at 5-year follow-up. We hope that the reconstruction option can be used in selective indications to restore lateral stability of first metatarsophalangeal joint (MTPJ).
75 Intraoperative Use of Infrared Thermal Imaging Camera – a Clinical Aid for Pedicled Flaps in Hand Reconstruction
Authors: Lam C M , Begaj A , Patel N
Published: August 2023

Introduction

Venous insufficiency remains one of the commonest causes for flap failure. Forward-looking infrared (FLIR) thermography measures infrared emissions from dissipated heat and converts temperature values into an image. This has various advantages to the current use of indocyanine green (ICG) angiography to assess flap perfusion.

Case

A man in his mid-30s was involved in a road traffic accident and sustained extensive injuries to his right hand. These included multiple metacarpal fractures, degloving of the proximal aspect of the entire thumb and significant skin loss on the volar distal forearm. After several washouts and tissue debridement, a pedicled chest wall flap was performed. Five weeks later the chest wall flap was divided using an infrared thermal imaging camera (FLIR E5) intraoperatively as a clinical aid to assess perfusion. This detected a small area of venous congestion which was not detectable by clinical assessment.

Discussion

There are drawbacks to the current intraoperative use of ICG angiography to assess flap perfusion. These include hot flushes and skin rashes, and the technique requires an intraoperative injection, extensive equipment involving a screen and a specialised camera. In comparison FLIR cameras are handheld, easy to use and involves a one-off cost of purchasing the camera that is relatively inexpensive compared to ICG angiography.

Conclusions

Thermal imaging techniques such as FLIR provides an alternative intraoperative option for patients who are unable to have ICG, for centres that do not have access to ICG and for surgeons looking for more convenient alternatives.
199 A Giant Left Atrial Myxoma: An Atypical and Fortuitous Mode of Revelation Case Report
Authors: Zebirate L , Djilali Saiah R , Draou N E , Hamdi T , Atbi M
Published: August 2023

A large atrial myxoma was discovered fortuitously in a patient that had a seizure, showing the importance of further investigations even after assuming a diagnosis.

A 63-year-old male with no medical issues was admitted to the emergency department after having tonic-clonic seizure. Initial examination found a hemodynamically stable patient scored 8/15 Glasgow, 48 hours later a contrast cerebral CT was performed showing no abnormalities, but electroencephalogram revealed epileptic foci in the left temporal-parietal territories. The staff decided to complete the investigations with a transthoracic echocardiography which visualised an enormous left atrial mass. A cardiac magnetic resonance imaging (CMR) confirmed the atrial mass, measuring (87*47) mm over 73mm attached to the interatrial septum with a surface of insertion of 30mm that does not protrude through the mitral valve. The patient underwent open heart surgery. Left atriotomy found a myxoid-looking mass adhering to the posterior-inferior wall of the left atrium of 11 cm over 5 cm. The patient was discharged uneventfully on his 8th post-operative day and pathoanatomical analysis revealed a myxoma. We oriented the patient to neurology after surgery and no complications were reported on his 3 months follow-up.

The aim of this case is to highlight three points: myxomas can remain asymptomatic for a long time despite their size, transthoracic echocardiography is a rapid and efficient bedside assessment, and a symptom can reveal more than one diagnosis.
273 Open Split Fracture of the Patella in a 14-Year-Old Child: An Unusual Occurrence
Authors: Sain B
Published: August 2023

Background

Patella fractures in children are rare, accounting for approximately 1 % of all paediatric fractures. Due to resilience and adequate flexibility, transverse patellar fractures are extremely rare. This case accounts for less than 10 cases of open transverse or split patellar fracture reported in literature among the paediatric population.

Case Presentation

A 14-year-old boy was brought in as a pediatric trauma call following a fall and collision of his right knee against a concrete wall on a turf ground while playing football. He had Crohn's disease (on Prednisolone). No history of bone or joint pain, fever, rashes, or juvenile idiopathic arthritis was noted.

On clinical examination, a 5cm open horizontal wound in the right knee with no visible bony fragments was noted. Imaging showed a split fracture of the right patella with wide separation of the superior and inferior fragments. Adjacent gas locules and haematoma which extended into the joint space were noted.

Clinical outcomes

Tension band wiring was done and the patient was placed in a full weight-bearing hinge knee brace with initial range of motion(ROM) of 0-30 degrees followed by an increase of 30 degrees at every 2 weeks.

Discussion

While sleeve fractures of the patella is more common, a transverse or split pattern is rather unusual and an open fracture in the paediatric population is rare. Other anomalies of the knee joint should be always excluded. The treatment protocol for children is the same as for adults. Restoring the extensor mechanism and realigning the articular surface is essential.
314 Isolated Tuberculosis of Appendix: A Case Report
Authors: Mathew M , Yilmaz O , Mathew T
Published: August 2023

Introduction

Stump appendicitis is a rare and delayed complication of appendectomy. In India, abdominal tuberculosis (TB) represents about 10% of the extra pulmonary TB and the appendix is involved in only about 1%. A combined occurrence of both conditions is very rare.

Case Presentation

A 24-year-old male presented to the General Surgery outpatients’ clinic with a 2-week history of right iliac fossa pain with no other associated symptoms. The patient had undergone an open appendectomy for perforated appendicitis 3 months prior to the current presentation. Per abdominal examination showed tenderness at the McBurney’s point. A CT abdomen revealed thickened and enhanced stump appendix along with adjacent fat stranding and multiple mesenteric nodes, suggestive of stump appendicitis. In light of the upward trend seen in white blood cell count, the patient was planned for a diagnostic laparoscopy and pre-anesthesia clearance was obtained. Intra-operatively, adhesiolysis of dense bowel and omental adhesions were performed. About 3.5 cm appendicular stump was resected. Micro-nodular peritoneal nodules were resected. The specimens were sent for histo-pathology examination.

Results

The postoperative period was uneventful with symptomatic relief. The biopsy of the stump described morphological features of caseating granulomatous inflammation, suggesting the possibility of tuberculosis while the peritoneal nodules showed infiltration of inflammatory cells. The patient was started on specific anti-tubercular treatment.

Conclusions

Appendicular TB is rare and of uncertain physiopathological etiology. The peculiarity of our case was the finding of abdominal TB presented as stump appendicitis. This may even be the first report with similar findings.
432 A Rare Case of Ipsilateral Foot Drop Due to Common Peroneal Nerve Palsy at the Level of Fibular Head Following Total Hip Arthroplasty
Authors: Sain B
Published: August 2023

Background

Common peroneal nerve (CPN) palsy after primary total hip arthroplasty (THA) is a rare complication with poor functional outcome and has a prevalence of 0.3-2.1%.

Case Presentation

A 77-year-old gentleman was diagnosed with severe osteoarthritis of the left hip and underwent a hybrid left total hip replacement via posterior approach in right-lateral position. There was no usage of spinal anaesthesia, leakage from the wound, intra-operative nerve injury or any localised haematoma. Post-operatively on day 3, he was noted to have foot drop with loss of foot eversion and dorsiflexion with sensory loss along the distribution of the superficial peroneal and tibial nerve.

Clinical Outcomes

Nerve conduction study of left lower limb showed absent left superficial peroneal sensory response, absent left peroneal to extensor digitorum brevis and tibialis anterior motor responses with denervation across the anterior and lateral left lower leg muscles suggestive of a severe partial lesion of the left common peroneal nerve at the level of fibular head. Patient was placed in a foot drop splint with follow-up neurological evaluation.

Discussion

Post-operative CPN palsy are mostly neuropraxias caused due to direct compression, either by surgical instruments or anatomical structures, or from tension or ischemia to the nerve during intra-operative limb manipulation or limb lengthening. Additionally, usage of cement less components combined with Enoxaparin or due to any haematoma may compress the nerve. Age, BMI and initial severity of sensory and motor neurological deficits are prognostic factors indicating recovery. Full recovery is between 16-56% of cases at an average of 15 months.
436 Total Arterial Revascularisation Complicated by Unexpected Vasoconstrictor Requirements
Authors: Raj Krishna G , Taylor M , Nwaejike N
Published: August 2023

Introduction

The debate surrounding conduit selection in multi-vessel coronary artery bypass grafting (CABG) persists. Whilst combined arterial and venous conduits remains the gold standard approach, some studies report superior long-term outcomes with total arterial revascularisation (TAR).

Case Description

A 48-year-old male was admitted with acute coronary syndrome. Investigations demonstrated significant triple vessel coronary artery disease with preserved biventricular systolic function. He had no major comorbidities. He underwent uneventful urgent off-pump CABG x 3 with TAR. Conduits used were a skeletonised left internal mammary artery (LIMA) and a radial artery. They were anastomosed to make a Y configuration. The LIMA was anastomosed end-to-side to the mid-LAD and the radial artery was anastomosed side-to-side to the first obtuse marginal and end-to-side to the posterior descending artery. Post-operatively the patient had significant drain output, resulting in haemodynamic instability and a significant increase in vasoconstrictor requirements. This led to vasoconstrictive spasm of the arterial grafts and cardiac arrest ensued. The patient underwent emergency re-sternotomy and institution of cardiopulmonary bypass. The arterial grafts were removed, and the patient was re-grafted with three saphenous vein grafts. The patient was successfully discharged home in a stable condition on the tenth post-operative day.

Discussion

Careful management of post-operative complications in patients who underwent TAR is required in order to reduce the risk of arterial graft spasm. Pre-operative planning should include the consideration of alternative conduit strategies in patients where higher post-operative vasoconstrictor requirements are anticipated.
439 A Rare Cause of Flap Loss and Wound Dehiscence After Immediate DIEP Flap Breast Reconstruction - Raising Awareness of Pyoderma Gangrenosum (Case Report & Literature Review)
Authors: Sayed M A , Wain R , O' Ceallaigh S
Published: August 2023

Aim

To raise awareness of post-surgical pyoderma gangrenosum (PSPG) as an uncommon but potentially devastating sequelae of free-flap breast reconstruction. Our patient developed PSPG ∼1 week after a DIEP flap. Symptoms and signs were of wound infection, and she was managed as such. Histology and MDT confirmed diagnosis 3 weeks later. Once appropriate treatment was commenced, a good response was seen. However, diagnostic delay meant multiple procedures, antibiotics, and a suboptimal outcome requiring secondary reconstruction.

Method

Retrospective case report compiled using CARE guidance. Literature review using PubMed/Science Direct.

Results

PSPG in free-flap breast reconstruction is rare (∼20 reported cases). Symptoms occur 4 days to 6 weeks post-op. Deteriorating wounds mimicking infection/ischaemia are classical, often associated with ulceration, irregular, raised borders. Positive wound cultures and late evolution of classic signs clouded diagnosis in our case. Our patient had several microbiological, haematological, and radiological investigations in the first 3 weeks; most were equivocal and, in retrospect, likely unhelpful.

Conclusions

PSPG should be considered when post-op wound infection is suspected in cases with non-classical signs. Given its potentially devastating effect on free-flap reconstruction, we recommend PSPG be discussed as a rare but serious complication during consent. A high index of suspicion is needed to avoid unnecessary antimicrobials, detrimental surgical procedures, and initiate appropriate medical management in a timely fashion. Good outcomes can be obtained if recognised early.
448 Case Study of a Giant Duodenal Perforation: Where Is the Ampulla?
Authors: Bin Mohamed Ebrahim M E , Lim C
Published: August 2023

Concurrent duodenal and gallbladder perforation is a rare finding. Whilst cholecystoduodenal fistulas have been observed in literature, massive duodenal perforation with gallbladder erosion has not been recorded. We present the case of a 77-year-old female who was found to have a giant duodenal perforation (measuring 10cmx5cm) with an associated gallbladder perforation as well. On patient’s first presentation, a Computed Tomography of the abdomen was performed due to abdominal pain and constipation. Images showed pneumoperitoneum and intra-abdominal free fluid. Upon performing an explorative laparotomy, findings of duodenal and gallbladder perforations were observed. Distal gastrectomy, cholecystectomy and gastrojejunostomy were performed. Due to uncertainty of the location of the ampulla to the ulcer edges, a cholangiogram catheter was advanced into the Ampulla of Vater via the Cystic Duct to definitively identify it prior to D1/D2 stapling. Gastrograffin study was conducted on Day-5, showing good contrast flow. No major events occurred during her post operative recovery. The main concern is inadvertent stapling of D1/D2 together with the ampulla. The passage of a catheter down the Cystic Duct, into the Common Bile Duct and through the ampulla is a definitive way to locate its position. In addition, Common Bile Duct patency with cholangiography can be ensured. Intra-operative improvisation such as advancing a cholangiogram catheter into the ampulla would assist surgeons in safely resecting proximal duodenum especially when it encroaches on the D1/2 junction.
539 Antegrade Manipulation and Retrieval per Rectum: A Novel Management Approach for Gallstone Coleus
Authors: Rosen J
Published: August 2023

Gallstone ileus is a rare complication of gallstone disease, while gallstone coleus is rarer still. Like gallstone ileus, it affects mainly elderly female patients. It is associated with high mortality and morbidity, as frailty is a significant issue in the patient demographic.

In this case report, we discuss a 94-year-old, who presented with large bowel obstruction secondary to a large gallstone in the mid-sigmoid colon. Neither conservative management nor retrieval via flexible sigmoidoscopy were successful. Due to worsening bowel obstruction, the decision to operate was made. Due to frailty, a pre-operative decision was made that she would not be for bowel resection or enterotomy. A hybrid flexible sigmoidoscopic/ laparotomy assisted removal was successful: a Pfannenstiel incision was made, the stone was milked distally, and eventually retrieved with flexible sigmoidoscopy via the anus.

We propose that in frail patients, a combined approach using laparotomy and flexible sigmoidoscopy may be considered as a method of gallstone removal. This avoids the significant risks associated with enterotomy or bowel resection.
569 Resection of Massive Pelvic Chondrosarcoma Using Custom Made 3D Printed Jig: A Case Report
Authors: Cohen C , Chandrashekara N , Hindiskere S , Chinder P S
Published: August 2023

Background

The pelvis is a complex structure associated with major neurovascular structures and so pelvic surgery can be challenging. In the field of skeletal tumours, the surgeon's main aim is to achieve adequate margins, which modern 3D printed technology can assist with.

Method

A 43-year-old man was found to have a 20(CC) x 13(AO) x 9.3(TR) cm chondrasarcoma at the inner aspect of the right iliac bone. The patient was consented for right sided type 1 hemipelvectomy and tumour resection using customised 3D Printed Jig. A 64-slice spiral CT pelvis was transferred to an image processing software (Materialise Mimics 21.0 and Materialise 3 Matic 13.0) to generate a 3D model. The Jig was printed by the FDM machine in ABS material and sterilised. Incision was made through standard ilioinguinal approach and tumour was visualised. Soft tissue was dissected over the posterior aspect of the Ilium for the placement of the jig and then fixed with k wire, following which osteotomy was done.

Results

Postoperatively the patient had no complications. At final follow up of 4 years, the patient was independently ambulant. Post op x-ray showed no signs of tumour recurrence at the operated site.

Conclusions

This case highlights the importance of preoperative planning and the use of modern technology in surgical resection. Customised 3D printed jigs help surgeons achieve good resections with R0 margins.
572 Pseudoaneurysm of Profunda Femoris Artery in a Patient Post Dynamic Hip Screw Fixation for a Neck of Femur Fracture: A Case Report
Authors: Cohen C , Chandrashekara N , Jamil W
Published: August 2023

Background

Profunda femoris artery (PFA) pseudoaneurysm as a complication of hip fracture is rare [1]. The majority of recorded cases of PFA pseudoaneurysm are caused by femur fractures, surgical operations, and penetrating trauma [2]. We present a case of PFA pseudoaneurysm following surgical fixation for neck of femur fracture with dynamic hip screw (DHS) and canulated cancellous screw.

Case Presentation

The patient sustained a fractured neck of femur fracture following a fall and was on long term antiplatelet therapy for ischaemic heart disease. Thery underwent surgical fixation with DHS and canulated cancellous screw but developed an unexpected drop in their haemoglobin post-op. Initial thigh ultrasound indicated a large, localised hematoma. Further investigation with CT angiography however demonstrated pseudoaneurysm of the branch of the profunda femoris artery. The patient was treated with coil embolization and was able to fully weight bear with support.

Discussion

Vascular injuries following hip fractures are becoming more common complications [2-4]. Pseudoaneurysms of the profunda femoris artery are an unusual but well-recognized consequence of proximal femoral fractures. When post-operative pain is unexplained, or the haemoglobin level drops, there should be a high index of suspicion for vascular injury. Ultrasound and CT angiography are useful investigations.

Conclusions

We present a case of pseudoaneurysm of the PFA in a patient following DHS for fractured neck of femur. This is a rare yet recognised complication of femur fractures and should be suspected where pain is increased or there is a sudden decrease in haemoglobin.
580 A Surgical Dilemma; Complicated Case of Dandy Walker Malformation
Authors: Chaudhary A , Salah R
Published: August 2023

Case summary

A 24-year-old male presented to the department with a 1-week history of sudden onset posterior headache and multiple episodes of vomiting. He reported similar episodes 8 months prior with ataxia which resolved itself. He has a past medical history of dandy walker malformation (DWM) diagnosed in early infancy and a shunt inserted at 3 months old due to hydrocephalus.

Initial blood investigations revealed extremely low platelets, low TLC and markedly raised potassium along with splenomegaly. Neurological examination was unremarkable with GCS of E4V5M6. A CT scan revealed hydrocephalus requiring revision shunt surgery. However, surgery was avoided due to the risks associated with thrombocytopenia therefore multiple specialists were consulted before a final decision could be reached.

Discussion

DWM is a rare congenital malformation typically presenting in early childhood characterised by hypoplasia of the cerebellar vermis, posterior fossa dilation and cystic enlargement of 4th ventricle. A complication of DWM is hydrocephalus, which requires surgery to correct via shunt insertion. However, this patients’ haematological instabilities risks deterioration and even death during surgery as preoperative thrombocytopenia has been associated with increased intra- and post-operative mortality. As such the patient was not advised surgery initially however the hydrocephalus was causing severe headaches to the patient ultimately making it difficult for surgeons to decide when surgery should be performed. On follow up, the patient was discharged with no shunt revision due to resolution of symptoms. This case highlighted the need for skilled physicians across multiple specialities to make a shared decision about surgical or conservative management.
621 Delayed Presentation of Retained Gallstones Post Laparoscopic Cholecystectomy - Complicated by Falciform Ligament Abscess Formation
Authors: Shulman N , Chen N
Published: August 2023

Case

30-year-old female presented with six days of intermittent epigastric pain, increasing severity, with associated nausea and vomiting. Past history included depression, smoking and a laparoscopic cholecystectomy and intraoperative cholangiogram (IOC) performed interstate 8mths prior for acute cholecystitis. The operation report described a normal IOC, significantly inflamed gallbladder, requiring needle decompression and retrieval of two 15-20mm gallstones from Morison’s pouch.

Investigations showed elevated white cell count(13x10^9/L) and C-reactive protein(56mg/L), with mildly cholestatic liver function tests. Computed Tomography revealed two 1.5cm lesions abutting the inferior margin of the liver; one with shadowing on Ultrasound suspicious for a gallstone, with surrounding inflammatory mass and fat stranding.

A laparoscopic exploration and removal of retained gallstone was performed. Intraoperative findings included adhesions between the gastric body and falciform ligament; with chronic abscess cavity containing pus and a 1.5cm gallstone within the falciform ligament. She recovered well and discharged with antibiotics the next day.

Discussion

Gallstone spillage occurs in 6-40% of laparoscopic cholecystectomies, potentially causing complications (abscess, fistula, or haemorrhage) in 8.5% if retained. Abscess formation (as above) is often recurrent if the gallstone is not removed, thus a laparoscopic technique is preferable.

Attempted removal during surgery and documentation of spilled gallstones in the operation report is imperative to alert medical teams to the possibility of a complication if the patient were to represent. A high level of suspicion aids in the early recognition and intervention; particularly given the time post initial operation and limitations of standard imaging in detection of retained gallstones.