bluuebunny/crossref_metadata_2025 huggingface dataset:
SP2.2.6 Long-term outcome predictors in laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK
Authors: Schneider Crispin , Bogatu Diana , Leahy John , Patel Priya , Heaton Nigel , Menon Krish
Published: November 2022

Aims

Minor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR.

Methods

Consecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014–2021 were compared. Selection from a plethora of factors potentially impacting disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR).

Results

There were 111 liver resections with 55 and 56 patients undergoing LLR or OLR, respectively. LLR patients had a shorter hospital stay (5±2 vs. 7±2 days; p<0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p=0.006). Mean DFS (33.9±3.4 vs. 36.5±3.6 months; p=0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC (HR 3.79; C.I. 1.56–9.22; p=0.0033) or satellite lesions (HR 3.32; C.I. 1.80–6.10; p=0.0001), tumour size (HR 1.15; C.I. 1.03–1.28; p=0.0107) and AFP level (HR 1.01; C.I. 1.00–1.01; p=0.016) predicted DFS.

Conclusions

In the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. Neoadjuvant and adjuvant therapy for HCC are increasingly being employed and it is hoped that the outcome predictors identified here, may aid in selecting patients who are most likely to benefit from these adjuncts.
SP3.1.1 Follow-up After Acute Diverticulitis: Can We Reduce the Burden on Endoscopy Services?
Authors: Dean Harry , Britton Emily , Farrow Emily , Abdel-Khaleq Sameerah , Bradbury Molly , Cook Tim
Published: November 2022

Background

Acute diverticulitis (AD) is a common cause of presentation to emergency surgical services. Follow-up with endoluminal investigation to exclude colorectal cancer (CRC) remains controversial. Guidelines are increasingly moving to a more restrictive follow up based on severity of disease and age. The purpose of this study was to assess the prevalence of CRC in AD patients and the impact of follow-up on endoscopy services.

Methods

Patients admitted with a diagnosis of AD over a 2-year period were reviewed. The proportion of patients undergoing endoscopic follow-up and the CRC detection rate were recorded. The potential impact of a more conservative approach to follow-up was evaluated.

Results

There were 484 patients with AD presenting 546 times (M:F = 198:286; median age = 63 years). 80% of admissions were aged 50 or older. There were 43 emergency interventions in 39 patients (10 percutaneous drain; 33 surgery). The remainder were managed conservatively. 28 patients (5.1%) underwent colonic resection with cancer found in one specimen (3.6%). 286 patients underwent endoluminal follow-up with cancer diagnosed in 3 cases (1.0%). There was no significant difference in the prevalence of CRC between patients requiring emergency surgery and those managed conservatively, or between patients with complicated versus uncomplicated diverticulitis.

Conclusion

CRC masquerading as acute diverticulitis is rare. The incidence of neoplasia both at endoscopic follow-up and in patients requiring emergency intervention is low. Conservative follow-up strategies appear safe, but their effectiveness in reducing the burden on endoscopy services may be limited by current age-based recommendations.
SP3.1.2 Antibiotics therapy may not be required in patients with CT proven uncomplicated acute diverticulitis: A systematic review
Authors: Imsirovic Anja , Peristeri Dimitra V , Nour Hussameldin M , Swaminathan Christie , Sajid Muhammad S
Published: November 2022

Aims

Acute diverticulitis (AD) is one of the major acute surgical conditions which need either hospital admission or a dedicated ambulatory care services in order to provide conventional antibiotics therapy. Regular use of antibiotics for all cases of acute diverticulitis has recently been challenged. The aim is to evaluate the necessity of antibiotics in patients presenting with CT proven uncomplicated AD.

Method

A systematic search was undertaken and relevant published randomized controlled trials (RCT) were shortlisted according to the inclusion criteria. Summated outcomes, including failure to response to intervention, recurrence rates and surgery during the acute admission, were analyzed using the principles of meta-analysis on RevMan 5 statistical software.

Result

Four RCTs on 1756 patients who presented with CT-proven uncomplicated diverticulitis were included in this review. There were 879 patients in the antibiotics group (AG) and 877 patients in the no-antibiotics group (NAG). The failure to response to intervention (use of intravenous antibiotics) was not statistically significant between the two groups, however slight statistical favour was observed in AG [OR 0.49, 95% CI (0.22–1.06), z=1.81, p=0.07]. There was no statistical difference related to recurrence rates of acute diverticulitis between the two groups. Finally, the need of surgical intervention following both interventions was also statistically similar [OR 0.63, 95% CI (0.29–1.36), z=1.18, p=0.24].

Conclusion

The use of antibiotics in patients with CT proven uncomplicated AD does not seem to improve the short-term outcomes; therefore it can be carefully omitted in selected patients. More RCTs of robust quality are required to validate these findings.
SP3.1.5 Can Acute Uncomplicated Diverticulitis be managed Ambulatory?
Authors: Kronberga Madara , Hussain Shaista , Hama Bawan , McLaughin Kate , Peter Mark , Saha Arin
Published: November 2022

Introduction

The most common complication of diverticulosis is diverticulitis, which can be described as complicated or uncomplicated if the inflammation is confined to the bowel wall and/or pericolonic fat. Acute uncomplicated diverticulitis (AUD) is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. However, newest World Society of Emergency Surgery (WSES), ACPGBI and NICE guidance suggest that AUD should be managed in ambulatory setting.

Aims

To establish if Calderdale and Huddersfield NHS Foundation Trust is complaint with national standards and if this can be carried out safely.

Methods

Retrospective data collection of patients diagnosed with AUD between June and August 2021. Inclusion criteria used: CT proven AUD, age <80, patient able to tolerate oral intake, have full capacity and be immunocompetent.

Results

69 patients were diagnosed with acute diverticulitis between June and August 2021. 31 of these patients matched inclusion criteria, with 17 been treated as inpatient (IP) and 14 as outpatient (OP). The average length of hospital stay was of 24h for IP vs 4,5h for OP. The average deprivation index for IP was 16891 vs 15961 for OP. From the OP group, 2 patients re-presented in hospital, however, none of them needed admission.

Conclusions

Our results show that despite our low compliance with national standards (45%), patients with AUD can be safely managed in OP setting with low risk of re-admission. Additionally, by improving our compliance, Trust resources could be saved and bed pressures alleviated without compromising patient safety.
SP3.1.6 Robotic versus Laparoscopic and open colorectal resections – comparison of short term postoperative outcomes over 3 years
Authors: Nair Nandu , Kobylarz Matthew , Gaunt Anne , Garimella Veerabhadram , Roy Sudipta , Varghese Philip
Published: November 2022

Aim

To compare the short terms surgical and oncological outcomes of elective robotic versus laparoscopic and open colorectal resections done over a period of 3 years at a single centre.

Methods

All robotic colorectal resections performed during a three year period (2017–2019) at a single centre were compared with laparoscopic and open resections from the same period. Data including patient demographics, preoperative and postoperative oncological staging, length of stay, 30 day readmission, need for critical care stay, 30 day complication rate (using clavien dindo classification) and immediate oncological outcomes were collected from electronic patient records.

Results

During the three year period, 188 robotic resections (82.9% - rectal resections, 17.1% colonic resections) of which 178 were cancer resections were performed. In the same period 585 laparoscopic and 116 open colorectal resections were performed. Conversion rate for robotic resections was 3.72%. Median lymph node harvest for the robotic resections was 20. Major complication rate in the robotic group was 5.3% as compared to 6.1% for the open and laparoscopic group. Median length of stay in the robotic group was 5 days which was significantly lower than for open rectal resections (11 days, p<0.0001). Although there was no statistically significant difference in length of stay between robotic (5 days) and laparoscopic rectal resections and colonic resections (7 and 6 days respectively).

Conclusion

Robotics is a safe approach for colorectal resections with good oncological outcomes and our experience demonstrates a shorter length of stay and reduced complications.
SP3.1.7 Does using intra-operative indocyanine green impact the clinical suspicion of anastomotic leak?
Authors: Ng Samantha , Komolafe Olusegun
Published: November 2022

Aims

To see if the beneficial impact of indocyanine green (ICG) angiography on anastomotic leak (AL) rate was reflected in the “suspicion” of leak in patients undergoing rectal or sigmoid cancer resection.

Methods

Patients who have intra-operative ICG fluorescence have reduced clinical AL rates, with a shorter length of stay (LOS). Recent publications have suggested stricter criteria to categorize AL. A prospectively-maintained database was reviewed to see if there was a difference in the suspicion of AL between patients who did and did not receive intra-operative ICG. A total of 159 rectal and sigmoid cancers were diagnosed between 1 April 2020 and 31 March 2021 in our health board, with 75 patients proceeding to surgery. Only patients receiving primary anastomosis were included in this study (n=33). Post-operative CT scans performed, diagnosis of AL, Clavien-Dindo complication rates, use of antibiotics beyond 48 hours, and LOS, were studied.

Results

39.4% (n=13/33) received intra-operative ICG whilst 60.6% (n=20/33) did not. The median LOS was 3 days in the ICG group and 6.5 days in the non-ICG group. There were less CT scans, antibiotic use, complications, and post-operative interventions in the ICG cohort.

Conclusion

This is a small-sized snapshot audit, however it demonstrates that the reduced AL rate in patients having intra-operative ICG is reflected in their post-op journey of care, with a clear difference in interventions, and no greater number of “sub-clinical” leaks in the ICG cohort. The study will be expanded to see if this data is consistent in a larger study.
SP3.1.8 2ww Colorectal referral proformas: is the inclusion of recent bowel investigations relevant?
Authors: Nunn Rebecca , Hassan Adil , Allgrove Carol , Vivekanandan Shanmugam , Vijay Vardhini
Published: November 2022

Aims

Straight-to-test (STT) decisions are made on the basis of the details contained within the referrer's documentation. This is particularly important for Two-week wait (2ww) referrals where incomplete or missing information may result in unnecessarily duplicating investigations- incurring a cost to resources as well as exposing patients to potential harm. Through reviewing GP 2ww referrals, we highlight the prevalence of incomplete information relating to recent bowel investigations.

Methods

A prospectively maintained database consisting of 2ww Colorectal referrals from primary care was analysed over a 12-month period (January 2021- December 2021). The agreed local standard is that any bowel investigations within the last 3 years are included on the referral proforma. Proformas compliant with this requirement were marked as ‘Yes, complete’. A total of 3410 referrals took place during this period- 36 were excluded from analysis as no information regarding their status was available.

Results

Only 37% of proformas included a complete history of recent bowel investigations over the past 3 years, and 62% had no documentation regarding this information. Between January-April 2021 the proportion with complete documentation was 42%, which fell to 30% by September-December 2021.

Conclusions

Including details of recent bowel investigations over the past 3 years appears to be an area that is commonly overlooked by referring local GPs. Given that patients may have had investigations at different Trusts, in the absence of a cohesive data sharing network between Trusts, GPs are best placed to collate this important information when referring to the Colorectal unit.
SP3.2.1 Management and outcomes of patients with small bowel obstruction in Denmark – a multicentre prospective cohort study
Authors: Smith Henry , Skovsen Anders Peter , Jensen Thomas Korgaard , Lolle Ida , Tolver Mette Astrup , Nielsen Liv Bjerre
Published: November 2022

Aims

The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, the traditional approach to patients with SBO is less conservative than that of the UK, but to what extent patient outcomes differ is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark.

Methods

This was a prospective cohort study conducted at 6 acute hospitals in Denmark over a 4-month period. Patients aged > 18 years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30-day mortality and major complication rates.

Results

316 patients were included during the study period. The median age was 72 years and 56.0% were female. Diagnosis was made by computed tomography (CT) in 314 patients (99.1%), with the remaining 2 diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 120 (78.9%). Immediate surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The 30-day mortality rate was 7.3% with major complications occurring in 61 patients (19.3%).

Conclusions

The management of SBO in Denmark differs significantly to that of the UK, with more liberal use of CT, a higher proportion of patients undergoing immediate surgery and a higher success rate of non-operative management. Despite these differences, patient outcomes are broadly similar. Adoption of the best components of both strategies may improve patient outcomes in both nations.
SP3.2.2 Improving Acute Surgical Services and Establishing Same Day Emergency Care Clinic in a District General Hospital
Authors: Swamad Mohamed , Badawi Marwa , Vitkauskas Raimundas , Cutcu Dilan , Klimovskij Michail
Published: November 2022

Introduction

Surgical Same Day Emergency Care (SDEC) clinic service is a new challenging trend nationwide. We would like to share our experience establishing SDEC in a DGH setting. Our clinic runs two sessions daily Monday to Friday with capacity of 16 patients.

The patients presented for; clinical follow-up post-discharge, radiological imaging and blood tests. All referrals are triaged by specialist nurses, seen by doctors of different grades - core surgical trainees and specialty doctors and supervised by the Consultant on-call.

Methods

Prospective ongoing audit carried out in SDEC monitoring the number of patients reviewed, diagnosis, investigations and outcome. We audited the documentation on the hospital's electronic system.

Results

In October 2021, 62 patients were reviewed, 97% had decisions made same day and only 3% required admission to SAU, 50% were allocated to a named consultant, 69% had blood tests, 53.2% had radiological investigations, 25% of patients were discharged with plans to follow up in elective clinics, and 1 patient was booked for elective operation.

Our recommendations to improve quality of service were to allocate a dedicated staff nurse and healthcare assistant for more efficient workflow. Improving documentation of outcomes and allocating patients to named consultant for follow up.

Conclusion

Our model demonstrated successful service to provide semi-urgent care to surgical patients. SDEC has the capacity for more patients and subsequently will offload pressure from the emergency services provided by A&E and surgical admissions unit. This also makes a significant impact for on-call team to allow more focus on treatment of acute emergencies.
SP4.1.2 Management and Ambulation of Uncomplicated Acute Diverticulitis during the COVID-19 Pandemic – A Clinical Audit in a District General Hospital
Authors: Elghazaly Hussein , Dahaghin Payman , Drymousis Panagiotis
Published: November 2022

Aims

To audit the management (ambulation versus admission) of acute diverticulitis presenting to a London DGH.

Methods

A retrospective clinical audit. Data on cases of acute diverticulitis presenting to the general surgical department at Ealing Hospital were collected over a period of 92 days. The medical notes were screened and the indication for admission in hospital was recorded. Each admission was then assessed for compliance with standard criteria for appropriate admission, derived from national guidelines by NICE. Patients admitted despite not meting these criteria were deemed as inappropriate admissions.

Results

mAll patient referrals to General Surgery at Ealing Hospital were screened from 1/7/21 to 30/9/21. 618 patients were identified. A total of 18 patients presented with radiologically-confirmed diverticulitis in this period (2.9%). Of these, 14 patients were admitted (77.8%). None of the patients ambulated met the criteria for admission. If the admitting teams were to adhere to National Guidelines, 15 of the 18 patients presented and 11 of the 14 patients admitted could have been safely ambulated. In inappropriately-admitted cases, none received surgical intervention. The mean number of days spent in hospital for inappropriate admissions was 3.27 (Range 1–8 days). This translates to 49 patient-days that could have been safely avoided according to national guidelines. The cost incurred by the NHS by the inappropriate admission of these patients is estimated at £78,400 p.a.

Conclusions

Safe ambulation of patients presenting with acute uncomplicated diverticulitis can improve departmental efficacy, patient flow and ultimately reduce bed pressures and expenditure associated with hospital admissions.
SP4.1.4 Bowel injury in gynaecological laparoscopic surgery: a systematic review
Authors: Westby Kealan , Mannion Evan
Published: November 2022

Aims

Often general surgical opinion or assistance is sought in the presence of an iatrogenic bowel injury. The objective of this review was to analyse the literature on bowel injury in those undergoing laparoscopic gynaecological surgery and determine incidence rate, nature & site of injury and treatment.

Methods

Data sources included Pubmed, EMBASE, ClinicalTrials.gov and the Cochrane library databases. Timeframe for studies included was from 1990–2021. All studies in English reporting the incidence of bowel injury were included. Those not in English, case reports or that did not define bowel injury were excluded. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used when assessing the studies.

Results

Two reviewers extracted data from each study. A total of 515 papers were initially identified, 134 met inclusion criteria. Total of 512,098 laparoscopic gynae procedures were represented with 720 bowel injury reported giving an incidence rate of 1/711 (0.14%, 95% CI 0.13–0.15%) The rate of bowel injury varied with type of procedure, highest being in a hysterectomy. Small bowel was most common structure injured and the majority of bowel were identified intraoperatively. Delayed recognition of bowel injury led to high mortality rate.

Conclusion

The incidence for bowel injury in laparoscopy gynaecological procedures is 1/711. There is a variation in incidence rate & complexity of procedure. Early recognition and collaboration between gynaecologists and general surgeons is essential for a favourable outcome.
SP5.1.1 Novel in vitro model of neurotrauma to study neurotherapeutics
Authors: Basit Raja Haseeb , Wiseman Jessica , Chari Divya Maitreyi
Published: November 2022

Introduction/Aims

Penetrating traumatic brain injury (pTBI) is a surgical emergency, with poor clinical outcomes. Management is supportive including surgical wound debridement, anti-epileptic administration and infection prophylaxis; no clinical neuroregenerative therapies exist. Surgical biomaterial scaffolds have therapeutic potential, but developmental testing relies heavily on highly invasive live animal injury models which are low throughput, expensive, technically challenging, and present significant ethical challenges. We recently developed a high throughput, multi-glial and facile in vitro pTBI model within which neural cell interactions with a surgical grade scaffold, DuraGen PlusTM could be investigated. A key limitation was the lack of a neuronal component, meaning axonal transection and regeneration could not be assessed. Here, we report an advanced version of the model, which (i) encompasses all the major neural cell types including neurons; (ii) within which penetrating lesions can be induced and biomaterials implanted.

Methods

Cerebral cortices from postnatal mice were extracted and cultured in vitro with a novel supporting medium. Cultures were transected at 8 days post-culture simulating penetrating injury in vitro, with immunocytochemistry used to analyse neural-cell responses/interactions.

Results

We demonstrate the utility of the model in reproducibly simulating pTBI in vitro with key pathological features such as glial scarring, microglial invasion and axonal outgrowth, p<0.05, n=5). The benefit of the model to study nanomaterial-neural cell interactions is demonstrated.

Conclusion

Our new model offers significant benefits for high throughput, facile developmental testing of novel nano/biomaterials in preclinical studies.
SP5.1.2 Splenic Artery Embolisation: Reviewing 10 years of practice at a Major Trauma Centre
Authors: Jones Benjamin , Elbakri Adil Salim , McLaughlin David , Murrills Christopher , Patil Pradeep , Scollay John
Published: November 2022

Introduction

Splenic Artery Embolisation (SAE) has transformed the management of splenic trauma. The aim of this project was to review the outcomes and post procedural management of splenic trauma patients managed by SAE at a Major Trauma Centre over a 10-year period.

Methods

Details of all patients undergoing SAE for trauma between 2011–2021 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information and details of mechanism / grade of splenic injury, success of embolisation, complications, associated injuries and mortality. Data relating to post-procedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained.

Results

26 patients (19 male, 7 female) with a median age 44 years (range 13–97) were identified. 25/26 injuries were due to blunt trauma. AAST splenic injury grades were III (n=5), IV (n=16) and V (n=5). SAE succeeded first time in 25/26 cases, and upon second attempt in 1/26 case. 3 patients died prior to discharge; 2 due to associated traumatic injuries and 1 from multi-organ failure. Complications secondary to SAE occurred in 4/26. Vaccinations were administered in 12/26 cases, and long-term antibiotics initiated in 11/26 cases. Formal follow up imaging was arranged in 5/26 cases.

Discussion

These data shows SAE is an effective means of controlling splenic haemorrhage with no patient requiring subsequent laparotomy. Complications occurred in 15% of cases. Great variance was found in terms of follow up practice regarding further imaging, antibiotics, and vaccinations. Increasing knowledge about SAE offers the opportunity to standardise post-procedure care for these patients.
SP5.1.3 Early initiation of chemical venous thromboembolism (VTE) prophylaxis following traumatic spleen injury is safe and effectively reduce VTE events
Authors: Lee Sheah Lin , Rizkallah Georges , Mahmoud Adel , Long Joe , Modi Sachin , Elberm Hassan
Published: November 2022

Aims

Within the first 48 hours (h) of trauma, hyper-coagulation state occurs which put trauma patients at risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to an increase rate of mortality. Non operative management (NOM) is now the standard of care for traumatic splenic injuries (TSI). However, timing of initiating chemical venous thromboembolism (VTE) prophylaxis, heparin or low molecular weight heparin (LMWH), remains controversial due to concern of rebleeding. This study examines the safety and timing of initiating VTE prophylaxis post TSI.

Methods

Patients with TSI were identified from prospectively maintained Trauma Audit and Research Network (TARN) database from 2015–2020 in a single tertiary trauma centre. Clinical and radiological information were collected retrospectively. TSI were graded using AAST classification. VTE prophylaxis initiation were categorised as not given, <48h and >48h following the injury.

Results

In total 102 patients were included. Fifty-three percent (54/102) had Grade 3 injury and above. Majority 90/102 (88%) of patients were treated non-operatively. VTE prophylaxis was not given for 31 (30.4%), initiated for 37 (36.3%) within 48h and given to 34 (33.3%) patients after 48h. Seven (7%) patients developed thromboembolic events, majority of which (6/7) received VTE prophylaxis after 48h. None of the patients who received VTE prophylaxis had rebleeding.

Conclusions

This study showed that early initiation of chemical VTE prophylaxis (<48h) is safe, resulted in lower incidence of DVTs/PEs without increase risk of bleeding. Results from this study supports recommendation from other studies to initiate chemical VTE prophylaxis after TSI as early as 24h post injury.
SP5.1.4 Prevention, Diagnosis, and Management of Fracture Related Infections in accordance with the BOA FRI Guidelines
Authors: Lu Victor , Zhang James , Thahir Azeem , Krkovic Matija
Published: November 2022

Aim

Fracture related infections (FRI) are common and serious complications of musculoskeletal trauma. With average hospital health care costs for infected patients being 6.5 times higher than uninfected patients, FRI poses a significant social-economic burden to the patient and healthcare system.

We aim to audit current practice in preventing and diagnosing FRIs, and improve management of infections in patients with fractures. The guidelines covered are the British Orthopaedic Association (BOA) FRI guidelines.

Method

Our sample included patients who suffered an infection as a direct consequence of fracture and/or subsequent surgical management procedures over a seven-year period. Surgical procedures were performed for fractures in 8826 patients. In total, 102 patients with a FRI were reviewed. Audit results and recommendations have been presented at a clinical governance meeting.

Results

Seven out of sixteen items had poor compliance (<80% compliance). Ultrasound-guided aspiration was done in 21.6% (22/102), even if debridement surgery is delayed. 1.96% (2/102) received adequate advice about responding to a suspected FRI. 56.9% had recommended 2-week antibiotic-free duration before sampling. Our recommendations include pre-written template in discharge documentation providing guidance on responding to a suspected FRI, better communication between microbiology, surgical team, and GPs regarding antibiotic prescription timing, including weekly bone and joint infection MDT review for FRI patients.

Conclusions

Lowering FRI-related burden requires a three-pronged approach: uniform set of standards for infection prevention in trauma and orthopaedic surgery, robust diagnostic workup for suspected FRI cases, effective management scheme for confirmed FRI cases. These systems should be a key element of orthopaedic trauma service.
SP5.1.5 Risk factors for Septic Arthritis and need for Arthroscopic Washout: Minimum two year follow-up at a major trauma centre
Authors: Lu Victor , Zhou Andrew , Hussain Hassan , Thahir Azeem , Krkovic Matija
Published: November 2022

Introduction

A hot swollen joint is commonly encountered in orthopaedics and rheumatology. With a broad range of differentials, septic arthritis (SA) is perhaps the most concerning, with delayed treatment leading to osteonecrosis, loss-of-joint-function, and mortality. To facilitate clinical decision making, we aimed to determine the risk factors for development of SA.

Methods

All patients presenting to the emergency department, orthopaedic and rheumatology clinics at our major trauma centre between January 2020 and January 2021 with a hot, swollen joint were retrospectively evaluated.

The frequency of variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients using univariate analysis. A multiple logistic regression model was formed for covariates that were significantly associated with SA (p<0.05), which underwent a backwards elimination process to identify a predictive model for SA. Multi-collinearity was assessed between covariates and variables with significant intercorrelation were removed. Statistical significance was set at p<0.05.

Results

221 patients were included (SA: 28; periprosthetic joint infection: 24; pseudogout: 32; gout:26; other conditions: 111). Multivariate analysis showed that RA, skin infection, and liver disease were risk factors for SA, with odds ratios of 2.656 (95%CI:1.090–6.475;p=0.032), 3.162 (95:CI:1.269–7.883;p=0.013), 4.993 (95%CI:1.156–21.559;p=0.031), respectively.

Conclusion

With a high mortality and morbidity rate, early diagnosis of septic arthritis is crucial. This requires understanding what the risk factors are, namely RA, skin infection, and liver disease. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint.
SP5.2.2 Our Management of Distal Femoral Comminuted Fractures with Femoral Defects
Authors: Zhou Andrew , Jou Eric , Patel Shaan , Lu Victor , Zhang James , Krkovic Matija
Published: November 2022

Aim

Distal femoral fractures account for 3–6% of all femoral fractures. Current management of distal femoral fractures involve reducing bone fragments and placing a locking plate against it. In this study, the surgeon used a ‘selective approach’, whereby only key bone fragments in the comminuted fracture were reduced and fixed whilst the rest were either removed or left unreduced/unfixed.

Method

All patients underwent AxSOS plate/less invasive stabilisation system (LISS) surgery for their comminuted femoral fracture after adopting the “selective approach” during pre-surgical planning. A significant proportion of patients had a degree of bone defect, and most had open fractures. Primary outcomes included post-operative functional ability, quality of life assessed using EQ-5D-5L, Oxford Hip Score (OHS), Oxford Knee Score (OKS), range of movement.

Results

Average OKS and OHS for our cohort (n=10) is 23 and 35, respectively, with a mean knee-flexion of 86° (45°-120°). Average EQ-5D- 5L index value is 0.551; the most common response for mobility, self-care, usual activities, pain/discomfort, and anxiety/depression was moderate. 20% developed pin site infections, 40% reported significant knee stiffness.

Conclusions

Despite a complex cohort whereby many patients had bone defects, and 80% had open fractures, the “selective approach” adopted in the present study achieved comparable outcomes to other studies with less-severe fracture characteristics, with similar operation times and range of knee-flexion. These results suggest that this alternative should be considered as a treatment option, although more studies on a similar cohort of patient to ours is needed to allow better comparison of the surgical approaches.
SP5.2.4 Machine learning development of novel triage tools for major incidents
Authors: Malik Nabeela , Xu Yuanwei , Chernbumroong Saisakul , Bowley Douglas , Belli Antonio , Gkoutos Georgios
Published: November 2022

Aims

Major incidents (MI) are an important cause of death and disability. Triage tools are crucial to identifying patients requiring time-critical, life-saving surgery and/or resuscitation (Priority 1 (P1) patients). We employed machine learning to develop novel primary and secondary triage tools, including external validation.

Methods

Adults from the Trauma Audit and Research Network (TARN) registry (January 2008-December 2017) acted as surrogates for MI victims, divided chronologically (70:30) to yield model training and internal testing datasets, respectively. P1s were identified using predefined criteria. Input variables included physiology, age, mechanism and injury location. Random forest, extreme gradient boosted (XGB) tree, linear regression and decision tree models were trained, including cross-validation, to predict P1 status. Primary and secondary tool candidates were selected; the latter was validated using the UK military's Joint Theatre Trauma Registry (JTTR). Existing tools served as comparators.

Results

Models were internally validated in 57,979 TARN patients. Several outperformed the best existing tool (Battlefield Casualty Drills Triage Sieve: sensitivity 68.2%, AUC 0.688). Inability to breathe spontaneously, presence of chest injury and mental status were most predictive of P1 status. A three-variable decision tree model (sensitivity 73.0%, AUC 0.782) was selected as a candidate primary tool. A four-variable XGB model (sensitivity 77.9%, AUC 0.817) is proposed as a secondary tool, applicable via a portable device; and validated amongst 5,956 JTTR patients (sensitivity 97.6%, AUC 0.778).

Conclusions

Models outperformed existing triage tools in a nationally representative trauma population, these may serve as evidence-based novel tools. The proposed secondary tool demonstrates excellent external validity.
SP5.2.6 The Challenges Experienced by Female Surgeons in Africa- A Review of the Existing Literature
Authors: Jesuyajolu Damilola , Okeke Charles , Obuh Otomi
Published: November 2022

Aims

There has not been any comprehensive analysis of the challenges faced by female surgeons in Africa on a continental scale. These challenges, when brought to the forefront, can be tackled by the necessary stakeholders to increase the participation of women in surgery. This article will review the existing literature, across the African continent, to highlight the challenges experienced by female surgeons.

Methods

We conducted a search using keywords ‘Challenges' ‘Female’ ‘Surgeon’ ‘Africa’ and ‘Bias' on PubMed, Google Scholar, and AJOL from inception till 21st of January 2022. We then searched these keywords on Google in addition to the names of each of the individual countries. 10 papers satisfied the eligibility criteria by discussing the specific challenges that female surgeons faced in practice.

Results

There was a paucity of data from most of the individual African countries, highlighting the need for more research in this aspect. Out of the 10 published papers that were eligible, problems with work-life balance was the most common challenge with underrepresentation being second. Harassment, insufficient support, disrespect from colleagues, exclusion from activities, and stereotypes were also part of the challenges identified.

Conclusion

Despite the increasing participation, female surgeons continue to face different challenges ranging from the unfavorable work environment to the pressures put on them by society. This narrative review serves as a stimulant for major health stakeholders in Global surgery to promote gender inclusivity in the African surgical workforce; a feat that will ultimately benefit the people who need access to quality surgical care.
SP5.2.7 Direct line: Implementation of a novel clinician triage service to safely prevent unnecessary surgical admissions
Authors: Shahid Mishal , Gurowich Louise , Dru Rebecca , Barton Jessica , Lock Kate , Hollyman Marianne
Published: November 2022

Introduction

With the NHS under increasing pressure, the number of patients being referred to secondary care is increasing. Ambulatory clinics are being set up to reduce admission in some patient groups.

In our unit, GP referrals to General Surgery were previously being accepted to the admissions ward, without triage. A new system which allowed referrers to contact senior on-call team members was trialled to identify whether patients could be safely diverted to an ambulatory clinic, avoiding inpatient admission.

Methods

A cascade triage system of referrals was trialled between September 2021 and January 2022, over a total of 30 days. Data were collected on who triaged the call, outcome of the call, and admission rate of patients.

Results

Some 195 calls were analysed. Consultants were able to divert 62%(66/106) of patients to an ambulatory clinic compared to 30%(14/46) for junior doctors and 35%(15/43) for specialist nurses(p<0.001). The overall admission rate was 50%, with half of patients being successfully managed ambulatorily.

Improvement was shown over time in triage by junior doctors, with 1/10 in first 10 patients versus 4/10 in the final 10 patients triaged to the ambulatory clinic.

Average weekday admissions to the ward dropped from 12.1, to 7.5 on trial days.

Conclusion

The trial has demonstrated senior decision makers are the most effective at directing patients to an ambulatory pathway, while junior doctors have scope to improve their skills with experience.

Clinician triage is successful at reducing the number of surgical admissions when there is access to an ambulatory clinic.
SP5.2.8 Management of Small Bowel Obstruction: Are we improving?
Authors: Cox Kofi , Kenington Cleo
Published: November 2022

Aims

Recently 2 national audits evaluating the management of small bowel obstruction (SBO) have been published, recommending areas for improvement (NASBO and NCEPOD: delay in transit). We conducted a retrospective audit to evaluate if the management of SBO at a University Hospital reflects these recommendations.

Methods

The audit questionnaire and standards were designed using recommendations from the national audits. Patients were identified using hospital coding data over a 6-month period: February-July 2021. Patient data was extracted using electronic patient records.

Results

81 patients were identified. Adhesions (59%) and hernias (26%) were the predominant aetiologies. 53% were managed conservatively, 36% with early surgery and 11% with delayed surgery. 93% of cases received a CT; time to CT diagnosis was slower in patients also investigated with abdominal radiographs. Mean time from triage to CT diagnosis was 7.5 hours (2.2 days in NASBO). 84% of surgical cases arrived in theatre less than 72 hours after triage and 65% of conservatively managed cases received Gastrografin (28% in NASBO). Dietician review occurred in 68% of patients at moderate-severe risk of malnutrition (39% in NASBO). 48% of patients had urine output recorded within 24 hours of admission and AKI incidence was 14% (8% in NCEPOD: delay in transit). No surgical cases were successfully managed laparoscopically and 20% of frail patients had geriatrician input.

Conclusion

Whilst improvements have been made since the NASBO and NCEPOD: delay in transit, fluid balance consideration, care of frail patients, laparoscopic surgery and use of abdominal radiographs remain key areas for improvement.
SP6.1.1 The Safety of Laparoscopic Feeding Jejunostomy Insertion in Patients with Oesophago-gastric Pathology
Authors: Ahmed Babur , Dasa Michael , Mitra Roshni , Alasmar Mohamed , Alkhaffaf Bilal , Farooq Naheed
Published: November 2022

Aims

Feeding jejunostomy (FJ) to support enteral nutrition has traditionally been placed using an open approach (OA). As minimally invasive surgery (MIS) for oesophageal and gastric surgery gains popularity, it is imperative to develop a standardised technique and examine its safety. We describe our MIS approach to FJ insertion and compare outcomes to OA.

Methods

This was a retrospective analysis of patients undergoing FJ insertion via MIS and OA in a high volume tertiary oesophago-gastric centre, from 2018 to 2020. Identifying and placing FJ in first jejunal loop at low pneumoperitoneum pressure, constructing Witzel tunnel and placing antitorque sutures are our institution's standardised steps. Outcomes assessed included catheter-related adverse events.

Results

Of 226 patients, 130 (57.5%) had MIS, while 96 (42.5%) had OA. Median age (63.0 vs. 66.0 years, p=0.04), BMI (26.1 vs. 26.2 kg/m2, p=0.30), Charleston comorbidity index (4.0 vs. 4.0, p=0.73) and gender (75.4% vs. 76.0% males, p=1.00) were comparable. Median days FJ remained in situ was 162, 85.0% were placed in patients undergoing cancer resection, while MIC tube was used in 80.5%. A higher peri-catheter infection was seen with MIS (p=0.01); however, no differences (p≥0.42) were observed between MIS vs. OA, in tube dislodgement (9.0vs.6.0), fracture (2.0vs.2.0), blockage (2.0vs.0.0), peri-catheter leakage (6.0vs4.0), bowel obstruction (5.0vs.2.0) and perforation (0.0vs1.0). No feed inspissation or enterocolitis was observed. Misplacing FJ beyond first jejunal loop caused volvulus, necessitating reintervention.

Conclusion

FJ insertion via MIS is safe, provided standardised steps are followed meticulously. Evaluating confounding factors for better understanding of MIS-associated peri-catheter infection is recommended.
SP6.1.3 A Decision-Analysis Study of Endoscopic, Surgical and Pharmacological Treatment Options for Chronic Gastro Oesophageal Reflux Disease
Authors: Bradley Alison , Wong Li Siang , Mcmillan Paul , Buter Anton
Published: November 2022

Aims

To compare emerging endo-luminal interventions for the treatment of chronic gastro-esophageal reflux disease (GORD) to pharmacological and surgical interventions.

Methods

An advanced decision-tree model was constructed and populated with data from 19 randomised controlled trials to compare competing treatment pathways that included: Laparoscopic Fundoplication, Stretta, Transoesophageal Incisionless Fundoplication (TIF) and medical management with proton pump inhibitor (PPI). Model transition probabilities were calculated using weighted pooled estimates of proportions calculated using Freeman-Tukey arcsine square root transformation under random effects model to account for heterogeneity.

Model uncertainties for all included components were tested with one-way deterministic sensitivity analysis. Monte Carlo Probabilistic Sensitivity Analysis (PSA) was set to 10000 iterations with model probabilities sampled from the entirety of the data distribution of each variable.

Results

Base-case analysis at 12months follow-up showed that Laparoscopic Fundoplication had the highest probability of treatment success followed by TIF, Stretta and PPI respectively.

Conclusion

Endo-luminal interventions, although not shown to be superior to surgery, may have an emerging role in the management of GORD, but data on long-term follow-up and cost-effectiveness is lacking.
SP6.1.4 Novel methods to enhance anti-tumour immunity in oesophageal adenocarcinoma; hypofractionated radiotherapy may be superior to CROSS regimen chemo-radiation
Authors: Donlon Noel , Davern Maria , Sheppard Andrew , Donohoe Claire , Reynolds John , Lysaght Joanne
Published: November 2022

Background

CROSS regimen (41.4Gy;carboplatin&paclitaxel) is a standard trim-modality treatment for locally advanced oesophageal adenocarcinoma (OAC). The addition of adjuvant immunotherapy targeting PD-L1 may improve outcomes, hence the impact of radiation therapy on the tumour microenvironment is of considerable interest. The dosing has not been studied in this context, especially hypofractionation, and this study explored immunogenic cell death, specifically Damage Associated Molecular Pattern (DAMPs) release,and the impact of immune checkpoint blockade(ICB).

Methods

The ability of CROSS-regimen (3×1.8Gy) and hypo-fractionation (3×4Gy) to induce immunogenic cell death was assessed by flow cytometry of DAMPs calreticulin&HMGB-1.Expression of DAMPs were evaluated on OAC tumour and whole blood samples (n=10) pre and post conventional therapies versus hypofractionation. The immunostimulatory effect of CROSS and hypofractionation using post-treatment tumour cell secretomes with/without ICB on the cytolytic ability of OAC-donor lymphocytes was interrogated by CCK8-assay.

Results

The expression of Calreticulin&HMGB1 was significantly higher on tumour tissue compared to whole blood post chemo(radio)therapy(p<0.01). Hypofractionation increased TNF-α&IFN-γ production by T-cells greater than CROSS fractions ex vivo(p<0.01). The post-CROSS and hyporfractionated tumour cell secretome enhanced lymphocyte mediated killing of tumour cells(p<0.01), further enhanced with dual immune checkpoint blockade (nivolumab&ipilimumab)(p<0.01). High expressors of DAMPs pre-operatively had a significantly (P<0.01) better Tumour Regression Grade (TRG1–2) compared to low expressors.

Conclusions

The current CROSS regimen radiation for OAC is immunogenic,however,hypo-fractionated doses boosted the immune response to OAC, and was synergistic with ICB. This may warrant further exploration in a clinical and translational trial.
SP6.1.5 The effect og major Oesophageal oncological surgery in promoting a pro-tumour, pro-metastatic phenotype that is partly inhibited by immunotherapy
Authors: Donlon Noel , Davern Maria , Sheppard Andrew , O'Connell Fiona , Reynolds John , Reynolds Joanne
Published: November 2022

Background

Adjuvant immunotherapy for oesophageal cancer is set to become a standard of care following the Checkmate-577 trial proving the efficacy of adjuvant nivolumab. Scientifically, the key mechanisms are unclear. This study profiled systemic anti-/pro-tumour immunity and circulating pro-metastatic factors perioperatively in patients, and the impact of immune checkpoint blockade on key pathways.

Methods

Systemic immunity in oesophageal cancer patients (n=14) was immunophenotyped prior to surgery (postoperative day(POD)-0) and POD-1,3,7 and week-6, using flow cytometry. Longitudinal serological profiling was conducted by multiplex ELISA characterising systemic immunity and pro-metastatic signalling. The cytolytic ability of circulating lymphocytes against oesophageal cancer cell lines was assessed with and without immunotherapies; nivolumab/ipililmumab.

Results

PD-1+ and CTLA-4+ T-cells peaked on POD-1, significantly decreasing by week 6(p<0.01). Circulating soluble checkpoints significantly (p <0.001) increased from POD-3, with decreases in Th1 cytokines (IFN-Y,IL-12p40,IL-1RA,CD28,CD40L) and increases in Th-2-cytokines(IL-4, IL-10) observed(p<0.001). Circulating pro-inflammatory cytokines (TNF-α,MCP-1) and pro-metastatic factors(VEGF-α,FLT-1,Tie-2,PIGF) significantly (p<0.001) increased in the immediate post-operatively. In an ex-vivo model, the cytolytic ability of circulating lympohcytes peri-operatively (p<0.01) was propagated with the use of nivolumab/ipilimumab. Surgery decreased the frequency of circulating Th-1 like cells, an effect inhibited by nivolumab/ipilimumab.

Conclusions

Major oesophageal cancer surgery promotes a switch from Th1 to Th2 cellular immunity, dampening the cytolytic ability of T-lymphocytes. In an ex-vivo model, PD-1/CTLA-4 inhibition induced a shift to a Th1-like cytotoxic phenotype, highlighting a potential pathway through which such therapies can effect minimal residual disease, and a need to study optimal timing of adjuvant therapy.