bluuebunny/crossref_metadata_2025 huggingface dataset:
TH1.13 The Role of Metanephrines in the Diagnosis of Pheochromocytoma
Authors: Rezkallah Emad , Elsaify Wael
Published: November 2022

Introduction

Pheochromocytomas are rare neuroendocrine catecholamine-producing tumors that arise from either the adrenal medulla (PHEO) or extra-adrenal paraganglionic tissues (paraganglioma/PGLs). PHEO is responsible for about 0.01–0.1% of the cases of hypertension. Assessment of the plasma/urinary levels of metanephrines (catecholamines metabolites) is now considered the gold standard for the diagnosis of PHEOs.

In this study, we aimed to investigate the role of the plasma and 24-hour urinary metanephrines levels in the diagnosis of PHEO/PGLs.

Patients and Methods

Retrospective review of 26 patients diagnosed with PHEO/PGLs. We measured the plasma/ 24-h urinary metanephrines. The data were compared with another set of 26 patients with other adrenal pathologies. The correlation coefficient between the tumor sizes and the plasma/24-hour urinary metanephrines levels was calculated.

Results

The mean tumor size was 4.88 ± 1.99 cm. The sensitivity and specificity of the plasma metanephrines were about 95.8% and 98%, respectively, while for 24-hour urinary metanephrines were about 83.3% and 98%, respectively. We found a strong positive relationship (r = 0.472, P = 0.05) between the tumor size and the summed plasma concentrations of metanephrines. The relation between the tumor diameter and summed 24-hour urinary metanephrine was potentially strong (r = 0.354, P = 0. 083).

Conclusion

Plasma/24-hour urinary metanephrines are of great value in the diagnosis PHEOs/ PGLs as they are continuously produced by the tumor. There are strong relations between the size of these tumors and the plasma and urinary concentration of these metabolites, which can help to predict the size of the tumor even before imaging.
TH1.14 Major limb amputation during the Covid-19 pandemic – Have we seen a change in practice?
Authors: Fatima Kinza , Trinder Thomas , Rodger Chloe , McGivney Feldheim , Orr Douglas , Hussey Keith
Published: November 2022

Introduction

There have been significant changes in the delivery of health care as a consequence of the Covid-19 pandemic. Standard operating procedures have been re-defined to minimise harm from the reduction in access to services, whilst at the same time protecting hospitals (and in particular critical care units) from admissions.

We have explored major limb amputation (MLA) practice and compared this with a historical series.

Methods

Retrospective review of major limb amputations (March 2019 to October 2021). Historical datasets have also been scrutinised (2008–2010). Specific variables of interest included the annual number of major limb amputations, primary versus secondary amputation and ratio of transtibial (TTA) to transfemoral (TFA) amputations.

Results

A complete dataset was available for 282 patients during the Covid period. Patient demographics were as anticipated - 206 (73%) male, mean age 63-years (range 23 to 90-years). Peripheral arterial disease (190) and diabetes mellitus (149) were common. These demographics were comparable to the historical data. The annual number of MLA has not changed over the Covid period. The ratio of primary to secondary MLA was 1:1.3 in the historical series and 1:1 during the Covid period. The ratio of TTA to TFA was 3:1.8 in the historical series and 2:1 during the Covid period.

Conclusion

The trends suggest that practice has not changed significantly during the Covid period. There has been a slight change in the ratio of transtibial to transfemoral amputation, which may reflect patients presenting with later stage disease.
TH2.1 Antibiotics during Pancreatitis… Is it “NICE”??
Authors: Rai Anil , Singh Rhea , Mehana Omar , Kudchadkar Shantata , Mahmood Ahsan , Munasinghe Aruna
Published: November 2022

Aim

National Institute for Health and Care Excellence (NICE), British Society of Gastroenterology, the American College of Gastroenterology and the trust guidelines do not recommend prophylactic antibiotics in patients with uncomplicated acute pancreatitis. Our three-cycle study was focused on finding out adherence to these guidelines.

Method

Three cycles of the study were conducted over a span of 2 years with 87, 78 and 121 patients with the peak age range of 20–40 in the first, 41–60 in the others respectively. Unspecified acute pancreatitis and gallstone pancreatitis were the most common diagnosis in the second and third cycles respectively. Majority of patients were prescribed antibiotics on 1–2 days after admission in the first and second cycle and on the day of admission in the third cycle.

Results

44.8%, 39.7%, 35.5% of the patients admitted with pancreatitis were prescribed antibiotics in the three cycles respectively. Interestingly, in the first cycle 74.3% patients were prescribed antibiotics without any clear indication. However, we saw an improvement in the trend of prescribing antibiotics without indication from 45% in the second cycle to 37.2% in the last cycle. The maximum number of patients had a hospital stay of 2–4 days in all the cycles. Co-amoxiclav was the most prescribed antibiotic in the first and the third cycle. In the second cycle, the order was Metronidazole followed by Amoxicillin.

Conclusion

The prescription of empirical antibiotics in acute pancreatitis doesn't improve the duration or outcome of the disease. Therefore, antibiotics must be used judiciously in this era of ever-increasing antibiotic- resistant microbes.
TH2.7 Pancreatitis and Cancer. An evaluation of clinical practice with focus on links to the development of pancreatic cancer
Authors: Singh Gautam , Ghorpade Ashwini , Martindale Aleksis , Maroof Hannah , De'Ath Henry , Veeramootoo Darmarajah
Published: November 2022

Aim

Pancreatitis is a common surgical pathology that burdens all healthcare systems. Acute or chronic presentations require dedicated resources and evidence-based management. Literature suggests increased risk of cancer is two-fold with acute and up to 8-fold with chronic pancreatitis. Our study aims: 1. Assess current practice against NCEPOD 2016 guidelines, 2. Explore the incidence of cancer.

Method

Prospectively collected electronic records and clinical systems were interrogated from Jan 2015 to Feb 2018. Data was collected on patient demographics, analytics, clinical outcomes and follow up. All patients and hospital episodes’ data were included.

Results

Over the 3 years, 337 patients presented with a male: female ratio of 1:1. Median age was 61.2 (IQR 51.3–74.4). Diagnosis was acute pancreatitis 82% and chronic 18%. Aetiology was biliary 63%, alcohol-related 20% and idiopathic 10%. Ca19–9 was performed in 10% overall; and IgG4 in 10% of unknown aetiology. Ultrasound scan within 24 hours performed in 62% (improved to 79% on re-audit after an educational campaign). Within the study period, 120 patients completed 5 years follow up. 4 patients developed cancer: 3 (1.1%) in acute group and 1 (1.6%) in chronic pancreatitis group. All had Ca19–9 levels done at initial presentation with values of 6310, 19, 14 and 239u/ml respectively.

Conclusions

Compliance with guidelines is improved through awareness and clinical focus, to the benefit of patients. Pancreatitis can be an early marker of cancer, and Ca 19–9 (best validated serum tumour marker) may help clinical suspicion. Larger multi-centred collaborations may further the knowledge base.
TH2.9 The Incidence and Outcomes of Delayed Laparoscopic Cholecystectomy and Bile Duct Exploration on a Unit Adopting Index Admission Surgery for all comers. A Review of 5750 patients
Authors: Welsh Silje , Nassar Ahmad , Sallam Mahmour
Published: November 2022

Background

The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management.

Methods

Analysis of prospectively maintained data in a unit adopting “intention to treat” during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications and postoperative outcomes with index admission LC.

Results

Of 5750 LC performed 20.8% had previous biliary admissions; one in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p<0.001), longer operating times (86.9 v 68.1 minutes, p<0.001), more post-operative complications (7.5% v 5.2%, p=0.002) and longer hospital stay (8.1 v 5.5 days, p<0.001). However, conversion and mortality rates showed no significant differences.

Conclusion

Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and post-operative outcomes of biliary emergencies.
TH2.10 YouTube videos as a source of patient information for gallstone disease
Authors: Westby Kealan , Mannion Evan
Published: November 2022

Aim

YouTube is a widely accessible platform & a popular source of health information for patients. This information has been shown to be generally of poor quality. The purpose of this study was to identify and assess the quality of YouTube videos as a source of information for patients with gallstone disease.

Methods

A cross-sectional study was carried out with the keyword “Gallstones” used to search the YouTube database. Only videos In English were included. Duplicated videos, advertisements and those videos in other language than English were excluded. Videos were listed by relevance and the first 50 videos identified were evaluated. Recorded video features included likes, dislikes, length and source. DISCERN + JAMA benchmark criteria were used for quality analysis

Results

50 videos were analysed, the majority of which were uploaded by healthcare professionals (60%). Mean DISCERN and JAMA scores were 40.5 and 2.5. Overall quality of the videos were low. The correlation between length of video and DISCERN and JAMA scores was positive.

Conclusions

There are a number of videos on YouTube concerning gallstone disease that are frequently viewed but unfortunately are of low quality. Health professionals should be aware of this and caution patients on their unreliable nature.
TH3.1 Implementation of a home finger-prick CEA test for follow-up of colorectal cancer - a pilot study of patient perspectives
Authors: Quinn Marcus , Reilly Annie , Niewdach Emma , Rodgers Sam , Pullyblank Anne
Published: November 2022

Aim

NICE guidance advocates 6 monthly CEA blood testing following curative colorectal resection. This usually takes place through face to face appointments with a phlebotomist, with associated monetary and resource cost to local services, as well as impacting on patient lives. This project piloted use of self-taken finger-prick blood tests in this patient population, to assess feasibility, patient perspectives and preferences.

Methods

During colorectal outpatient clinics, patients undergoing face to face CEA surveillance in primary care were offered postal finger-prick assessment. Recruitment stopped once 50 patients had been recruited. Recruited patients were sent finger-prick blood testing kits with pre-paid return packaging. Follow-up questionnaires were undertaken to assess patient perspectives and future preferences.

Results

67.6% (50/74) of eligible patients agreed to participate. 76.0% (38/50) of patients successfully completed finger-prick CEA assessment. 46.8% (22/47) of patients felt they would prefer finger-prick rather than phlebotomy for future CEA testing, whilst 19.1% (9/47) had no preference. 38.3% (18/47) patients felt finger-prick testing was worse than their previous experience. No significant differences in preference existed between patients aged <65 and 65+. Qualitative data showed difficulties with pain, discomfort and sample collection. Patients felt that finger-prick samples were convenient and easier to fit in with their lives.

Conclusions

Whilst some patients prefer finger-prick CEA assessment, there are significant numbers for whom it is challenging, unnecessary or less preferable. Finger-prick CEA testing may represent a future strategy for reducing burden of follow-up blood tests on resources, but this would currently be acceptable only to limited patient groups.
TH3.2 Audit of acute lower GI bleed admissions - outcomes and management
Authors: Sami Sharukh , Hemadasa Niroshini A , Loh Cheryl , DeCruz Antony , Mirza Muhammad
Published: November 2022

Background

Lower GI bleeding (LGIB) is a common surgical emergency. The British Society of Gastroenterology (BSG) in 2019 developed a UK national guideline on the management of LGIB. Our aim is to audit the current practice and standards for patients admitted with LGIB.

Methods

This retrospective audit identified patients presenting to the Emergency department and Surgical assessment unit between September 2020 to February 2021 with LGIB. The shock index and Oakland score (OS) at first presentation were calculated.

Results

A total of 27 patients satisfied the inclusion criteria. Average age of patients was 64.7 years. Three patients had an OS of ≤8 with 1 patient being hospitalised. 21 patients had an OS of >8 and 7 out of the 21 patients were discharged instead. 14 patients (51.8%) were on anticoagulants/antiplatelets of which 1 was on dual antiplatelet therapy. 10 patients had their drugs suspended appropriately and 2 did not. Eight patients were referred for OP endoscopy.

Conclusion

We found that improvements can be made with respect to suspension of anticoagulant and antiplatelet drugs and duration to colonoscopy. A more pragmatic approach to both intervention and interval to endoscopy may have to be applied due to service constraints.

A checklist has been developed based upon the guidelines to
TH3.3 “Closing the loop”: what is the delay in Reversal of Hartmann's procedure?
Authors: Roberts Victoria , Mandagere Vinay , Crisp George , Biggs Sarah , Shabbir Jamshed
Published: November 2022

Reversal of Hartmann's procedure is performed to restore intestinal continuity. There is conflicting literature on the best time for reversal, with little evidence suggesting waiting longer than a year is beneficial. We assessed the experience of our patients.

Patients were identified from the local Enhanced Recovery After Surgery (ERAS) database over a 9-year period (2012–2021) at a University Hospital. Data was collected from digitalised hospital notes on patient demographics; timings to reversal of Hartmann's; defunctioning stoma; reasons for delay; length of stay; and complications.

Forty-three patients underwent reversal of Hartmann's procedure. Median age was 57 (38–83) years; 19 (44%) of patients were female. Surgery was performed laparoscopically in 18 (42%); laparoscopic converted to open 6 (14%); open in 19 (44%) patients. Average length of stay was 6 days. Indications for primary Hartmann's procedure were diverticular disease (67%), malignancy (21%), and other causes (14%). Median time from the index operation to reversal of Hartmann's was 85.2 weeks (range 19.9–312.4 weeks). Only 9 (21%) patients underwent reversal Hartmann's within 1 year of primary surgery. Of the reasons known for the delay in reversal; 15 (35%) were due to patient complications, 6 (14%) were due to administrative reasons, 2 (5%) were due to COVID-19 associated delays and 1 (2%) patient choice.

This retrospective analysis highlights the varied patient experience within just one centre, further research incorporating detailed patient experience is needed. It also highlights a paucity of national evidence-based consensus on optimal timing for challenging revisional surgery.
TH3.5 Completeness of operative reports for rectal cancer surgery
Authors: Bae Inmook , Spinks William , Saravanan Balakrisanan , Moscalu Andrei
Published: November 2022

Introduction and Objectives

Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation, which ultimate improves quality of care. We set out to assess whether post-operative reports, made at the JPUH, include the primary components recommended by the National Accreditation Program for Rectal Cancer. The JPUH does not currently use synoptic templates to guide post operative note making.

Methods and materials

We retrospectively looked at the post-operative reports for 71 patients who had undergone surgery for rectal cancer from March 2018 to October 2020 at the James Paget University Hospital. These reports were evaluated to establish how many of the primary components were included.

Results

Of the 71 reports assessed, none included all 23 components. The areas well documented included the nature of the operation (100%), completeness of resection (93%), the type of reconstruction (85%) and anastomosis testing method (97%). The areas that were poorly documented included en bloc resection (8%), metastectomy (0%), intra-operative complications (0%) and blood transfusion (0%).

Overall there was 53% completeness of documentation.

Conclusion

Rectal cancer post-operative note making at the JPUH does not meet the standard expected by the NAPRC. Some points were documented well and others were infrequently documented. Plans are in place to introduce accessible templates to guide note making and re-audit will be completed.
TH3.6 Comparison Between Preoperative MRI and Postoperative Histopathological Staging in Rectal Cancer Surgery (RCS)
Authors: Rehman Masood , Gendia A , Nasir M T , Ahmed J , Gupta Nishil
Published: November 2022

Aim

To evaluate diagnostic values of preoperative MRI imaging staging in comparison to postoperative histopathological staging (HPS) in rectal cancer surgery.

Methods

A retrospective chart auditing was performed on all RCS patients from 2019 till 2021. Data collected included patient demographic, preoperative MRI imaging and postoperative histopathological analysis.

Results

A total number of 83 rectal surgeries were performed during the given period, mean age was 67(±11) and 60% were males. 62.7% (52) of patients underwent anterior resection (low AR 27.7%). APR and Hartmann's procedure were performed in 27.7% and 6% of patients. Complete resection was achieved in 95.2% with average LN harvest of 20.5 (±5.8) nodes. The most common Tumour (T) burdens on preoperative MRI and postoperative HPS were T2 (45.6%) and T3 (44.5%) respectively with MRI diagnostic accuracy of 47%. Lymph nodes analysis showed diagnostic preoperative predictive values of 56.6%. Extramural vascular invasion (EMVI) was accounted in 68 Pre-MRI with diagnostic accuracy of 50.6%. Pre-MRI evaluated 69 CRM and accurately commented in 73.5%. Although Pre-MRI staging had tendency to over-stage tumour burden, lymph nodes analysis and EMVI in around 30% of reported cases. It showed accuracy in diagnostic values in CRM prediction with around 73%.

Conclusion

Preoperative MRI diagnostic values showed differences when compared with postoperative histopathological analysis. Pre-MRI showed a tendency to over-staging in tumour size, LNs and EMVI. However, Pre-MRI showed favourable values in accurately describing CRM which is the main factor affecting the outcome of surgery and the ongoing treatment.
TH3.7 Is There a Benefit for Routine Doughnuts Histopathological Examination After Anterior Resection (AR) in Colorectal Cancer Surgery?
Authors: Rehman Masood , Gendia A , Nasir M T , Ahmed J
Published: November 2022

Aim

To evaluate the oncological benefits and cost-effectiveness of routine histological examination of the doughnuts from stapled anastomoses in patients undergoing colorectal cancer surgery.

Methods

A retrospective chart auditing was performed on all consecutive rectal cancer surgery (RCAS) patients performed in NGH from January 2019 till August 2021. Data collected included patients' demographic, procedure performed and postoperative histopathological analysis including doughnuts examination.

Results

Fifty-two patients underwent AR during the given period. 37 (71%) patients had doughnuts histopathological examination. median age was 68.59 (±11) years old and 62.1% were male. The histopathology of all resected specimens was adenocarcinoma. 48.6% and 51.4% underwent low anterior resection and high anterior resection respectively. Proximal doughnuts sent in 70.2% patients whereas distal doughnuts were sent in all resections. Mean distal resection margin from tumour was 21.7 mm and the shortest distance from the tumour to resection margin was 6 mm. All the doughnuts as well as resection margin were negative for any malignancy. Additionally, each doughnut costs our pathology laboratory around 150 pounds with total preparation time of 72hours and around 10 mins of microscopic examination. This makes total costs and time of examining all specimens of around 9,300 pound and 4,470 hours in resources.

Conclusion

There was no additional oncological benefit in sending routine examination of doughnuts. It should only be sent in those deemed of a higher risk of a positive margin. This will result in significant reduction in cost and time burdens on our resources.
TH3.8 Retrospective study on the use of colonic stents in malignancy; a bridge to surgery or the end of the line?
Authors: Williams N , Reeves N , Chandler S , Jones H
Published: November 2022

Aim

Colonic stenting is a management option for obstructed left sided colorectal malignancy in the emergency and elective setting. Stenting can provide a bridge to curative surgery or to adjuvant treatment. The aim of this study was to assess the role of colonic stenting in management of obstructed colorectal cancer.

Methods

This retrospective cohort study analyses prospectively collected data from two centres within one Health Board in Wales. Patients were recorded in a cancer database, who underwent colonic stenting for left sided colonic malignancy between January 2008 and December 2021. Patient demographics, treatment pathways, length of admission, stoma formation rates and morbidity were recorded.

Results

In total, 98 patients, with a mean age of 73.5 years (range 37–97) underwent a colonic stent. The majority were elective 55% (n=54). The sigmoid colon was the commonest site of tumour in 33 patients, with metastatic disease in 82% (n=80). The study found 86% (n=84) of patients were successfully stented. The mean length of admission was 13 days. The complication rate was 23% (n=23), most commonly stent obstruction (n=6). Stenting was a bridge to curative surgery for 3 patients, and 47% (n=46) received adjuvant treatment. Five-year survival was 19.3% (n=19). The overall stoma rate was 10.2% (10 patients).

Conclusion

This study shows colonic stenting is a viable alternative in surgical management for advanced obstructing colorectal malignancy but not as a bridge to surgery. The majority of this cohort returned home following stenting, had a low overall stoma rate and 19% survival at 5 years.
TH3.9 Cleft closure is an effective procedure for the treatment of pilonidal disease with low recurrence rate
Authors: Ali Ambeur , Di Fabio Francesco , Yao Caroline , Venkatasubramaniam Arcot , Arnold Steve , Daniel Mahesh
Published: November 2022

Aims

The surgical treatment of pilonidal sinus disease has evolved over time, with reported time to healing, post-operative complications and disease recurrence rates still significant. The modified Karydakis procedure such as the Bascom's cleft lift operation or “cleft closure” flattens the cleft and has shown promising results. The purpose of this single-centre study is to analyse outcomes of this technique.

Method

This is a retrospective study of 192 patients undergoing cleft closure as a day case over 10 years. The technique involves an off-midline cleft closure with an advancement flap and primary closure. Outcome measures were postoperative complications, time to healing and recurrence requiring surgery.

Results

The median age at surgery was 25 years (IQR 21–33), with males representing 76%. Overall, 91 (47%) were smokers. 141(73%) patients had previous emergency treatment. The median numbers of pits/sinuses were 3 and in 71% of patients were localized in the midline. The median time to wound healing was 3 weeks (IQR 2–6). Twenty-five (13%) patients had postoperative complications including infection (n=21) and hematoma (n=4). Disease recurrence requiring surgery occurred in 7 (3.6%) patients. Median time to recurrence was 9 months (IQR 5–15).

Conclusion

Cleft closure is an effective procedure for the treatment of pilonidal disease, with a low rate of postoperative complications and recurrence.
TH3.11 Standardised Follow-up for Patients with Acute Diverticulitis – Quality Improvement Project
Authors: Gavrila Ana , Mehta Chaitanya , Siddiqi Najaf Nawaz
Published: November 2022

Aims

Historical guidelines recommended routine colonoscopy some weeks after an episode of acute diverticulitis. Our project aimed to analyse outpatient follow up in our unit for patients with a clinical diagnosis of uncomplicated diverticulitis who did not require any inpatient investigations or intervention. Following on from this we proposed a pathway to standardise follow up care in this group of patients.

Methods

A retrospective audit was undertaken of outpatient follow up received by all patients coded with a primary clinical diagnosis of diverticulosis or uncomplicated diverticulitis in 2015, 2017 and 2019. Follow up investigations included a colonoscopy, flexible sigmoidoscopy, CT colonogram (CTC) or none of the above due to frailty or recent endoscopic investigation within the previous 2 years.

Results

Overall 118 patients were included in the audit. There was a reduction in patients who had a clinical diagnosis of uncomplicated diverticulitis in the second and third cycle of the audit from 67 to 22 and 29 respectively. This overall led to less outpatient endoscopic evaluation.

Conclusion

Departmental consensus guided the formation of a standardised pathway whereby appropriate patients without any colonic investigation within the last 24 months were investigated with an outpatient CTC six weeks after discharge. This led to a significant reduction in outpatient colonoscopy numbers.
TH4.3 Walk the extra mile!!
Authors: Griffiths Aimee , Archer James , Singh Gambhir Raghvinder Pal
Published: November 2022

Aim

Limb salvage and mortality remain high in patients with critical limb ischaemia. The present study looks at outcomes of a multimodality 24x7 service at a major diabetic foot centre.

Methods

We retrospectively reviewed surgical outcomes of bypass procedures done to identify patients that needed to go have further procedures within the same admission for limb salvage. Electronic patient records were reviewed and data analysed to assess the outcomes of overall limb salvage rates and mortality.

Results

68 patients underwent bypasses in the study period. 38 (55%) of patients who had procedures performed in the study period needed to have an additional intervention after the index procedure. 9 needed redo surgery (thromebctomy and further extension of graft with jump grafts), 27 needed angioplasties and 2 patients needed both. Majority of the intervention were done within 24–72 hours. Among those grafts which failed one of the causes identified was prolonged hypotensive episodes in perioperative period. All these additional interventions delayed discharge, prolonged hospital stay but were essential for limb salvage.

64 patients (94%) had intact limbs at discharge, 4 required a major amputation - 1 below knee and 3 above knee. At 1 year follow up 56 patients (82%) were alive.

Conclusion

If the patients have to retain the ability to walk we have to be prepared for some extra effort. Additional procedures planned or unplanned are sometimes necessary to save the limb. A multimodality 24x7 service willing to go the extra mile goes a long way in preventing major amputations.
TH4.4 Real-world mid to long term mortality after Abdominal Aortic aneurysm (AAA) repair
Authors: Muthukumar Ananya , Nair Meghna , Singh Gambhir Raghvinder Pal
Published: November 2022

Aim

Centralisation of vascular services has decreased 30-day AAA mortality from 7% to 3% across UK, but does it have an effect on their long term survival?

Methods

Electronic patient records for 264 patients with AAA repair between 2009–2018 submitted to national vascular registry (NVR) from a single centre were analysed.

Results

231 of 264 patients (88%) had endovascular aneurysm repair (EVAR) while 19 (12%) had open repair (OR). Male to Female ratio 8:1; Mean age 76.5 years at time of surgery (TOS). 251 elective, 13 were emergency repairs. 192 (72%) of patients have died since surgery- a median survival of 4 years (IQR 2–7) post-surgery. Of these, 171 were male, with a median survival of 4 years (IQR 2–7); 21 were female, with median survival 3 years (IQR 1–5). Cause of death could be ascertained only in 27 & 23 were attributable to non-aortic reasons. Median survival post-surgery in 70–80 years age group (n-89) and 80+ (n-82), was 5 years (2–7) and 3 years (1.25–5), respectively. Cohorts of patients who lived either greater or less than median survival years were aged similarly at TOS; 79.7 and 80.4 years, Mean survival post-EVAR was 4.5 years, while post-OR was 2.3 years.

Conclusion

With a median and mean survival post surgery of about 4 years, is it time we had mandatory involvement of Geriatric physicians/older person assessment units like POPS (Perioperative medicine for Older People Undergoing Surgery) in patient risk assessment preoperatively especially in those that require costly customised stent grafts.
TH4.5 The introduction of a custom made endograft service for patients with complex thoracoabdominal aneurysm
Authors: Duncan Nicola , Pilkington Antony , Dearie Larissa , Hennessy Martin , Hussey Keith
Published: November 2022

Introduction

Custom made endografts represents a technological advance that has been widely adopted across vascular centres in the United Kingdom. The most recent National Vascular Registry report describes in-hospital mortality for complex as 2.3%. We have reviewed the outcome associated with the introduction of a custom made endograft program in a single Scottish Health Board.

Methods

Index cases were identified from a prospective radiology database with cases identified from 2008 to 2021. We collected patient demographics, pre-operative assessment, peri-operative and procedure related details and information on surveillance and re-intervention.

Results

There have been 49 cases performed. Most patients were males over the age of 70-years with significant medical co-morbidity. The mean AAA size was 5.8cm. Most of the procedures have been performed under general anaesthesia with percutaneous common femoral access. Procedural complications have included inability to stent target arteries (coeliac axis twice and right renal artery twice). Other complications have included limb ischaemia and haemorrhagic complications from access. Two critical care bed days have been used. The mean duration of hospital stay is 9-days. There have been no deaths on the index admission. During the follow-up period there have been 6 deaths. One of these deaths was from rupture of abdominal aortic aneurysm (secondary to Type III endoleak).

Conclusion

These data suggest that the case selection for custom made endografts is good. The cost of the device may be off set by a reduction in critical care utilization/hospital bed stay.
TH4.6 Is major limb amputation the most appropriate means of palliation for patients with non-reconstructable arterial disease?
Authors: Trinder Thomas , Rodger Chloe , Fatima Kinza , Dearie Larissa , Hussey Keith , Orr Douglas
Published: November 2022

Introduction

Major limb amputation (MLA) is the highest risk lower limb surgical procedure performed in the United Kingdom with reported in hospital mortality 9.1%. For patients with non-reconstructable arterial disease it offers palliation of symptoms. The primary aim of the current work was to define if surgical palliation with major limb amputation is being offered to patients who may have been best managed medically

Methods

Retrospective review of major limb amputations (March 2019 to October 2021). Historical datasets have also been scrutinised (2008–2010). Specific variables of interest included the annual number of major limb amputations, mortality on the index admission and place of discharge.

Results

A complete dataset was available for 282 patients during the Covid period. Patient demographics were as anticipated - 206 (73%) male, mean age 63-years (range 23 to 90-years). Peripheral arterial disease (190) and diabetes mellitus (149) were common. The number of major limb amputations was comparable with the historical series. In-hospital mortality was 7% (n=20). The median duration of admission for patients who survived was 26-days and 38% of patients were limb-fitted (which was also comparable with historical data). Most patients (71%) were discharged to their own home.

Conclusion

The outcomes described are better than the comparable local historical and national data both in terms of in-hospital mortality and place of discharge. These data imply that we make the correct decision about MLA more often than we don't.
TH4.7 Seventeen years experience of surgical management of Thoracic Outlet Syndrome at a District General Hospital
Authors: Jaskani Sadia , Farquharson Barnaby JMc , Collis Justin , Andrews Brian
Published: November 2022

Aims

To evaluate the outcomes of patients who underwent first rib resection (FRR) for Thoracic Outlet Syndrome (TOS) over a period of 17 years at a single District General Hospital (DGH).

Methods

Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021.

Results

Sixty patients underwent 65 subclavian approach FRR for indications neurogenic (n=45 (69%)), venous (n=6 (9%)), arterial (n=14 (22%)) TOS. Forty-four female patients underwent FRR (68%) and mean age at time of surgery 34 years (range 27 to 64 years). Five patients (7.6%) had bilateral FRR and seven patients (10.6%) diagnosed with cervical rib. Mean length of time from initial symptoms to diagnosis 24 months (range 2 to 60 months). Forty patients (62%) underwent a failed trial of conservative management with physiotherapy before proceeding to surgical management. Fifty-two patients (80%) reported complete resolution of symptoms at follow up. Complications included wound infections 2(3%), pneumothorax 4(6%), haemothorax 1(1.5%), phrenic nerve complications 3(4.6%) and chronic pain 1(1.5%). One patient with phrenic nerve injury underwent diaphragmatic plication procedure with resultant resolution of symptoms. Mean length of stay 1.6 days.

Conclusions

This series presents the difficulty of diagnosis and management of TOS with the majority of patients enduring symptoms for a prolonged period of time before referral and definitive management. Phrenic nerve complications are an underreported complication of subclavian approach FRR, it is essential to counsel patients accordingly before proceeding to surgery. FRR for TOS can be performed safely and effectively in a DGH environment.
TH4.8 Antiplatelet therapy used in vascular patients post CEA
Authors: Zolfaghari Yasmin , Gambhir Raghvinder
Published: November 2022

Aims

To review antiplatelet therapy of vascular patients who had undergone CEA post TIA over a 1-year period and to compare their antiplatelet therapy to European Society of Vascular Surgery (ESVS) guidelines for atherosclerotic carotid disease.

Methods

We reviewed all patients admitted under the vascular team who underwent elective CEA from 1/1/20 to 1/1/21 (n=65). We reviewed the antiplatelet therapy that were prescribed on discharge summaries, and compared to current ESVS guidance. According to ESVS guidance, it is stated that dual antiplatelet therapy (DAPT) is not recommended in patients undergoing carotid endarterectomy unless indicated for cardiac reasons.

Results

Out of the 65 patients who were discharged over one year, 55% were discharged on DAPT, with the remaining 45% prescribed either aspirin or clopidogrel alone. Additionally, there was heterogeneity in the treatment duration for antiplatelet therapy across patients. However, on 3 month follow up appointments, 100% of patients were advised to continue on SAPT long-term in accordance to guidance.

Conclusions

Given the heterogeneity in treatment plans for CEA patients over the studied time period, we believe there is value in introducing weekly teaching sessions for MDT members of all grades, to keep all members up to date on current guidance. Additionally, use of posters incorporating up to date antiplatelet therapy guidance may also serve as a useful tool for doctors discharging post CEA patients. Despite the heterogeneity noted on discharge summaries, 100% of patients were advised to continue on SAPT long term in follow up clinic appointments.
TH4.9 Patient Reported Outcome Measures (PROMs) – A Key to Understanding Laparoscopic Cholecystectomy Outcomes?
Authors: Melly Conor , McGeehan Gearoid , O'Connor Niall , Donohoe Claire , Bucholc Magda , Sugrue Michael
Published: November 2022

Aims

Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient reported outcome measures PROMS in laparoscopic cholecystectomy.

Methods

A PROSPERO registered (ID: CRD42021261707) systematic review was undertaken of English language articles, published from January 1st, 2011 to June 2nd, 2021, and underwent MINORS grading, using PubMed version of Medline, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards including key words: laparoscopic cholecystectomy AND patient outcome OR patient reported outcome OR patient reported outcome measure OR PRO OR PROM.

Results

A total of 4960 individual articles were reviewed, 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy. 21 articles spanning 19 countries and 4 continents were included in the qualitative data synthesis. There was significant heterogeneity in PROMs, with eight different PROM tools used in 21 studies. Wide variation in the time points at which PROMs were recorded. Fourteen of twenty-one studies recorded PROMs pre- and post-operatively, seven of twenty-one recorded PROMs post-operatively only. Follow up periods ranged from 3 days to 2 years post-operatively. All PROMs detected changes in quality-of-life over time.

Conclusions

This study identified that while post laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. EuroQOL EQ-5D provides a simple platform for the modern digital era.
TH4.10 Prophylactic cholecystectomy offers best outcomes following ERCP Clearance of Common Bile Duct stones
Authors: Geehan Gearoid Mc , Melly Conor , O'Connor Niall , Bass Gary , Bucholc Magda , Sugrue Michael
Published: November 2022

Aims

Clearance of choledocholithiasis reduces recurrent cholangitis, but following clearance of the CBD, cholecystectomy is required. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post ERCP clearance offers more favourable outcomes than a wait-and-see approach.

Methods

A Prospero-registered meta-analysis of the literature using PRISMA guidelines incorporating articles relating to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research demonstrating outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine key events, complications, and mortality. Odds Ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses using OR with either fixed- or random-effect models, depending on heterogeneity of studies.

Results

13 studies (n=2,598), published between 2002 and 2019 were included in this meta-analysis: six retrospective studies, two retrospective propensity score matched studies, three prospective studies and two randomised control trials from a total of 11 countries. There were 1,433 in the no cholecystectomy cohort (55.2%) and 1,165 in the prophylactic cholecystectomy cohort (44.8%). Cholecystectomy resulted in a decreased risk of cholecystitis (OR= 0.15; CI, 0.07–0.36; p<0.0001), cholangitis (OR= 0.51; CI; 0.26–1.00; p=0.05) and mortality (OR= 0.38; CI; 0.16–0.9; p=0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis.

Conclusions

In patients undergoing CBD clearance consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.
TH5.4 Robustness of morbidity and mortality documentation before emergency laparotomies
Authors: Muehlschlegel Charlotte , Rees Chantal , Borgas Pia , Taheem Muhesh , Bedwani Nader , Kalidindi Venugopala , Bhanot Kunal
Published: November 2022

Introduction/Aims

Participation in the National Emergency Laparotomy Audit (NELA) is a national requirement, highlighting areas for improvement in patient care and service provision . When consenting for emergency laparotomy, NELA Morbidity and Morality scores (NMMS) should be clearly documented, informing the consent process and guiding surgical intervention.

Aims

Method

A retrospective (C1) (13/02/21–06/07/2021) and ongoing prospective (C2) (24/10/2021-present) analysis of emergency laparotomies in our local hospital was performed before and after implementation of interventions respectively. Laparotomies were categorised by operation time, NMMS documentation time, patient age and gender. Results were presented locally. Interventions included departmental education and a bright orange supplementary sticker placed on consent forms, providing fields for NMMS documentation. Fischer's exact t-test was used to calculate p values.

Results

30 and 21 patients were included in C1 and C2 respectively. More patients had clear NMMS documentation in C2 (10/30 vs 16/21; p<0.005). Within C2, sticker use was associated with more frequent NMMS documentation (7/7 vs 8/13; p=0.1107).

Conclusion

Use of NMMS informs consent, guides surgical decision making and improves accountability. Whilst important for both legal and governance reasons, utilisation and documentation of clinical decision-making tools whilst managing unwell patients can be onerous. We found combining both education and a visual adjunct has improved compliance with the NMMS documentation NELA standards.
TH5.7 Spontaneous pneumomediastinum case series: Lessons learnt in assessment and management
Authors: Manku Bhagat , Krishnamoorthy Ashwin , Thomson Luke , McLaughlin Euan
Published: November 2022

Aims

Spontaneous pneumomediastinum (SPM) is usually a self-limiting condition in clinically stable patients with no obvious causative factor. SPM can be difficult to distinguish from important secondary causes such as tracheobronchial injury or oesophageal perforation. Therefore, thorough clinical history and examination is of paramount importance. We aim to highlight lessons learnt from our experience to improve rapid diagnosis and clinical management of these patients.

Methods

Patients were identified through hospital records between October 2019 – December 2021. Data was collected on clinical presentation, precipitating events, radiological confirmation of SPM and compared with current reported literature.

Results

11 patients were identified, 8 males (72.7%), 3 females (27.3%) with a mean age of 29 ± 17 years. The most frequent symptom was retrosternal chest pain 27.3%; and vomiting the most common precipitating event (54.5%). Mean white cell count was 14×109/l on admission. All patients underwent plain film chest radiography, and subsequent computerised tomography of thorax, abdomen and pelvis. Patients underwent gastroscopy selectively, showing no acute pathology. Mean length of stay was 4.6 days. No patients required operative intervention or any other intervention beyond antibiotics. No complications or recurrence were found in patients at follow up.

Conclusion

SPM is a self-limiting condition with low morbidity and mortality. If life-threatening causes have been excluded, SPM can safely be managed expectantly at a local level, without the need of transfer to tertiary centres and prolonged hospital admission. We propose a structured approach to aid in the management of SPM and help address these challenges.
TH5.8 Use of Botulinum Toxin A infiltration in conjunction with negative pressure wound dressing and mesh-mediated traction in the management of the ‘open abdomen’
Authors: Mohamed Imran , Egeler Christian , Ford Simon , White Thomas , Harris Dean , Harries Rhiannon
Published: November 2022

Aims

Botulinum Toxin A (BTA) is widely used in complex abdominal wall reconstruction (CAWR). It temporarily paralyses the oblique muscles allowing medialisation of the rectus sheath and decreases tension on the closure. This analysis presents the use of BTA in management of the ‘open abdomen’ (OA).

Methods

Retrospective series of patients with OA where BTA was used in conjunction with AbtheraTM negative pressure wound therapy (NPWT) and polypropylene mesh-mediated traction (MMT) to attempt fascial closure. BTA was performed by Anaesthetists with experience of BTA use in CAWR using Dysport® 600 IU.

Results

We include 5 patients since 2020. Median age at index operation was 55 years (range 39–81); four were male. Index operations were intra-abdominal catastrophe where fascia closure impossible (n=2), dehiscence after Vertical Rectus Abdominis Myocutaneous (VRAM) flap for pelvic malignancy (n=2) and colectomy for obstructing colorectal cancer complicated by rectus sheath necrotising fasciitis (n=1). There were no immediate complications from BTA infiltration. All patients achieved primary fascial closure with a median of five re-looks (range 3–7). There were no full-thickness dehiscences after final closure. One patient died within 1 month from unrelated cause. One patient had no clinically palpable incisional hernia at six months and a further two had no incisional hernia at six and 12 months, respectively, on cancer surveillance CT.

Conclusion

BTA in the setting of the OA in conjunction with NPWT and MMT appears safe and effective in achieving fascial closure, and can potentially reduce the risk of incisional hernia. Further studies are welcomed.