bluuebunny/crossref_metadata_2025 huggingface dataset:
699 Gender Inequality in Orthopaedic Radiation Protection: An Audit
Authors: Kovacs L , Wang J , Lee R
Published: July 2024

Aim

The literature demonstrates an increased prevalence of breast cancer in female orthopaedic surgeons compared to the population baseline. One contributor to this alarming statistic may be exposure to frequent low-dose radiation inherent to orthopaedics. The British Orthopaedic Association (BOA) has emphasised the importance of wearing lead aprons that provide adequate coverage, especially of the axillary region in women. To assess the availability of vests that fulfil such criteria, an audit of the lead aprons available at our local adult tertiary centre was undertaken.

Method

Lead protective equipment used by the orthopaedic theatres were documented by type, size, and brand. Data collection occurred prior to theatre activity requiring lead use, to ensure all equipment was present.

Results

115 pieces of equipment were identified - 43 standard vests, 9 tabard gowns with side coverage, 4 tabard gowns without side coverage, 48 skirts and 11 thyroid covers. Vests, skirts, and tabard gowns ranged from XS (n=4), S (n=21), M (n=15), L (n=46), to XL (n=12), unidentifiable size (n=6). Vests, skirts and tabard gowns ranged from several different brands including Xenolite Male (n=45), Xenolite Female (n=29) and Kenex (n=23).

No boleros, high axilla vests, or vests with wings/sleeves/axillary shields, were identified.

Conclusions

This audit demonstrated inadequate adherence to BOA recommendations and a lack of size diversity. With increasing numbers of women in orthopaedics, there is a need to raise more awareness and address this safety concern to mitigate a larger concerning trend.
1190 Clinical Features and Outcomes from the Acute PresentatiOn of coLorectaL Cancer – an internatiOnal Snapshot (APOLLO) – an International Prospective Audit
Authors: Essa N ,   Eurosurg Collaborative
Published: July 2024

Aim

The APOLLO study aimed to describe the international variation in the presentation, management and outcomes of patients presenting acutely with colorectal cancer.

Method

APOLLO was an international prospective, multicentre cohort study delivered through the EuroSurg student and trainee-led collaborative network. Adult patients presenting acutely with colorectal cancers were included. The primary outcome was 90-day mortality. Country-level variation was analysed using funnel plots.

Results

1414 patients (216 centres, 39 countries) were enrolled (median age 70 years; 645 females [45.6%]; ASA Grade I-II: 689 [48.7%]). Common presentations were bowel obstruction (n=774, 54.7%), gastrointestinal haemorrhage (n=297, 21.0%),bowel perforation (n=161, 11.4%). Overall, 56.9% of patients presented with a new diagnosis of cancer (n=804), 13.9% presented while awaiting elective surgery (n=196), and 9.3% while undergoing neoadjuvant therapy (n=132). Most cases were managed with curative intent (n=805, 56.9%). Of the 1022 patients undergoing surgery, 813 underwent surgical resection (79.5%), 582 underwent stoma formation (56.9%), and 498 (48.7%) underwent primary anastomosis. Only 57 patients underwent colonic metallic stenting (4.0%). Overall, 90-day mortality was 19.4%; 90-day surgical mortality was 13.9% and 90-day non-operative mortality was 33.7%. There was significant variation in overall mortality, but not surgical mortality, between countries after case-mix adjustment.

Conclusions

Emergency colorectal cancer presentations carry significant mortality with and without surgery. Many acute presentations are in patients with known colorectal cancer awaiting treatment. Operative mortality is similar globally, but overall mortality varies between countries. Further work is needed to guide individualised decision making on who benefits from acute surgery with curative-intent.
820 “Antibiotics Because We’re Inserting a Mesh”: A Study to Evaluate Antibiotic Prophylaxis in Elective Hernia Repairs
Authors: Harry H , Lingam G , Kirmani N
Published: July 2024

Aim

Inguinal hernias are one of the most common pathologies worldwide. Over 20 million inguinal hernia repairs are performed each year. The HerniaSurge Collaboration recently updated their international guidelines for groin hernia management. They concluded that antibiotic prophylaxis is not recommended in elective open inguinal mesh hernia repairs in average-risk patients in a low infection risk environment. In laparoscopic hernia repairs, antibiotics are never recommended. This study aimed to identify current practice for antibiotic prophylaxis use in elective inguinal hernia repairs within our district general hospital environment.

Method

A retrospective study was performed, evaluating all elective inguinal hernia repairs with mesh between 1st June 2022-31st December 2022. Both laparoscopic and open techniques were included in this study. Operative notes were reviewed to ascertain if patients had been given antibiotics intra-operatively.

Results

The study identified 84 patients who underwent an inguinal hernia repair with mesh across a 7 month- period. Of these, all were operated on in a low-risk environment. 94% (N=79) were given antibiotic prophylaxis intraoperatively.

Conclusions

Antibiotic prophylaxis is still being used for low-risk patients undergoing elective inguinal hernia surgery. This is not in keeping with current hernia guidelines which suggests that there is no significant benefit to antibiotic use. Excessive antibiotic use is associated with an increase in adverse events, an increased rate of antibiotic resistant organisms and increased healthcare costs.
807 Reliability of Simulation-Based Assessment of Surgical Technical Skills
Authors: Campioni-Norman D , Mavroveli S , Boshier P , Hanna G
Published: July 2024

Aim

To examine the reliability of surgical trainees’ assessment data from a structured simulation training and assessment programme.

Method

The General Surgical Skills Programme is a simulation-based surgical training programme integrated within the clinical training pathway for surgical trainees across London. It is tailored to each trainee’s level of training and subspecialty. The ‘Junior’ pathway involves nine training sessions and one assessment session performing three procedures (Inguinal hernia [IH], laparoscopic cholecystectomy [LC] and small bowel anastomoses [SBA]).

Within the scope of the Programme, skills assessment data collection was initiated in 2012. Data collected includes demographics and training data (grade/subspecialty/case numbers). Each procedure is assessed by two consultant surgeons using two procedure specific assessment tools, a visual analogue scale (VAS) and competency assessment tool (CAT). Reliability analyses were performed using SPSS for ‘Junior’ data over a four-year period.

Results

In total, 355 surgical trainees (Male = 199, Female = 154, Missing = 2) were assessed from 2014 to 2017 (2014 n=105; 2015 n=92; 2016 n=89; 2017 n=69). Both assessment tools showed satisfactory inter-item reliability (IH-CAT α=.794-.903, LC-CAT α=.837–910, IH-VAS α=.851-.991, LC-VAS α=.831-.986, SBA-VAS α=.778-.984). Inter-rater reliability, ICC (1,2), was good to poor across all tools. (IH-CAT .345-.510, IH-VAS .243-.600, LC-CAT .271-.766, LC-VAS .157-.678, SBA-VAS .225-.278).

Conclusions

The assessment tools used within the Programme both demonstrate satisfactory inter-item reliability. Inter-rater reliability is variable, highlighting a potential utility for assessor training within the Programme.
645 Time to Cholecystectomy for Gallstone Pancreatitis
Authors: Powell S , Froggatt P
Published: July 2024

Aim

AUGIS 2016 guidelines state that patients with mild gallstone pancreatitis should undergo a cholecystectomy within the same admission or if discharged within two weeks of presentation. This reduces readmission and leads to shorter hospital stays. In 2020, compliance at Poole hospital was 57%. This audit aimed to identity current compliance and opportunities for improvement.

Method

Retrospective study of patients admitted at Poole Hospital from 01/12/22 to 31/05/23. This was followed by presentation of findings and discussion at staff meeting and staff education and re-audited from 10/07/23 to 10/11/23.

Results

29 patients with gallstone pancreatitis were admitted during the initial study period. 22 fit for surgery, 2 patients passed away and 5 were unfit for surgery. 9 had cholecystectomy within 2 weeks giving a guideline compliance of 41%. Median hospital stay overall was three days. Median wait time to cholecystectomy was 5.5 days. Three patients who did not have a cholecystectomy within 2 weeks were later readmitted with pancreatitis. Five patients had previously been admitted with gallstone related diseases. The main barrier to compliance identified was a lack of regular theatre slots for cholecystectomy leading to regular cancellation on CEPOD.

The later re-audit showed a compliance of 32%.

Conclusions

Compliance with AUGIS guidelines has fallen since 2020. Unfortunately, staff education and presentation of findings failed to improve compliance and a high rate of readmission wastes resources. To improve, service configuration is needed with dedicated theatre slots, this should be considered for the planned Poole and Bournemouth general surgery department mergers.
666 Audit of Tip-Apex Distance in Dynamic Hip Screw Fixation of Proximal Femoral Fractures
Authors: Potter M , Hickey B
Published: July 2024

Aim

Lag screw cutout is the commonest mechanical failure in dynamic hip screw (DHS) fixation of proximal femoral fractures. Tip-apex distance (TAD), the combined distance from the tip of the lag screw to the apex of the femoral head on AP and lateral views, is the most important predictive factor for cutout. TAD >25mm is associated with a high risk of cutout. The aim was to determine the proportion of DHS fixations performed in our department with ‘acceptable’ TAD (<25mm) and assess the impact of weekly departmental metalwork meetings.

Method

Retrospective data was collected of all DHS fixations performed in our department in a 6-month period. Intraoperative imaging was reviewed to determine TAD. Posters illustrating TAD recommendations were displayed in theatre, and a weekly departmental metalwork meeting was introduced, reviewing imaging from all surgeries performed. Post-intervention, a further audit cycle over a 6-month period was performed.

Results

50 patients underwent DHS fixation during the initial audit cycle. Mean TAD was 22.85mm (range 15mm – 36mm); TAD exceeded 25mm in 13 cases (26%). In the second cycle (n=53), mean TAD reduced to 14.95mm (range 8.5mm – 29.4mm), with 1 case exceeding 25mm (2%).

Conclusions

The introduction of a weekly departmental metalwork meeting has significantly reduced the mean tip-apex distance of DHS fixations in our department, as well as the proportion of fixations with an unacceptable TAD. This should reduce the risk of lag screw cutout in these patients.
182 Keyboard Warriors Sparking a Digital Renaissance: The New Frontier in Traumatology Documentation
Authors: Ridha M , Ventour G , McParlin J , Cartner E , Khalid Z , Zaffar A , Ross-Thriepland S
Published: July 2024

Aim

To align clinical records with the high-caliber examinations performed, specifically targeting the vague "Neurovascularly Intact" or 'NVI' term. By enhancing record accuracy, the initiative sought to improve patient recovery tracking and provide robust medicolegal documentation, all while easing the workload of on-call doctors.

Method

Our audit evaluated the initial clerkings by on-call doctors for trauma patients, analyzing 59 records (n=59) against NICE and BOAST standards pre-intervention. To rectify the prevalent use of 'NVI', we introduced an autotext template, activated by 'NVIL' or 'NVIU', which auto-populates with a detailed assessment while allowing clinician customization. Post-intervention, we examined a further 57 records (n=57) to assess the impact on documentation quality.

Results

Before intervention compliance was poor: Nerve listed (11.86%), motor tested using MRC grading scale (8.47%), sensory tested (22.03%), blood vessel listed (18.64%), CRT tested (18.64%), and limb color recorded (6.78%). After intervention, compliance increased: nerve listed (91.23%), motor function (96.49%), sensory (96.49%), blood vessels (92.98%), CRT (94.74%), and limb color (82.46%). Documentation of 'NVI' reduced from 55.93% to 3.51%. Fisher's Exact Test with post hoc Bonferroni correction shows results were statistically significant (P<0.05).

Conclusions

This audit heralds an innovative breakthrough by adeptly leveraging system one thinking through technology to enhance documentation in the NHS. By introducing the autotext template, we've elevated documentation precision, strengthened medicolegal safeguards, and shifted the focus from service-dominated tasks to allow time for physician professional growth.This advancement is a significant stride towards balancing the scales, emphasizing the importance of both patient outcomes and physician development in a system under pressure.
355 Predictors of Textbook Outcome Following Oesophagogastric Cancer Surgery: A Single-Centre Analysis
Authors: Velayudham G , Dermanis A , Kamarajah S , Griffiths E
Published: July 2024

Aim

Textbook outcome (TO) is a multidimensional composite measure representing an ideal perioperative course, which has been utilised to assess the quality of care in oesophagogastric cancer surgery. We aim to determine TO rates among oesophagogastric cancer patients in a UK tertiary centre, investigate predictors of TO attainment, and evaluate the relationship between TO and survival.

Method

A retrospective analysis of a prospectively collected departmental database between 2006-2021 was conducted. Patients that underwent radical oesophagogastric cancer surgery with curative intent were included. TO attainment required margin-negative resection, adequate lymphadenectomy, uncomplicated postoperative course, and no hospital readmission. Predictors of TO were investigated using multivariable logistic regression. The association between TO and survival was evaluated using Kaplan-Meier analysis and Cox regression modelling.

Results

667 oesophageal cancer and 312 gastric cancer patients were included. TO was achieved in 35.1% of oesophagectomy patients and 51.3% of gastrectomy patients. Several factors were independently associated with a low likelihood of TO attainment: T3 stage (OR:0.41, 95% CI [0.22-0.79], p=0.008) and T4 stage (OR:0.26, 95% CI [0.08-0.72], p=0.013) in the oesophagectomy cohort and high BMI (OR:0.93, 95% CI [0.88-0.98], p=0.011) in the gastrectomy cohort. TO attainment was associated with greater overall survival in oesophagectomy and gastrectomy cohorts, however, it was not associated with recurrence-free survival in the gastrectomy cohort.

Conclusions

TO is a relevant multidimensional metric that can be utilised to compare surgical quality between centres and investigate patients at risk of TO failure. Enhancement of preoperative care measures can improve TO rates and subsequently, long-term survival.
682 Impact of Regionalisation of Major Trauma Services on Hip Fracture Care in England: A Comparative Study
Authors: Potter M , Uzoigwe C , Azhar S , Symes T
Published: July 2024

Aim

Following the establishment of Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may negatively impact their care of hip fracture patients. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs).

Method

National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs).

Results

487,089 patients were included from 167 hospitals (23 MTCs, 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p<0.001) and mobilisation by first postoperative day (81.9% vs 79.7%, p<0.001). Fewer patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p<0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p<0.001), and fewer MTC patients were discharged to their original residence (60.4% vs 63.5%, p<0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825).

Conclusions

This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, with similar mortality rates compared to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.
973 Managing Primary Endocrine Treatment (PET) in Breast Cancer Patients: An Audit of Resource Utilisation and Risks
Authors: Abolanle P , James S , Obilanade F , Zabkiewicz C
Published: July 2024

Aim

Primary endocrine treatment (PET) is considered in patients with oestrogen receptor (ER) positive breast cancer who decline or are deemed unfit for surgery. This treatment can affect bone density resulting in osteoporosis and risk of fractures. With increasing demand on resources, our aim was to examine clinical practices in this vulnerable patient group, balancing risks whilst ensuring good patient selection for treatments.

Method

We reviewed patients who had PET for ER positive breast cancer from a single consultant database in a district general hospital in South Wales between May 2018 and March 2023. We examined use of bone density (DEXA) scans, bone protection medications, outcomes, and complications.

Results

48 patients were included, aged 50-95 years (median 80) and male: female (1:47). All were ER positive, excepting 2 with limited prognosis empirically started on treatment. Reasons for PET included patient choice (15%), palliative treatment (8%), co-morbidities (65%), late stage (4%) and other (8%). There were 27 deaths (54%), with mean time from diagnosis to death 14 months (range 1-50 months). 5 patients (10%) had DEXA scan and 16 (33%) were on bone protection. 3 patients had fractures whilst on PET, likely due to pre-existing conditions. 

Conclusions

The frail breast cancer patient population has limited life expectancy and should not be over-investigated unnecessarily. It could be debated as to how much benefit bone protection provides, given the low fracture rate. Further studies are required to determine benefits of empirical bone protection in PET patients.
789 Alternative Operative Procedures in Repeat Mitral Valve Surgery: A Systematic Review and Meta-Analysis
Authors: Shirke M , Soh V , Wee A , Harky A
Published: July 2024

Aim

Median sternotomy remains the gold standard redo mitral valve surgery. However, this can be physically demanding for patients and affect mortality and morbidity. Alternative procedures such as the right anterolateral mini thoracotomy have been explored to mitigate the risks of a re-sternotomy. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery.

Method

A systematic, electronic search was performed according to PRISMA guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via an MS approach.

Results

Twelve studies were identified, enrolling 4,514 patients. Length of hospital stay (MD= -3.71, 95% CI[-4.92, -2.49]), 30-day mortality(OR = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR=0.38, 95% CI [0.22, 0.65]) were statistically significant in favour of the MT approach. Infection rates(OR=0.56, 95% CI[0.25, 1.21]) and length of ICU stay (MD= -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD=-2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD= -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR=1.03, 95% CI[0.55, 1.92]).

Conclusions

Right MT offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis and hence, can be considered a safe alternative. This review calls for robust trials in the field to further strengthen the evidence.
888 Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type an Aortic Dissection Patients: An Epidemiological Systematic Review and Meta-Analysis
Authors: Chandiramani A , Al-Tawil M , Rajasekar T , Elleithy A , Kakar S , Haneya A , Harky A , Zeinah M
Published: July 2024

Background

Acute type A aortic dissection (ATAAD) is a life-threatening emergency which is associated with high morbidity and mortality. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aim of this meta-analysis is to summarise the findings of observational studies investigating the utility of the Penn classification system as well as analyse the incidence rates and mortality patterns within each class.

Method

Electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were then filtered by multiple reviewers to meet the inclusion criteria. The extracted data included patient characteristics and primary outcomes included incidence rates of different Penn classes, along with the corresponding mortality for each class.

Results

Out of 1512 studies identified during the initial search, ten studies met the inclusion criteria. Pooled incidence of Penn A was the highest at 0.55 [0.52, 0.58] followed by Penn B at 0.21 [0.17, 0.25], and Penn C at 0.14 [0.11, 0.17]. Patients with both Penn B+C were found to be at the highest risk of death as their mortality rates were 0.36 [0.31, 0.41]. Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 [0.15, 0.27] followed by Penn B at 0.19 [0.15, 0.23] and Penn A at 0.07 [0.05, 0.10].

Conclusions

In conclusion, amongst patients presenting with ATAAD, Penn class A was the most frequently observed, followed by classes B, C, and BC. Our findings indicate an incremental increase in mortality rates with the progression of Penn classification.
327 Impact of Adjuvant Chemotherapy/Radiotherapy on the 5 Year Overall Survival of Patients with Non-Metastatic Rectal Cancer in Bulgaria - a Retrospective Population-Wide Observational Study
Authors: Ravendran K , Balagumar K , Raja A
Published: July 2024

Introduction

Survival rates of patients with non-metastatic rectal cancer (RC) have increased, due the use of adjuvant chemotherapy/radiotherapy post-surgery, recommended by the National Comprehensive Cancer Network (NCCN) [1–3]. The aim of the study was to analyse the impact of adjuvant chemotherapy/radiotherapy on the 5-year overall survival (OS) of patients diagnosed with non-metastatic RC patients in Bulgaria.

Method

This is a retrospective population wide observational study of 8968 cases registered with Colorectal cancer in the Bulgarian National Cancer Registry (BNCR) between 2015 and 2016. The mean and median age of patients with left colon (LCC) and right colon (RCC) along with rectal cancer (RC) was analysed. The impact of adjuvant chemotherapy and radiotherapy on the 5-Year OS for non-metastatic RC was analysed. Kaplan-Meier curve with log rank, ANOVA and chi-squared tests were used to estimate the statistical significance.

Results

The mean age at diagnosis for RCC, LCC and RC was 68.9, 67.41 and 66.4 respectively (p-Value=<0.001). The median age at diagnosis was 69, 68 and 67 for RCC, LCC and RC respectively.

Our study showed that patients with non-metastatic RC that received both adjuvant chemotherapy and radiotherapy had a higher 5-year OS compared to patients who received either chemotherapy, radiotherapy or neither therapy (61.4%, 59.5%, 56.2%, 51.8%), p-Value=0.007. Less than 40% of patients received either adjuvant chemotherapy or radiotherapy.

Conclusions

Adjuvant chemotherapy/radiotherapy improves the 5-Year OS for patients with non-metastatic RC. NCCN guidelines should be implemented in Bulgaria [1–3]. Bulgaria will benefit by implementing an organised screening programme [4].
825 Still FIT for Purpose? Learning From False Negative Faecal Immunochemical Tests in Symptomatic Colorectal Cancer Patients
Authors: Louden E , Rao P , Oo K
Published: July 2024

Aim

Faecal immunochemical testing (FIT) is a non-invasive screening tool used to aid the detection of colorectal cancers (CRC) by measuring microscopic levels of blood in the stool. The symptomatic threshold is recommended as ≥10μg Hb/g. The use of FIT alongside red flag symptoms provides a higher positive predictive value for diagnosing CRC. We aim to identify delays in the diagnosis and treatment in false negative FIT patients and to improve the pathways of urgent suspected CRCs.

Method

A prospective cohort of CRC 439 patients under Hywel Dda University Health Board multidisciplinary team (MDT) was reviewed. Exclusion criteria consisted of patients with anorectal mass, anal ulceration or emergency presentation. Data were collected and analysed to appraise the referral process, FIT timing and results, clinical, pathological and oncological outcomes.

Results

A total of 366 patients (175F:191M) were analysed. There was a false negative rate of 3.8% (n=14). The mean time taken from FIT to diagnosis for these patients was 53.9 days. The main subsequent diagnostic modality was CT (n=10). The average times taken from referral to the first diagnostic modalities (CT colonography and Endoscopy) were 51.6 days and 106 days respectively.

Conclusions

This study examined the clinical and oncological consequences of false-negative FIT results in CRC patients. It highlighted the need for expert clinical judgment through MDT input and complementary diagnostic modalities to minimize diagnostic delays and improve patient outcomes. This analysis has helped improve referral pathways in a single centre MDT for urgent suspected CRCs.
370 Do Prolonged Surgery Waiting List Times Affect the Incidence of Post-Tonsillectomy Haemorrhage, in the Context of the COVID-19 Pandemic?
Authors: Kieu P L , Izzat S
Published: July 2024

Aim

The United Kingdom was affected by the COVID-19 pandemic with the reduction of many services within the NHS, including suspension of elective surgical procedures from March 2020. We hypothesised that delayed surgery caused by the pandemic may increase the risk of post-tonsillectomy haemorrhage due to increased episodes of tonsillitis. The aims of this review were to investigate the relationship between prolonged waiting times and post-tonsillectomy haemorrhage.

Method

We performed a single-site, retrospective review from March 2019 to August 2023, with data collected from electronic hospital records. Both adults and children were included in the analysis and only procedures performed for recurrent tonsillitis were included.

Results

We identified 234 cases: 184 adeno/tonsillectomies in the pre-COVID (March 2019-20) and 50 in the post-COVID (August 2020-21) cohort. In the pre-COVID cohort, 7.6% (n=14) experienced a post-tonsillectomy haemorrhage, with 1.1% (n=2) experiencing a primary haemorrhage and 6.5% (n=12) experiencing secondary haemorrhage. The return to theatre rate was 2.2% (n=4). Median waiting time for surgery was 78 days. In the post-COVID cohort, secondary haemorrhage occurred in 6.0% (n=3). No patients experienced a primary haemorrhage and return to theatre rate was 0%. Median waiting time was 345 days. Simple logistic regression was performed which showed no significant association between waiting times and post-tonsillectomy haemorrhage across the whole (p = 0.90, 95% CI [-0.0002, 0.0002]) cohort.

Conclusions

Our cohort demonstrated no significant relationship between prolonged waiting times and post-tonsillectomy haemorrhage. Small sample size was a significant limitation; we recommend a larger scale, multi-centre study to investigate this further.
1114 Evaluation of the Ethical Controversies in Separation Surgery of Conjoined Twins: A Critical Review of the Literature
Authors: Woo Y T
Published: July 2024

Aim

To further examine the ethical concerns involved in separation surgery of conjoined twins, through analysing the relevant discussions in the published literature.

Method

A critical review on the ethical issues surrounding separation surgery of conjoined twins was conducted. A literature search on PubMed and Embase was carried out using three terms - ‘ethics’, ‘conjoined twins’ and ‘separation’. Relevant papers published in the past ten years (2013-2023) were included based on the PRISMA standard.

Results

Seven papers were included in this review. Most papers approached the ethical issues in separation surgery of conjoined twins from the four pillars of ethics. There are contradicting arguments with regards to beneficence and non-maleficence, depending on the perspective of the twins taken. All papers looked into autonomy and some into consent, specifically regarding decision-making. Most papers agree that the parents should be making the decision due to the patients lacking capacity. However, some argue that the patients should be making their own decisions where there is no urgency. Equality has been explored around the distribution of shared organs and survival opportunities. Other ethical principles, including the act-omission and double effect doctrines which support separation, have also been discussed.

Conclusions

There does not seem to be a definite answer to whether separation surgery is justified. Every case’s unique situation should be scrutinised differently, with guidance from the four pillars of ethics, and involvement of the families and ethical committees. Decisions should not be based on ethical considerations alone, but to take into account other factors.
1179 Navigating the AI Landscape: Surveying the Use of AI Language Tools for Medical Portfolios
Authors: Harris M , Majchrzak J , Baig F
Published: July 2024

Aim

Recent advances in artificial intelligence (AI) driven natural language processing have made it possible to use tools such as ChatGPT to generate pieces of text which are realistic, eloquent, and challenging to distinguish from human-generated content. This work aims to answer the question: could the use of these tools for medical portfolios represent a positive opportunity to enhance learning, or would it detract from the purpose of reflective practice?

Method

In total, 98 post-graduate doctors from across the UK were surveyed to gather data on their awareness of, previous use of, disclosure of use and experience with these tools for their professional portfolios. Their opinions on the need for future guidance in this area were also explored.

Results

From 90 respondents who currently maintain a professional portfolio, 18 (20%) had used AI-driven tools in some form to generate content for it and none disclosed this use. Regarding disclosing the use of AI-driven tools, 67.3% advocate for this whereas 32.7% believe disclosure is unnecessary. There was slightly stronger consensus regarding how useful guidance from regulatory bodies on this practice would be, with 73.5% in support of guidance and 26.5% in opposition.

Conclusions

Clearly, there is an urgent need for larger studies, discussion, and consensus from regulatory bodies so that guidance can be put in place. Without this, maintaining the integrity of CPD will become challenging for both trainee doctors and assessors of medical portfolios.
198 Overcoming Developing-World Challenges in Cochlear Implantation: A Nigerian Perspective
Authors: Jesuyajolu D , Obuh O , Zubair A
Published: July 2024

Introduction

The emergence of cochlear implantation (CI) in the mid-20th century was a transformation to the field of restorative otology. The advance in this field has not been felt in lower-income countries where a huge burden of profound hearing loss lies. We sought to review the literature on the practice of cochlea implantation in Nigeria.

Method

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, we conducted a study of the literature on CI in Nigeria. All observational studies with information on cochlear implants and/or implantation in Nigeria were included with no limitations on outcomes. We extracted the following data: age, sample size, sex, aetiology, outcome, type of devices, complications, challenges, and the location of the surgery. The results were pooled and reported as frequencies and percentages. Three studies were utilised in this review.

Results

The study included 25 patients. The age of the identified patients ranged from 1.2 months to 63 years. There were slightly more males than females (52% males). The most common aetiology of deafness in the participants was following a febrile illness (40%), followed by deafness post-meningitis (24%). The challenges identified included high cost, lack of full rehabilitative facilities and staff, scepticism, and lack of funding.

Conclusions

CI remains the most effective for those who are profoundly deaf. Although successful CI programmes exist in Nigeria, the number of implant programmes and the affordability are not yet commensurate to the needs of the entire Nigerian population.
260 Barriers to the Delivery of Obstetric Care Within Primary Health Centres (PHC) in India- a Scoping Review
Authors: Veerappan V , Kundu S , Arora H , Virk S , Goshal R , Gadgil A , Raykar M
Published: July 2024

Aim

This scoping review aimed aims to identify challenges in delivering obstetrics care within PHCs in India, using the 6 WHO healthcare building blocks.

Method

A literature search covered PubMed, MEDLINE databases, and Google Scholar. Studies published from 2012 to 2022, discussing PHC-based obstetrics care in India, were included based on predefined criteria. Title, and full-text screenings were conducted using Covidence, involving 2 reviewers for screening and 1-2 reviewers for conflict resolution. Data extraction on the 6 WHO building blocks was performed by 4 reviewers.

Results

Twenty-two studies were included for final review, mostly cross-sectional (59%), mainly from the state of Bihar (23%). Service delivery (77%) and health workforce (73%) were the most extensively discussed building blocks. Leadership and governance were the least discussed (14%). Challenges in service delivery encompassed limited antenatal care uptake, inadequate emergency obstetrics care and adjunct services, inadequate infrastructure, equipment and space and poor transport, and onward referral services. Health workforce issues included staffing levels and competency and training deficiencies in existing staff.

Conclusions

This review highlights significant challenges in obstetrics care delivery within Indian PHCs in India, primarily related to service delivery and health workforce. Our scoping review identified literature gaps within the four building blocks outside service delivery and health workforce, and geographical literature gaps from the Northeast of India. PHCs play a crucial role in the equitable delivery of obstetrics services that can reach the most underserved population across India. It is imperative that surgical and obstetrics plan strategies include primary care within them.
282 Emergency Laparoscopic Parastomal Hernia Repair Around Ileal Coduit in a Morbidly Obese Patient - a Surgical Challenge Managed Successfully
Authors: Pal S , Basu S , Shrestha A
Published: July 2024

Aim

Management of a strangulated parastomal hernia (PH) around the ileal conduit can be a surgical challenge. We demonstrate here a safe and effective laparoscopic repair of a strangulated PH in the emergency setting for a 53year-old morbidly obese woman (BMI: 40).

Method

Entry to abdominal-cavity was by Veress-needle technique. PH defect was identified – containing strangulated part of ascending-colon that reduced spontaneously during creation of pneumoperitoneum. Adhesiolysis around stomal defect up to lateral attachment of ileal conduit was completed. 3cm defect was opposed using transfascial nonabsorbable sutures. 15cm circular-composite-mesh was fashioned U-shaped and introduced in medial to lateral direction with the U lips overlapped and fixed snug laterally around the ideal conduit. Mesh was further fixed through double-crown fixation.

Results

Patient had an uneventful recovery and discharged on the second post-operative day. A 10-month CT as a part of bladder cancer follow up showed no PH recurrence.

Conclusions

This case shows that strangulated PH around an ileal conduit, an uncommon presentation, can be successfully managed laparoscopically even in the emergency setting especially for patients of high BMI with proper assessment and appropriate expertise. Successful management of this challenging presentation of strangulated PH around ileal conduit demonstrates the safe and effective use of laparoscopic surgery especially in the emergency setting for patients of high BMI.
732 Does Intraoperative Urinary Catheterisation Decrease Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair? a Systematic Review and Meta-Analysis
Authors: Romman S , Fagbemi O , Hajibandeh S , Ghessemi N , Evans D , Athwal T
Published: July 2024

Aim

To evaluate comparative outcomes of laparoscopic inguinal hernia repair with and without use of intraoperative urinary catheterisation.

Method

A systematic search of MEDLINE, CENTRAL and Web of Science and bibliographic reference lists were conducted. All comparative studies evaluating outcomes of laparoscopic inguinal hernia repair with and without use of intraoperative urinary catheterisation were included and their risk of bias were assessed using their risk of bias were assessed using ROBINS-I tool. Postoperative urinary retention was analysed as the primary outcome parameter and an odds ratio (OR) was determined using Random-effects modelling.

Results

We included 6 comparative studies reporting a total of 8,675 patients who underwent laparoscopic inguinal hernia repair with (n=3,318) and without (n=5,357) use of intraoperative urinary catheterisation. There was no significant difference in postoperative urinary retention between the two groups (4.3% versus 3.7%, OR 0.93; 95% CI 0.55-1.58, p=0.80). There was significant heterogeneity among the included studies (I2: 75%, p=0.001). Results of sensitivity analyses were consistent with the results of the main analysis.

Conclusions

Meta-analysis of best available evidence (level 2a) demonstrated that use of intraoperative urinary catheter has no advantage in prevention of postoperative urinary retention following laparoscopic inguinal hernia repair. Future randomised controlled trials are required to control for confounding factors that increases the risk of urinary retention.
30 Does the Use of Antibiotics Prophylaxis Affect the Rate of Postoperative Fistula Rates in Cleft Palate Patients?
Authors: Singh S , Narayan N , Cobb A , Chummun S
Published: July 2024

Aim

Assess whether post-operative antibiotic prophylaxis affected the incidence of oronasal fistula formation in cleft palate patients. Design and setting: Institutional retrospective study using data from patients undergoing primary palatoplasty.

Gold standard

Fistula rate of no more than 8-10%.

Method

In the first cycle, there were two groups (A and B). In group A, the patients had antibiotics on induction and 24 hours after, in group B, the patients had further antibiotics for a week. Our work from the cleft collective showed no evidence of change in fistula rates in relation to the antibiotic regime. Therefore, group A surgeon changed practice had antibiotics only on induction and group B remained the same from the first cycle.

Results

In cycle 1, we found little evidence to suggest a difference in fistula rate between the use of an antibiotic regimen as binary variables: Grp A(P=0.171) and Grp B (P=0.69). Cycle 2 also demonstrated the following: Grp A (P=0.557) and Grp B(P=0.443).

Conclusions

The use of antibiotics and differing regimes, postoperatively do not influence the incidence of postoperative fistulae in cleft palate.
1088 The Quality of Information Recorded in Neurosurgical Operation Notes: A Closed Loop Audit
Authors: Chaudhry D , Konakanchi J , Ratnayaka R , Momin S
Published: July 2024

Introduction

Operation notes are critically important documents which serve as record for significant events in the lives of patients. They serve multiple functions, but chiefly to help guide peri-operative management. Surgeons must keep records that are accurate, thorough, and readable. This is fundamental part of the GMC’s Good Medical Practice as well as the Royal College of Surgeons of England Good Surgical Practice guidelines which lays out 18 various parameters for what should be included in an operation note.

Aim

This retrospective audit aimed to evaluate the compliance of neurosurgical operation notes with the Royal College of Surgeons guidelines, identifying areas for improvement.

Method

All neurosurgical procedures between October 1 and October 31, 2023, at a Major Trauma Centre in the West Midlands were retrospectively audited. Two independent reviewers used a standardized proforma in Microsoft Excel for data extraction, comparing compliance.

Results

91 operation records were examined and found high compliance (100%) in key fields: date, surgeon's name, assistant's name, operative procedure, operative diagnosis, and signature. Negligible compliance was found in identification of prosthesis (0%), estimated blood loss (1%), extra procedures (1%), elective/emergency classification (1%), time (4%), and problems/complications (19.8%). Notably, detailed post-op instructions were lacking in over 1 in 3 operation notes, with 19.7% omitting DVT prophylaxis, and 20% neglecting clip/suture removal instructions.

Conclusions

While certain aspects showed exemplary compliance, critical deficiencies were identified, particularly in post-operative instructions. A template proforma for post op instructions is required in addition to more targeted guidelines for operation notes within neurosurgery.
1203 Early Surgery on Patients with Aneurysmal Subarachnoid Haemorrhage WFNS Grades 4 and 5
Authors: Noureldin F
Published: July 2024

Aim

This review aims to evaluate timing and approach of management of poor-grade aneurysmal subarachnoid haemorrhage, WFNS grade IV and V.

Method

We used PubMed, Cochrane Library, and the reviews and reference lists of relevant articles to search for studies published from 1999 till 2018 to review 16 articles, with a total of 2032 patients, for ultra-early, early, or late timing of surgery and 7 articles, with a total of 1294 patients, for surgical clipping or endovascular coiling.

Results

Studying the outcome of timing of surgery of total population revealed, 50.6% of patients had favourable outcome: 18.4% receiving ultra-early surgery, 20.5% early and 11.8% late surgery. While 42.6% of patients had poor outcome: 20.2% undergoing ultra-early surgery, 14.3% early surgery and 8% late surgery. Analysing the total population for modality of choice revealed, 25.6% of patients who underwent surgical clipping had favourable outcome compared to 15.8% who received endovascular coiling, while 32.1% and 20.9% of patients had unfavourable outcome. In addition to 3.9% of patients refusing the aneurysmal treatment, all suffered poor outcome.

Conclusions

All the reviewed articles agreed on the consensus that management within 24 hours from ictus is the timing of choice in managing poor grade SAH, which can reduce the increased intracranial pressure and increase cerebral perfusion to improve outcomes. Outcomes of both neurosurgical clipping and endovascular coiling were not appreciably different. However, clipping is preferred in small aneurysm with wide neck and MCA aneurysms. Coiling is preferred in larger aneurysms and aneurysms in ICA and posterior circulation.
1152 Soft Tissue Infections of the Hand – Reducing Inpatient Cost and Duration of Stay in a London Plastic Surgery Department
Authors: Sagoo H , Vinayachandran G , Kazzazi F , Pywell M
Published: July 2024

Introduction

Soft tissue infections of the upper limb referred to plastic surgery units often require hospital admission for intravenous antibiotics, irrespective of surgical intervention.

Aim

We explored approaches to reducing the cost and duration of inpatient admission for antibiotic treatment for soft tissue infections.

Method

We sampled data over a two-month period in 2023 to explore the number, type, and severity of soft tissue infections of the upper limb seen in London Plastic Surgery department.

Results

35 patients with soft tissue infections of the upper limb were included. We found no correlation between age; white cell counts or c-reactive protein levels on day of presentation with duration of inpatient stay. Our studies showed that 78% of patients were discharged within 72 hours of admission or procedure, with a greater number of inpatient bed-days for patients receiving intravenous antibiotics without surgery, compared to patients receiving antibiotics and discharge within 3 days of receiving surgical intervention (36 days vs 25 days). 84% of patients were not located within post-codes accessible to existing outpatient antibiotic therapy (OPAT) services. By extending outpatient antibiotic cover for these patients, we projected a total 568 bed-day saving through 202 bed days annual avoidable inpatient bed-stay savings (3+ days, non-OPAT post-codes) and 366 bed days for additional annual avoidable short inpatient bed-stay savings (≤3 days admission, all post-codes), with projected annual cost savings of £319,558.

Conclusions

Our study projects a possible reduction in inpatient cost and duration of stay through extended OPAT cover in patients requiring intravenous antibiotics for soft-tissue infections of the upper limb.
378 Workload Assessment of Suturing Tasks and AI-Task Classification Using Electromyography
Authors: Karaiossifides H , Naik R , Rubio-Solis A , Jin K , Mylonas G
Published: July 2024

Aim

It is well established that excess surgeon workload results in poorer performance. Workload can be divided into physical workload (PWL) and cognitive workload (CWL). The study aims are twofold: 1. Assess how the subjective PWL of suturing is affected by varying PWL and CWL 2. Develop an AI-classification algorithm for task detection using electromyography (EMG).

Method

Novices were trained in interrupted suturing and asked to suture under four conditions of varied workload. Tasks included were: 1. Control, 2. Different suture material (Silk), 3. Simultaneously undertaking a neurocognitive task and 4. Suturing at depth. Subjective workload was recorded using a validated workload questionnaire (SURG-TLX). EMG sensors recorded physiological data from the biceps brachii and extensor ulnar carpi. A convolutional neural network (CNN) was created for AI-task classification using EMG data.

Results

The depth task had the highest subjective workload. Subjective depth raw workload was significantly higher than Control (p=<0.01) and Silk (p=<0.001) but comparable to the neurocognitive task. Subjective depth weighted workload was significantly higher than the neurocognitive task (p=<0.05). Subjective depth adjusted workload was significantly higher than the neurocognitive and silk tasks (both p=<0.05). The CNN training accuracy was 76.4% (95%CI 75.5-77.4) and had a classification accuracy of 76.5% (95%CI 75.7-77.2).

Conclusions

The relationship between PWL and CWL on subjective PWL is complex. Despite this, the CNN was able to differentiate between tasks using objective EMG data with good accuracy. This CNN has potential to characterise CWL which can be further developed to detect excess workload to improve surgical training through objective benchmarks.