bluuebunny/crossref_metadata_2025 huggingface dataset:
995 Skin Closure in Laparoscopic Surgery – a UK Based Cross-Sectional Survey
Authors: Freer F , Shakir T , Iqbal M
Published: November 2022

Introduction

Effective port site closure is a major mediator of patient-reported outcome measures. Traditionally, subcuticular sutures are used to close laparoscopic trocar sites. However, this can be challenging and time-consuming to achieve an effective cosmetic outcome. Skin re-approximation using tissue adhesives, such as octylcyanoacrylate, has benefits associated with aftercare, cosmesis, time-efficiency, and wound complication rates attributed to favourable bacteriostatic properties. Despite this, there remains poor uptake of its use in clinical practice. Our aim was to gain insight into port-site closure techniques favoured by a sample of laparoscopic surgeons.

Method

A standardised questionnaire was developed and distributed electronically to surgeons in the United Kingdom. Questions were pertaining to closure material and technique. Data was collected prospectively and analysed using Prism GraphPad.

Results

63 surgeons; including 32 consultants, 22 senior trainees, 8 junior trainees and 1 allied healthcare professional participated in the study.

Regarding port sites <5mm we found; 50.79% (n=32) used subcuticular sutures, 14.28% (n=9) used glue alone, and 23.80% (n=15) used glue in combination with sutures or steri-strips.

For larger port sites >5mm we found 61.90% (n=39) used subcuticular sutures, 6.34% (n=4) used glue alone and 22.22% (n=14) used subcuticular sutures and glue in combination. 9.52% (n=6) used other methods of closure such as staples and sutures in combination with steri-strips.

Conclusion

Despite the many benefits of skin adhesive assisted closure, its uptake remains low in clinical practice. We suggest an approach targeting improvements in awareness and education to positively impact decision making regarding methods of trocar site closure.
568 A Very Rare Presentation of Angioleiomyoma in the Oral Cavity
Authors: Smith M , Yasen Z , Mani R
Published: November 2022

On the maxillofacial department, we receive many referrals of lumps or swellings in the oral cavity. The majority of these lesions are diagnosed clinically as fibroepithelial polyps or mucoceles, with excisional biopsy recommended for histopathological confirmation and removal. We report on the rare case of a 69-year-old male patient, who presented following referral from his General Dental Practitioner for a lump clinically representing a fibroepithelial polyp but was diagnosed histopathologically as an angioleiomyoma. Angioleiomyoma is a rare benign vascular smooth muscle tumour; it is very rarely seen in in the head and neck, with oral and maxillofacial lesions accounting for less than 0.5% of angioleiomyomas. We report this case to discuss clinical and histopathological diagnosis and raise awareness of it as potential differential diagnosis of lumps in the oral cavity.
507 Seizure Control in Glioma Related Epilepsy: Proposal of a Qualitative Attribute Selection for a Discrete Choice Experiment into Patient Priorities for Treatment Goals
Authors: Clynch A , Elliott M , Holmes E , Marson T , Jenkinson MD
Published: November 2022

Introduction

Seizures occur in ∼50% of high-grade glioma and >80% of low-grade glioma patients. Recurrent seizures affect >50% of low-grade gliomas. Both seizures and anti-epileptic drugs (AEDs) can impact health-related quality of life (HrQOL). Little is known about the patient preferences that feed into prescribing decisions in glioma-related seizures.

Aim

To explore key outcomes patients value in the treatment of glioma related epilepsy. To select attributes for a future Discrete Choice Experiment (DCE) that analyses the attributes traded by patients in decision making.

Method

Attribute lists will be formulated in 3 stages: (1) systematic review of glioma and epilepsy literature; (2) clinician review to highlight missing outcomes and (3) patient focus groups. There will be ∼6 focus groups on total: 4 initial concept development focus groups and 2 detailed focus groups analysing the phrasing of attributes. Patients’ recruitment starts in November 2021.

Results

Focus group transcripts will be analysed using qualitative analysis methods of thematic analysis and case deviant analysis to identify common themes and how they relate to population variables. If thematic analysis suggests a high level of heterogeneity between group sessions additional focus groups may be required. A ranked list of variables will be generated based on factors including tumour grade, primary vs recurrent tumour, seizure type and time since diagnosis.

Conclusion

There is limited research examining outcomes patients value throughout their own treatment. This study will allow clinicians to gain a much-needed insight into patient priorities during the management of glioma-related seizures.
622 Tranexamic Acid Use in Meningioma Surgery – a Systematic Review and Meta-Analysis
Authors: Gillespie CS , Clynch A , Richardson GE , Mustafa M A , Islim AI , Kumar S , Keshwara SM , Millward CP , Jenkinson MD
Published: November 2022

Aim

Meningioma surgery is associated with increased intraoperative bleeding and transfusion requirement. Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. This review aimed to evaluate the effect of TXA use on bleeding and transfusion requirement, and functional outcomes in meningioma surgery.

Method

A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021. Random effects meta-analysis was performed to delineate blood loss, transfusion requirements, postoperative complications, operation time, and hospital stay.

Results

Four studies (181 patients) were included (three randomised control trials, one clinical trial). TXA use significantly reduced Intraoperative blood loss (mean difference 315.69mls [95% CI -532.94 to -98.54]) and transfusion requirement (OR 0.52 [95% CI 0.27–0.98]). Factors not affected by TXA use were operation time (mean difference 0.09 hours [95% CI -0.11 to 0.29]), Post-operative seizures (OR 0.87 [95% CI 0.31–2.49]), hospital stay (mean difference -2.4 days [95% CI -3.18 to -1.62]), and disability after surgery (OR 0.47 [95% CI 0.14–1.61]). Risk of bias was low (n=3) or unclear (n=1) in all included studies. Heterogeneity was high in length of operation (I2= 90%), and hospital stay outcomes (I2= 92%), and low in all others.

Conclusions

TXA use reduces blood loss and transfusion requirement in meningioma surgery, but not post-operative complications, or disability after surgery. Larger trials are required to investigate the impact of TXA on patient-focussed post-operative outcomes.
605 Assessment of Radiological Exposure Dosage and Time Among Surgeons During On-Table Cholangiography
Authors: El Zayat I , Farrow H , Wilson I
Published: November 2022

Background

On-table Cholangiography (OTC) is an important diagnostic tool in biliary surgery, allowing for assessment of biliary duct patency. However, debate remains over its overall benefit and safety vs peri-operative imaging. Research into the radiation exposure to both patients and surgeons and its subsequent risks remains minimal.

Aim

The aim of this retrospective study was to assess the average radiological dosage exposure as well as total exposure time for on-table Cholangiograms performed during Laparoscopic Cholecystectomies. We also aimed to assess for any clear difference in dosage and time exposure between different levels of trainee surgeons and consultants.

Results

A total of 157 OTCs were identified over a 12-month period; 57% performed by consultants (n=91), 23% by senior trainees’ level ST6-ST8 (n=36) and 29% by trainees level ST3-ST5 (n=36). The median radiological exposure time for all cases was 27 seconds, while median dosage/area exposure was 54.84 (uGy*m2). There were no significant differences in mean and median results between the different training levels of the performing surgeon.

Conclusions

Average radiological exposure dosage/area and time was consistent throughout the different groups of surgeons. While the exposure appears to remain at relatively low levels, further research into the risk of exposure during OTCs is needed to provide guidance to surgeons performing such procedures.
704 Laparoscopic Cholecystectomy for Ultrasound Proven Gallbladder Polyps – an Unsound Indication?
Authors: Bezzaa S , Clements C , Patel P , Kumapley L , Burney K , Nehra D
Published: November 2022

Aim

Current European guidelines recommend cholecystectomy for ultrasound proven gallbladder polyps based on size. Over-diagnosis of gallbladder polyps by conventional transabdominal ultrasound may lead to unnecessary surgery. The aim of this study is to correlate the ultrasound findings of gallbladder ‘polyps’ with histology of the removed gallbladder specimens.

Method

Data from transabdominal ultrasound reports was collected over a 5-year period and cross-referenced with the histology from patients undergoing a laparoscopic cholecystectomy over the same time-period.

Results

60 patients who underwent laparoscopic cholecystectomy with ultrasound proven gallbladder polyps were identified. The age range was 19–79 years. There were 36 females and 24 males. On imaging 30 patients (50%) had a solitary polyp (size range 2–24mm) and 30 (50%) had multiple polyps (largest polyp size range 4–13mm). The indication for cholecystectomy was gallbladder polyps with or without gallstone disease in 32 patients (53%) and gallbladder or gallstone disease with incidental polyps in 28 patients (47%). Only 2/60 (3.3%) patients had adenomatous polyps on histology (9mm and 9.7mm on ultrasound), whilst 18/60 (30%) had pseudopolyps and in the remaining 40 specimens, no lesion of polypoidal type was found. No specimens had evidence of dysplasia or malignancy.

Conclusion

We propose that an ultrasound abdomen is an inadequate imaging modality alone to diagnose gallbladder polyps and that patients require further imaging or MDT discussion as adjuncts to decision making for those referred for consideration of cholecystectomy.
274 Retrospective Cohort Study of the Long-Term Outcome of Posterior Urethral Valve – A Single Centre Experience
Authors: Zuling ET , Mashinchi J , Radford A , Subramaniam R
Published: November 2022

Aim

Posterior Urethral Valves (PUV) are the most common cause of bladder outlet obstruction in male infants. Despite definitive management by endoscopic valve resection, some patients develop persistent bladder dysfunction and progressive chronic kidney disease (CKD). This study aims to evaluate the long-term complications of PUV, as well as evaluate bladder and renal dysfunction pre- and post-operatively.

Method

A retrospective review of all the patients who received PUV ablation between 2012 to 2016 in a tertiary paediatric urology centre. Data collected included demographics, laboratory and radiographic investigations, and surgical outcomes. The data were analysed with SPSS.

Results

Twenty-three patients were included in the study; antenatal diagnosis was made in 43.5% (n=10) with 56.5% (n=13) postnatally. Mean follow-up time was 7.1±2.3 years (4.8–9.4). Voiding dysfunction was the most common complication in later life (34.8%, n=8), followed by CKD (13.0%, n=3), kidney transplant (8.7%, n=2), hypertension (8.7%, n=2) and mortality (8.7%, n=2).

There was a statistically significant difference (p=0.003) between pre- and post-operative creatinine values. 5 patients who had creatinine values postoperatively of >88.4μmol/L (21.7%) sustained poor renal outcomes.

Radiologically, there was a significant improvement in the anteroposterior (AP) diameter of the renal pelvis and kidney growth based on current, post-operative and preoperative ultrasound (p<0.05). Nevertheless, there was no statistically significant improvement in ureteric dilatation.

Conclusions

Post PUV ablation, urinary incontinence and CKD remain the most substantial long-term outcome. Proactive multidisciplinary management with careful follow-up are essential to reduce the burden of the disease.
612 Sentinel Lymph Node Biopsy for Patients with Cutaneous Malignant Melanoma. an Audit of the First 30 Months of a New Regional Service
Authors: French B , Bond J , Tohill M , McAllister SE
Published: November 2022

Aim

In this region, the Sentinel Lymph Node Biopsy (SLNB) Service was established in 2018 and suspended in 2020, due to the COVID-19 pandemic. Service has resumed under interim criteria, accounting for COVID-19 constraints. Patients not fulfilling these criteria (SLNB for tumour stage pT3a or greater) had wide local excision (WLE) alone. This audit aims to examine quality of Service delivery to date, plan full-Service resumption, and generate a cohort for ongoing outcomes research.

Method

A prospectively collected database captured patients with tumour stage pT1b or higher. Data were analysed for demographics, tumour characteristics and outcome of Service referral, and compared to predetermined performance indicators.

Results

Data were collected on 410 patients, from December 2018 to April 2021; 94.4% had complete datasets. Of the remaining 5.6%, none underwent SLNB.

The mean age was 62 (range 12–96). 187 patients were male; 220 were female. The most frequent tumour location in males was the trunk (36.0%), differing from females (41.8% lower limb). The most common tumour stage was pT2a, occurring in 34.7% (27.9% males, 40.7% females).

141 eligible patients were investigated with SLNB (18.4% positive, 75.9% negative, 5.7% failed). 7.9% were unsuitable for SLNB and 4.5% declined. The remaining 168 patients did not fulfil interim criteria for SLNB and underwent WLE.

Conclusions

This audit assesses Service quality and will be used to facilitate full-Service provision. Interim criteria reflect a higher rate of positive SLNB. Ongoing research investigates the rate of false negative SLNB and impact of the COVID-19 pandemic on rates of recurrent/disseminated disease.
39 Improving Orthopaedic Morbidity and Mortality Meetings at a District General Hospital
Authors: Hunt C , Duke K , Conyers R , Plail J , Hibbard A , David L
Published: November 2022

Aim

M&M meetings are an integral part of Clinical Governance but can be of varying quality. They should be a learning platform and represent an opportunity to work across disciplines. We identified that these standards were not being met in our department and have sought to improve this.

Method

We compared three Orthopaedic M&M meetings against standards set out by both the Royal College of Surgeons and Physicians. Initial results suggested that documentation during the meetings did not meet these standards.

A template was created with guidance from the Royal Colleges which aimed to encourage reflection and consideration of agreed actions. This was embedded and is now part of the M&M meetings. A brief educational intervention was also undertaken during the first M&M meeting post-intervention.

Results

Data was obtained regarding the new presentation template and format. Compliance with RCS guidelines went from an aggregate 53% to 80%, following intervention. Qualitative data sought via a survey revealed agreement that the new template is superior to the old model in including relevant information, facilitating constructive discussion, and identifying learning points.

Conclusions

The new template has been well received and has helped facilitate more useful discussions around how to improve patient care. Comparison of the presentations against RCS guidelines has shown an improvement in the quality of data collected and presented. We will continue to re-audit areas such as identifying learning points to better refine and define the outcomes of M&M meetings for the benefit of patients and the multi-disciplinary team.
316 Improving Electronic Prescribing of Mechanical VTE Prophylaxis in General Surgery Patients
Authors: Gunn C , Alam I
Published: November 2022

Aim

Mechanical VTE prophylaxis forms part of NICE guidance in general surgical patients. Locally, thromboembolic deterrent (TED) stockings are used but not available as a prescription item on the electronic system. They are often prescribed verbally or via noted plans but do not appear on the medication administration record. Importantly, multiple incidents of patient harm through pressure damage have been seen due to poorly checked TEDs. Our aim was to audit and improve safe mechanical VTE prophylaxis prescribing.

Method

At each cycle, we retrospectively collected data from two weeks of admissions. Data relating to VTE assessment completion, VTE score, TEDs in use, TEDs prescription and LMWH prescription was collected. Our initial intervention consisted of departmental education regarding a work around enabling TEDs to be prescribed as a freehand extra-formulary item. This was reaudited at 12 months.

Results

All patients in both cycles had VTE assessments completed. TED stocking use increased significantly from 5.1% to 26.4% and prescription of TEDs, when used, increased from 0% to 61.1%. However, documentation regarding daily checks was non-existent.

Conclusions

Our QIP showed a significant improvement in TEDs use and prescription. However, the intervention is difficult and time consuming. Subsequently from this project, a TEDs stocking item is in the final approval phase for integration into the online prescribing system and will come with associated safety checks built into the nursing medication administration system. Once this is live, we will complete a third cycle to assess uptake and again at 6 months to assess for lasting change.
406 Appendicectomy: Consenting for a Normal Appendix
Authors: Probert S , Choy B , Iqbal M , Walton SJ
Published: November 2022

Aim

To assess consent forms for appendicectomy and ensure that patients are consented for an intraoperative finding of a normal appendix.

Method

Retrospective audit assessing consent forms (for mention of Normal appendix finding) for patients who underwent appendicectomy over a 2-month period.

Results

A total of 68 patients underwent appendicectomy. The age range of these patients was 3 to 84 years old (median 20 years). 58 of these procedures were performed laparoscopically. 23 (33.8%) of the consent forms have mention of a normal appendix. The remaining 45 patients (66.2%) had no mention of normal appendix on the consent form. In analysis of the operative notes, 7 patients had no intraoperative finding of macroscopic inflammation. Of these 7 patients, only 1 was consented for a normal appendix finding.

Conclusion

During the consent process for an appendicectomy, it is important to warn the patient (or caregiver) about the possibility of finding a normal appendix. The appendix is routinely removed regardless of the intraoperative findings (normal or inflamed). The patient should be made aware, as the appendicectomy may not result in the resolution of their symptoms, or further procedures may be required. This audit found that there is currently a deficit in consenting patients, undergoing appendicectomy, about the possibility of finding a normal appendix intraoperatively. A quality improvement project is currently underway, wherein a combination of departmental education and patient information booklets aims to improve consenting practices.
450 Patient Care and Flow in Patients Admitted with Rib Fractures Under General Surgery: One Centre's Experience
Authors: Niina A , McKenna M , Williams G
Published: November 2022

Aim

Following the introduction of the ‘South Wales Trauma Network’ in September 2020, patients admitted with traumatic rib fractures who meet the criteria for conservative management are admitted under the care of General Surgery at the Grange University Hospital (GUH). Conservative management includes chest drain placement, pain management, respiratory physiotherapy, and rehabilitation. Our aims were to look at the outcomes of these patients and the efficacy of patient flow.

Method

Quality improvement methodology was followed. Retrospective data collection on patients (115) diagnosed with rib fractures between January to September 2021 at GUH, Aneurin Bevan University Health Board. Demographics, method of injury, management, admission duration, discharge destination, readmission rate and mortality were collected.

Results

The mean age of the 115 patients admitted was 68 years (range 20 to 97). Mean age increased to 80 in those who were stepped down for rehabilitation. Over half (60%) of patients sustained rib fractures from mechanical falls. A third of patients needed simple analgesia and 10% had chest drains. Half of patients had no antibiotics and 20% received prophylactic antibiotics. Mean admission duration was 13 days (range 0–103 days). Eleven percent of patients were readmitted within one week. The one-year mortality rate was 2.6%.

Conclusions

Those who require admission following traumatic rib fractures commonly have complex medical and rehabilitation needs. There is currently a paucity of National Guidelines for these patients, despite advances in ‘Silver Trauma’. We believe a multi-specialty approach towards the establishment of such guidelines is needed and are in the process of coordinating a multi-centre re-audit.
479 Closed Loop Quality Improvement Project Improving Time to Peripherally Inserted Central Catheters (PICCs) and Intravenous (IV) Antibiotic Administration in Patients with Complex Orthopaedic Infections
Authors: Balfour J , Holland G , Powell-Bowns M
Published: November 2022

Aim

Bone, joint and soft tissue infections often require long term antibiotic therapy. Reliable IV access is essential for IV antibiotic administration and monitoring. PICCs provide consistent, long-term IV access. Aim: improve time to PICC request, insertion, and reduce issues with poor IV access in patients requiring long term IV antibiotics.

Method

Standard audit protocol. Data tool was developed and tested. Data was collected retrospectively from departmental database and online records for all patients admitted with suspected bone, joint or soft tissues infection from 01/11/19–29/2/20. Department policy and induction programme were updated. Cycle 2 included all patients from 1/8/20–30/11/21.

Results

Cycle 1 included 91 patients. 30 PICCs were requested with 26 inserted. Mean time to PICC request from diagnosis was 8.7 days(1–33). Mean time to PICC from request was 6.7 days(1–15). Mean time to PICC from diagnosis was 15.9 days(4–39). 10 of 30(33.3%) patients missed antibiotics due to lack of IV access. Cycle 2 included 156 patients. 36 PICCs were requested with 18 inserted. Mean time from diagnosis to request was 4.4 days(1–15). Mean time from request to insertion was 4.2(1–8) days. Mean time from diagnosis to insertion was 8.6 days(1–21). Missed IV antibiotics were reduced from 33.3% to 15.4%.

Conclusions

Time to PICC insertion was improved through education and introduction of new policy at departmental induction. This low-cost change can significantly improve both treatment and patient experience when admitted for complex orthopaedic infection through reliable antibiotic administration and reducing the number of IV access attempts.
683 Improving CEPOD Efficiency: The ‘Golden Patient’
Authors: Curley D , Shahmiri A , Arulampalam T
Published: November 2022

Aim

Delayed start times in the CEPOD theatre were observed locally and a ‘Golden Patient’ initiative was proposed, whereby a patient is identified the day before as the first case for the following day. We aimed to increase the percentage of CEPOD theatre list patients sent for before 08:15.

Method

We conducted a retrospective analysis of the first case on the CEPOD theatre list each day between 18th May 2021 and 8th August 2021 and theatre timings were recorded. We introduced the ‘Golden Patient’ concept on 9th August 2021. The proposal included the prospect of using recovery as a holding bay prior to 08:00. A second retrospective analysis was conducted between 9th August 2021 and 28th October 2021.

Results

Prior to the ‘Golden Patient’ intervention 0 patients were sent for before 08:00 and 12 (14.6%) patients were sent for before 08:15. Following the introduction of the ‘Golden Patient’ 17 patients (21%) were sent for before 08:00 and 31 (38%) of patients were sent for before 08:15. Sending times were earlier on the whole post intervention and sending prior to 08:15 appears to occur in consecutive days, suggesting a proactive team on duty.

Conclusion

The ‘Golden Patient’ initiative has been a success and appears to be most productive with a proactive team on duty. We can see clear and obvious change but there is still room for further improvement. We hope to engrain the ‘Golden Patient’ concept into our local culture, show further improvement and sustain this over time.
887 Design and Implementation of a Standardised Protocol to Assess the Pre-Operative Prophylactic Antimicrobial Guidelines in Vascular Surgery – a Trust-Wide Experience
Authors: Ford A , Charlwood N , Morton H
Published: November 2022

Aim

The project's aim was to design and implement a replicable protocol in order to assess the pre-operative prophylactic antimicrobial prescribing that could be universally applied to all patients undergoing major vascular surgery.

Method

A retrospective audit was undertaken to establish existing guidelines in circulation and current practice trends at Worcestershire Acute Hospitals NHS Trust. Multiple theoretical models to stratify procedure and infection risks were designed including clean verses dirty site surgery, procedure specific surgery, procedures with or without utilisation of prosthesis, universal one size fits all guidelines. A panel consisting of consultant vascular surgeons, the antimicrobial stewardship lead consultant microbiologist, and a core surgical trainee co-ordinating the project appraised the results. Criteria included ease of implementation minimising prescribing errors, anaphylaxis, and the need for a tailored guideline for different major vascular procedures to determine suitability of the guideline.

Results

The initial audit signified a need to standardised guidelines in order to provide patients with a standardised care pathway that utilises best practice. In this instance an anatomical approach to the pre-operative prophylactic antimicrobial guideline for major vascular surgery was adopted and implemented at Trust level.

Conclusions

A replicable protocol has been established in order to appraise, design, and implement antimicrobial guidelines that can be transferable between departments and trusts alike.
138 Lung Cancer Surgery in the Early Phase After Acute COVID-19 Pneumonitis
Authors: Robinson D , Smith A , Okiror L
Published: November 2022

As the number of post-COVID-19 patients requiring surgery increases, it becomes pressing to develop guidelines outlining time requirements between active COVID-19 infection and surgery. We present a case of successful pulmonary segmentectomy 6 weeks following an acute COVID-19 infection in a 65-year-old female.

The case patient was scheduled for a robotic assisted left upper lobectomy for radiologically diagnosed early-stage lung cancer. Unfortunately, prior to surgery she contracted Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), resulting in the operation being rescheduled for 6 weeks’ time. She was managed in the community for COVID pneumonitis and developed significant shortness of breath. At admission, with resolution of breathlessness, a repeat chest computed tomography scan showed the nodule had increased in size from 2 to 2.5cm, and widespread interstitial pneumonitis. The patient was saturating at 91% on air with no respiratory compromise. On balance of risk, surgery went ahead as planned due to concerns over tumour progression. A smaller lung resection was undertaken, with robot-assisted left upper division segmentectomy preferred to lobectomy. Post-operatively the patient received aggressive physiotherapy and high flow nasal oxygen to aid sputum expectoration. Chest tube was removed on day 2 post-operatively and the patient discharged 5 days following surgery without complication. Final histology confirmed a fully resected stage T1cN0M0 adenocarcinoma of the lung.

This case highlights the importance of timing surgery correctly in post-COVID-19 patients to achieve the most favourable outcomes. We must balance clinical priority and the risk of disease progression against the severity of COVID-19 infection and the patient's comorbid status.
593 Squamous Cell Carcinoma in Renal Pelvis of a Fused Pelvic Kidney; Case Report and Literature Review
Authors: Ilangovan S , Neves J , Bex A , Tran M
Published: November 2022

This case report details a rare case of squamous cell carcinoma present in the renal pelvis of a fused pelvic kidney, a congenital complete renal fusion anomaly. A 52-year-old man with no previous urological history presented with intermittent haematuria and weight loss. He was found to have a large complex mass (14.3 cm×4.5 cm×15.5 cm) in the right moiety of a pelvic fused kidney on CT and subsequently underwent an open hemi-nephrectomy. He recovered well following surgery, however, unfortunately developed rapid recurrence, and died from disease progression after 6 months.

This report demonstrates the use of 3D anatomical reconstruction to help pre-operative planning of complex surgical cases. We also include histological analysis of the tumour in detail. This case report emphasises that squamous cell carcinoma can occur due to precipitating factors such as renal calculi or infection, which are more prevalent in fusion anomalies of the kidney. Although a rare malignancy, this tumour type is associated with an aggressive behaviour and poor prognosis.
1006 Supersized-Simulation vs Traditional Cardiothoracic Surgery Education: A Prospective, Randomised Controlled Trial
Authors: Hirniak J , Adil S , Hayes J , Vaghela M , Mani K , Abbas A , Aboulelea Y , Syed N
Published: November 2022

Aim

Exposure to cardiothoracic surgery is limited during medical school in the United Kingdom. This study evaluated the effectiveness of a supersized simulation model (SSM) compared to traditional methods (TM) in developing coronary anastomosis surgical skills.

Method

This was a prospective, randomised controlled trial with a 1:1 allocation ratio. Undergraduate medical students with no prior cardiothoracic surgical skills training were eligible for inclusion. Both groups received a guided didactic lecture followed by modified Objective Structured Assessment of Technical Skills (OSATS) assessment for baseline. The control group then received traditional teaching and the intervention group received additional teaching with SSM before being reassessed. Modified OSATS score were the primary outcome, adjudicated by two senior cardiothoracic registrars. Performance time (PT), self-assessment (SA), confidence (CON) and global rating scale (GRS) were secondary outcomes.

Results

48 novice medical students were randomised. OSATS scores were significantly higher in SSM group compared to TM group (13.2 vs 9.8, p<0.01). The secondary outcomes PT (17.7 minutes vs 22.2 minutes, p<0.01) and CON (3.04 vs 1.73, p<0.01) were also significantly different between groups, favouring SSM. SSM participants were more likely to want to pursue a career in cardiothoracic surgery (12 participants vs 2 participants). All participants agreed that SSM improved visualisation and comprehension of surgical procedure. SSM cost £0.75 per model.

Conclusions

Supersized simulation is effective for coronary anastomosis surgical training with technical skills successfully transferred to a clinical task. Supersized models can accelerate the novice trainee's surgical skill progression and represents a valuable resource in one's educational armamentarium.
740 Improving the Management of Epistaxis in Clinical Practice
Authors: Kabaso M , Vanker R , Townsley R
Published: November 2022

Aim

Improving the standard of epistaxis management in Ayrshire & Arran.

Method

A survey was distributed to doctors assessing their familiarity with epistaxis assessment and management. Working with the ENT department, a teaching programme was then developed aimed at improving skill in nasal packing, cautery and first aid, based on local guidelines. After the first session, all participants filled in a post-education questionnaire and results collated.

Results

The survey collected information throughout Ayrshire & Arran, from 21 doctors across 10 different specialities, ranging from Foundation, Clinical Fellows, and Core Trainee's. Using a rating of one to five, least confident to most confident respectively. 95% of participants chose between one and three when asked about independently managing epistaxis, which significantly reduced to 0%. 52% of participants chose ‘least confident’ with familiarity of nasal packing and nasal cauterisation, reducing to 0%. In addition, 40% of doctors were unfamiliar with options for packing, which increased to 100%.

Conclusions

Epistaxis is one of the most common acute ENT presentations. 86% of cases will be initially managed by junior doctors using first aid management, packing, or cauterisation. This is not taught as standard in undergraduate or postgraduate education. Currently, there are no nationally accepted guidelines for its management, regardless of its high presentation, readmission, and mortality rate. There is an observable gap in epistaxis education, crucial when considering majority of its’ management will be handled by junior doctors. We have seen an increase in participants confidence and familiarity of the condition which merits running this teaching programme.
789 The Impact of a Virtual Orthopaedic On-Call Survival Course on Junior Doctors’ Confidence in Managing an Orthopaedic On-Call
Authors: Pennock H , Cheema K , Swafe L
Published: November 2022

Aim

Junior doctors often feel underprepared for their orthopaedic on-call shifts during their foundation placements. Studies have shown that medical schools are failing to prepare students to manage trauma and orthopaedic patients. The aim of this study was to assess the effects of an orthopaedic on-call survival course on the confidence levels of junior doctors in managing an orthopaedic on-call.

Method

We developed a one day orthopaedic on-call survival course, designed to provide junior doctors with the relevant knowledge to be able to confidently navigate an orthopaedic on-call shift. We designed a pre-course and post-course questionnaire which were distributed to the participants. Self-assessed confidence levels were recorded in managing an orthopaedic on-call and a number of orthopaedic knowledge domains using visual analogue scale 1–5. The course was delivered over 4 hours using Microsoft Teams.

Results

We received 47 matched pre- and post-course questionnaires. Overall, 87% of participants reported an increase in confidence in managing an orthopaedic on-call shift. 83% of participants reported an increase in confidence in orthopaedic radiology teaching. 80% of participants reported an increase in confidence in both upper limb emergencies and lower limb emergencies. 91% of participants reported an increase in confidence in spinal trauma.

Conclusions

An orthopaedic on-call survival course can provide junior doctors with the knowledge to be able to confidently manage trauma and orthopaedic patients during on-call shifts.

We recommend that an orthopaedic on-call survival course can be used as an effective teaching method towards preparing junior doctors for their on-calls during foundation training.
879 Attitudes to Research and Academic Careers Among Surgical Trainees and Medical Students: A Survey of Attendees at the 2021 Oxford Surgical Innovation Conference
Authors: Hennessy C , Brameier D , Williams M , McVeigh J , Handa A
Published: November 2022

Introduction

Participation in research throughout medical training is essential in developing and implementing evidence-based practice. Increasing competitiveness across many surgical specialties has led to increased desire to participate in research by medical students and surgical trainees of all grades, with the aim of increasing their employability.

Method

The Oxford surgical innovation conference (OxSI) took place on the 23rd of April. The 121 attendees were surveyed regarding their attitudes to medical research, levels of research experience, and their confidence in seeking out and engaging with research opportunities. Survey respondents included clinical medical students, foundation trainees, core surgical trainees and higher specialist trainees.

Results

From 121 surveyed attendees at OxSI 2021, we received 88 responses (72%). 90% of respondents were interested in/pursuing a surgical career, with 70% interested in a career in academic surgery specifically. Furthermore, 97.8% agreed that engaging in research and innovation are an important part of surgical training. However only 48.9% were actively engaged in research. Furthermore only 26.2% of respondents were confident in engaging in independent research, with 56.8% stating they would not know how to engage in research or pursue new surgical innovations without outside assistance.

Conclusions

There is significant interest among medical trainees in research and academic surgical careers. However, many struggle to engage with research due to time constraints, or inadequate exposure to research opportunities. This survey suggests a larger study examining barriers to research exposure and participation could assist in addressing the discrepancy between desire to engage with research and opportunities to do so.
436 Barriers for Cadaveric Kidney Organ Utilisation: Results of a National Transplant Access to Theatre (NTACT) Pilot Study
Authors: Borbas B , Mujeeb M , Tanase A , Aroori S
Published: November 2022

Background

There are various barriers to cadaveric organ utilisation across the UK. However, there is a paucity of data on the barriers after the arrival of organ/s at the implanting centre. We set up the national “NTACT” study to identify barriers after arrival of organs at implanting centre.

Method

Prospective pilot study collecting data on adult kidney/pancreas cadaveric organs across five UK transplant centres in July 2021. Data collected includes time intervals between significant checkpoints prior to transplantation and perceived reasons for delays after arrival at implanting centre. Data was recorded on RedCap and analysed for delays using descriptive statistics.

Results

Between five transplant centres, data was entered on 27 transplants. Five patients were excluded from the study (live transplant-2, incomplete data-3). There were six donations after circulatory death (DCD) and 16 donations after brainstem death (DBD) organs. Fifty percent (n=3/6) of DCD and 12.5% (n=2/16) of DBD allografts surpassed the national recommendations for CIT. The majority of crossmatches were virtual (15 virtual and seven full). Delays included crossmatch results (median=03:37:30), time between the arrival of the kidney and patient into theatre (median=03:13:00), time between anaesthetic induction and knife to skin (median=00:52:00). The median warm ischaemia time was 00:41:30 (IQR-00:33:00–00:49:30). Qualitative answers highlight themes: “surgical team occupied in another case”, “emergency theatre occupied”, “porter availability for transporting patients”.

Discussion

Our pilot study identified various barriers to implantation, and a significant proportion of kidneys are implanted beyond nationally accepted CIT. Further work is required to get a national picture over an extended period.
864 The Efficacy and Safety of Bariatric Surgery in Patients with Previous Kidney Transplantation: A Systematic Review and Meta-Analysis
Authors: Varma J , Fernando S , Dengu F , Menon V , O'Callaghan J
Published: November 2022

Introduction

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

Method

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

Results

Ten observational studies met the inclusion criteria with a total of 198 patients (45.1% male). Mean change in BMI following BS was -11.0 (-14.9 to -7.1, p < 0.001) within a median follow up time of 30 months (IQR 25 to 139 months). Gastric bypass (49.5%, n=98) was the most common procedure. Mean age at BS was 46.5 years (SD = 5.5) with a mean time from KT to BS of 4.9 (SD = 1.9). The 5-year graft failure rate (Post BS) was 18.6% (n = 7).

Conclusions

This review highlights that BS is both safe and efficacious on patients with a previous history of KT.
2 A Retrospective Analysis of the Definitive Management of Open Talus Fractures at a Major Trauma Centre and an Audit of BOAST 4 Guidelines
Authors: Zhou A , Jou E , Bhatti F , Patel R , Zhang J , Lu V , Krkovic M
Published: November 2022

Currently, the management of open talus fractures is based upon BOAST 4 guidelines although there is no suggested definitive management, thus definitive management is based upon surgeon preference. This retrospective analysis aims to clarify the debate between ORIF and tibiocalcaneal fusion (FUSION).

A review of open talus fractures from 2014–2021 returned foureen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, five cases were definitively managed with FUSION. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines.

Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group.

FUSION is typically used as second line to ORIF or failed ORIF. However, there are a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time, that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate, and quality-of-life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.
60 Comparison of Comorbidities and Need for Further Surgery of Adolescent and Adult Patients Who Undergo Carpal Tunnel Release
Authors: Bapty J , Riyat H , Johnson N
Published: November 2022

Aim

To compare the presenting comorbidities and need for further surgery following carpal tunnel release (CTR) surgery between the adolescent and adult populations.

Method

36 consecutive patients under 25 years old who underwent CTR in a single centre were identified (43 hands). Comorbidities and further surgery in the follow up period were recorded from electronic medical records. The same data was collected from 100 randomly selected adult patients who underwent CTR in the same centre aged within one standard deviation of the mean. Outcomes included: comorbidities pre-and post-surgery, further operations and follow up in the region. Data for both cohorts were compared.

Results

Mean follow up was 13.3 years for adolescents and 8.6 years for adults. Adolescent patients undergoing CTR surgery were associated with higher rates of obesity (22%), mental health problems (19%) compared with the adult CTR population (11% and 7% respectively). 47% of the adolescents required at least one further nerve decompression surgery compared with 41% in adults. This was most likely to be a contralateral CTR in both patient groups. The revision rate of CTR was higher in adolescents (11%) than in adults (4%).

Conclusions

Mental health problems were significantly higher in younger patients undergoing CTR. Rate of further nerve decompression surgery is high in both groups. Adolescents especially should be informed of the risk of requiring future surgery following a CTR. Given the likelihood for further surgery in both cohorts, patients undergoing CTRs should be advised to reduce their modifiable risk factors for nerve entrapments.
104 Our Management of Distal Femoral Comminuted Fractures with Femoral Defects
Authors: Zhou A , Jou E , Patel S , Lu V , Zhang J , Krkovic M
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 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 having a complex cohort where many of the 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 potential treatment option, although more studies on a similar cohort of patient to ours is needed to allow better comparison of the surgical approaches.