bluuebunny/crossref_metadata_2025 huggingface dataset:
871 The Efficacy and Safety of Bariatric Surgery in Patients with End-Stage Renal Disease Awaiting Listing for Kidney Transplantation: A Systematic Review and Meta-Analysis
Authors: Varma J , Fernando S , Dengu F , Menon V , O'Callaghan J
Published: November 2022

Aim

Obesity is associated with adverse outcomes in end-stage renal disease (ESRD) and hinders changes for waiting list allocation of kidney transplantation (KT). Bariatric surgery (BS) is an effective solution to obesity. The authors aim to summarise the evidence for the efficacy and safety of BS in ESRD awaiting KT.

Method

We performed a systematic review and meta-analysis to determine the efficacy and safety of BS in patients with ESRD awaiting KT. A literature search of MEDLINE, EMBASE and Web of Science was conducted from inception to April 2021. The methodological quality of selected studies was assessed using the Newcastle-Ottowa tool. Our primary outcome was change in BMI, with secondary outcomes including adverse events, graft outcomes and KT listing rate.

Results

Nine observational studies met the inclusion criteria with a total of 1903 patients (43.9% male). Mean change in BMI following BS was -11.3 (-15.3 to -7.3, p <0.001) within a median follow up time of 27.6 months (IQR 12 to 36.6 months). Sleeve gastrectomy (44.6%, n=849) and gastric bypass (43.6%, n=829) were the most common procedures. Mean age at BS was 47.3 years with a mean rate to KT listing of 59.9% (SD = 1.13).

Conclusion

This review highlights that BS is both safe and efficacious on patients with ESRD and can aid with optimisation for waiting list allocation.
179 A Retrospective Analysis of a Single-Centre Experience with Administration of Neoadjuvant Chemotherapy Prior to Surgical Removal of Breast Tumour
Authors: Reveendran D , Tait C , Hogan B
Published: November 2022

Introduction

Neoadjuvant chemotherapy (NACT) is increasingly used to aid breast preservation surgery for patients with non-conservable disease at presentation. NICE guidelines recommend offering primary systemic therapy to patients with ER- disease and/or HER2+ disease and for those with ER+ disease to reduce tumour size. This retrospective study aimed to analyse the incidence of local and systemic recurrence post NACT.

Method

A retrospective analysis of NACT usage was conducted from January 2011 to December 2020 at the Bradford Royal Infirmary. Clinical data of patients who received NACT were collected using the local Breast Unit database, Electronic Patient Record (EPR) and Systm1. Data included patient demographics, type of breast and axillary surgical procedure, histopathology of breast tumour, pathological response to NACT and time to local and/or systemic recurrence.

Results

202 patients received NACT for breast cancer between January 2011 to December 2020. Analysis showed an increasing use of NACT ranging from 2.19% of all cancers in 2013 to 14.5% in 2020. 89/202 patients underwent breast preservation surgery. 1 patient developed local recurrence at median follow up of 26 months. 42 patients developed systemic recurrence, and 40 of them had residual disease found at surgery post NACT at median follow up of 24 months.

Conclusion

Our unit has been increasingly using NACT over the last 8 years in line with guidance. Breast conserving surgery post NACT is associated with a low risk of local recurrence. The risk of systemic disease progression post NACT is very low for patients who have complete pathological response
285 Utility of Virtual New-Patient Clinics in Women Under 30
Authors: Morton J , Shaker H , Wilson R , Abbas A , Absar MS , Ntanos I , Williams K , Wright C , Nasir N
Published: November 2022

Aim

Virtual consultations (VC) in breast surgery have been successfully utilised during the COVID pandemic and have potential to reduce the costs of outpatient clinics as well as increase patient satisfaction. We aimed to assess the utility and safety of VC in new patient clinics in women under 30, which are considered a low-risk subgroup.

Method

Data was prospectively collected on 118 women aged under 30 who were referred from primary care to the breast clinic between December 2020 and April 2021. Clinicopathological data was collected on referrals, imaging and follow up.

Results

Median age was 24 years (range 17–30). The commonest presenting symptoms were a lump (69%), breast pain (16%) and nipple symptoms (14%). The VC was performed via video in 63 (53%) patients and via telephone alone in 55 (47%).

Nineteen patients (16%) were reassured and discharged directly from VC. Ninety-four patients (80%) underwent an outpatient ultrasound with a sonographer trained in clinical palpation. Twenty-six (27%) ultrasounds showed benign pathology with the remainder being normal. Six biopsies were performed, all of which were benign.

Seventeen (14%) patients required a face-to-face appointment with a breast surgeon after ultrasound or biopsy. Ninety-four (79%) patients were discharged after VC + ultrasound alone. No patients required surgery.

Conclusions

Utilising VC, the majority of new referrals in women under 30 did not require face-to-face appointments. VC have potential to reduce burden on new patient clinics whilst improving patient convenience. Early data suggest a low risk of compromising safety in this subgroup.
287 Retrospective Review of a Single Surgeon 5-Year Experience of Paediatric Breast Reconstruction - Challenges, Experience, and the Increasing Role of Lipofilling
Authors: Nelson A , Taghizadeh R , Hassan D
Published: November 2022

Aim

This case series reviews the presentation, clinical and surgical management of paediatric breast cases undertaken by a single surgeon. The series demonstrates the powerful role of lipomodelling when used with breast reshaping techniques to achieve good outcomes and avoid the need to commit young patients to breast implants.

Method

Retrospective analysis of paediatric breast referrals to a single surgeon at a regional plastic surgery breast reconstruction unit over a 5-year period.

Results

In a 5-year period, 15 cases which presented in childhood to a tertiary paediatric centre were referred on to our regional plastic surgery breast reconstruction unit. Two patients underwent correction of breast hypoplasia secondary to Poland's syndrome. Nine patients presented for breast asymmetry with associated tuberous deformity. One patient had maldevelopment of a breast secondary to a burn's contracture. Two patients presented with gigantomastia and one patient with juvenile fibroadenomas.

Conclusions

Paediatric breast abnormalities represent a small but important caseload for a breast reconstructive surgeon. This case series demonstrates the need for careful assessment and an individualised surgical plan for each patient. The surgical plan must achieve a satisfactory outcome whilst minimising the need for further procedures as the patient grows. It is the senior surgeon's preference to avoid breast implant-based reconstruction where possible. In all but one case lipomodelling combined with reshaping of the native tissue was used to good effect.
336 Reasons for Choosing Delayed Rather Than Immediate Contralateral Prophylactic Mastectomy (CPM) in Patients with Unilateral Breast Cancer
Authors: Soh CL , Muktar S , Malata C , Benson J
Published: November 2022

Introduction

Reasons for requesting CPM include prevention of recurrence, peace of mind and moving on after breast cancer. Some women seek CPM as a delayed procedure but factors influencing this are poorly understood.

Method

A retrospective analysis examined patients undergoing CPM as either an immediate or delayed procedure with or without breast reconstruction (BR) between January 2009 and December 2019. A cross-sectional survey based on validated questionnaires (5-point Likert scale) explored patients’ decision-making process in terms of timing of CPM and any BR.

Results

A total of 123 patients with unilateral breast cancer underwent CPM with 39 (32.5%) delayed procedures with or without BR. The response rate amongst patients receiving questionnaires (n=33) was 22/33 (66%). Within this delayed CPM cohort were three reconstructive scenarios 1) unilateral immediate BR with CPM (n=12); 2) delayed CPM with concomitant bilateral BR (n=22); 3) delayed bilateral BR after delayed CPM (n=3). Two patients had delayed CPM without BR. The most common reason for delayed CPM was to complete all cancer treatments (including radiotherapy) before surgery on the unaffected breast (score 2.91). The second reason was unavailability of genetic test results at the time of therapeutic mastectomy (score 2.64) whilst the third most cited reason was a subsequent change in family cancer history.

Conclusions

Factors for delayed CPM are patient-driven with few women spontaneously changing their mind having initially decided against immediate CPM for reasons also including surgical duration. CPM should be offered as a potentially delayed option with informed discussion of risks and benefits.
556 Case Report: Diagnosis of Bilateral PASH (Pseudoangiomatous Stromal Hyperplasia) in an 11-Year-Old Female
Authors: El Zayat I , Elzayat A , Farrow H
Published: November 2022

PASH (Pseudoangiomatous stromal hyperplasia) is a rare pathological finding, defined as a benign mesenchymal proliferative lesion of the breast, presenting more frequently in premenopausal women. Although benign, differentiation from low grade Angiosarcoma due to their histological similarities. Management guidelines for PASH remain primitive due to the rarity in diagnosis and reporting of such cases.

We present a very interesting case of an 11-year-old female assessed for her rapidly enlarging breasts. Initial management entailed right breast reduction Mammoplasty due to the presumed diagnosis of Macromastia. Histopathological assessment of the specimen initially reported the presence of Fibroadenoma. However, re-assessment by a senior Pathologist subsequently diagnosed the lesion as Pseudoangiomatous Stromal Hyperplasia (PASH).

Further MRI imaging of both breasts revealed multiple, large, bilateral lesions.

All identified bilateral breast lesions were excised, with a cumulative weight of 1.6 Kg, combined with WISE pattern reduction of the right breast overlying skin was carried out in due course.

There has been no previous reporting of PASH in an 11-year-old female, which itself is a rare condition. Further studies on PASH are recommended to reduce the risk unnecessary surgical management of such cases due to misdiagnosis.
572 Staging Breast Cancer Patients at a District General Hospital: The Colchester Experience
Authors: Kankam H , Akotat O , Gurung A , Saha S
Published: November 2022

Aim

Metastatic disease is detectable in 4% of breast cancer patients at the time of initial diagnosis. However, there are regional and national variations in staging criteria. We evaluated the outcomes of staging breast cancer patients at our unit before and after the introduction of the new trust guidelines.

Old Staging Criteria

Indications:

Staging investigations:

New Staging Criteria

Indications:

Staging investigations:

Method

A retrospective chart review of patients undergoing staging investigations for breast cancer was performed. The cohort was divided into group A (old staging criteria) and group B (new staging criteria). Each group spanned a period of sixteen weeks. Demographic, tumour, and radiological data were collected.

Results

Group A (30 patients staged): 22 CT abnormal findings (73.3%), 3 distant metastasis (10%), 1 new primary tumour (3.3%).

Group B (18 patients staged): 13 CT abnormal findings (72.2%), 2 distant metastasis (11.1%), 1 new primary tumour (5.6%).

Conclusions

A change in the staging criteria for breast cancer patients at Colchester Hospital has led to a 40% reduction in the number of patients staged, without compromising the rate of detection of malignant disease. This has obvious physical and psychological benefits for patients.
913 Patient Satisfaction with Personalised Stratified Follow-Up After Treatment for Breast Cancer at West Middlesex University Hospital
Authors: Arooj S , Elhadi L , Rawcliffe S , Rickute D , Phyu S , Khan A , Barkeji M , Riddle P , Elfadl D
Published: November 2022

Aim

Personalised stratified follow up (PSFU) is a programme that ensures safe follow-up of breast cancer patients following treatment completion, avoids un-necessary appointments, whilst offering rapid access to clinicians when required. A protocol for PSFU was designed and the programme introduced to West Middlesex University Hospital in 2019. We aim to assess patient satisfaction with nurse-led end of treatment consultations.

Method

200 Patients were enrolled from January 2019 to September 2021.The study was registered with the Clinical Governance department. All patients were initially contacted by telephone and later questionnaires were sent out either by post or using Google Docs via text messaging. Data was collected both from questionnaires and Somerset cancer registry platform and analysed using Microsoft Excel.

Results

Out of 200 patients, 150 were successfully contacted by telephone and sent questionnaires, with 68% response rate. This was largely electronic.

48% had video or phone consultations, with the rest attending in person. 90% thought they had sufficient time for discussion, with 82% feeling well informed regarding their management at the end of the consultation. 86% were satisfied or very satisfied with the consultation. 35% had their consultation within 3 months of completing treatment and 29% within 6 months.

Conclusion

Patients were largely satisfied with their end of treatment consultations. This was in spite of delays caused by the COVID-19 pandemic. Longer term follow up is required to determine satisfaction with the PSFU programme as a whole, and its efficiency.
1004 A Review of Over 300 Sentinel Lymph Node Biopsies, Is Magtrace Reliable?
Authors: Khan S , Wilson RL , Shaker H , Hobbs N , Abbas A , Absar SM , Nasir N , Wright C , Williams KE
Published: November 2022

Introduction

With the ever-growing evolution of sentinal lymph node biopsy techniques, Magtrace was introduced to our department as a radiation free technique. This study aims to review the outcomes of Magtrace for SLNB.

Method

Consecutive procedures invoking SLNB were conducted from 1st April 2020 to 29th July 2021. Retrospective data collection via theatre logs and patient notes was also performed.

Results

316 SLNB procedures were conducted during the above time period. In 197 (62.5%) procedures, Magtrace alone was used. Magtrace and blue dye was used in 104 (33%) procedures, radioisotope, and blue dye in 10 (3%) procedures, whilst radioisotope was used in 5 (1.5%).

Overall, there were five (1.5%) failures of SLNB (i.e., axillary node sample was required), three with Magtrace and blue dye, two with Magtrace alone. Radioisotope was used as a precautionary measure when there was either a retroareolar magseed or multiple magseeds to guide the wide local excision. There were no reported adverse events following the injection of Magtrace. There was one anaphylaxis following injection of blue dye. One patient required postoperative MRI after Magtrace was used making interpretation more difficult.

Conclusion

Magtrace outcomes are comparable to those reported for the traditional dual technique with blue dye and radioisotope and can be safely used as a single agent.
4 The Rise in Trauma & Orthopaedic Trainee-Led Research and Audit Collaborative Projects in the United Kingdom Since the Start of the COVID-19 Pandemic
Authors: Khaleeq T , Kabariti R , Ahmed U
Published: November 2022

Introduction

There has been a rise in trainee-led trauma & orthopaedic multi-centre research collaborative projects globally. These increase trainee involvement in research with an opportunity to deliver highly generalisable results on a particular topic.

Objective: To evaluate the number of trauma & orthopaedic trainee-led research collaborative projects that took part since the start of the COVID-19 pandemic in the UK and compare them to projects from 2019.

Methods

This was a retrospective study that evaluated trauma & orthopaedic trainee-led national collaborative projects within the UK since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021). Our exclusion criteria included any regional collaborative projects, pre Covid- 19 projects and projects of other surgical specialities.

Results

In 2019, 0 trainee-led collaborative projects were commenced nationally in the UK. Since the COVID-19 pandemic, we identified 10 trainee-led collaborative trauma & orthopaedic projects with 6 being published so far. The level of evidence ranged between 3 and 4 and included 5 Audits and 5 cohort studies. The patients that were included in the studies ranged from 927 to 140,231 from a total of 2249 centres.

Conclusion

Covid-19 has placed significant challenges across healthcare. However, one positive aspect is the increase in multi-centre trainee-led collaborative projects within the UK. Our study highlights the feasibility of a trainee-led high quality collaborative research projects in the UK and the availability of new tools such as social media and centralised confidential online databases such as Redcap® facilitates such projects. Therefore, we recommend expanding this trainee-led collaborative platform in the field of trauma & orthopaedics worldwide.
144 Head and Neck Cancer and the COVID-19 Pandemic: Impact on Presentation and Management
Authors: Maqsood R , Flynn W , Douglas C
Published: November 2022

Introduction

We aim to establish if the first wave of COVID-19 has caused HNC patients to present later or with more advanced disease and if there have been delays in time to imaging, treatment or MDT discussion.

Method

Patients were identified retrospectively from a database of cases discussed at head and neck MDT between June and October of 2019 and 2020. New HNC cases were included, and benign or recurrent disease excluded. Data was extracted from electronic patient records and statistical comparisons were performed using JASP.

Results

Data was analysed from 216 patients (2019 n=98, 2020 n=118). No statistically significant differences were observed in age, ECOG, smoking and alcohol use. Significantly more patients presented with >6 weeks history of red flag symptoms in 2020 than 2019 with an odds ratio (OR) of 2.44 (95% CI, 1.38 to 4.23), (p=0.002). Patients in 2020 were also significantly more likely to present as an emergency, OR 5.94 (95% CI 1.31 to 27.02), (p=0.013). The OR of being in a higher AJCC stage in 2020 versus 2019 was 1.69 (95% CI, 1.00 to 2.84), (p=0.05). There were no significant differences in time to MDT discussion, first dedicated imaging, or time to initiation of treatment.

Conclusion

This data supports concerns that COVID-19 has caused delays in patient presentation, evidenced by longer symptom duration, higher AJCC stage and more emergency presentations. The management was not impacted. HNC services are functioning well despite the pandemic and patients should be encouraged to present to facilitate earlier intervention.
253 Hospital Consultant Remote Consultations During COVID 19 - Experiences at a Large NHS Trust
Authors: Ahmed H , Oni G
Published: November 2022

Aim

COVID-19 has intensified the need for the NHS to almost utilise remote consulting technology overnight, with clinicians under increasing pressure to provide virtual services preferentially, in line with the NHS digital ideals. This study explores the clinician experience of virtual working during the pandemic in a large acute NHS Teaching Trust, and to identify the facilitators and barriers to remote consultations (RC).

Method

A multi-format online questionnaire was constructed and emailed to all 816 consultants across the trust. The survey was open for one month and during that time two reminders were sent. The data was tabulated and analysed using Microsoft excel.

Results

270 consultants responded to the questionnaire, giving a response rate of 33%, with 208 (77%) performing RCs. 92.8% of these (N=193) have increased the number of RC during the pandemic. 45.9% did not have their own office (N=124), with over half of those (N=63) sharing an office with 3 or more people. The majority of remote consultations were over telephone (82%) with only 54.4% feeling they had the right equipment for video consultations. The biggest barriers were patient related issues (technical, poor environment or not available at scheduled time).

Conclusion

The main challenges facing consultants, in the provision of virtual services were lack of appropriate hardware, an absence of a suitable environment, the prevalence of technical complications, and difficulties experienced by their patients. It is, therefore, important to recognise, both at an organisational level, and nationally, that virtual consultations may play a role in the worsening of health inequalities.
315 The Impact of COVID-19 on Training Opportunities and Long-Term Career Aspirations of UK Based Doctors
Authors: Khan A , Omakobia E , Rehman A , Khan S
Published: November 2022

Background

The onset of the COVID-19 pandemic in November 2019 has witnessed a reactive ‘covidisation’ of NHS care services. Training opportunities for junior doctors have suffered and psycho-social impacts are anticipated. This study will seek to assess these factors and their impact on doctors’ career aspirations.

Method

A five question survey was disseminated to 350 junior doctors in the Yorkshire and Humber deanery. 115 responses were gained; 78 Foundation doctors (FY1–2), 24 Core/Early specialist trainees (CT 1–2/ST1–2) and 13 Specialist Registrars.

Results

Negative impacts on training include teaching commitments (61.7%) and work-based assessments (48%). A change in treatment protocols (67%) and acute referrals (58%) were also identified. Concerns regarding personal wellbeing were highlighted by 65%, with a greater willingness to consider taking time out of training (32%) or leave UK medical practice altogether (22%).

Discussion

The number of doctors immediately progressing into specialist training has almost halved. COVID era practice has impacted on training opportunities, clinical experience, and the ability to meet ARCP requirements. It has also led to high levels of personal concern amongst junior doctors surveyed. These factors may stimulate a greater willingness to take time out of training (1/3) or leave UK based medical practice (1/4).

Conclusions

It is evident that new and existing concerns amongst junior doctors have been heightened by COVID-19. This data provides a useful snapshot and may be utilised in ensuring the continued health and robustness of the UK's junior doctor workforce and its ability to meet the evolving challenges of global healthcare.
394 The COVID-19 Pandemic's Impact on Deep Neck Space Infections: A Retrospective Cohort Study
Authors: Charlton A , Simon R , Simons A
Published: November 2022

Aim

This study aimed to evaluate whether changes in practice and patient behaviour due to the covid-19 pandemic impacted the presentation, management, and outcomes of patients with deep neck space infections (DNSI).

Method

Retrospective cohort study including all adults presenting to the otolaryngology department at a tertiary UK centre with a DNSI during the first 12 months of the covid-19 pandemic (n = 27), and those from the previous 12-month period (n = 26). Patients with peritonsillar abscess which did not involve deep neck spaces radiologically were excluded.

Results

The covid-19 pandemic cohort tended to present later after onset of symptoms (5.96 days vs 3.25 days, p = 0.0277), have abscess formation rather than inflammation only (77.8% vs 34.6%, p < 0.01), and develop complications (33.3% vs 7.7%, p = 0.0394). Not reaching statistical significance, the covid-19 pandemic cohort also had larger volume abscess (25.18cm3 vs 14.5cm3, p = 0.291), longer hospital stays (14.48 days vs 6.35 days, p = 0.114), and longer intensive care stay (7.88 days vs 1.78 days, p = 0.0992). Non-significant changes were noted in management, with the covid-19 pandemic cohort being seven times more likely to undergo tracheostomy (25.9% vs 3.8%, p = 0.0504), and more likely to undergo trans-cervical drainage (37% vs 19.2%, p = 0.224) and hot tonsillectomy (11.1% vs 0%, p = 0.236).

Conclusion

This study demonstrates the covid-19 pandemic led to delayed presentation and more severe infection, requiring more radical management in patients with DNSI.
401 Squamous Cell Carcinoma Surgery During a Global Pandemic – a Single UK Tertiary Centre Experience
Authors: Pasha T , Okorocha C , Okafor C , Manoharan S , Roszpopa J , Shahid S
Published: November 2022

Aim

To determine excision rates for squamous cell carcinoma (SCC) both before and during the COVID 19 pandemic.

Method

Between April 2020 to March 2021, a retrospective cohort study of patients undergoing SCC surgery in Cambridge University Hospitals (CUH) was undertaken. Data was collected from the hospital patient record system (EPIC) and included preoperative diagnosis, excision margins, histological subtype, and operative technique.

Results

287 primary SCCs were excised during this period. 70% of SCC patients were male, with the commonest site being the head and neck (72%). The rate of incompletely excised SSCs doubled from 5.5% in 2018–19 to 11.3% in 2020–21. Of these, most incomplete excisions were due to inadequate deep margins (9.8%). The majority of incomplete excisions were performed by registrars (14.8%) followed by consultants (9.1%).

Conclusions

Whilst diagnostic accuracy remains high, we report a decline in complete excision rates. Deferral of non-urgent visits due to the COVID-19 pandemic may have resulted in delayed diagnosis of SCCs, resulting in larger and deeper cancers. The more invasive SCCs may have then resulted in a higher rate of inadequate excision. A potential solution is the use of templates in operative notes, in order to ensure an accurate record of deep and peripheral margins is made.
571 Evaluating the Effectiveness of Extracorporeal Shockwave Lithotripsy (ESWL) for Ureteric Stones During COVID-19 Pandemic - A Single Centre Experience
Authors: Farah M , Rizvi I , Fernandes R , Patel A
Published: November 2022

Aim

Reliance on ESWL for treating ureteric stone has increased during the COVID-19 pandemic. We examined the outcomes for ureteric stones treated with our on-site lithotripter to assess the success rate and determine the variables that could affect the outcome results.

Method

A retrospective review using electronic records and images of patients who underwent ESWL for ureteric stones (January to December 2020). Univariate and multivariate analysis used to determine stone-free rate predictors (Stone Free rate/SFR: No residual stones on post-ESWL imagining).

Results

A total of 36 patients underwent ESWL for ureteric stones. Mean age was 58 years (21–90), and mean stone size was 8 mm (5–20). Stones were located in the proximal (67%) or lower ureter (33%). Overall SFR was 64% (67% proximal, 33% distal). 64% of patients required only one session to be stone free, with 60% stone free after two sessions. Stones <10mm had a SFR of 67%, compared to 58% for stone >10 mm. The only statistically significant predictor was stone size (longest dimension, p=0.04). No statistical significance with stone location (P=0.09), skin-to-stone distance (SSD) (P=0.7), stone density (P=0.3) or stone volume (P=0.3). In treatment failure, time to definitive ureteroscopy was 4 weeks.

Conclusion

Our overall SFR was slightly lower than expected but comparable to available literature. This data highlights the importance of patient selection for ESWL and would be useful in counselling about local success rate. More than half of the patients required only one session for stone clearance and stone size was the only significant predictor for successful ESWL.
608 Optimising Return to Elective Total Hip Arthroplasty (THA) Following the COVID-19 Pandemic: Lessons Learned and Future Directions
Authors: Paluch A , Tariq H , Small O , Ratford E , Sokolowski S , Kassam AA , Hubble M , Howell J , Charity J , Gowda S , Panteli M , Wilson M
Published: November 2022

Aim

COVID-19 has led to unprecedented waiting times for elective surgery. Optimising patient pathways is paramount in tackling the backlog. Length of hospital stay (LOS) is an accepted surrogate for successful elective surgery.

The aims of our study were: 1) report on changes in LOS after restarting our elective THA service; 2) identify barriers to early discharge, 3) investigate effectiveness of implemented changes.

Method

A retrospective review of consecutive patients undergoing elective THA, comparing three groups: 1) enhanced care pathway (n=96; 09/2019–12/2019); 2) COVID group (n=56; 03/2021–04/2021); 3) intervention group (n=96; 05/2021–08/2021).

Results

LOS in the enhanced care pathway group was 2.6 ±2.1 days. During initial resumption of elective operating (COVID group) the LOS was 4.8 ±4.5 days (statistically significant increase; p=0.011). Factors affecting LOS included reduced physiotherapy provision; lack of pre-operative occupational therapy review; loss of educational classes and worse pre-operative functional status.

To address these our department employed three new physiotherapists, introduced training for nursing staff and created a post-operative proforma. The LOS subsequently reduced to 3.7 ±4.6days (p=0.166).

Subgroup analysis of the intervention group showed age <75 (p<0.001) and ASA1–2 (p=0.036) were associated with reduced LOS (2.1±1.5 days). Other variables analysed did not significantly affect LOS.

Conclusions

COVID-19 has had a significant effect on LOS, which is still not reversed. For effective resumption of THA services, pre-pandemic enhanced care pathways should be reinstated. With current restrictions preventing face-to-face classes, online educational sessions could be offered. Those younger than 75 years and ASA1–2 are most likely to be discharged without delay.
650 “Promoting Adequate Consenting for the Risks of Peri-Operative COVID-19 Complications in Patients Undergoing Surgery During the Pandemic”
Authors: Mazumdar E , Valenzuela T
Published: November 2022

Introduction

Patients with COVID-19 infection peri-operatively can suffer with significant cardiovascular and pulmonary complications, increasing mortality. Clinicians should discuss these risks with their patients as per the Royal College of Surgeons of England guidance (2020), so that patients can make informed decisions.

Method

Our aim was to identify whether the complications associated with COVID-19 in the peri-operative period was documented on the consent forms of both emergency and elective general surgical patients. To encourage clinicians to consent their patients, we devised a colourful poster, the ‘COVID-19 Consent Poster (CCP)’ which was placed next to the consent form on wards, outpatient clinics and the emergency department.

Results

A total of 49 procedures took place in the two-week period, of which 67% (n= 34) of patients were consented for the COVID-19 risk, and 33% (n= 15) were not. Following implementation of the CCP, data was recollected to identify whether practice had changed. During this time frame, 26 procedures took place out of which 50% (n=13) were not consented for the risks of COVID-19 complications.

Conclusions

Following implementation of the CCP, we saw initial rise in the number of consents, but this soon declined. We believe, this might be due to the rates of COVID-19 decreasing in the hospital and the community during the data collection period. Despite these figures, the importance of informed consent around peri-operative complications of COVID-19 remains with more of the population still getting infected with new variants emerging each year.
664 Superior Mesenteric Vein and Portal Vein Thrombosis in a Patient With COVID-19: A Rare Case
Authors: Jeilani M , Riad M
Published: November 2022

A 68-year-old man was referred to the general surgeons on account of his abdominal pain of unknown cause. He had contracted COVID-19, 9 days prior. CT chest abdomen and pelvis revealed an extensive thrombus extending from the portal vein to the superior mesenteric vein. Further investigation ruled out haematological causes, and COVID-19 was determined to be the cause. He was treated with an extended course of therapeutic dose low molecular weight heparin under the guidance of the haematology team. He was discharged once he was clinically stable and pain-free, with a plan to be followed up by both the surgeons and haematologists. This case highlights the different ways in which COVID-19 presents, and the need for clearer guidance on the treatment and prevention of thromboembolism in COVID-19.
701 Outcomes for Paediatric Patients Awaiting Bilateral Myringotomy and Ventilation Tube Insertion for Otitis Media with Effusion Listed Prior to the COVID-19 Pandemic
Authors: Lovett A , Walters B , Kumar Bhimrao S
Published: November 2022

Aim

The decline in the incidence of otitis media with effusion (OME) during the COVID-19 pandemic has become apparent. This review investigates the outcomes for children with OME awaiting bilateral myringotomy and ventilation tube (BMT) who were referred prior to the COVID-19 pandemic.

Method

All patients were reviewed in otolaryngology clinics between 1st February and 30th April 2021. Patients included were referred due to hearing, vestibular or developmental disorders prior to the first COVID-19 lockdown on 23rd March 2020. Analysis of routine consultation and audiological assessment was completed from records.

Results

There were a total of 48 patients awaiting BMT. The average age was 6.8 years, with a male to female ratio of 1.38:1. Most initial referrals (54.2%) were due to hearing loss, followed by recurrent ear infections (33.3%). Forty-four patients were diagnosed with OME. Of those, only 9% remained awaiting BMT. All others were removed from the waiting list. One patient remained listed for an adenotonsillectomy, 30 were discharged, and nine required follow-up appointments.

Conclusion

Our review demonstrates a significant reduction of BMT for OME following COVID-19. Further research on public health measures and changes in clinical practice during the 2020 lockdown would clarify the impact on OME.
947 COVID19 and Its Impact on the North and East of Scotland Orthopaedic Trainees
Authors: Lim JW , Rehman H
Published: November 2022

Aim

We conducted a trainee survey at the first peak of the pandemic to investigate the impact of COVID-19 on the North of Scotland (NoS) and East of Scotland (EoS) orthopaedic trainees.

Method

An online survey was distributed to all NoS and EoS orthopaedic trainees. All data collection was anonymous.

Results

Across both Scottish deaneries, 28 trainees had responded: 39% from EoS and 61% from NoS. Trainees at all stages of training responded to the survey, with the most responses received from specialist trainees in third year of training (ST3) (25%). In response to the pandemic, 18% of trainees had been redeployed and they were from NoS. Since the reconfiguration of service, 18% of trainees had done >20 operations in a month and they were senior trainees. If COVID-19 outbreak is likely going to reduce operating opportunities for a long period, only 36% of trainees would be open to the idea of making standard surgical specialty training longer whereas 57% of trainees would be open to longer working hours to achieve certification in Trauma and Orthopaedic surgery within 96 months.

Conclusion

The outbreak of COVID-19 has impacted both deaneries orthopaedic training and urgent restoration of surgical training is essential for individual trainees. Changes in working practices necessitated by COVID-19 have known to impact theatre efficiency. Actions should be taken to improve the theatre efficiency while prioritizing training opportunities.
985 The Impact of COVID-19 on Cardiac Surgery Services at a Tertiary Cardiac Surgery Centre in the UK
Authors: Abu Taha K
Published: November 2022

Aim

This project aims to assess the impact of COVID-19 on cardiac surgery services at one UK tertiary cardiac surgery centre.

Method

Data was collected from 2nd January 2020 to 1st April 2021. Three timeframes were selected, each encapsulating a 9-week period: pre-COVID (2nd January 2020 to 28th February 2020), during the first wave (Peak 1: 23rd March 2020 to 22nd May 2020, where peak infection date is 22nd April 2020), during the second wave (Peak 2: 30th November 2020 to 29th January 2021, where peak infection date is 29th December 2020). The data comprised of number of operations performed and cancelled, including cancellations due to lack of critical care bed availability. Mean and standard error was calculated in Microsoft Excel.

Results

The results show a substantial reduction in the service provided, with the average number of operations performed per week decreasing from 15.8 during the pre-COVID timeframe to 3.2 during the first wave, and 7.6 during the second. There was a greater percentage of cancellations due to lack of critical care beds during the first wave (50%) and the second wave (35%), compared to pre-COVID (34%).

Conclusions

During this pandemic, many health services, including tertiary cardiac surgery centres, were faced with significant burden, and forced to shift focus towards managing an unknown disease. This cardiac surgery department has adapted admirably and is gradually resuming to normal service. It is vital that insight gained from this pandemic is maintained and utilised to develop guidelines to improve and prepare services for future unprecedented events.
1009 Severe Thoracic and Abdominal Surgical Emphysema in a Patient with COVID-19 Pneumonia
Authors: Dada O , Baig F , Johnston A
Published: November 2022

Introduction

Surgical emphysema is a relatively common occurrence in intensive care unit but its degree of spread in our patient is unusual. We present a case of a young adult with rapid widespread crepitus and worsening respiratory dynamics.

Case description

35-year-old male with hypertension, type 2 diabetes and obesity was invasively ventilated for severe COVID-19 pneumonia. He developed reduced chest compliance, required high driving pressures, and had persistent hypoxia despite a high fraction of inspired oxygen. He was ventilated using protocolised ARDSNet lung protective ventilation (LPV) including periods of ventilation in the prone position. After 19 days of ventilation, worsening surgical emphysema was noted following a tracheostomy. Chest radiography demonstrated extensive extra-pulmonary air. Subsequent computed tomography confirmed widespread surgical emphysema from the face to the scrotum, bilateral pneumothoraces and pneumoperitoneum. Bilateral intercostal drains were inserted and LPV was continued. The pneumoperitoneum resolved with conservative management. The patient was mechanically ventilated for 59 days and was discharged home on day 104.

Discussion

Pneumothorax, pneumomediastinum and surgical emphysema can occur following high-pressure ventilation and surgical tracheostomy. However, pneumoperitoneum with extra-alveolar air collections communicating via potential fascial planes, perivascular sheaths or trans-diaphragmatic extension is rare. The cytokine storm postulated to occur in COVID-19 infection may cause alveolar destruction, leading to Macklin's phenomenon whereby air tracks along peri-bronchial vascular sheaths towards the mediastinum following alveolar rupture. In this patient, prolonged ventilation and high airway pressures probably compounded this effect and led to the complications described.
1030 Did the COVID-19 Pandemic Impact on Medical Students Knowledge of Plastic Surgery Emergencies?
Authors: Hunt K , Herron J
Published: November 2022

Aim

The aim of this study was to look at the teaching and knowledge of plastic surgery emergencies and referral criteria in medical students from 3rd to 5th year.

Method

400 students were sent a survey via email and invited to participate 278 replied (69.7%). Students were asked 20 questions including demographics, if they were interested in surgery/ED, if they had teaching in B+P and what type, if there was clinical exposure, how to classify TBSA and factors deciding considered in classifying the burn, if they were confident to treat a burn, when to make a referral and burn mechanisms, common complications of burns, what is a flap and types and how to assess, what a plastic surgeon does.

Results

58% (161) declared an interest in surgery or ED, 32% (88) had teaching in B+P with 63% (252) attending a lecture and 5% (13) a formal Placement, others were adhoc and 21% (59) had clinical exposure. 74% (205) identified depth as important, 42% (117) TBSA. 58% (161) could not classify TBSA, 97% (271) did not feel confident treating a burn + only 8% (32) knowing when to refer although most could identify mechanisms. 92% (368) knew infection was a complication but only 1 knew why smoking was contraindicated. 1 student knew what a flap was with non able to classify or assess. few could identify what B+P do.

Conclusions

There is a lack of consistent undergraduate education on plastic emergencies and knowledge, perhaps resulting from less experience from cancelled placement.
119 Axillary Intra-Aortic Balloon Pump, Biventricular Assist Device Implantation and Subsequent Orthotopic Heart Transplantation in a Patient with Sickle Cell Trait
Authors: Mouyer Z , Taylor M , Callan P , Shaw S , Venkateswaran R , Nwaejike N
Published: November 2022

A 38-year-old Caucasian male presented to a local hospital with breathlessness. After thorough investigation, transthoracic echocardiography demonstrated dilated cardiomyopathy. He continued to deteriorate and developed florid pulmonary oedema, necessitating transfer to our centre. Routine work-up for cardiac transplantation found him to be a carrier of the HbS sickle cell trait, with an HbS concentration of 34.4%. Due to uncertainty of candidacy and further deterioration, axillary-IABP supported his bridge-to-decision. An IABP was inserted under fluoroscopic guidance via the right axillary artery using Seldinger technique. He continued to deteriorate requiring implantation of a BiVAD. He developed cardiac tamponade 23 days after BiVAD implantation demanding surgical evacuation. His condition improved with recovery of renal and liver function and resolution of pulmonary oedema. As there was no evidence of myocardial recovery, he was placed on the super-urgent heart transplant (HTX) list. After 45 days of BiVAD support, he underwent orthotopic HTX. The donor heart was from a 31-year-old male transported on cold storage. The patient remained normothermic throughout and diastolic arrest was achieved with cold blood cardioplegia delivered via the aortic root. Upon completion of anastomoses, bleeding from the posterior aortic wall occurred, requiring further aortic cross-clamping, cold-blood cardioplegia and administration of multiple blood products. Subsequently, the right ventricle distended, and the septum became dyskinetic. Central veno-arterial extracorporeal membrane oxygenation was initiated uneventfully. VA-ECMO was weaned on the 5th-postoperative day, and he was discharged from the CTCCU six days later, he returned home 28 days after HTX. He maintained recovery and remains alive and well 34 months after discharge.
137 Salvage Pulmonary Resection in Stage IIIb-IV Lung Cancer After Treatment with Immune Checkpoint Inhibitors - A Case Series
Authors: Robinson D , Smith A
Published: November 2022

Aim

Immune checkpoint inhibitors (ICIs) have been shown to prolong survival in patients that have locally advanced stage III/IV and metastatic non-small cell lung cancer (NSCLC). The role that salvages surgery plays in persistent localised disease and unresponsive synchronous cancer following treatment with a course of ICIs is not yet fully clear. We present a case series of nine patients with stage III/IV NSCLC that underwent surgical resection after treatment with the ICI, pembrolizumab.

Method

Six cases underwent salvage surgery after downstaging of the primary cancer following pembrolizumab treatment and three patients had resection of contralateral lung nodules that were unresponsive to ICI therapy. Three of the cases were open thoracotomies, 3 were robotic-assisted and 2 were video-assisted. One case was converted to open due to pulmonary artery involvement.

Results

There was complete, successful macroscopic resection in all cases with each showing histological evidence for active cancer cells. One patient died of COVID pneumonitis in the community within 60 days of surgery. All other patients are alive with no evidence of localised disease or of any disease reoccurrence within 3–18 months of their surgery.

Conclusions

Our case series demonstrates the potential for salvage pulmonary resection in select patients with advanced stage NSCLC who have persistent localised disease or unresponsive synchronous cancer after treatment with the ICI, pembrolizumab. Salvage surgery in this group of patients is safe and pragmatic despite high levels of post-immunotherapy hilar fibrosis. Further studies will be required in order to assess overall survival rates.
192 Uniportal Non-Intubated Subxiphoid VATS Thymectomy Compared to Uniportal Intubated Subxiphoid VATS Thymectomy: The Technical Feasibility, Safety, Level of Post-Operative Pain, and Adequacy of Oncological Resection
Authors: Bushra R , Nizami M , Hogan J , Peryt A , Coonar A , Aresu G
Published: November 2022

Aim

Subxiphoid video-assisted thoracoscopic surgery (SVATS) has been associated with less pain and subsequent opioid requirements. Furthermore, a non-intubated approach reduces sedatives and opioid requirements and may enhance recovery. The current retrospective comparative study is aimed to compare the technical feasibility, enhanced recovery, safety, and adequacy of oncological resection in patients undergoing non-intubated subxiphoid video-assisted thoracoscopic thymectomy and in patients who underwent a traditional intubated subxiphoid resection.

Method

We conducted a retrospective study of 42 patients who underwent Subxiphoid VATS thymectomy from September 2016 until June 2021. Among them, 21 carefully selected patients underwent non-intubated SVATS thymectomy.

Results

A total of 42 patients were included in the analysis, of which the mean age was 59.6 years, and 52% were female. The mean age for the non-intubated group was 57.5 and 54.5% female. Among them, 12 patients had myasthenia gravis. Significant complications were bleeding, mandating conversion, acute kidney injury, prolonged air leak and vocal cord palsy. In total, for Group 2, there were 3 cases converted to sternotomy, compared to Group 1. Both groups' median hospital length of stay was two days. Complete resection was achieved in all cases in Group 1, whereas, in Group 2, 4 patients were reported with an R1 resection margin.

Conclusion

Non intubated subxiphoid thymectomy is technically feasible, safe and associated with adequate oncological resection. Reduced sedation and opioid requirement lower the risk of postoperative respiratory failure and delirium, thus enhancing early recovery. However, more extensive studies are required to confirm this hypothesis.