bluuebunny/crossref_metadata_2025 huggingface dataset:
671 The Effect of Supplementary Simulation-Based Procedural Training: The SIMULATE Randomised Controlled Clinical and Educational Trial
Authors: Aydin Abdullatif , Ahmed Kamran , Raison Nicholas , Abe Takashige , Brunckhorst Oliver , Van Hemelrijck Mieke , Ahmed Hashim , Shinohara Nobuo , Zhu Wei , Zeng Guohua , Sfakianos John , Tewari Ashutosh , Gözen Ali , Rassweiler Jens , Skolarikos Andreas , Kunit Thomas , Knoll Thoman , Moltzahn Felix , Thalmann George , Powers Andrea Lantz , Chew Ben , Khan Muhammad Shamim , Dasgupta Prokar
Published: November 2022

Aim

To evaluate whether surgical trainees undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes.

Methods

This international, multicentre randomised controlled superiority trial recruited urology trainees (n=94) who had performed ≤10 ureterorenoscopy (URS) cases, as a selected index procedure, with no prior simulation experience. Recruits were randomised to simulation-based training or non-simulation-based training groups, the latter of which is the current standard of training. Training sessions were conducted for the simulation arm, utilising an expert-developed multi-modality training curriculum. The primary outcome was the number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on an OSATS scale, on 3 consecutive operations, without complications. Inpatient surgical complications were also recorded. All participants were followed up for 25 procedures or over 18 months.

Results

A total of 1140 cases were performed by 65 participants where proficiency was achieved in 21 simulation and 18 conventional participants over a median of 8 and 9 procedures, respectively (HR: 1.41 [95% CI 0.72–2.75]). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring fewer number of procedures (HR 0.89 [95% CI 0.39–2.02]). Significant differences were observed in overall comparison of OSATS scores between groups (mean difference 1.42 [95% CI 0.91–1.92]; p<0.001), with fewer total complications (15 vs 37; p=0.003) and ureteric injuries (3 vs 9; p<0.001) in the simulation group.

Conclusions

Simulation-based training demonstrated higher overall proficiency and fewer procedures were required to achieve proficiency in the complex form of the index procedure with surgical complications.
898 The Fragility Fracture Post-Operative Mobilisation (FFPOM) Study – a UK-Wide Audit of Lower-Limb Fragility Fractures
Authors: Zargaran Alexander , Bretherton Christopher , Richardson Charlotte , Raza Mohsen , Eardley William , Trompeter Alex
Published: November 2022

Aim

This study quantifies the epidemiology and weight-bearing practice of operatively managed fragility fractures of the lower limb in the National Health Service.

Method

A multicentre audit of all adult patients aged 60 and over receiving surgery for a fragility fracture of the lower limb between 01/01/2019–30/06/2019 and 01/02/2021–14/03/2021 was conducted. The British Orthopaedic Association (BOA) guidance was used as the standard.

Results

430 collaborators from 84 hospitals submitted data from 20193 patients. 19557 patients with a median age of 83 (70.4% female) were included in the analysis. Data from 16241 hip fracture patients and 3316 non-hip fracture patients were analysed. In the non-hip fracture population, the most common fractures were of the foot and ankle (45.1%). 15543 (95.7%) of hip fracture and 1071 (32.3%) non-hip fracture patients were allowed to weight-bear immediately post-operatively. Despite being demographically similar, the proportion of patients instructed to weight-bear without restriction following operative fixation of the shaft (47.8%) and distal (64.6%) femur was lower than patients receiving surgery for a proximal femoral fracture (95.7%). 45.6% of distal femur and 44.2% of femoral shaft fractures were periprosthetic compared to 2.2% of proximal femur fractures.

Conclusions

This UK-wide collaborative study of over 19,000 patients demonstrates a significant disparity in weight-bearing restrictions placed on patients with fragility fractures despite the publication of a national guideline. Surgeons intentionally restrict post-operative weight-bearing in the majority of fractures outside the hip, but by contrast are content with unrestricted weight-bearing following operations for hip fracture.
174 The EXTEND Trial: EXTENDed Antibiotics to Improve Outcomes in Patients with Complicated Intra-Abdominal Infection
Authors: O'Connor Olivia , Kirby Andrew , Ahmed Shadia , Harmston Rebecca , Hewitt Catherine , Knowlson Catherine , Pinkney Thomas , Szakmany Tamas , Tharmanathan Puvan , Vargas-Palacios Armando , Welch Charlie , Burke Dermot
Published: November 2022

Introduction

Complicated intra-abdominal infections (cIAI) pose a major challenge in surgical patients. Despite the heterogenous aetiology they have a common disease process, which is bacterial infection of the peritoneal space. Hence, all cIAIs are managed with source control, plus antibiotic therapy. However, there is uncertainty regarding the optimal antibiotic treatment strategy in order to prevent relapse or extra-abdominal spread of infection1. At present, there is no UK guidance on the management of cIAIs2. For other serious infections outside the abdomen microbiologists often advise at least 28-days of antibiotic therapy. Currently the effectiveness of extended duration antibiotics in patients with cIAI is unknown. This trial aims to compare the clinical and cost effectiveness of 28-day duration antibiotics with standard care with respect to rate of treatment failure in patients with cIAIs. Secondary outcomes include complications and quality of life.

Trial Design

A multicentre, open label, two-arm, parallel group, pragmatic, randomised controlled trial with internal pilot. 1166 consenting adult patients with cIAI will be recruited over 3 years and randomised on a 1:1 basis between 28-days antibiotic course and standard care antibiotics, based on local protocol and clinical assessment. Patients will be recruited from ICUs and hospital in-patient wards across 30 sites.

Trial management and funding

EXTEND is sponsored by University of Leeds, hosted by York Trials Unit and funded by NIHR. The Trial Management Group will oversee design and running of the trial. Each site will have a Principal Investigator (PI) with local responsibility. The NIHR Associate PI scheme will enable trainees to participate in the trial.
408 Audit - Diagnostic Pathways in Suspected Renal Colic
Authors: Siddique MH , Rauf M , Klair A , Mohsin S , Pearce S , Ali D , Anwar A
Published: November 2022

Introduction

Ureteric colic is common clinical condition but has significant morbidity. Prompt diagnosis and treatment are key to overcome. Therefore, both BAUS and NICE have produced similar guidance which forms the audit standards below

Aim

Audit of local practice to national and aspirational guidelines

Standards

Method

Perform a retrospective review of consecutive 705 patients with suspected ureteric colic who had CT-KUB

Data collection tool

Conclusion

705 patients only 335 patients had CT KUB in 14 hours. Calcium checked was of 305 out 636 patients. Urate being the lowest only 2.6% that's 14 out of 523 patients was checked. Lastly NSAID's 67 patients out of 200 have received it as initial pain management. Summary as follows

Recommendations
708 An Audit of Blood Transfusion Prescription in Peri-Operative Orthopaedic Patients for Those with and Without a Coronary History
Authors: Wauchope E , Letch E
Published: November 2022

Aim

Correct prescription of red blood cells (RBCs) is essential for treatment of peri-operative anaemia and preventing complications to post-operative recovery. However, over prescription is costly, inefficient, and not free of complication. We compared the threshold and targets for the prescription of RBCs in a secondary care orthopaedic department to the NICE Blood Transfusion Guidance (2015) and whether altered thresholds were used or if iron was prescribed.

Method

Retrospective analysis of all surgically managed orthopaedic patients over a 3-month period receiving peri-operative RBCs in 2020. Pre and post transfusion haemoglobin (Hb) levels, concurrent prescription of iron and documented reasons for altered transfusion thresholds were collected. Exclusions included major trauma, major haemorrhage, or intra-operative transfusion.

Results

62 patients were transfused on average 1.5 units post-operatively. 21.4% were transfused in line with the NICE threshold (Hb<70g/dL) and targets (Hb70–90g/dL.) Average Hb threshold was 75.5g/dL (range 60–110). 0% had an ACS on the day of RBC transfusion. In 54.2% 1 unit was prescribed at a time. Iron deficiency anaemia was identified in 11.4% and treated in 7% pre-operatively.

Conclusions

RBCs are being prescribed out of line with NICE guidance with a 21.4% compliance to the standard. The most common reason was a ‘coronary history’ which was inconsistently defined with no patients having an acute coronary syndrome - the only reason given by NICE for changing this threshold. Departmental education, identification of pre-operative anaemia and a protocol explaining the use of oral and intravenous iron peri-operatively may reduce the amount of erroneous blood transfusion prescribing in this cohort.
896 The Effect of a Simple Intervention on Emergency Department Breaches in Trauma and Orthopaedics Patients: A Multi-Cycle Audit in a District General Hospital
Authors: Burnett-Jones L , Greenwood K , Mead A , Eltagy H , Elashry S
Published: November 2022

Aim

We present a re-audit of Emergency Department (ED) waiting times following an intervention to improve surgical bed flow with the aim of further reducing the number of Trauma and Orthopaedics (T&O) patients that breached the four-hour wait target.

Method

An initial two-cycle closed-loop audit of ED waiting times of patients admitted under T&O was undertaken. Protocols were updated and new guidelines were synthesised and implemented in collaboration between the ED and T&O departments. This intervention reduced the number of patients that breached in ED and identified bed availability as the primary cause of these breaches. A third cycle was done. Posters were placed in key prescribing areas of the T&O department, detailing the need for ‘to take-out’ (TTO) prescriptions ‘to be completed before 15:00 as after this time pharmacy will not dispense the prescription’. Data was collected retrospectively from clinical e-documentation. P-values were calculated by Fishers Exact test.

Results

57 patients were included in cycle 1 and 51 patients in cycle 2. ED breaches reduced from cycle 1 to cycle 2: 86% to 65% respectively (p < 0.05). In cycle 3, 42 patients were included, and breaches increased to 67% of patients, representing no significant change from cycle 2 (p > 0.05). The number of breaches due to a shortage of hospital beds increased from 45% in cycle 2 to 75% in cycle 3 (p < 0.05).

Conclusion

Bed shortages remained the main cause for T&O admissions to breach in ED. Earlier completion of TTO prescriptions did not solve the problem.
958 Enoxaparin Venous Thromboembolism Prophylaxis in Bariatric Surgery: A Best Evidence Topic Update
Authors: Pathmaraj B , Sufi P
Published: November 2022

Aim

To examine the literature and identify the best dosing regimen of enoxaparin for perioperative venous thromboembolism (VTE) prophylaxis in patients undergoing bariatric surgery. This presentation reviewed publications from 2015 to 2021 to determine whether previous recommendations based on a similar examination of evidence conducted in 2015 needed to be updated, considering new evidence.

Method

A literature search was conducted in accordance with a structured format. One hundred and one papers were identified using a standardised literature search from 2015 to 2021 on Medline and EMBASE using the same search terms “bariatric surgery” AND “venous thromboembolism” AND “enoxaparin”. The author, date and country of publication, patient groups and VTE prophylaxis strategy, level of evidence, outcomes, key results, and study weaknesses were tabulated.

Results

Three studies were selected as the best available evidence to answer the question. All three articles were non-randomised cohort studies analysing VTE and major bleeding rates following different bariatric thromboprophylaxis regimens. There was still no level 1 evidence available to answer this question.

Conclusion

Enoxaparin 40mg/day starting 12 hours after the operation, continuing for at least one-week post-discharge may be the best enoxaparin dosing regimen for VTE prophylaxis in bariatric surgery patients based on the best evidence available to 2021. New evidence suggests that the previously recommended 40mg enoxaparin twice daily for in-hospital patients may increase major bleeding risk. A Randomised Controlled Trial would probably require 3500 patients in each arm to identify the best enoxaparin dosing regimen.
266 Breast Cancer in Women Under 30: A Multidisciplinary Approach in a Unique Cohort
Authors: Khan S , Shaker H , Shrestha D , Shaw S , Wilson R , Abbas A , Ntanos I , Williams K , Wright C , Absar MS , Nasir N
Published: November 2022

Aim

Breast cancer in younger women is relatively rare, tends to be more aggressive and is associated with unique challenges. We sought to examine our practice in managing cancer in patients under 30.

Method

A retrospective case-note review was performed on patients under 30 years of age diagnosed with invasive breast through our pathology database since 2007. Clinical and pathological data was collected on patients’ cancers, management and follow up as well family history, genetic testing, and fertility management.

Results

Forty-five patients were identified. Median age was 28 years (range 20 to 30). Mean tumour size was 30mm (range 4–65mm). Seventeen (38%) of cancers were ER negative, 16 (36%) were HER2 positive.

Twenty-three patients (51%) had positive lymph node metastases. SIx patients (13%) had a strong family history and 9 (20%) were BRCA 1 or 2 gene positive. Seven patients (15%) underwent contra-lateral risk-reducing mastectomy. Twenty-5 patients (55%) had no children at diagnosis. Fertility management was discussed with >90% of patients and 12 patients (26%) underwent ovum or embryo preservation.

Over a median follow up of 40.5 months (range 4.5 to 128 months), 8 patients (18%) developed local or distant recurrence and 6 patients (13%) died (due to metastasis).

Conclusion

In our experience, breast cancer patients under 30 had more aggressive cancers with a relatively high rate of axillary metastases at presentation. Young patients with breast cancer face unique management challenges such as fertility, genetic testing and survivorship issues that are best addressed in a multidisciplinary setting.
267 Axillary Recurrence Following Negative Sentinel Lymph Node Biopsy for Symptomatic Invasive Breast Cancer: A Ten-Year Review
Authors: Khan S , Shaker H , Evans S , Wilson R , Abbas A , Nasir N , Ntanos I , Williams K , Wright C , Absar MS
Published: November 2022

Aim

Sentinel node biopsy (SNB) became established as the standard approach (versus axillary clearance) for axillary staging in the 2000s. This was based on studies showing reductions in short-term morbidity. Symptomatic cancers are biologically more aggressive than screen-detected cancers and are more susceptible to late loco-regional recurrence. Few studies have examined long-term axillary recurrence following SNBs in this subgroup.

Method

A retrospective case-note review was performed on 82 symptomatic breast cancer patients who had a negative SNB between 2009 and 2010. Clinicopathological data was collected on cancers, axillary nodal pathology, recurrence, and survival.

Results

Median age was 57 years (range 23–87). Mean tumour size was 20mm (range: 5–50). Fourteen cancers (17%) were ER negative, 11 (19.3%) HER2 positive and 30 (36.3%) were grade 3. Sixty-one (74%) patients had breast-conserving surgery and 21 patients (26%) underwent a mastectomy.

After a median follow up of 11.8 years, 3 (3.7%) local, 1 (1.2%) axillary and 10 (12.2%) distant recurrences were seen. Twenty patients (25%) died. The median OS was 11.64 years (range: 1.20–12.47) and median DFS was 11.50 years (range: 1.14–12.47). Axillary recurrence rates were comparable to other studies that contained predominantly screening cancers (0.7–1.6%).

Conclusion

The risk of axillary recurrence and remains low at 10-year follow up after a negative SNB in symptomatic patients. This is comparable to that of follow up studies in mixed (screening and symptomatic) cohorts demonstrating equivalent long-term oncological safety in this biologically more aggressive cohort.
817 Our Experience of Management of Nipple Discharge
Authors: Khitab N , Hudson-Phillips S , Joshi S , Vig S
Published: November 2022

Aim

Evaluation of nipple discharge is a multidisciplinary practice requiring careful evaluation of the patient, their age and history. This study considers whether smoking is a contributory factor and if microdochectomy or Hadfield's procedure offered any additional benefit.

Method

A retrospective analysis of all patients undergoing microdochectomy or a Hadfield's procedure for nipple discharge over the last three years (2019–2021) at a DGH breast unit was undertaken. Patient demographics, smoking history, pre-operative imaging, and histopathological findings were accessed from the patient electronic records.

Results

38 patients were included in this study, 29 patients undergoing a Hadfield's procedure, and 9 a microdochectomy. 82% of patients were non-smokers (n=31), 8% (n=3) were ex-smokers, 3% (n=1) heavy smokers, and 8% of records were not available. 45% (n=17) presented with bloody discharge.

Histologically the main diagnoses were duct ectasia found in 29% (n=11) of patients, papilloma in 47% (n=18), combined duct ectasia and papilloma in 5% (n=2), benign breast changes in 13% (n=5), duct ectasia and squamous metaplasia of lactiferous ducts (SMOLD) in 3% (n=1) and focal apocrine metaplasia in 3% (n=1). In 5% (n = 2) there was a small focus of low-grade DCIS which needed further wide local excision.

Conclusion

Smoking was not found to be a major contributing factor in the aetiology of nipple discharge. Although less surgically invasive options such as microdochectomy should be considered, the duration and age of a patient should be considered to reduce the small risk of missing non-calcifying DCIS, not visible on preoperative imaging mammogram.
100 Triaging Two Week Wait Referrals According to ABS Guidelines Established During the COVID-19 Pandemic Is Safe Practice
Authors: Sadik N , Rutherford C , Ledwidge S , Johnson L
Published: November 2022

Aim

CoVid-19 has affected healthcare globally, disrupting cancer care. Two weeks wait (2ww) breast cancer referrals were triaged according to Association of Breast Surgery (ABS) guidelines with patients with no red flag symptoms deemed low risk and able to be discharged back to their GP. This study aimed to assess the safety and efficacy of implementing these guidelines.

Method

A database was established to prospectively collect 2ww breast cancer referrals from the outset of CoVid-19. Two Consultants triaged the referrals and if there was disagreement, a third Consultant arbitrated. Data were recorded for patient age, gender, presenting complaint, assessment, investigations, diagnosis, and outcome and also time from initial referral to discharge letter to the GP.

Results

188 patients were referred via the 2ww pathway to St Bartholomew's Hospital from 22/03/2020 to 08/04/2020. 43 (22.9%) were discharged with a median age of 34 (22–83 years) at the time of referral. The mean time from referral receipt to response was 12.1 (0 – 60 days). 15 (34.9%) patients were subsequently re-referred. Mean time from re-referral to one-stop clinic assessment was 9.1 (2 – 22 days), in keeping with NICE two week wait criteria. Of the patients re-referred, all patients underwent imaging in the form of mammogram and/or ultrasound scan. No patients were found to have pre-invasive or invasive disease.

Conclusions

Triaging patients based on GP referrals is a safe way of streamlining low risk patients. This has the potential to become standard practice worldwide but requires larger multi-centre studies prior to implementation.
191 The Effect of Covid-19 on the Management of Acute Ureteric Colic in a Tertiary Hospital
Authors: Sen P , Edison E , Smith D
Published: November 2022

Introduction

The Covid-19 pandemic forced changes to care pathways. We have analysed the difference in provision of care to patients presenting with ureteric colic during the pandemic (PC) compared to a pre-pandemic cohort (PPC).

Method

A list was generated of all CT KUB scans requested in the emergency department. Imaging and notes were reviewed to identify acute ureteric colic presentations in September to December 2019 and 2020. Statistical significance was calculated using either the Student T-test or Chi-squared test.

Results

There were 92 patients in the PC, and 107 in the PPC.

Primary treatment was provided for more patients during the pandemic (25% vs 10%, p<0.05), mainly by extracorporeal shockwave therapy (ESWL, 21% vs 7%, p<0.05).

The rate of conservative management (64% vs 76%, p>0.05), temporising stent (11% vs 14%, p>0.05), and nephrostomy insertion (1% vs 1%, p>0.05) was similar in PC and PPC.

The PC had a shorter time to intervention (17 vs 39 days, p<0.05), to ESWL (4 vs 12 days, p>0.05), to ureteroscopy (35 vs 45 days, p>0.05), and to stone passage confirmation (44 vs 91 days, p<0.05) respectively.

There was no follow up for 15% and 30% respectively (p<0.05).

Conclusion

During the pandemic, a reduction in electives created capacity for urgent interventions, (21% vs 7% ESWL, 4 vs 12 waiting days). Accordingly, the stone passage confirmation time was more than halved (44 vs 91 days). In accordance with recommendations from NICE, TISU and GIRFT, this demonstrates the importance of ringfencing ESWL, particularly as we emerge from the pandemic.
213 Impact of COVID-19 Pandemic on Surgical Education and Training: A Resident Survey in a Low-Income Country
Authors: Fatima S , Arham M , Shafique MS , Waqar Bhatti H
Published: November 2022

Aim

The COVID-19 pandemic has adversely affected medical education and training programmes worldwide. This study aims to assess the impact of COVID-19 pandemic on surgical education and training in a low-income country.

Method

This cross-sectional study was conducted in Allied hospitals of Rawalpindi Medical University, Rawalpindi, Pakistan, from June 2021 to July 2021. A structured questionnaire designed by the researchers was distributed to all surgery departments, and surgical residents who consented to participate in this study were included. Data was analyzed using IBM SPSS v25.

Results

A total of 152 residents participated in this study, of which 53 (34.9%) were in general surgery and 99 (65.1%) in various surgical allied specialties. A large number of respondents reported a severe to complete reduction of elective surgical procedures (78, 51.3%), outpatient clinical activity (54, 35.6%) and academic sessions (86, 56.6%). A signiﬁcantly higher number of general surgery residents (52.8%) reported increase in emergency surgical procedures as compared to surgical allied specialties (35.4%) (P=0.037). Majority of the respondents believed that loss of surgical training opportunities had a negative impact on their training and job performance (127, 83.6% and 130, 85.5%, respectively) with 43 (28.3%) residents suggesting an extension in training program. 137 (90.1%) residents reported increased stress and anxiety levels with the number of surgical allied residents signiﬁcantly higher than general surgery residents (P=0.031). 125 (82.2%) respondents claimed that fear of contracting the virus affected proper patient evaluation.

Conclusions

COVID-19 pandemic has severely impacted the training and psychological wellbeing of surgical residents and drastically affected patient evaluation.
996 Impact of Extremes of BMI on Outcomes Following Lung Resection
Authors: Ahmed-Issap A , Mushtaq R , Jain S , Abah U
Published: November 2022

Aim

Body Mass Index (BMI) has been shown to be an independent predictor of survival following lung resection for non-small cell lung cancer. This study aimed to quantify the short-term impact of abnormal BMI on outcomes following all lung resections.

Method

Lung resections at UHNM were examined from 01/01/2012 to the 07/07/2021. Variables were extracted from a retrospective database. Patients were divided into three cohorts: low BMI (<18.5), normal/high BMI (18.5–29.9) and obese BMI (>30). Post-operative complications, length of stay and 30-day mortality were examined.

Results

2439 patients were identified. 2341 BMI values were available and included. 2.6% (n=60) had a low BMI, 67.7% (n=1586) had a normal/high BMI and 29.7% (n=695) had obese BMI. Post-operative complications were found to be higher in the low BMI group (43.3%) when compared to a normal/high and obese BMI group (30.8% and 23.2%, respectively). Length of stay was higher in the low BMI group (10.2 days) compared with normal/high or obese BMI group (7.5 and 6.3 day, respectively). 30-day mortality was higher in the low BMI group (8.3%) compared with the normal/high and obese BMI group (2.0% and 1.7%, respectively).

Conclusions

Low BMI is associated with significantly worse immediate post-operative outcomes and approximately a four-fold increase in mortality when compared with obese BMI. Obesity appears to incur a protective effect in mortality.
758 Unique Case of Recurrent Non-Neutropenic Typhlitis
Authors: Sahni D , Stockdale H , Leiberman D , Stevenson R
Published: November 2022

Tacrolimus is an important component of the immunosuppressive regime used after solid organ transplantation. It is known to predispose patients to typhlitis also known as neutropenic enterocolitis, which presents with the characteristic triad of abdominal pain, fever, and neutropenia.

A 66-year-old lady was referred with vomiting, abdominal pain, and passage of blood per ileostomy. The patient had an extensive medical history including a panproctocolectomy for Crohn's disease, cholecystectomy and a liver transplant. Her immunosuppressive regime included prednisolone, azathioprine, and tacrolimus. Based on her presentation, a presumptive diagnosis of ischemic bowel was made, and non-contrast (due to AKI) CT scan demonstrated evidence of intramural gas with marked mesenteric and portal venous gas. The decision was made to proceed to laparotomy, the findings of which included dense adhesions but with normal healthy small bowel. After several investigations, it was concluded that her symptoms were caused by typhlitis secondary to her tacrolimus therapy.

In 2020, the patient presented with similar symptoms. She was able to undergo a contrast-enhanced CT scan during this episode as she had presented early with preserved renal function. Her radiological findings were similar to the previous episode. However, owing to her known past history, she was managed conservatively.

To the authors knowledge, no similar cases have been reported so far, which makes this case unique and makes a strong motion for the clinicians to maintain a high suspicion for typhlitis inmmunocompromised patients, even in absence of classical feature of neutropenia
446 Efficacy of Early Gastrografin Use in Adhesional Small Bowel Obstruction
Authors: Hama B , Khawgali M , Elsharif M , Peter M
Published: November 2022

Aim

The aim of this audit was to establish the outcomes in patients who receive gastrografin versus patients who do not receive gastrografin in patients with adhesional small bowel obstruction (SBO).

Method

This was a retrospective data collection of patients admitted with “small bowel obstruction” between June and September 2021. Further patient selection criteria were applied. Data was collected using the EPR system and assimilated using Excel spreadsheet.

Results

A total of 76 patients with SBO were identified. 32 patients were diagnosed with adhesional SBO. Of these, 21/32 had previous maximally invasive surgery, 7/32 has previous minimally invasive surgery, and 4/32 had no previous surgery.

17/32 patients received gastrografin, of which 15 resolved and 2 needed surgery (1×laparoscopic adhesiolysis and 1×laparotomy). Average length of stay in patients who received gastrografin was 4.2 days.

15/32 patients did not receive gastrografin, of which 6 resolved and 9 needed surgery (7×laprascopic adhesiolysis and 2×laparotomy). Average length of stay in patients who did not receive gastrografin was 10.3 days.

Conclusions

Early use of gastrografin in stable patients with adhesional SBO appears to have good outcomes and should be considered after discussion with senior clinicans. Patients who are septic, severely tender on examination or who show signs of ischaemia should not have surgery delayed. Formal standard operating procedures (SOP) should be developed for the management of adhesional SBO.
776 Patient Outcomes Vary with Surgeons’ Experience Following Emergency Laparotomy: An Observational Study
Authors: Sultana E , Naumann DN , Williamson A , Griffiths E , Bedford M , Karandikar S
Published: November 2022

Aim

There is some evidence that patient outcomes for surgeons improve with years of experience. We aimed to investigate the relationship between surgeon experience and patient outcomes following an emergency laparotomy in a large sample of the UK National Emergency Laparotomy Audit (NELA) database.

Method

A 5-year retrospective observational study was undertaken using data extracted from NELA for patients who underwent emergency laparotomies at a large UK multi-site NHS Trust. The association between 30-day mortality and surgeon years of experience was investigated using logistic regression, adjusted for ASA grade, patient age and gender, Index of Multiple Deprivation (IMD) score, and time of surgery.

Results

There were 3153 patients with a median age of 66 (IQR 51–76), and 49.4% were male. Patients in the group who died within 30 days were more likely to be older, have a higher ASA score, and have an operation during the night. Increasing years of surgeon experience, patient age, and ASA were all significantly associated with increased odds ratio of death within 30-days.

Conclusions

Increasing years of surgical experience appears to be related to worse patient outcomes for an emergency laparotomy. This is likely due to surgeons taking on more complex and challenging cases as their career progresses. Further explorations of how surgeons’ activity changes over their full career are warranted.
875 Atraumatic Splenic Rupture Secondary to Ruptured Pancreatic Pseudo Cyst- a Rare Phenomenon
Authors: Okpala A , Chew M , Shaaban M
Published: November 2022

Introduction

Chronic pancreatitis can be complicated by the development of a pancreatic pseudocyst in 20 – 40% of cases. Splenic rupture is usually associated with blunt trauma but can be associated with non-traumatic causes like pancreatic pseudocysts associated with chronic pancreatitis.

Atraumatic splenic rupture (ASR) is rare, and a life-threatening process with a mortality of about 12%. Possible mechanisms of action of pancreatic pseudocysts causing ASR to have been described in literature, with some of them involving the action of proteolytic enzymes on the splenic vessels, parenchyma and hilum. Management of these cases involves resuscitation, and emergency splenectomy because they usually present with haemodynamic instability.

Case report

A 50-year-old woman with a background of pancreatic pseudocyst secondary to alcoholic chronic pancreatitis presented with severe left sided abdominal pain. A Computed Tomography (CT)scan confirmed the presence of splenic rupture with moderate haemoperitoneum. Emergency laparotomy revealed a ruptured and necrotic spleen adjacent to a ruptured pancreatic pseudocyst. A splenectomy was performed with abdominal packs left insitu with the view to a relook surgery 24 /48 hours later. She recovered uneventfully after HDU care.

Conclusions

ASR secondary to pancreatic pseudocyst as a complication of chronic pancreatitis is a rare phenomenon which requires a high index of suspicion for diagnosis. CT is the gold standard imaging modality for investigation in a haemodynamically stable patient. Management is surgical with adequate resuscitation and perioperative critical care.
1018 Emergency General Surgery; Physiology and Frailty Assessment with Surgical Outcome Analysis, in a Single-Centre Retrospective Cohort Study
Authors: Elamin A , Torzilli G , Ceolin M , Kurihara H , Jaly Y
Published: November 2022

Introduction

Emergency General Surgery (EGS) deals with the most critical of patients. It is a field that requires the precise and timely execution of life-saving interventions. For this reason, many studies have been conducted in order to find the optimal management plans.

Our research compared different scoring systems, to see which performed best in regard to Geriatric patients. Scoring systems included: APACHE II, ASA, ACS-NSQIP, MPI, and Frailty Score. The Clavien Dindo classification was utilised as a comparative tool.

Our secondary objective was to determine which variables had the greatest effect on patient outcomes. These variables included Age, Sex, BMI, Time to Surgery, Beta-blockers, ‘Open Abdomen’ treatment, Blood Transfusions, Anticoagulants, and Vasopressors.

Method

The database included 212 patients who underwent EGS in a consecutive 24-month period.

Results

All of the scoring systems proved to be statistically significant with the ACS and the ASA being most effective for predicting death and short-term complications.

Regarding variables, we performed both univariate and multivariate testing. For predicting the risk of death, ‘Open Abdomen treatment’, Blood Transfusions, and Vasopressors were statistically significant. For estimating the risk of short-term complications only Blood Transfusions and Vasopressors proved significant

Conclusions

We must take into consideration that the other systems had significant results, therefore we must contemplate if there were compounding factors. To rectify this, further studies should be conducted ensuring correct parameters are respected, for example, the APACHE II should only be used in ICU patients and within the first 24 hours of admission.
330 Gender Differences in Mortality After Stroke in Thai Patients. a National Cohort Study
Authors: Abdel-Fattah AR , Pana T , Tiamkao S , Sawanyawisuth K , Kasemsap N , Mamas M , Myint P
Published: November 2022

Aim

Gender differences in patients hospitalised with stroke is a major public health concern carrying important implications to service provision. There has not yet been a study specifically focussing on patients in Thailand. We aimed to assess the gender differences in mortality following ischaemic-stroke (IS) and haemorrhagic-stroke (HS) in a large Thai-cohort.

Method

All stroke admissions of patients between 2004–2015 were included from a Thai national-insurance database. The association between gender and mortality by stroke-type was assessed at one, 12 and 60-months using multivariable Cox-regression models.

Results

There were 543,763 patients included women made up 46.6% of patients with IS (n=172,800) and 41.3% of patients with HS (n=69,828). Women were older than men in both IS and HS groups (mean age:67.1, SD(13.4) vs. 64.1(12.9) and 64.2(14.3) vs. 59.1(13.9)), respectively. Women had higher prevalence of comorbidities and stroke-specific risk factors compared to men. When comparing mortality by stroke-type, mortality was higher in women post-IS at one-month (HR:1.17, 95%CI:1.15–1.20), one-year (HR:1.10, 95%CI:1.09–1.12) and five-years follow-up (HR:1.02, 95%CI:1.01–1.03). Similarly, mortality post-HS was also higher in women at all three follow-up timepoints (one-month HR:1.08, 95%CI:1.06–1.10, one-year HR:1.04, 95%CI:1.03–1.06, and five-years HR:1.09, 95% CI:1.08–1.11).

Conclusions

In Thai patients hospitalised with stroke, women have a greater burden of stroke-specific risk factors. The mortality outcome of women with stroke is consistently higher than that of men, which appears to be irrespective of stroke-type or duration following stroke, up to five-years after discharge. Whether this difference is attributable to differences in management or physiology warrants further evaluation.
599 Bullying and Harassment Awareness Amongst Junior Doctors – an Audit in Morriston Hospital Plastic Surgery Department
Authors: Hadjikyriacou E , Mistry R
Published: November 2022

Aim

Determine junior doctors’ awareness of bullying and harassment policy and legal requirements of the health board. If lack of knowledge/training, provide required training in the form of staff teaching. Improve workplace culture and staff safety.

Method

All junior doctors (total of 10) in the plastic surgery department were asked to fill in questionnaire about their experience of bullying and harassment in the workplace. They were asked about their personal experience of bullying and harassment, awareness of the health boards duty, reporting culture and barriers to reporting. The change implemented was staff training and information on where to access health board policies and protocols. After training, a second questionnaire was filled in to see if there was better understanding of the health board policy and the necessary steps in the event of a bullying or harassment incident.

Results

The health boards policy was easy find on the health board intranet. In the initial questionnaire: 6 out of 10 junior doctors reported experiencing bullying or harassment in the NHS, all 10 reported not being able to define bullying and harassment; and a lack awareness of NHS Wales’ bullying and harassment policy. All 10 reported that they had not reported any bullying and harassment experienced. The junior doctors were asked about barriers to reporting, all 10 identified concerns about repercussions professionally as the main barrier.

Conclusions

Training on how to identify bullying and harassment, the pathways of escalation and a change in culture over professional repercussions are vital for surgical trainees going forward in the NHS.
235 A Closed Loop Clinical Audit on the Implementation of WHO Surgical Safety Checklist at a Tertiary Hospital in India
Authors: Sinha AV , Kadam S
Published: November 2022

Aim

To complete an audit on the level of compliance to the WHO surgical safety checklist in surgical operating theatres at a tertiary hospital in India.

Method

A total of 40 surgical operations were observed at the operating theatres at a tertiary hospital to confirm the practice of the WHO surgical safety checklist which formed the prospective part of our study. The study was conducted for a period of 2 months starting from July to August 2021. The results were then compared with standard guidelines and analyzed. Interventions were carried out by a series of rigorous meetings and discussions with the medical and the nursing staff. Results were re-audited after 2 weeks.

Results

Of all the operations audited, 45% Sign-In and only 1% Sign-Out were performed in the first cycle. After the re-audit, a significant change was reported as the Sign-In improved to 80% and a 55% Sign-Out was conducted. The Time-Out was observed to increase from 15% to 65%.

Conclusion

Compliance is seen to be greater in major surgeries than in minor surgeries. Compliance with all items in the checklist and active participation by all medical and nursing staff is mandatory for successful implementation of the Surgical safety checklist.
610 A Case Report of Furuncular Myiasis Affecting the Glans Penis of a Young Boy Caused by the Larvae of Cordylobia Anthropophaga (The Tumbu Fly)
Authors: Jesuyajolu D
Published: November 2022

Introduction

Cutaneous myiasis is endemic in West Africa, and it is most commonly caused by the larvae of Cordylobia anthropophagia. In English literature, there has been no recorded case of this cutaneous myiasis affecting the glans penis. Its rarity calls for a need to consider this as a differential when looking at furuncular lesions of the glans penis. This awareness is important for practitioners who may come across this case.

We report a case of furuncular myiasis of the glans penis due to the larvae of C.anthropophaga of an 11-year-old boy living in Lagos, Nigeria.

Case presentation

We present an 11-year-old boy who presented to the surgical department with a lesion on his glans penis, initially thought to be a boil. Upon examination, the lesion contained a single larva of C.anthropophaga. It was extracted in the minor theatre with a non-toothed forceps, and the area healed well following discharge. (Pictures of extracted larvae are available upon request).

Discussion

Although endemic, furuncular myiasis of the glans penis is a very rare condition, likely related to the living circumstance of the patient. An awareness of the clinical features is important so as to prevent misdiagnoses of foruncular lesions that occur on the glans penis, especially in people with identified risk factors.

Health education and promotion of good hygiene are important in reducing the incidence of Cordylobia anthropophagia infestation.
655 Is It Time to Change Practice in Patients with Unilateral Inguinal Hernia – a Comparative Study of Laparoscopic vs Open Hernia Repair in LMIC Country
Authors: Hakeem A , Saqib S , Zafar H
Published: November 2022

Aim

Our aim was to assess if a return to regular activity is improved in patients undergoing one-sided inguinal hernia repair. This is critical in LMIC countries where finances are constrained, and the cost of laparoscopic repair is significantly higher than the open technique.

Method

The study was conducted at Aga Khan University Hospital, Pakistan. Patients between ages 16 to 65 planned for unilateral inguinal hernia repair were selected using non-probability consecutive sampling. Patients were selected from 1st May 2016 till 30th April 2017 and were divided into two groups. Group A included patients having laparoscopic TAP repair while Group B consisted of Liechtenstein hernia repair. All patients were followed at 1 week for resumption of regular activities, at 1 and 3 years for recurrence, the study was concluded on 30th April 2020.

Results

A total of 60 patients were enrolled in this study. Group A and B each had included 30 patients. The mean duration of return to work in group A was 5.33 ± 4.46 days and for group B it was 6.83 ± 4.58 days. There was 1 recurrence seen at 3 years in Group A.

Conclusions

Hernia recurrence is not different from the technique of repair at 1-year follow-up. Laparoscopic repair although is associated with little early return to work when compared with open technique but this difference was not statistically significant in our study. The decision of the type of repair should be balanced between surgeon expertise and patient's wishes.
288 Re-Audited QIP on Accuracy of Documentation in the Surgical Notes and Discharge Letter
Authors: Karki BB , Wolff J , Tsao A , Basamh M , Runau F
Published: November 2022

Aim

To identify and review the discrepancy between the documentation in the surgical operation notes and discharge summaries. To evaluate the surgical operation notes and assess its compliance with the RCS standard.

Method

Prospective audit of 64 General Surgery operation notes and their respective discharge letters was carried out in two cycles from March- June 2021. Royal College of Surgeons England Good Surgical Practise, 2014 was used to audit the general surgery notes. Teaching sessions were carried out after the first cycle for the use of Electronic Operation Notes. Furthermore, comparison of this audit results with the different trust following Electronic Operation notes were carried out.

Results

Operation notes and discharge letters were reviewed on variables like date of procedure, quality of performa based on RCSEng guidelines. There was 50% increase in the use of Typed Operation Notes in the second cycle which showed a significant decrease (almost 50%) in the mentioning of incorrect operation dates. 65% of the handwritten notes were not comprehensive enough or legible. However, Electronic operative note had significant adherence to the RCS guideline. When these data were compared to the other trust using Electronic Operation Notes all the highlighted issues were found in a negligible ration.

Conclusions

As the data suggests that handwritten Operation Notes were not comprehensive and legible hence replacing these with the electronic operation notes would be best practice. Fully compliant electronic operation notes, reducing in variability by opting single and procedure specific Performa will help to mitigate the issues highlighted.
424 High Volume vs. Low Volume Transversus Abdominis Plane (TAP) Blocks and Post-Operative Pain in Elective Colorectal Surgery- the More the Merrier?
Authors: McQuillian J , McCulloch L , Bruce E , Ramsay G
Published: November 2022

Introduction

Transversus abdominis plane (TAP) regional anaesthetic blocks are often performed by surgeons and provide effective anaglesia in the immediate postoperative period. It is not known whether the volume and concentration of local anaesthetic used for TAP blocks influences the quality of analgesia when the total drug dose is similar.

Aim

This pilot aimed to compare low volume versus high-volume TAP block and post-operative pain in patients undergoing elective colorectal surgery, using analgesic consumption as a proxy for pain.

Method

Single centre cohort study. Data were collected for patients undergoing elective colorectal resections from April – December 2021. Patients were cohorted into those receiving low-volume, high-concentration TAP block (40–50ml 0.25% levobupivacaine) and those receiving high-volume, low-concentration TAP block (100ml 0.125% levobupivacaine). Data including PCA (patient-controlled analgesia) type (morphine/ oxycodone) and post-operative consumption were collected.

Results

107 patients undergoing elective colorectal resections were identified. Data regarding TAP block usage was available for 55 patients. 23 (41.8%) patients were given high volume TAP blocks. 78.3% (p=0.56) of patients in the high-volume group were prescribed a PCA postoperatively, compared to 84.3% in the low-volume group. Median morphine PCA consumption was 11mg in the high-volume cohort, compared to 18mg in the low volume cohort (p=0.23).

Conclusions

High volume TAP block was associated with reduced requirement for a post-operative PCA and a reduced consumption of morphine PCA. Although not statistically significant in our small sample size, our results may be of interest to surgeons and suggest that the use of high-volume TAP blocks warrants further study.