bluuebunny/crossref_metadata_2025 huggingface dataset:
841 The Management of Post-Operative Haemorrhage in Thyroid and Parathyroid Surgery: An Educational Quality Improvement Project in ENT
Authors: El-Hassan M , Kumaresan K , England R
Published: August 2024

Aim

To improve understanding of the protocol and critical urgency of post-operative haemorrhage and actions needed to secure a safe airway in patients’ post-thyroid and parathyroid surgery, in the ENT department of Castle Hill Hospital.

Method

Employing the guidelines established by The British Association of Endocrine & Thyroid Surgeons (BAETS), we devised identical questionnaires to be completed before and after the intervention on google forms. The intervention was a delivered as a video on acute haemorrhage management and one-to-one teaching. In November 2023, the survey was circulated to all ward and theatre staff responsible for the care of these patients. The pre- and post-intervention questionnaire included qualitative and quantitative questions, measuring competence in identifying and managing post-operative haemorrhage. Statistical analysis involved a paired t-test to evaluate differences in pre- and post-intervention data.

Results

19 responses were collected, yielding an 83% follow up rate. On a Likert-scale of 1-10, the confidence of managing a post-operative haemorrhage increased from 5.05 to 6.63, showing a significant increase (p>0.0015). Similarly, the overall score of the questionnaire increased from 6.68 to 8.68, showing a significant increase (p<0.0001). Qualitative feedback indicated the need for formal departmental teaching in the management of a post-operative haemorrhage.

Conclusions

Staff interacting with patients following thyroid surgery should be trained to recognise and manage a haemorrhage. There is no formal inclusion of acute haemorrhage management in the departmental induction for staff, which should be added in subsequent rotation inductions. Simulation exercises will be trialled to improve retention in subsequent cycles of this quality improvement project.
929 An Audit of the Perioperative Clinical Assessment and Documentation of Delirium in Older Patients Following Vascular Surgery
Authors: Chand C P , McCarthy T , Anthony R
Published: August 2024

Aim

Guidelines established by the Centre for Perioperative Care recommend daily screening for delirium using a validated tool such as the 4-AT and proactively documenting delirium in patients aged 65 years and over. This audit evaluated the assessment and documentation of delirium in older patients following vascular surgery.

Method

Patients aged ≥ 65 years who had undergone vascular surgery in August 2023 were identified. Data was collected retrospectively with access to the Trust electronic patient record system on a bespoke Microsoft Excel spreadsheet and analysis was carried out using SPSS®.

Results

Of the 51 patients identified, delirium was screened using the 4-AT tool in only 39.2% (n=20) of patients and on average 90 hours post-operatively. The highest documented score was 7 (n=1), with 7.8% (n=4) of patients scoring 1, 2 or 3 and the majority scoring 0 (n=15). The 4-AT was never documented in a consultant-led surgical post-operative review (100%, n=51). Additionally, there were concerns of delirium documented in 7 instances in the post-operative period, with the 4-AT documented in 5 of those instances.

Conclusions

This audit demonstrates poor compliance with perioperative care standards on screening for delirium using the 4-AT and documenting delirium, highlighting the need to increase awareness and improve the perioperative clinical pathway for older people undergoing vascular surgery. Our recommendations include discussion with stakeholders to identify barriers to assessment and documentation of delirium, (2) use of the mantra: 'Post-op bloods and 4AT' during post-operative reviews, and (3) education of various healthcare professionals in completing the 4-AT proforma on the ward.
940 Mobility in Acute Care Surgery Patients - Are We Neglecting the Basics?
Authors: Tannirandorn P , Zeidaabadi B , Zhou S , Zhang H , Zuzarte J , Jose A , Frith D
Published: August 2024

Introduction

Immobility is a harmful yet preventable issue in healthcare. Complications such as DVTs and pressure ulcers require intervention, leading to a prolonged hospital stay. NICE guidelines on trauma rehabilitation suggest tailored exercise rehabilitation programmes as soon as possible after traumatic injuries. However, these guidelines are rarely quantified. Our aim was to assess mobility of surgical patients admitted under the General Surgery (GS) and Major Trauma (MT) teams at a London Teaching Hospital and Major Trauma Centre.

Method

We conducted separate cross-sectional studies on each respective ward. Patients were observed for 3 weeks at 2-hourly intervals commencing at 0800 until 1800 for GS and 1000 to 1600 for MT. They were classified under the following: Bed, Chair, Absent, Mobile. Individuals unable to mobilise were identified through review of notes and excluded. Data-points are a bed surveyed at each time point.

Results

Datasets were combined, and 1309 data-points analysed. Results showed severe lack of mobilisation, with only 4.8% MT and 0.9% GS patients mobilising. Statistical analysis indicated no significant difference between both groups at all time points. Although suitable to mobilise, 98 patients remained in bed over a cumulative 221 days. There was increased tendency to mobilise during lunchtime and visiting hours.

Conclusions

Immobility is prevalent and preventable in acute-care surgical patients. Our study demonstrates that despite guidelines recommending early mobilisation, these are patient-specific and not adhered to. Potential causes include lack of healthcare and physiotherapy staff to assist patients. Patient-specific goals are required to avoid physical, social, and financial costs of acute surgical immobility.
1009 Surgical Site Infection: An Overview
Authors: Ravichandran S , Kumar A , Mohan Palliyil M M
Published: August 2024

Aim

Getting It Right First Time (GIRFT) in the UK is a national programme led by frontline clinicians to help reduce variations in various service parts in different medical specialities. Through this study, we can help mitigate enormous human pain and suffering and will save doctors' and nurses’ time and government/patients' money. This is the 2nd cycle of this audit. The aim is to reduce surgical site infection with measures to reduce hospital infections and disease-associated morbidity and mortality.

Method

Study conducted over one month- 1st to 30th June 2021. All General Surgical elective and emergency cases are included. Visited A&E and GP as Wound infection postop 30 days. Retrospective analysis of all case records of the admitted and readmitted patients in general surgery.

Results

22 patients had wound infection (15%) in this audit cycle out of 151 patients. Although most SSIs are post-emergency surgery, the ‘elective bowel resection’ category has the highest 30-day wound infection rate. More patients received antibiotic prophylaxis in this audit compared to the previous one. Most are superficial wound infections, with 6 delayed discharges in this audit compared to 11.

Conclusions

Surgical site infection (SSI) is a common complication after colorectal surgery, with a reported incidence ranging from 3% to 30%. Using alcohol preparation on the skin will reduce infection. In an era of enhanced recovery, early recognition and prompt treatment of SSIs should be at the forefront of medical care for patient safety and the cost-effectiveness of treatment.
1142 National Audit of NICE Guidance for Endovascular Repair of Popliteal Aneurysms: The Kings Experience
Authors: Green J , Eves J , Ammar T
Published: August 2024

Aim

To evaluate care for patients undergoing covered stenting for popliteal aneurysms against NICE guidance, and to assess peri-procedural and post-procedural outcomes of patients.

Method

Retrospective collection of data in patients who had undergone endovascular repair of popliteal aneurysms from 30/5/2010 to 30/5/2023. 11 patients met inclusion criteria. Data collection was based on the NICE guidance clinical audit tool for endovascular repair of popliteal aneurysms. This included presenting symptoms, demographics, pre-procedure imaging findings, procedure details, duration of patency of the stent, peri-procedural complications, post procedure medical management and whether limb salvage was achieved.

Results

All 11 patients had vascular MDT discussion prior to procedure. Mean age was 71, 9 patients were male and 2 females. 5 stents remained patent to time of data collection or at the time of their death from other causes. There were no significant immediate complications. Of 6 failed stents, only one patient required amputation. Three patients had stents which remained patent for over a year with mean patency of 37 months, and 3 remained patent for less than a year. Stents that failed <1 year had reduced run-off vessels (mean 2). The smallest stent diameter (6mm) failed within 7 months. All patients had appropriate antiplatelet therapy.

Conclusions

Local experience of 11 endovascular stent for popliteal aneurysms. 6 failed and 3 failed within one year of insertion, with 1 patient requiring amputation. MDT input and full patient consent are mandatory prior to endovascular management of popliteal aneurysms. Technically, reduced run-off and narrower stents may be associated with poorer outcomes.
1274 Adherence to Best Practice Tariffs for Femoral Fractures Excluding Neck of Femur Fractures (NOF's)
Authors: Tathgar A , Gouveia S , Bleibleh S , Fenton P
Published: August 2024

Aim

In 2020/21 the UK BPT extended their patient cohort to include distal femur and femoral shaft fractures for time to surgery (TTS) of 36hrs. In 2018 UHB merging resulted in a new policy whereby all NOFs would be fixed at Birmingham Heartlands Hospital (BHH) and all other femoral fractures would be transferred to Queen Elizabeth Hospital (QEH) for fixation. This audit aims to assess the impact of this policy on both patient care and financial impact.

Method

The inclusion criteria were patients >65 with a femoral fracture. We collected data on 50 patients’ pre-merger (2017) that presented to QEH and compared this to patients presenting in 2022 to QEH (30 patients) and BHH (28 patients) (post-merger). The main data points for comparison were TTS, length of stay (LOS) and 90-day mortality.

Results

In the pre-merger group, 22(48%) of patients had a TTS ≤36 hours. In the post-merger groups, 15(50%) QEH vs 2(7%) BHH patients had a TTS ≤36 hours. There was no statistical significance when comparing the pre-merger TTS with post-merger QEH (p=0.61); however, there was statistical significance when comparing: TTS QEH vs BHH (p=0.00034) and LOS QEH vs BHH (mean 15 vs 21 days, p=0.0092). There was a trend but no significance between mortality (13% QEH Vs 21% BHH, P=0.41).

Conclusions

This data demonstrated longer TTS and LOS for patients presenting to BHH. This not only could result in worse morbidity/mortality for patients but also has a financial impact on missed tariffs/penalties and hospital bed costs.
1296 A Closed Loop Audit to Evaluate the Enhanced Recovery After Surgery (ERAS) Protocol in a Tertiary Oncoplastic Breast Reconstruction Unit
Authors: Samuels S , Tamimy S
Published: August 2024

Aim

A closed loop audit to assess the enhanced recovery after surgery (ERAS) protocol before and after implementation of an ERAS proforma, in patients who have undergone breast free flap reconstruction. To analyse the impact on patients after implementation.

Method

Retrospective data collection from March to June 2022 and September to November 2023, in a tertiary oncoplastic breast unit. Inclusion criteria: all patients who had undergone breast free flap reconstruction for breast cancer. Thirty-one patients in total. An ERAS proforma was designed in line with Trust standards and based on input from the oncoplastic breast MDT. The proforma included the following categories: pre-operation, operation day, day one, two and three post operation. The data was collected, analysed, and compared to data collected before implementation.

Results

The first audit showed poor adherence to the ERAS protocol, this improved after implementation of an ERAS proforma in the following areas: location of the proforma in notes, 0% found in notes before, 92% after. Anti-emetics prescribed 32% before and 100% after. Anti-inflammatory medication plus proton pump inhibitor prescribed 32% before and 100% after. Analgesia, laxatives, and enoxaparin prescribed in 100% of patients before and after implementation. Day 1 TWOC occurred 0% before and 50% after implementation. Day 2 drain documentation/management 26% before and 100% after. The average length of hospital stay was 5.5 days before, 3.75 days after. Therefore, inpatient hospitalisation was reduced by 1.75 days.

Conclusions

Adherence to an ERAS protocol is beneficial in managing patients during the perioperative period and leads to reduced inpatient hospitalisation.
574 The Incidence of ‘Negative’ Axillary Node Clearance Following Neoadjuvant Therapy, Its Potential Clinical Significance, and Recommendations: One Breast Unit Review of Practice
Authors: Miah C , Akhtar Z , Yip C
Published: August 2024

Aim

To assess our unit’s approach in managing breast cancer patients with ‘negative’ axillary node clearance (ANC), following neoadjuvant systemic therapy (NST). ‘Negative’ ANC referred to scenarios where histologically proven metastasis were identified prior to treatment, but evidence of a positive node could not be found in the final surgical specimen.

Method

We retrospectively reviewed all ANCs performed in our unit over 8 months. Specifically, we focused on cases of ‘Negative ANC’. Each individual case was examined, reporting the incidence of ‘negative’ ANC and follow up investigations.

Results

Seventy ANCs were performed during the study period (September 2022 – April 2023). Notably, four cases, of which 3 patients had NST, were identified: indicating an incidence of 5.7%. Following surgery, each patient underwent numerous radiological investigations such as axillary ultrasound scans, CT chest, PET scans, over various timelines, ranging from 1 to 7 months post-surgery, to exclude the possibility of finding any residual node(s).

Conclusions

There was inconsistency in following-up these four patients with ‘negative ANC’. Although the possibility of achieving complete pathological response (pCR) existed, it was necessary to ensure all nodes within the axillary basin were retrieved, especially when post-NST nodal status is an important determinant of disease-free and overall survival.

To address this oncological and histological concern, our unit will be clipping the biopsy proven node, prior to NST. This pre-NST localisation allows radiological assessment of the response during NST, providing an opportunity to de-escalate axilla surgery and re-evaluate the axilla in cases with ‘negative’ ANC outcomes.
218 Septal Myectomy and Left Atrial-to-Left Ventricle Valved Conduit for Severe Calcific Mitral Stenosis and Obstructive Hypertrophic Cardiomyopathy: A Case Report
Authors: Qamar Y , Schaff H
Published: August 2024

Mitral annular calcification with severe mitral valve (MV) stenosis can be difficult to treat with conventional MV replacement. Annular decalcification can cause atrioventricular groove disruption and bleeding. An alternative is to bypass the narrowed MV using a valved left-atrial-to-left-ventricle conduit.

A 48-year-old gentleman with obstructive-hypertrophic cardiomyopathy and severe calcific MV stenosis presented with progressive dyspnea, syncope, and fatigue. Medical history included hypertension, dialysis dependent ESRD, chronic-AF, pulmonary-hypertension, and NSVT. A grade III/IV mid-systolic murmur was audible at the LSE, and a grade II/IV mid-diastolic rumble. Echocardiography showed sigmoid septum with maximum thickness of 24-mm, severe calcific MV-inflow obstruction (MVA 0.87 cm2, mean gradient 15-mmHg, heart rate 60-bpm), and midventricular LVOT obstruction (resting gradient 96-mmHg). Because of NYHA class III symptoms, surgery was performed with plans for MV-bypass using a valved-conduit and midventricular myectomy. Following institution of CPB and cardioplegic arrest, the LAA was excised and a 26-mm Hemashield graft was beveled and sewn into the atriotomy. An anterolateral ventriculotomy was made near the apex of the heart and an extensive midventricular myectomy was performed through the incision. A 25-mm Hancock-II bioprosthesis was sewn into the conduit. Distal end of the conduit was beveled and anastomosed to the ventriculotomy. Postoperatively, median native-MV gradient reduced to 7-mmHg (heart rate 86-bpm). Recovery was uneventful. He was dismissed on postoperative-day 8 and continues to do well 5-months later.

MV-bypass using a valved LA-to-LV conduit is safe alternative to conventional MVR for relief of severe MS with MAC, particularly in patients with oHCM who require midventricular myectomy.
299 Small Right Coronary Artery Diameters in Two Turner’s Syndrome Patients Requiring ECMO Post-Bentall Procedure
Authors: Lysomirski A , Sypula Z , Mittal M , Von Klemperer K , Uppal R , Oo A
Published: August 2024

Aim

We aimed to establish the impact of coronary artery diameters (CAD) on the risk of ECMO requirement in patients with Turner’s Syndrome (TS) undergoing cardiac surgery.

Method

We reviewed 27 TS patients who underwent cardiac surgery. Out of these, only two cases developed severe cardiac complications (Case1: VF, Case2: STEMI) requiring ECMO post-Bentall procedure. CAD measurements (proximal RCA, LAD, LCX) were obtained from the post-operative CTCA for Case1. CAD were adjusted for the body surface area (BSA) using the Mosteller formula and compared to average BSA-adjusted CAD in Caucasians (Ghaffari et al., 2015).

Results

Case 1: CTCA report confirmed low-lying RCA ostium and left dominant coronary system. Our calculations showed small BSA-adjusted proximal RCA diameter. Case 2: Radiological reports (EPR) revealed “small caliber RCA with low lying origin, and a right dominant coronary system”. Other variables: CPB time >150min increases the risk of right ventricular failure (Schuuring et al., 2013). CPB time Case1: 239 min, Case2: 171 min.

Conclusions

Coronary artery anomalies in Turner’s Syndrome (TS) patients are common but rarely considered in the perioperative plan (Silberbach et al., 2018). The only two patients who experienced complications related to the conduction system and heart muscle requiring ECMO post-operatively showed evidence of small caliber RCA for BSA. Small caliber RCAs, together with extended CPB time, may predispose to severe postoperative cardiac complications requiring ECMO. This suggests that preoperative CTCAs may be useful in identifying TS patients that require a closer involvement of the ECMO team preoperatively.
615 Audit of Documentation of Operation Name During Hospital Stay
Authors: Hampson S , Springthorpe T , Hara N , Kassouf M , Tully L , Yates M
Published: August 2024

Background

Errors in the handover of patients from the cardiothoracic operating room (OR) to the intensive care unit (ICU) can compromise patient safety. We have previously shown that standardising the operation names and educating junior medical staff enhanced the accuracy of operation note titles.

Aim

This study aimed to assess operation name accuracy and consistency in OR and ICU notes, evaluating the impact of operation name standardisation and staff education.

Method

A prospective study of cardiac surgery patients at St. Bartholomew's Hospital was undertaken from November 29 to December 10, 2021. Operation notes were the standard and documents collected from the patients’ records were classed as fully accurate, containing acceptable/unacceptable variation, or inaccurate. Operation names were then standardised, and staff education followed. A subsequent data collection occurred from November 13 to November 19, 2023, under the same criteria.

Results

Pre-intervention, 30% of OR notes and 9% of ICU notes accurately named the operation. Post-intervention, this increased to 84% and 23%, respectively. Pre-intervention, the urgency was either incorrect or not documented in 2% of OR notes and 87% of ICU notes, which decreased to 0% and 29% post-intervention, respectively.

Conclusions

Improvements in documentation were observed post-intervention in both OR and ICU notes. However, significant discrepancies persisted in ICU notes. This is likely due to frequent staff turnover (every 2 years for surgical training, 3 months for ICU) and inadequate understanding of surgical details. In conclusion, continuous education is essential for sustained improvements in documentation accuracy.
222 Percutaneous Deep Venous Arterialization (pDVA)- a Realistic Option for No Option- Chronic Limb Threatening Ischaemia (CLTI)- a Case Report
Authors: Mishra A , Patel S , Zayed H
Published: August 2024

Background

No option- CLTI constitutes up to 20% of patients who are not candidates for revascularization and have a high risk of limb loss (40%) without further intervention.

pDVA is an endovascular procedure for patients with no option- CLTI, where arterial blood is channelled into the tissues via the venous network. We present two such cases with varying presentations.

Case presentation

A 52-year gentleman presented with bilateral Diabetic Foot infection and CLTI. CT Angiogram demonstrated bilateral occlusive Tibial disease. While the right leg underwent a major amputation, the MDT felt that although there were no arterial revascularisation options, pDVA was possible. This was successful with significant improvement in the foot. Four months post -procedure the foot had extensive dry gangrene with good Lateral Plantar doppler signals. Trans- metatarsal amputation and debridement followed by a Split- thickness skin graft was performed. At 8 months post- pDVA, the foot has healed well.

Another 65-year gentleman presented with left sided Rutherford Category 5 CLI. CT Angiogram concluded occlusive distal Tibial disease. He underwent Tibial angioplasty which soon re-occluded. Based on follow-up scans, the MDT declared him suitable for pDVA which was successful. Four weeks post- operatively the foot showed extensive necrotic tissue. Trans- metatarsal amputation followed by Split- thickness skin graft was performed. At 1- year post- pDVA, the foot has healed well.

Discussion

pDVA should now be considered for all patients with CLTI that are anatomically suitable, as it can be performed with high degree of procedural success to promote wound healing and prevent major amputations.
631 A Case Report of an Epiploic Hernia – a Mobile Right Colon Herniating Through the Foramen of Winslow
Authors: Jain S , Nessa A , Gandhi M , Ganesh R
Published: August 2024

Introduction

An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1% incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here.

Presentation of Case: A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications.

Discussion: There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel’s diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02%. Less than 10% of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50%.

Conclusions

A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.
736 Spontaneous Adenosquamous Carcinoma of the Prostate, a Case Report
Authors: Ndonga S , Opondo D , Etabale M
Published: August 2024

Spontaneous adenosquamous carcinoma of the prostate is a rare and aggressive subtype of prostate cancer with no well-established treatment guidelines.

A 63-year-old man presented with chief complaints involving the lower urinary tract and bowel. He complained of urgency urinary incontinence, frequency, and hematuria. He reported fecal urgency with hematochezia and no history of constipation. He had scrotal and penile pain with erectile dysfunction. He did not report any history of low back pain or lower limb paresthesia. He had no significant medical or surgical history.

On clinical examination, the prostate was enlarged, non-tender with a palpable nodule and a TRUS volume of 35 grams. The serum PSA was 18.9 ng/dl.

Multiparametric MRI of the prostate was done with instillation of a rectal gel given both his lower urinary tract and bowel symptoms. It showed an enlarged prostate with irregular prostatic outlines, heterogenous signals in all sequences, a prostatic cyst and a preserved recto-prostatic plane.

A systematic trans-rectal ultrasound guided biopsy of the prostate showed a Gleason grade 5 + 5 in all cores, with glandular features on < 10% and squamous features in > 90%.

There were widespread bone metastases with no visceral metastases. We initiated androgen deprivation therapy with Goserelin 10.8 mg pending evaluation for docetaxel chemotherapy. The patient had a rapid downhill clinical decline and died 6 months after the diagnosis and initiation of Goserelin. This case illustrates the aggressive nature of adenosquamous carcinoma and its poor response to hormone ablation therapy.
1044 Colo-Colic Intussusception with Large Bowel Obstruction in Adults
Authors: Salam A , Chikr B , Barghash M , Mansour M
Published: August 2024

Background

Intestinal intussusception in adults is rare and accounts for 1% of all bowel obstructions. Almost 90% of adult intussusceptions are caused by a pathological lead point like malignancy, polyp or a benign neoplasm. Colonic adenocarcinoma account for 60% of the cases, whereas colonic lipomas are the most common among benign pathologies.

Case Presentation

60-year-old female presented with crampy abdominal pain and bloody diarrhoea with mucous discharge. On examination, she was tender in the left lower quadrant and had raised white cell count (WCC) and C-reactive protein (CRP). Computed Tomography (CT) scan reported colo-colic intussusception from proximal to mid sigmoid colon with early ischemic changes. Patient underwent a laparoscopic assisted en-bloc sigmoid resection with end colostomy. The patient had uneventful recovery. The histopathology showed benign lipoma with intussuscepted portion ischemic and necrosed.

Discussion

Intussusception is common presentation in children with bowel obstruction, often caused by enlarged lymphoid tissue and the treatment is usually conservative. However, in adults, it is a rare occurrence and presents with sub-acute abdominal pain and vague obstructive symptoms. CT scan is a useful investigation with diagnostic accuracy of 58-100%. The standard treatment involves surgery, with controversy about reduction of intussusception prior to surgery. Due to the risk of perforation and dissemination of malignancy, en-bloc resection is often recommended.

Conclusions

Colo-colic intussusception in adults is a rare presentation of acute bowel obstruction. A thorough history, appropriate investigations and timely intervention can ensure safe patient outcomes.
1193 Could Acute Severe Pancreatitis Have Caused These Oesophageal Strictures?
Authors: Feyang Limbu D , Campbell T , Aravind B
Published: August 2024

Introduction

Benign oesophageal strictures, primarily characterised by dysphagia, have many causes with gastro-oesophageal reflux disease (GORD) being the most common. This case study presents an unusual occurrence of oesophageal strictures following necrotising pancreatitis.

Case

This woman in her 40s had an episode of acute severe necrotising pancreatitis secondary to gallstones, which was treated conservatively including ITU support and a prolonged hospital stay. Serial CT imaging revealed peri-pancreatic and distal oesophageal inflammation. During her hospitalisation, she experienced haematemesis and an OGD revealed distal oesophagitis. Four months post-discharge, she complained of dysphagia and multiple oesophageal strictures were found on OGD and barium swallow. Her symptoms are managed currently with regular balloon dilatations at a tertiary level centre where other causes of stricture were ruled out.

Discussion

Cases of oesophageal strictures associated with acute pancreatitis exist in literature, but the pathophysiology is poorly understood. Similarities with bowel strictures following acute pancreatitis hint at potential pathophysiology for oesophageal stricture formation. This reported benign oesophageal stricture is likely secondary to inflammation following the pancreatitis with imaging showing inflammation towards the distal oesophagus as other reasons are ruled out.

Conclusions

This case study suggests a link between acute pancreatitis and oesophageal strictures, particularly when peri-pancreatic inflammation extends to the oesophagus. We hope to improve the awareness of such long-term sequela following acute severe pancreatitis.
19 An Evaluation of the Quality and Readability of Online Information Regarding Foreign Bodies of the Ear, Nose and Throat
Authors: Ko T K , Tan D J Y , Fan K S
Published: August 2024

Aim

Foreign body (FB) inhalation, ingestion and insertion account for 11% of ENT emergency hospital admissions. Children are disproportionately affected, and urgent intervention may be needed to maintain open airways. High-quality, readable online information could help reduce poor outcomes from foreign bodies. The aim is to determine the quality and readability of online health information relating to FB.

Method

Google was used to conduct searches using 6 search phrases. For each search phrase, the first 30 results were captured for inclusion in the study. Eligibility criteria were applied to select only health information. The EQIP tool was used to assess information quality. Readability was assessed using the Flesch Reading Ease Score (FRES) and the Flesch-Kincaid Grade Level (FKGL).

Results

Of the information websites included (n=73), most (63%) were from the USA. The median EQIP score was 21 (IQR18-25, max29), suggesting moderate information quality. Precautionary measures were not mentioned on 40% of websites and 30% did not identify disc batteries as a risky FB. Red flags for urgent care were identified on 95% of websites, 89% advised patients to seek medical attention and only 38.4% of websites advised patients on safe foreign body removal. Readability scores (FRES:12.4 years; FKGL:6.2) showed most websites (56%) were below the recommended 6th-grade level.

Conclusions

The EQIP score suggests that information quality should be improved to provide patients and parents with clear information to help identify high-risk foreign bodies such as disc batteries and magnets, while providing guidance for removal of low-risk foreign bodies.
188 Assessing the Quality and Readability of Online Patient Information: ENT UK Patient E-Leaflets Versus ChatGPT Responses
Authors: Ko T K , Shamil E , Fan K S , Schuster-Bruce J , Jaafar N , Khwaja S , Eynon-Lewis N , D’Souza A , Andrews P
Published: August 2024

Introduction

The evolution of artificial intelligence has introduced new ways to disseminate health information, including natural language processing models like ChatGPT. However, the quality and readability of such digitally generated information remains understudied. This study is the first to compare the quality and readability of digitally generated health information against leaflets produced by professionals.

Method

Patient information leaflets for five ENT UK leaflets, and their corresponding ChatGPT responses, were evaluated using the Ensuring Quality Information for Patients (EQIP) tool and readability tools including the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL). Statistical analysis was performed to identify differences between leaflets, assessors, and sources of information.

Results

ENT UK leaflets were of moderate quality, scoring a median EQIP of 23. Statistically significant differences in overall EQIP score were identified between ENT UK leaflets but ChatGPT responses were of uniform quality. Non-specialist doctors rated the highest EQIP scores while medical students scored the lowest. The mean readability of ENT UK leaflets was higher than ChatGPT responses. The overall EQIP scores negatively correlated with readability metrics of ChatGPT responses. In short, the information quality of ENT UK leaflets was moderate and varied between topics. Equivalent ChatGPT information provided comparable content quality but with reduced readability.

Conclusions

ChatGPT patient information leaflets had comparable content, but were less readable, and required a higher reading age than ENT UK leaflets. With the increasing use of online health resources, this study underscores the need for a balanced approach that optimises both the quality and readability of patient education material.
331 Regional Anaesthesia Does Not Reduce Length of Stay, or Mortality Outcomes in Traumatic Rib Fractures
Authors: Bradley R , Manoharan G , Hodson A , Marsden M
Published: August 2024

Aim

Length of stay (LOS) and mortality for patients with traumatic rib fractures is influenced by multiple factors. We aimed to identify 1) factors correlated with LOS and 2) assess the impact of regional analgesia on outcomes.

Method

Consecutive adult patients admitted to two TUs with traumatic rib fractures were included. Data were collected on patients’ demographics, mechanism of injury, Battle score, in-hospital complications, regional anaesthesia (“nerve block”), LOS and mortality. Multivariable regression analysis (MVR) was performed to identify factors associated with LOS and mortality.

Results

We included 228 patients. Most were male (62%), median age 75 years (IQR 59-86). Most sustained a fall <2m (67%). Median LOS was 6 days (IQR 3-11), mortality was 7%. On univariate analysis only Battle Score was associated with increased LOS (p =<0.01). On MVR, with Battle score and nerve block in the model, nerve blocks did not affect either LOS (p=0.21, CI -4.5-1.0) or mortality (p=0.45, CI 1.1-1.3).

Conclusions

After traumatic rib fracture, once accounting for the Battle Score, nerve block did not reduce LOS or mortality. Further work is required to assess the impact of confounders in this observational study.
424 Damage Control Laparotomy – a Single Centre Experience
Authors: Terry C , Hawezi J , Phelan L , Bowley D , Dilworth M , Bedford M
Published: August 2024

Background

Damage control laparotomy (DCL) delivers life-saving primary surgery, and optimisation of physiology status with deferral of definitive anatomical reconstruction. Developed for major trauma, DCL may be used for non-traumatic abdominal emergencies. We aimed to assess our unit’s utilisation and outcomes of patients undergoing non-traumatic DCL.

Method

Observational study of consecutive adult patients (2014-2022) undergoing DCL within our National Emergency Laparotomy Audit (NELA) database.

Results

109 patients, median age: 61 years (range 21-92); 52% (57/109) were male. Of 109 patients, indications for DCL were post-procedural complications in 29%, bowel obstruction 22%, mesenteric ischaemia 23%, perforation 21%, and other 5%. Median number of relook laparotomies: 1 (range 0-5), median time to closure: two days (range 1-15). 30-day mortality: 27/109 (25%). 23/109 (21%) died before definitive surgery could be completed. 74/86 survivors (86%) had primary fascial repair at final relook surgery, the remainder undergoing laparostomy therapy. 1-year mortality was 38/109 (37%). 94/109 (86%) primary temporary closures used negative pressure therapy; the remainder used passive dressings (e.g., Bogotá bag, skin-only closure). Median ICU stay was 7 days (range 0-130). 42/86 (49%) had stoma formation at final surgery, enterocutaneous fistula occurred in 10/86 (12%) survivors. Incisional hernia was detected in 7/71 (10%) at follow-up.

Conclusions

Outcomes after DCL for non-traumatic abdominal emergencies demonstrate acceptable outcomes for this most critically ill cohort. Selection for DCL is currently individualised by surgeon and no national guidelines exist to support decision making. A national comparative trial would help define the place of DCL in non-traumatic abdominal emergencies.
762 Post-Operative Outcomes After Emergency Stoma Surgery in Frail Older Adults
Authors: Kulasekaran A , Yadala Venkata S , Bayne F , Macdonald S
Published: August 2024

Aim

To describe the post-operative outcomes of frail older adults who undergo emergency stoma surgery in the West of Scotland.

Method

A retrospective review of a prospectively maintained emergency laparotomy database (ELLSA) from 3 hospitals across 3 years (Dec ’19-’22) was performed in Dec ’23. Older adults (>65years old) who were frail (i.e., Rockwood frailty score >4) under-going emergency stoma formation per NELA criteria were included and clinical notes were reviewed, including prospectively maintained follow-up from stoma practitioners. Factors such as pre-morbid independence level, mortality within a year/as in patient, frailty score 1-year post-operation/at death, ability to manage stoma independently, and long term care were investigated. All patients had minimum 1 year follow-up.

Results

A total of 234 older adults underwent emergency stoma surgery and 23% were frail. Median age of frail patients was 77(IQR - 13.5) and 48% were male. 70.4% of patients were frailer by discharge or death and 2/3 were unable to manage their stoma independently. The 30-day mortality rate was 29.6%, and half of patients had died by 1 year follow-up.

Conclusions

Outcomes are poor for frail older adults undergoing emergency stoma surgery. A majority of patients get significantly frailer post-operatively. Mortality rates are high and very few independently manage their stoma. Therefore, patients within this cohort may benefit from an anastomosis rather than a stoma, in carefully selected cases. This data may help to further research to identify these patients and guide peri-operative shared decision making.
122 Monkeypox Correlations: Genital Symptoms, Immunocompromised Status and MSM
Authors: El Boghdady M , Youssef M , Marianne Ewalds-Kvist B , Nada H
Published: August 2024

Aim

The outbreak of the virus infection Monkeypox (Mpox) in England was on transmission level 2. Mpox and HIV infections may occur simultaneously among the MSM population, exacerbating the symptoms along with treating problems. We aimed to study if Mpox painful genital symptoms correlated with immunocompromised status, sexuality and length of hospital stay.

Method

A retrospective data analysis was conducted. The admissions were divided into four groups named: perianal, penile, rectal, and other symptoms. Correlations between patients’ pain groups, sexuality, or immunocompromised status as well as length of hospital stay were studied. Significances were computed by Spearman’s rho correlation and Kruskal-Wallis H analyses of variance.

Results

Sixty-nine patients were included, 65 males (mean age=38,5, SD 8.29; Md=39) and females mean age=35.5 (SD 9.04; Md= 39.5) years (n.s). The two gender’s Mpox pain areas differed from each other (p=0.014). A total of 38% of the men presented painful perianal or rectal lesions and 22 men displayed general symptoms and 17 acknowledged MSM. A total of 40% of the men were sexually active with multiple partners; an inverse correlation between men with MSM and men with HIV (rho [25]= -.385*, p= .029, 1-tailed) was revealed. Altogether 23% of men presented HIV and 8% suffered from additional STI. Those with rectal pain had the longest hospital stay with a mean of 6.0 (SD 7.63) days (p=0.017) compared to other groups.

Conclusions

Correlations between patients diagnosed with Mpox and genital symptoms were revealed as opposed to inverse correlations between immunocompromised status/HIV and MSM.
461 The Reality of Virtual Reality for Rural Surgeon Augmented Reality Training
Authors: Khera G , Gnanaraj J , Mishra A , Vohra R , Dhanda J
Published: August 2024

Aim

Virtual-reality (VR) and augmented-reality (AR) training workshops were undertaken in New Delhi and new surgical training content generated. This study aimed to gauge the perspective of medical students and rural Indian surgeons regarding VR and AR training.

Method

An online survey was administered to both workshop participants and rural surgeons not attending the workshop. We created surgical training 360-degree AR videos enriched with close-up and monitor views as well as conventional YouTube videos. Respondents were asked to compare their experiences whilst viewing videos on VR headsets or standard screen view.

Results

186 responses received and 41 were from workshop attendees. An overwhelming 82% of all respondents believed that 360-degree AR videos offered superior learning opportunities, with 83% reporting an improved learning curve. However, only 49% respondents had access to VR headsets and 84% respondents found it unnecessary to use them to watch videos. Non-availability of VR headsets (53%) and cost of VR headsets (19%) were limiting factors for not using VR headsets. Self-reported side effects with VR headsets were minimal, affecting less than 9% of respondents.

Conclusions

The consensus among respondents was that 360-degree AR videos were highly effective for learning. The flexibility to choose between VR headsets or standard viewing was crucial, underscoring the adaptability of the medium. However, the availability of VR headsets emerged as a challenge, particularly in rural areas. A small percentage encountered issues with VR headsets.

The results strongly suggest that virtual training, has the potential to transform the rural surgical education learning landscape.
847 Conflict Resolution in Surgery
Authors: Castelhano R , Riding D
Published: August 2024

Aim

Evidence from academic and public inquiries suggest that patient safety is threatened when interpersonal communication and professional behaviour breaks down within surgical multidisciplinary teams. Despite this available evidence, undergraduate and postgraduate curricula place a strong emphasis on the development of surgical knowledge and skill, with limited focus on optimal team working and the management of interpersonal conflict. The increasingly diverse surgical workforce will induce a commensurate diversity of personality types, and so an assessment of the evidence base defining the effects of interpersonal conflict and evaluating mitigating interventions, may inform future curricula.

Method

A systematic interrogation of relevant databases was undertaken. Keywords included “conflict resolution”, “surgery”, “healthcare professionals” and further related terms. The authors analysed the identified studies in line with PRISMA guidelines to assess relevance. Inconsistencies were resolved through discussion between the reviewers.

Results

Sixty-three studies emerged from the analysis. Interpersonal conflict negatively impacted healthcare professionals (HCPs), inducing stress, burnout, and job dissatisfaction, and threatened team effectiveness and patient safety. Common causes of conflict were categorised into systemic and interpersonal factors. Conflict resolution interventions focussed on communication skills training, team-building workshops, and debriefing sessions. Although studies recognised the value of conflict resolution, strategies varied across surgical specialties.

Conclusions

This systematic review defines conflict within surgical teams as a threat to patient safety and HCP wellbeing. There is strategic heterogeneity within the educational interventions reported in the literature. We argue that formalised teamworking and conflict resolution training is a neglected component of surgical curricula.
79 Neurovascular Status Documentation in Complex Limb Fractures: First Cycle Audit
Authors: Eisner A , Bradshaw F , Wakefield E , Zhang J , MacGregor M , Capburn E , Krkovic M
Published: August 2024

Aim

Assessing neurovascular status post-fracture is vital to detect complications and guide medical actions. Fractures can cause neurovascular problems and timely recognition prevents long-term damage. Neurovascular status should be recorded on admission to establish a baseline and identify those that need urgent surgery, and the findings should be well documented.

Method

Neurovascular documentation for patients with fractures of the tibia or femur was audited over the period of one year at a major trauma centre according to NICE guidelines. 885 patients met the inclusion criteria, giving a total of 959 fractures.

Results

Poor compliance was defined as <75% of guidelines followed. 911/959 (95%) of all fractures had a basic mention of neurovascular status in patient notes. 492/959 (51%) had gross sensation documented, 143/959 (15%) had a named nerve assessment, 71/959 (7%) had motility assessed using the MRC scale and 367/959 (38%) had a pulse assessment, with the pulses assessed documented. We recommend a pre-written template for clinicians detailing the different aspects of the neurovascular examination and documentation. This template will remind clinicians of examination and documentation, enabling ongoing monitoring, facilitating prompt detection of issues, thus improving outcomes, and reducing long-term complications.

Conclusions

Inadequate documentation of neurovascular status in patient records poses a risk to those requiring urgent surgery or experiencing neurovascular compromise, potentially leading to long-term complications. Ensuring an error-free documentation process is crucial and a primary goal for the trauma and orthopaedic department.
89 Can Poller Screws Decrease Pain Relief in Tibial Fractures?
Authors: Bradshaw F , Wakefield E , Tandon A , Zhang J , Krkovic M
Published: August 2024

Aim

Poller screws optimise fracture alignment in those fractures managed with intramedullary (IM) nails. They enhance stability, control nail insertion, and prevent translation. Indications encompass acute fractures, delayed unions/non-unions, and deformity. Classified into four generations, they've shown positive outcomes: improved alignment, reduced complications, and shorter healing. However, their pain management impact is understudied. This retrospective cohort study aimed to compare opioid medication needs in tibial fractures managed with IM nails with and without poller screws.

Method

Between January 2015 and December 2022, a retrospective analysis was conducted on tibial fractures treated at a major trauma centre. Patients primarily treated with IM nails were included. Patient and operation notes as well as radiographs, were reviewed to identify poller screw utilisation. Opioid medication data was collected and converted to “coverage” (days) and “strength” (morphine milligrams equivalent or MME). Two-tailed independent samples T-tests were performed to determine differences between patients treated with (n =205) and without poller screws (n=745).

Results

Patients with poller screws had fewer days with opioid prescriptions in the second post-operative month (6.8 vs.8.9 days, p=0.038) and significantly lower opioid strength requirements across the first post-operative year (688.4 vs.1295.4 MME, p=0.001), except the first month.

Conclusions

There is limited research on the connection between poller screws and pain. This study discusses their potential to reduce post-operative pain in tibial fractures. The results highlight the importance of using poller screws alongside IM. This combination appears to be effective in improving post-operative pain management and enhancing overall patient outcomes.