bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.TU.481Quality of Surgical Ward Rounds in a District General Hospital: an audit
Authors: Davis Heather , Achunine Portia , Jesuthasan Julia , Chowdhury Ashim , Harinath Gandrasupalli
Published: October 2021

Aims

The fast-paced surgical ward round, alongside numerous competing distractions and demands, can result in poor rounds and subsequent imperfect documentation. This carries significant medico-legal implications. This audit assessed the standard of surgical ward round documentation at a district general hospital, against Royal College and other published guidelines.

Methods

A retrospective data collection of adult general surgical patients was undertaken over a period of eight weeks. We excluded bank holiday, weekends and paediatric cases. Documentation during ward rounds in patient notes were analysed and compared against the guidelines.

Results

166 patient notes were included. Percentage compliance was assessed as a total, minus cases where not applicable.

Good compliance ( > = 75%) was achieved in the majority of data points, including: date (100%), time (83%), ward round lead (99%), legibility (88%), early warning score (78%), current issues (80%) and management (100%).

Poor compliance ( < = 25%) was seen in: presenting complaint (25%), fluid balance (16%), intravenous fluid review (21%), catheter review (23%), radiology results (25%), urinalysis (4%), beta HcG (0%), drug chart review (23%), antibiotic review (15%), assessment of venous thrombo-embolic risk (0%) and ceiling of care (1%).

Conclusion

Accurate, clear and complete documentation is crucial for patient safety and continuity of care, as well as for medico-legal reasons. This study shows there are several areas requiring improvement. The authors propose a proforma including the essential criteria to be integrated into the daily ward rounds.
EP.TU.521Does a foundation interim year one post improve confidence in general surgery in a district general hospital?
Authors: George Jayan , Mathew Alok , Robinson Edward , Ardley Rohan
Published: October 2021

Aims

1. Understand the confidence levels of current foundation year one (FY1) doctors.

2. Understand whether an interim foundation year one (FiY1) post improves confidence.

Methods

FY1s were surveyed throughout August – December 2020. Nine questions used Likert scales (1 to 5: not at all confident to very confident) over some common general surgical themes. Data was initially inputted using google docs and analysed in Microsoft Excel.

Results

32.1% (9/28) of FY1s completed the survey.

33.3% (3/9) did not undertake a FiY1 post where 66.7% (7/9) did.

Confidence levels were mostly the same between FY1s who had a FiY1 post and those that did not for dealing with patients with hepatobiliary disease, non-specific abdominal pain, appendicitis, speaking to a family when a patient is dying prescribing fluids for maintenance as well as resuscitation.

Confidence levels were higher for FY1s who did not have a FiY1 post compared to those that did in managing the deteriorating patient.

Confidence levels were lower for FY1s who did not have a FiY1 post compared to those that did in speaking to a patient when their diagnosis is unknown.

Conclusions

FY1s who have had a FiY1 post in a district general hospital have more confidence in most areas but not all. This data shows the value of the FiY1 post however work needs to be done to improve the experience to the role.
EP.TU.542Enterolith ileus secondary to small bowel diverticulum: a rare cause of small bowel obstruction
Authors: Dey Abhishek , Elmasry Mohamed , Marshall Robert
Published: October 2021

Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis or high intraluminal pressures. Enterolith formation within these diverticula and intra-luminal bowel obstruction from them are a less encountered complication.

A seventy-five year old man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces were noted on rectal examination. Biochemistry indicated raised inflammatory markers and an acute kidney injury. Abdominal CT scan revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract suggestive of passage of gallstone to ileum. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum.

The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.
EP.TU.651Training Opportunity In A Non Covid Private Hospital During The Initals Phase Of Sars-Cov-2 Pandemic-Our Experience
Authors: Bhandari Mayank , Virupaksha Suvi , Gopalakrishnan Palanivel raju , Rao Milind , Bussa Gopinath , Ahmed Ish
Published: October 2021

Aim

We would like to share our experience in the unique opportunity our surgical trainees had, while operating in a NON COVID private hospital.

Methods

We did a retrospective data collection from 1st of April till 31st May 2020. The data was collected about the patients who underwent elective surgery in a non COVID private hospital selected by our NHS trust. The selected patients were asked to self-isolate for 2 weeks prior to surgery date. They also underwent 2 swab tests, the first one a week before and another one 48 hours before the surgery date along with a chest X-ray. Only the patients who tested negative on swabs were operated in the private setup.

Results

There were 17 elective laparoscopic cholecystectomies and 42 breast surgeries performed. The primary operating surgeon were trainees in around 80 percent cases. Ours was the first NHS trust to start this in the North East England. There was no increase in operating time, but the turnover time was nearly doubled because the guidelines for safe anesthesia and surgery during this pandemic were strictly followed. We did not have any complications or readmission related to surgery in this cohort of patients. There was no reported SARS-CoV-2 infection to patients and the involved medical staff.

Conclusion

The opportunity for continuity of surgical training in a private setup is a possibility and should be explored more in future.
EP.TU.657Scoping the role and content of a simulator-based endosim curriculum
Authors: Eley Catherine , Hawkes Neil , Lewis Wyn
Published: October 2021

Background

Endoscopy training requires simultaneous acquisition of practical skill and knowledge. Virtual reality Simulators, such as EndoSim (SurgicalScience), offer the opportunity to deconstruct a skill into fundamental components (1), to allow repetitive practice, and achievement of task-specific objectives. Trainees with the least endoscopy experience benefit most from early simulated training (2,3), supporting the introduction of a simulation curriculum into SPRINT: Structured PRogramme for INduction and Training, an existing initiative to improve endoscopy training delivery in Wales. (4) The aim of this study was to design a pilot simulator curriculum for the EndoSim (Surgical Science, Gothemberg) simulator.

Methods

A focus group completed all EndoSim modules. Each EndoSim exercise was cross-examined against the relevant DOPS tool “Direct Observation of Procedural Skill” used by the Joint Advisory Group for Endoscopy Training and Certification. Exercises were chosen that represented each DOPS domain to teach basic skills in endoscopy scope handling.

Results

12 exercises were chosen. These exercises addressed the insertion and withdrawal, and visualisation components of the JAG DOPS tool. Pre-procedural skills, management of findings, post-procedural skills and endoscopic non-technical Skills (ENTS) are beyond the scope of this simulator and require additional taught sessions to provide the context for current simulation training.

Discussion

This is the first step in developing and refining appropriate exercises to inform the proposed curriculum. The next step will be validating the chosen exercises against expert benchmark performance.
EP.TU.947Rectosigmoid Cancer Resection in a District General Hospital – A single centre experience
Authors: Lim Jieqi , Khan Sharib Ziya , Sasapu Kishore
Published: October 2021

Aims

To identify common factors amongst patients who had undergone rectosigmoid cancer resections

Materials & Methods

This is a single centre retrospective study including patients who underwent recto-sigmoid cancer resections by a senior colo-rectal surgeon from year 2012 to 2018. Patients’ data were identified through a local trust database. Patients’ variables were subjected to Mann Whitney, Chi Square analysis and survival function plots.

Results

Of the 102 patients, we observed a mean age of 66 years with a slight male sex predisposition(58%) . Two-thirds were referred through the 2 week-wait GP pathway with predominant symptoms being bleeding and change in bowel habits (70 and 60% respectively).

Male sex was associated with longer length of stay (LoS), younger age at surgery, higher T-staging and tumour size. Patients who had laparoscopic surgery converted to open and those with stoma had the longest LoS.

Histological results of higher Dukes, T and N stage were associated with higher patient mortality rates. Advanced N and Dukes staging were also related to higher propensity of disease recurrence with new metastases.

In those with positive circumferential resection margin (CRM) on histology, there were higher correlation with local and distal disease recurrences as well as higher post-op mortality rate (all the above had p-values <0.05).

Conclusion

The factors identified in previous large scale studies do correlate with our experience in a district general hospital and identification of sub-groups of patients at higher risk of adverse outcomes can be identified in further studies.
EP.TU.1068Developing a Major Trauma Nursing Education Framework in Manchester
Authors: Honey Carly , Smyth Victoria , Wee Lisa , Ellis David , Smith Stella , Chan Anthony
Published: October 2021

Aims

The opening of the Major Trauma Ward (MTW) at Manchester University Hospitals NHS Trust represents a key milestone for managing major adult trauma within the Greater Manchester conurbation. We present an overview of the development of a novel Major Trauma Nursing Education Framework incorporating both the induction and continuing professional development of trauma nurses.

Methods

The MTW nursing skillset combines elements from acute surgical specialities and rehabilitation medicine. A framework for education was constructed from the Adult Nursing Competencies for the Major Trauma Patient (National Major Trauma Nursing Group) and the Trauma Intermediate Life Support curriculum. An induction programme was developed with a Competencies Workbook for an interim period including external courses for band 5 (Nurse Trauma and Critical Care course) and senior nurses (ALS and Neonatal, Adult and Paediatric Safe Transfer and Retrieval Course). An annual training programme will renew these competencies.

Results

Feedback from the first cohort for the induction programme has been positive, particularly with the third of nurses who did not feel confident managing trauma patients prior to induction (Wilcoxin-signed rank test, p = 0.00116). Free text comments ranged from the completeness of the topics covered to the delivery methods of the curriculum and how to work effectively within the wider multidisciplinary team.

Conclusions

The development of a formal Major Trauma Nursing Education Framework is necessary for a modern trauma workforce. Feedback has so far been positive. Continual audit of the framework will be necessary to ensure and improve the quality of delivery of education.
EP.FRI.32 Emotional Resilience and Bariatric Surgical Teams: a Priorityin the Pandemic
Authors: Graham Yitka , Mahawar Kamal , Riera Manel , Omar Islam , Bhasker Aparna , Wilson Michael
Published: October 2021

The infection control measures implemented as a result of COVID-19 led to a postponement of bariatric surgical procedures across many countries worldwide. Many bariatric surgical teams were in essence left without a profession, with many redeployed to other areas of clinical care and were not able to provide the levels of patient support given before COVID-19. As the pandemic continues, some restrictions have been lifted, with staff adjusting to new ways of working, incorporating challenging working conditions and dealing with continuing levels of stress. This article explores the concept of emotional labour, defined as ‘inducing or suppressing feelings in order to perform one’s work’, and its application to multidisciplinary teams working within bariatric surgery, to offer insight into the mental health issues that may be affecting healthcare professionals working in this discipline.
EP.FRI.35 Traumatic abdominal wall hernia (TAWH) in a 16 year old boy
Authors: Ahmed Elmurtada , Shaw Simon
Published: October 2021

Definition

Traumatic abdominal wall hernia is defined as: herniation of viscera through disrupted musculature & fascia associated with forceful trauma without skin penetration & no evidence of prior hernia defect prior to trauma 

Introduction

There are only about 30 reported cases of TAWH due to handlebar injury, it is a rare complication of blunt abdominal trauma it involves disruption of abdominal wall muscles with bowel loops herniating through the abdominal wall defect & may be accompanied by serious or lethal complications 

Case report

A 16 year old boy received trauma while cycling at about: 5 miles/hour & landed in the handle-bar with his right lower abdominal wall against the handle, the patient's vital signs were stable but there was bruising in the area, the diagnosis was missed by A&E doctor, but I saw him O/E there was a positive cough impulse & the diagnosis was confirmed by US examination, his haematological & biochemical investigations were normal, patient was taken to theatre & the hernia was repaired (image 2 & 3)

Conclusion

our case highlights the importance of clinical examination in blunt abdominal trauma & high index of suspicion plus using US/CT as appropriate to rule out mesenteric or visceral injury
EP.FRI.42 REBOA associated iatrogenic AV fistula
Authors: Gambhir Raghvinder , Grainger Charlotte , Davies Monica , Harris Matthew , Sudarsam Abhilash
Published: October 2021

Aim

To discuss a rarely reported complication of Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a trauma patient with exsanguating haemorrhage.

Case description

A 15 year old male sustained was brought in as a cod Red, following multiple stab injuries to his Rt thigh. A REBOA was inserted via the contralateral Femoral artery on the scene to control the bleeding. Once proximal and distal control was obtained on the Right leg, the REBOA was deflated and removed. The right leg needed an interposition vein graft and ligation of femoral vein. The patient had received 12 units of transfusion.

Post-operative CT-angiogram demonstrated an AV fistula between the Left Profunda femoris artery and Common femoral vein on the side of REBOA insertion. A Duplex scan showed flows of 2600ml/min on duplex and AVF diameter of 2.6mm. It was decided to wait for spontaneously closure as patient underwent rehab. At 6 weeks the AVF flow had reduced to 460ml/min however further expectant management did not lead to spontaneous closure of the AVF and he underwent surgical tie off during his next school holidays 6 months later.

Conclusion

AV fistula formation as a complication of REBOA insertion has not been reported in paediatric population. It highlights the need for a CT angio after surgical stabilisation. These post traumatic AVFs may need surgical repair if it does not spontaneously close in 3-6 month time.
EP.FRI.50 Morbidity of presumed temporary loop de-functioning stomas in patients with colorectal cancer
Authors: Alfred Joshua , Macdonald Siobhan , Kalaiselvan Ramaya , Bruce Susanna Schuster
Published: October 2021

Objectives

The incidence of parastomal hernia (PSH) can be up to 80% of patients who have a stoma following abdominal surgery (1). Surgical intervention is required in 70% of patients due to pain, obstructive symptoms or stoma appliance issues (2). This study aims to show the morbidity related to a presumed temporary loop stoma. 

Methods

This was a retrospective cohort study of all left-sided colorectal cancer resections undertaken in a single centre. Electronic healthcare records and Picture Archiving and Communication System (PACS) were used to gather data on patient demographics, operative details and details of de-functioning stoma fashioned. Morbidity related to de-functioning stoma was determined based on hospital admissions and length of inpatient stay related to stoma, complications in relation to the stoma, return to theatre, stoma reversal and fate of stoma site. 

Results

147 patients (87 M; 60 F, median age 69 (23-93)) underwent left sided colorectal cancer resections at a single centre. In total, 50 de-functioning loop stomas were fashioned (49 loop ileostomies and 1 loop colostomy.) At a median follow-up of 23 months (8-44), prior to reversal, 12 PSH were identified. 38 of the de-functioning stomas were reversed at a median time of 11 months (1-44), 5 of which were emergency procedures due to obstruction (n = 3) or high output (n = 2). There were 9 stoma related re-admissions identified in 7 patients. 

Conclusion

Presumed temporary defunctioning loop ileostomies in Low anterior resections is associated with significant morbidity, but low risk in terms of life-threatening complication.
EP.FRI.56 Spectrum of Clinical Presentation, Radiological Findings and Management of Tuberculosis on the Surgical Floor - An Experience from a Tertiary Care Hospital in Pakistan
Authors: Bhatti Hamza Waqar , Farooqui Marryam Riaz , Khalid Ayesha , Janjua Saad Ullah Sarfaraz , Khan Huma Sabir , Hanif Muhammad
Published: October 2021

Aim

Abdominal tuberculosis has varied presentation and can be confused with other conditions. The aim of the study is to assess and evaluate various clinical presentations and management of intestinal tuberculosis presenting to our tertiary care hospital.

Methods

This 3-year descriptive study was conducted on patients with diagnosed intestinal tuberculosis (by histopathology) in Surgical Unit-II, from Jan 2017 to Jan 2020. Detailed history and clinical examination were performed in all the cases. Investigations like Blood CP and ESR, Albumin, Ultrasound abdomen, X-Ray abdomen were carried out in all the cases. Preoperative assessment of anatomical site and variety of lesions were also noted. Per-operative findings and procedure performed was recorded.   

Results

A total of 85 patients with diagnosis of intestinal tuberculosis were admitted and operated. Diagnosis was confirmed by histopathology. Among these, 35 (40.7%) were male, and 50 (59.3%) were female. Variable clinical presentations were seen. Majority of patients 76(89.3%) had abdominal pain 55 (64.8%) had vomiting. Most common per-op findings included strictures 42 (50%), intestinal perforation 35 (40.7%)  and multiples tubercles in abdomen 24 (28.7%). Most common procedures performed were ileostomy 45 (52.8%) and right hemicolectomy 28 (33.3%). X ray and Ultrasound findings were positive in  79(91.6%) and  67 (79.6%)  cases only  respectively. 

Conclusion

High clinical suspicion is required for diagnosis of TB. Intestinal perforation, and strictures were the commonest lesions. Definitive surgical procedure like ilecolostomy and right hemicolectomy are the main surgical options.
EP.FRI.86 Spontaneous haemoperitoneum due to acute hemorrhagic pancreatitis in a child: A Case report
Authors: Tan May Ting , Rahman Mohammad Mahbub Akhter , Sasapu Kishore
Published: October 2021

Introduction

Hemoperitoneum resulting from acute pancreatitis (AP) is rare. It is more commonly associated with chronic pancreatitis. Seldom, it has been associated with paediatric population. Here we report a case of spontaneous hemoperitoneum due to acute hemorrhagic pancreatitis in a child presented with the clinical features suggestive of acute appendicitis.

Presentation of the case

A 9-year old girl presented with abdominal pain and clinical features consistent with perforated appendicitis, underwent diagnostic laparoscopy. This revealed hemoperitoneum due to acute hemorrhagic pancreatitis with fat saponification in the omentum around the splenic flexure. She was stable postoperatively and was transferred to a tertiary paediatric unit for further management.

Discussion

The incidence of paediatric AP is increasing at 1/10,000 children per year. The definition of paediatric AP is based on the Atlanta criteria in adults. Biliary condition, systemic illness, and medications remain the main causes of AP in children. Intravenous fluid therapy with crystalloids remains the mainstay of treatment. 

Conclusion

A high index of suspicion is required to reach the diagnosis as symptoms are commonly comprised of abdominal pain, irritability, nausea, vomiting, and epigastric pain. USS is the investigation of choice. Majority of the patient recovers completely with a recurrence reported only on 15-35% of the cases. 

Key Statement

Inclusion of amylase or lipase to be considered in the routine workup if there is a suspicion of an alternate diagnosis. Diagnostic laparoscopy remains a viable option for patients presented with features of peritonism to establish a diagnosis.
EP.FRI.99 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management
Authors: Shalaby Amr , Ibrahim Mohammed , El Faioumy Tarek , Elmessiry Mohamed
Published: October 2021

Aim

to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient candidates for non-operative management. 

Methods

In this comparative study 40 abdominal stab victims (admitted to Emergency Department) were selected during a 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome. 

Results

In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications. 

Conclusion

Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.
EP.FRI.178 Audit of rejected radiological referrals at Ninewells Hospital, Dundee: Reasons and outcomes
Authors: Patil Aishan , Scollay John
Published: October 2021

Background

Rejected radiology requests in emergency-settings can be time-consuming for clinical and radiological staff; and can delay or even affect patient management plans and outcomes. Inappropriate or duplicate radiological requests additionally can be resource-wasting (according to data from Fairfield Independent Hospital, BUPA, St. Helen’s) - the approximate costs / scan are £160 for Ultrasound, £450-£675 for CT, £350- £525 for MRI.

Methods

Results

Commonest reasons for rejection:

Conclusions
EP.FRI.183 Laparoscopic management of strangulated paracaecal hernia causing small bowel obstruction. Case report and review of the literature
Authors: Al-Ardah Mahmoud , Sisodia Heena , Clarke Michael
Published: October 2021

Background and Aim

Paracaecal hernia is a rare type of internal hernia usually presenting with a picture of small bowel obstruction. In this report we present a case of strangulated paracaecal hernia managed laparoscopically with aim to spot the light on this rare type of internal hernia. 

Case Report

A 68- year- old lady was admitted with colicky lower abdominal pain, vomiting and abdominal distention. CT scan of her abdomen and pelvis demonstrated  multiple dilated small bowel loops with a transition point in the right iliac fossa. The patient was taken to theatre where she underwent laparoscopic reduction of a strangulated paracaecal hernia. The patient had uneventful post-operative recovery and was discharged home on day four post-operatively. 

Conclusion

Despite being a rare cause for small intestinal obstruction, it should be part of the differential diagnosis especially in the absence of previous abdominal operations. Early recognition and prompt surgical treatment is the key to prevent complications. Laparoscopic approach is feasible if expertise is available.
EP.FRI.196 The Giant Hoqweed as a rare cause of chemical burns: A Case Series
Authors: Lim Su Kwan , Clements Jamie , Khan Khalid
Published: October 2021

Introduction

The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern. 

Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries. 

Description

We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings.  

Discussion

Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full skin thickness burns warranting operative intervention.
EP.FRI.199 Impacted common bile duct stone managed by hepaticoduodenostomy
Authors: Weledji Elroy
Published: October 2021

The management strategy of common bile duct stone will depend on personal experience, equipment availability, time and the availability of other departmental expertise. For a distally impacted common bile duct (CBD) stone in a low resource setting, an open approach will entail either leaving the stone where it is and carry out a choledochoduodenostomy, or removing the stone through a transduodenal sphincteroplasty. The latter has a significant risk of causing an acute pancreatitis. A case report of a hepaticoduodenostomy performed on a 40-year-old black African man for a retained, impacted distal CBD stone in a low resource setting with a good outcome is presented.   The impacted CBD stone had complicated an open cholecystectomy for acute cholecystitis by causing the dehiscence of the cystic duct stump as a result of distal biliary obstruction. A bypass procedure such as a hepaticoduodenostomy may be an alternative to the traditional choledochoduodenostomy in the management of the retained, impacted distal CBD stone especially in the presence of sepsis. A wide side- to-side hepaticoduodenostomy (>3cm d) is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis and the ‘sump’ syndrome. This case demonstrates that a hepaticoduodenostomy is safe and effective in rescuing the adverse sequelae of an impacted distal CBD stone in a low resource setting.
EP.FRI.300 Equine related trauma: a 20-year district general hospital experience
Authors: Dick Lachlan , Yule Michael , Green James , Young Jamie
Published: October 2021

Introduction

Although a popular recreational and competitive sport, horse riding carries risk of injury. We aimed to characterise demographics, injury patterns and outcomes of patients with an equine-related injury over a 20-year period.

Methods

Patients were identified through local coding. Data relevant to the study aims were extracted. Statistical analysis was used to determine any association between patient demographic with injury pattern or outcome.

Results

Of the 701 patients included, 71.3% were female and the mean age was 34.9 years. Simple head injury (25.4%) and upper limb fracture (21.3%) were the commonest injuries. Abdominal visceral injury occurred in 1.6% with 2 patients requiring laparotomy and splenectomy. Overall, operations were performed in 32.8%. Open reduction and internal fixation was the commonest procedure (42.4%). 30-day mortality was 0.3% and 3.1% required transfer to a tertiary centre. Older patients were more likely to have a rib (46.3 vs 33.5 years, p = <0.05) or lower limb fracture (37.9 vs 34.5 years, p = 0.04) whilst upper limb fractures were seen in younger patients (30.3 vs 36.1 years, p = <0.05). There was no statistical difference with other injury patterns or gender. 

Conclusion

Although mortality is rare, a significant proportion of patients sustain injury requiring surgical intervention. Given the predisposition towards orthopaedic injury, adequate rehabilitation facilities need to be available. Continued development and promotion of safety equipment are also required to reduced incidence.
EP.FRI.353 Repeat Amylase in Acute Pancreatitis
Authors: Osinkolu Ifeoluwa
Published: October 2021

Introduction

Acute pancreatitis is a common reason for acute surgical admission, with an annual incidence of 56 per 100,000 UK population. Studies have demonstrated that whilst serum amylase measurement is useful as a diagnostic tool, it has no correlation with disease severity, and its measurement after diagnosis has limited value.

The aim of this audit was to review the practice of obtaining repeat serum amylase levels in patients diagnosed with acute pancreatitis in two district hospitals within the same health board. Secondary outcome was to gain up-to-date demographic information on the patient cohort. 

Methods

This was a retrospective study, which reviewed records of those patients admitted with pancreatitis over a one-year period (January 2019 – December 2019). Electronic records were evaluated to check if serum amylase was repeated after diagnosis. Data on demographics, underlying cause and the use of CT for diagnosis were also collected. 

Results

174 patients were admitted during the study period, of which 53% (92) had their serum amylase inappropriately repeated. 14% (24) of cases were diagnosed using CT imaging. There was a 0.74:1 male to female ratio with an average age of 53. 51% of cases were caused by gallstones, 15% were caused by alcohol and 28% of cases had no identified cause.

Conclusions

Validated scoring systems remain the accepted method of predicting acute pancreatitis severity. This study highlights the frequent practice of inappropriately repeating serum amylase measurement in patients already diagnosed with acute pancreatitis. It also highlights the importance of CT scanning as a diagnostic tool.
EP.FRI.362 Improving Prescribing and Minimising Delay in Administration of Potassium Replacement Therapies: Surgical Audit on Management of Hypokalaemia in Emergency Surgical Unit at a District General Hospital in UK
Authors: Park Ji Young , Mai Dinh Van Chi , Tenovici George
Published: October 2021

Aims

Surgical patients are prone to hypokalaemia due to gastrointestinal losses1. Hypokalaemia prolongs ileus2 and thus prompt management is essential. No current guideline on hypokalaemia focuses on surgical patients. We aimed to identify the prevalence of hypokalaemia in emergency surgical patients as well as measure timeliness and appropriateness of replacement.

Methods

We retrospectively reviewed adult emergency surgical admissions exceeding 48 hours between 05/05/2020 and 15/07/2020.  A sub-group analysis assessed the timing of intravenous replacement and duration taken to normalise potassium (3.5 mmol/L). We used another NHS trust’s guideline3 as standard for appropriate potassium replacement. 

Results

Of 110 surgical admissions, 26 cases were hypokalaemic. Of these, 15 had initially normal potassium level. Three cases were likely iatrogenic secondary to inappropriate fluid prescribing. Mean potassium in the hypokalaemic group was 3.2 mmol/L (80.8% mild vs. 19.2% moderate). Mean length of stay was 11.3 days for hypokalaemia versus 6.54 days in normokalaemic cases. Mean duration of hypokalaemia was 2.13±1.45 days. Potassium replacement was prescribed correctly in only 50% of cases (23% not prescribed; 25% insufficient; 2% incorrect) and of these correct prescriptions, 46% were not actually administered. When intravenous replacement was given, there was a mean 3.55-hour delay between lab result and administration. 

Conclusion

The majority of hypokalaemic cases developed during admission. Only 27% of these patients had correct potassium replacement in terms of both prescription and administration. Consequently, we have created a local guideline for hypokalaemia in surgical patients to standardise both prevention and management.
EP.FRI.496 Does hospital volume effect time to theatre in patients undergoing emergency laparotomy? A retrospective analysis of NELA data
Authors: Tucker Stefan , Dick Lachlan , Bairstow Fiona , Green James , Young Jamie
Published: October 2021

Aims

Delays to theatre in patients undergoing emergency laparotomy are associated with poorer outcomes. It is unclear whether hospital volume impacts arrival to theatre within a time appropriate to urgency. We aimed to determine the association between hospital laparotomy volume and time to theatre for patients undergoing emergency laparotomy.

Methods

The National Emergency Laparotomy Audit aggregate hospital reports from years 1 – 6 were used to extract data relevant to the study aims. Hospitals were categorised into high, medium and low volume using inter-quartile ranges, with each year counting as a single episode. Statistical analysis was used to determine if there is a difference in arrival to theatre within a time appropriate to urgency.

Results

A total of 751 episodes were included, representing 193 high volume, 370 medium volume and 188 low volume hospitals. The mean proportion of patients arriving to theatre within a time appropriate to urgency were 81.5%, 83.5% and 85.3% respectively. There was no statistical difference between low to medium volume hospitals however, there was when comparing medium to high volume (p = <0.05) and low to high volume (p = <0.05) hospitals. 

Conclusion

Hospitals with low and medium emergency laparotomy volumes have fewer delays to theatre. Whilst it is likely to be multifactorial, it is important for hospitals to have efficient patient pathways in place to reduce delays.
EP.FRI.500 Establishing a protocol of management of acute bowel obstruction in a tertiary hospital in the Middle East
Authors: Alanany Amr , Moshref Leena , Gergi Patrick , Alotaibi Abdulrahman , Malaekah Haifaa , Abouleid Ayman
Published: October 2021

Aim

To establish a protocol of management of acute bowel obstruction in a tertiary hospital in the Middle East. 

Method

An online search in PubMed, Cochrane reviews and Google Scholar for the period between 2010 and 2020 was performed to identify all published guidelines and recommendations for the management of acute bowel obstruction including the keywords small/large bowel or intestinal obstruction, adhesive obstruction, complete/ partial obstruction and conservative/ surgical management of bowel obstruction. 

Results

A protocol of management of acute bowel obstruction has been developed, reviewed and approved by different concerned departments in the hospital. The indicators to monitor the implementation of the protocol had been approved by the Quality and Risk Management Committee of the hospital.

The protocol is divided into 7 sections. These sections include:1) ER assessment with all essential clinical, laboratory and radiological investigations required going hand in hand with resuscitation, hydration, pain control and antibiotic prophylaxis.2) Surgical assessment by senior trainee who will liaise with consultant surgery on call. 3) Radiological assessment guidelines done by senior Radiologist to review the CT scan. 4) Admission criteria. 5) Risk prediction scorings with involvement of critical care team if indicated. 6) Surgical management guidelines with rapid access to operating theatre if indicated. 7) Non- surgical management guidelines including conservative, radiological and endoscopic management. 

Conclusion

Multidisciplinary team approach is essential for the management of acute bowel obstruction. Hospital agreed guidelines and protocols can reduce the significant morbidity and mortality associated with common clinical conditions hence improving patient’s care.
EP.FRI.508 Improving Antibiotic Stewardship on General Surgical Wards
Authors: Clark Mhairi , Crumley Andrew , Wilson Michael
Published: October 2021

Aims

Good antibiotic stewardship is a core part of patient care. It has been shown to reduce antibiotic resistance and improve overall patient outcomes. The primary aim was to improve compliance with national antibiotic prescribing guidance. In doing so, we sought to improve documentation of antibiotic duration; reduce the duration of intravenous antibiotics and gentamicin courses; and length of stay in hospital.

Methods

50 general surgery inpatients at a district general hospital over a 2-week period were included in cycle 1. All eligible patients on antibiotics were included. Patients were excluded if under 18 years; discharged within 24 hours; or on antibiotics for prophylaxis. Intervention was a poster and education sessions with prescribers. Cycle 2 gathered data from a further 50 patients from the same wards over 10 days. 

Results

There were improvements in documentation of antibiotic duration (from 1% to 52%, p = 0.001); prescription of antibiotics in line with guidance (from 74% to 90%, p = 0.0376) and number of patients on intravenous antibiotics (reduced from 89% to 72%, p = 0.0307). Duration of gentamicin courses also improved: from 23% patients getting more than 72 hours of gentamicin, to 0% post intervention. Length of stay was also reduced, however was not statistically significant (4.98 days to 4.10 days, p = 0.259). 

Conclusions

This simple audit intervention improved antibiotic stewardship on surgical wards, which is an essential part of overall care for patients. Future work could be done to further improve on this, including a prompt via electronic prescribing and targeted interventions in other clinical areas, e.g. ICU.
EP.FRI.615 Assessing the reliability of the Adult Appendicitis Score in managing patients with suspected acute appendicitis
Authors: Zheng Carry , Lee Shiela , Brown Steven , Kanakala Venkat
Published: October 2021

Aims

To evaluate the effectiveness of using a clinical prediction tool in the management of suspected acute appendicitis

Methods

Retrospective data was collected on patients undergoing appendicectomy at a single tertiary centre from November 2019 to June 2020. Inclusion criteria were all patients aged 18 and above undergoing diagnostic laparoscopy for suspected appendicitis. Exclusion criteria were all patients that had a pathological finding other than appendicitis at laparoscopy. The pre operative AAS score at first presentation was calculated and patients grouped into low(0-10), intermediate(11-15), and high(16 and above) risk. These groups were then compared to the histological findings.

Results

A total of 74 patients were included, 44 male and 30 female. The age range was from 18 to 83, with a median age of 36. Of 10 patients in the low risk group, 4 (40%) had appendicitis on histology. 36 out of 40 (90%) patients in the intermediate risk group had appendicitis and 100% of the 24 patients in the high risk group. Pearson’s coefficient showed a significant correlation between the AAS risk (low, intermediate, and high) and the histological diagnosis of appendicitis (r = 0.48, p = 0.000016).

Conclusions

Our study did show a positive correlation between the AAS risk stratification and histological diagnosis. Based on our findings we would recommend the adoption of this score in assessing patients with suspected acute appendicitis and minimising the negative appendicectomy rate.
EP.FRI.623 Outcome of Rectus Sheath Catheters for Post Operative Analgesia in Patients Undergoing Laparotomies and Elective Colorectal Resections
Authors: Darwish Nourelhuda , Dhahri AdeelAbbas , Anad Adam , Sanwu David , Ivanov Bogdan
Published: October 2021

Aims

Multimodal analgesia combining regional and local analgesia and avoiding opioids are part of most ERAS protocols aiming to achieve good pain relief. We aim to examine the effectiveness of using rectus sheath catheters (RCSs) for pain relief in patients undergoing laparotomy surgery and wither this have affected the postoperative (30-day) outcome and the need of opioids.

Methods

This was a retrospective study involving patients who underwent midline laparotomy surgery, including elective colorectal resections in the period between 01/07/2020 and 23/12/2020.

Results

A total of 71 patients were included in the study, of which 40(56.33%) had RSCs while 31(43.66%) did not. Morphine was required for 24(60%) of those with RSCs and for 18 patients (58.06%) with no RSCs. PCA was used in 5 (12.5%) of those with RSCs and in 10 (32.25%) of those without RSCs. Of patients requiring non-PCA morphine, mean total morphine doses were 6.4 in patients with RSCs and 4.89 in patients with no RSCs.

Of patients with RSCs, (22.5%, 9/40) developed chest infection within 30 days (average onset at day-11) compared to (25.8%,8/31) of the other group (average onset at day-5). 20% (8/40) of the patients with RSCs had atelectasis postoperatively compared to 29.03% (9/31) of those who did not. The Average postoperative stay was 13.65 days and 21 days for those with and without RSCs, respectively.

Conclusions

Using RSCs did not reduce morphine usage, However, it is associated with lower incidence of chest infection and atelectasis in addition to shorter hospital stay.
EP.FRI.758 Management of Small Bowel Obstruction: A Retrospective Audit
Authors: Baggaley Alice , Clements Caterina , Tudyka Vera
Published: October 2021

Aims

How does management of small bowel obstruction (SBO) at a district general hospital in London compare with current recommendations from the BMJ Best Practice algorithm and the National Audit for Small Bowel Obstruction (NASBO)?

Methods

This retrospective audit captured patients admitted with SBO over a four-month period. Two authors searched the general surgery admission lists and extracted hospital numbers. A total of 59 patients were identified initially but nineteen of these patients were subsequently excluded, leaving 40 to be analysed. Inclusion criteria involved age 18 or over and SBO proven on imaging.

Results

The majority of the obstructions were secondary to adhesions (65%), with 10% due to hernia, 7% due to inflammatory bowel disease and 5% due cancer. All but one patient underwent computed tomography (CT) and in 90% of cases this was performed within 12 hours of initial assessment. For those who underwent a period of conservative management, 64% received a water-soluble study. Seven patients had immediate surgery within 12 hours of admission, and 5 patients proceeded to surgery after failed conservative management. Of the patients who failed conservative management, only one was operated on after the 72 hours.

Conclusions

Access to CT was excellent, as was time to theatre when the decision was made for immediate surgery. There was not a difference in access to imaging or theatre given the time or day of the week. Use of water-soluble studies in conservative management could be increased and the time to this study could be formalised.
EP.FRI.874 Laparoscopic Assisted Submucosal Excision of an Intussuscepted Colonic Lipoma through a Colotomy; A New Technique
Authors: Ejtehadi Farshid , Jesudoss Abraham , Hassan Adil Mubarak , Mohammed Elsamoual , Vivekanandan Shanmugam , Vijay Vardhini
Published: October 2021

Lipomas are the most common non-epithelial tumours of the colon. Nevertheless, symptomatic colonic lipomas are a rare entity in adults. Intussusception is the commonest complication of submucosal lipomas and often presents with absent, non-specific or intermittent symptoms, hence the diagnosis is challenging. 

In non-emergency situations, most patients undergo computed tomography scan as well as endoscopic evaluation of the colon prior to any surgical intervention. While successful endoscopic excision of lipomas has been reported, segmental resection of the colon is most commonly practiced. To the best of our knowledge, this is the first report of laparoscopic assisted submucosal excision of an intussuscepting colonic lipoma through a colotomy.

We present the case of a young female patient with few weeks history of intermittent abdominal pain associated with nausea. She had previously undergone various investigations including colonoscopy and was awaiting an elective left hemicolectomy. She presented to our Emergency department with subacute large bowel obstruction. A CT scan confirmed the diagnosis of colo-colic intussusception due to a large descending colon lipoma. The patient underwent a laparoscopic assisted procedure - following laparoscopic colonic mobilisation, submucosal excision of the large lipoma was performed through a colotomy placed through the taenia on the opposite wall. The mucosal defect and colotomy were closed following the excision. The patient recovery was uneventful and histopathology of the specimen confirmed the diagnosis.